MetLife 2022 FEDVIP Dental Plan Summary

2022 Dental Plan Summary

Wherever a job

is also an honor,

MetLife Federal

Dental is with you.

Enroll in the MetLife Federal Dental

Plan today. Get the benefits you’re

looking for:

• More Coverage

• More Dentists

• More Savings

• More Satisfaction

Contents

Plan Highlights 4

Covered Dental Services 5

Benefits Options 6

Rates 7

Member Benefits 8

Enroll 9

Exclusions and Limitations 10

Enroll November 8, 2021 –

December 13, 2021, midnight EST

www.BENEFEDS.com

1-877-888-FEDS (3337)

We’re with you in 2022

with big discounts and

access to one of the

nation’s largest dental

networks.

Open Season

November 8, 2021 –

December 13, 2021,

midnight EST

To enroll:

BENEFEDS

BENEFEDS.com

1-877-888-FEDS (3337)

TTY 1-877-889-5680

Find out more:

MetLife

MetLife.com/FEDVIP-Dental

1-888-865-6854

TDD 1-888-260-5376

Monday–Friday, 8am–9pm EST

OPM

opm.gov/healthcare-insurance

Plan Highlights

Enroll now

More Coverage

• Comprehensive coverage including child and adult orthodontia

in both plan options

• No waiting periods to receive benefits

• Unlimited annual maximum per person in the high option

• No annual deductible for in-network benefits

More Dentists

• One of the nation’s largest networks

• Over 492,000 participating dentist locations

• Find out if your dentist is in our network by using

our “Find a Dentist” tool at MetLife.com/FEDVIP-Dental

More Savings

• Big discounts up to 45% lets you save even more with

in-network dentists

• No out-of-pocket costs for in-network cleanings, X-rays and exams

• Competitively priced

More Satisfaction

• 98% of claims are paid within 10 days

• 97% of our members would tell you to chooseus

• Automatic claims submission to FSAFEDS with paperless reimbursement

MetLife Federal Dental is always with you,

even during the most unusual of times. Eligible

federal employees and retired uniformed

service members receive:

1. As of June 2021.

2. Based on MetLife data. Savings from enrolling in the MetLife Federal Dental Plan will depend on various factors,

including the cost of the plan, how often participants visit the dentist and the cost of servicesrendered.

3. Subject to frequency limitations.

4. MetLife claims data as of March 2021.

5. Based on the 2020 MetLife Federal Dental Plan Participant Satisfaction Survey.

MetLife Federal Dental Plan

Covered Dental Services

More coverage

With the MetLife Federal Dental Plan, it’s even easier

to get the coverage you need.

Covered Dental Services

Here is a summary of dental

services covered in each category:

Class A - Basic

Diagnostic and Treatment

Periodic oral evaluations; one every 6 months.

Bitewing X-rays; one set every 6 months for

children; one set every calendar year for adults.

Preventive Services

Prophylaxis (cleanings) for adults and children; one

every 6 months.

Topical application of fluoride; two every 12 months

for children; one every 12 months for adults.

Class B - Intermediate

Minor Restorative Services

Resin-based anterior composites; alternate benefit

of amalgam will be provided on molar teeth.

Prefabricated stainless steel crowns; one per tooth

every 60 months.

Endodontic Services

Therapeutic pulpotomy (exclusions apply).

Periodontic Services

Periodontal scaling and root planing; four or more

teeth per quadrant; one every 24 months.

Prosthodontic Services

Rebase of complete maxillary dentures; one in a

36-month period; 6 months after initial installation.

Oral Surgery

Removal of an impacted tooth. Surgical access of

an unerupted tooth.

Class C - Major

Major Restorative Services

Metallic onlays; four or more surfaces; one per

tooth every 60 months.

Porcelain or ceramic crown substrate; one per

tooth every 60 months.

Endodontics Services

Anterior, bicuspid and molar root canal

(exclusions apply).

Re-treatment of anterior, bicuspid and molar root

canal therapy.

Periodontics Services

Gingivectomy or gingivoplasty; one to three teeth

per quadrant; one every 36 months.

Prosthodontic Services

Porcelain, ceramic and cast metal retainers for resin-

bonded fixed prosthesis; one every 60 months.

Implant Services

Implant services subject to the guidelines of the plan.

Class D - Orthodontia

Adult (enrollee and spouse) and dependent children

orthodontia coverage.

No waiting periods for both Standard and

High Options.

Orthodontic benefits end at cancellation

of coverage.

The details in this document represent an overview of your

plan benefits. This document is not a complete description

of the plan. Please note certain services listed are subject

to dental review and the alternate benefit. Please visit

MetLife.com/FEDVIP-Dental for a full explanation of

plan benefits including exclusions and limitations. The

MetLife 2022 Federal Dental Plan Brochure will govern if

any discrepancies exist between that Brochure and this

Plan Summary or any other document. The MetLife 2022

Federal Dental Plan Brochure and 2022 Federal Dental

Plan Summary are available for viewing and printing at our

website, MetLife.com/FEDVIP-Dental.

Enroll now

MetLife Federal Dental Plan

Benefits Options

You can choose

We’ve made it simple to choose the right plan to fit your

budget with Standard and High plan options.

Both plans provide savings for you and your family including:

• No cost for in-network cleanings, X-rays and exams

• No annual deductible for in-network services

• Competitive pricing

• No waiting periods

Standard Option:

• $1,500 annual maximum per person

• Child orthodontia covered at 50% up to a plan

lifetime maximum of $2,000

• Adult orthodontia covered at 50% up to a plan

lifetime maximum of $2,000

igh Option provides you with additional

protection from unforeseen dental costs:

• Unlimited annual maximum per person

• Adult orthodontia covered at 70% up

to a plan lifetime maximum of $3,000

• Child orthodontia covered at 70% up

to a plan lifetime maximum of $5,000

Standard Option High Option

Coverage In-Network Out-of-Network In-Network Out-of-Network

Basic cleanings, X-rays and oral examinations 100% 60% 100% 90%

Intermediate fillings and periodontal maintenance 55% 40% 70% 60%

Major crowns, bridges, root canal treatment and dentures 35% 20% 50% 40%

Orthodontia comprehensive orthodontic treatment, fixed appliance 50% 50% 70% 70%

Annual Deductible Per Person

$0 $100 $0 $50

Annual Maximum Per Person $1,500 $1,000 Unlimited Unlimited

Orthodontia Lifetime Maximum Dependent Child Per Person $2,000 $2,000 $5,000 $5,000

Orthodontia Lifetime Maximum Adult Per Person $2,000 $2,000 $3,000 $3,000

In-Network

• Participating dentists charge negotiated fees that are typically 30-45% less than

average charges in the same community.

• Negotiated fees even apply to services your plan doesn’t cover, including any you

receive after reaching your plan’s annual maximum.

• The plan pays a percentage of the negotiated fee (the Plan Allowance) for a covered

service. The percentage of the Plan Allowance the plan pays for each type of service

is shown above.

• Your out-of-pocket amount is limited to the difference between the Plan Allowance

and our payment.

Out-of-Network

• A non-participating dentist sets his or her own fees, which are typically higher than the in-network Plan Allowance.

• The plan pays a percentage of the Plan Allowance for a covered service. The percentage of the Plan Allowance the

plan pays for each type of service is shown above.

• The Standard Option Plan Allowance for a covered service equals the in-network Plan Allowance for the covered service.

• The High Option Plan Allowance for a covered service equals the in-network Plan Allowance for the covered service.

• Your out-of-pocket amount is the difference between your dentist’s fee and our payment.

Your out-of-pocket cost

will generally be higher when you visit an out-of-network dentist.

Enroll now

1. Subject to frequency limitations. 2. Annual deductible applies to Basic, Intermediate and Major Services for out of network only.

3. Based on MetLife data. Negotiated fees refer to the fees that participating dentists have agreed to accept as payment in full for services rendered by

them, subject to any cost sharing, benefit maximums and terms of the plan. Negotiated fees are subject to change. Savings from enrolling in a dental

benefits plan will depend on various factors, including plan design and premiums, how often participants visit the dentist and the cost of services rendered.

4. Subject to any deductibles, cost sharing, benefit maximum and terms of the plan.

This document is not a complete description of the plan options. The 2022 MetLife Federal Dental Plan Brochure will govern these plan options and can be

viewed by visiting MetLife.com/FEDVIP-Dental

Rates

Premium rating areas by state

Finding your bi-weekly rate is simple.

1. Find your state and the first 3 digits of your zip code below

2. Match that Rating Area to your enrollment type and plan option

Standard Option High Option

Rating Area Self Self + One Self + Family Self Self + One Self + Family

1 $10.25 $20.51 $30.76 $18.82 $37.63 $56.45

2 $10.90 $21.79 $32.69 $19.85 $39.70 $59.55

3 $12.15 $24.30 $36.45 $22.04 $44.09 $66.13

4 $13.40 $26.81 $40.21 $23.98 $47.96 $71.94

5 $14.18 $28.37 $42.55 $26.70 $53.39 $80.09

State State/Zip (first 3) Rating

AK Entire State 5

AL Entire State 1

AR Entire State 1

AZ 856-857 1

850-853, 855,

859-860, 863, 865

AZ 864 3

919-921, 942,

956-959

CA Rest of State 5

CO Entire State 4

CT Entire State 5

DC Entire District 4

DE Entire State 3

FL 330-334, 349 3

320-328, 335-339,

341-342, 344,

346, 347

FL 329 1

GA Entire State 2

GU Entire Territory 1

HI Entire State 4

IA Entire State 1

ID Entire State 2

IL 600-609, 613 4

IL Rest of State 1

IN 463-464 4

IN Rest of State 1

KS Entire State 1

KY Entire State 1

LA Entire State 1

State State/Zip (first 3) Rating

MA 012 1

MA Rest of State 5

MD 219 3

MD Rest of State 4

ME 039-042 5

ME Rest of State 2

MI 480-485 3

MI Rest of State 2

550-551, 553-555,

563

MN Rest of State 2

MO Entire State 1

MS Entire State 1

MT Entire State 1

NC Entire State 2

ND Entire State 1

NE Entire State 1

NH Entire State 5

NJ 080-084 3

NJ Rest of State 5

NM 874, 877-884 2

NM Rest of State 1

NV 889-891 3

NV 897 4

NV Rest of State 2

NY 120-123, 127-149 1

NY Rest of State 5

OH Entire State 1

OK Entire State 2

State State/Zip (first 3) Rating

OR 970-973 4

OR Rest of State 3

PA 172-174 4

PA 180-181, 183 5

PA 189-196 3

PA Rest of State 1

PR Entire Territory 1

RI Entire State 5

SC Entire State 2

SD Entire State 1

TN Entire State 1

733, 739, 750-754,

760-762, 770, 772-

775, 786-787

TX Rest of State 1

UT Entire State 1

201, 205, 220-

227

VA 231, 233-237 2

VA Rest of State 1

VI Entire Territory 1

VT Entire State 2

WA 980-985 5

WA Rest of State 4

WI 540 4

WI Rest of State 2

WV 254 4

WV Rest of State 1

WY Entire State 2

INT All 5

1. Find your personalized rate and view monthly rates online by visiting us at MetLife.com/FEDVIP-Dental

Enroll now

MetLife Federal Dental Plan

Member Benefits

MetLife Federal Dental continues to be with you and is proud to offer

you and your families the following plan benefits:

• A choice between the MetLife Federal Dental Standard and High Options

• High annual and lifetime plan maximums

• One of the nation’s largest dental networks

• Significant discounts for covered services by in-network dentists

Many federal employees and retirees choose MetLife Federal Dental plans

over other FEDVIP carriers.

If you are not enrolled and want to receive FEDVIP dental coverage beginning

in 2022, you must enroll during the Federal Benefits Open Season, November 8–

December 13, 2021, midnight EST.

How we have changed for 2022:

The High Option Plan Allowance for Out-of-Network services will be equal

to the In-Network Plan Allowance for the covered service. This change will not

impact the way orthodontia reimbursement is calculated; however, In-Network

discounts are 10%–45% below community average charge and depending on the

Out-of-Network providers charge your out-of-pocket liability can vary from prior

experience for other procedures. As always, please proactively discuss both In

and Out-of-Network healthcare cost with your provider before care is rendered

so that your out-of-pocket costs are known and take advantage of the

Pre-Treatment Estimate process for any procedure which is anticipated

to cost at least $300.

We can’t thank you enough for your commitment to our

country and for the contributions you make day after day.

You more than deserve great dental benefits, savings

andsatisfaction.

Find out more:

MetLife.com/FEDVIP-Dental

1-888-865-6854

To enroll:

BENEFEDS.com

1-877-888-FEDS (3337)

MetLife Federal Dental Plan

Enroll

More Dentists

You’ll have access to one of the largest networks

in the country. And that means more choices for you.

Enroll in the MetLife Federal

Dental Plan now.

MetLife provides benefits for more than 700,000 federal government

employees, retirees and retired uniformed service members.

Online

BENEFEDS.com

Phone

1-877-888-FEDS (3337)

TTY 1-877-889-5680

Enroll now

MetLife Federal Dental Plan

Exclusions and Limitations

Exclusions and limitations

The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will not cover it

unless we determine it is necessary for the prevention, diagnosis, care or treatment of a covered condition.

We do not cover the following:

Services and treatment not prescribed by or under the

direct supervision of a dentist, except in those states

where dental hygienists are permitted to practice

without supervision by a dentist. In these states, we

will pay for eligible covered services provided by an

authorized dental hygienist performing within the

scope of his or her license and applicable state law;

Services and treatment which are experimental

or investigational;

Services and treatment which are for any illness or

bodily injury which occurs in the course of employment

if a benefit or compensation is available, in whole or

in part, under the provision of any law or regulation or

any government unit. This exclusion applies whether

or not you claim the benefits or compensation;

Services and treatment received from a dental or

medical department maintained by or on behalf of

an employer, mutual benefit association, labor union,

trust, VA hospital or similar person or group;

Services and treatment performed prior to your

coverage effective date;

Services and treatment incurred after the termination

date of your coverage unless otherwise indicated;

Services and treatment which are not dentally

necessary or which do not meet generally

accepted standards of dental practice;

Services and treatment resulting from your failure to

comply with professionally prescribed treatment;

Any charges for failure to keep a scheduled appointment;

Any services that are considered strictly

cosmetic in nature including, but not

limited to, charges for personalization or

characterization of prosthetic appliances;

Services related to the diagnosis and treatment

of Temporomandibular Joint Dysfunction (TMD);

Services or treatment provided as a result of

intentionally self-inflicted injury or illness;

Services or treatment provided as a result of injuries

suffered while committing or attempting to commit

a felony, engaging in an illegal occupation, or

participating in a riot, rebellion or insurrection;

Office infection control charges;

Charges for copies of your records, charts or

X-rays, or any costs associated with forwarding/

mailing copies of your records, charts or X-rays;

State or territorial taxes on dental services performed;

Charges submitted by a dentist, which are for

the same services performed on the same date

for the same member by another dentist;

Services provided free of charge by any governmental

unit, except where this exclusion is prohibited by law;

Services for which the member would have no obligation

to pay in the absence of this or any similar coverage;

Charges for specialized procedures and techniques;

Services performed by a dentist who is compensated

by a facility for similar covered services performed

for members;

Duplicate, provisional and temporary devices,

appliances, and services;

Plaque control programs, oral hygiene instruction

and dietary instructions;

Services to alter vertical dimension and/or restore

or maintain the occlusion. Such procedures include,

but are not limited to, equilibration, periodontal

splinting, full mouth rehabilitation and restoration

for misalignment of teeth;

Gold foil restorations;

Treatment or services for injuries resulting from

the maintenance or use of a motor vehicle if such

treatment or service is paid or payable under

a plan or policy of motor vehicle insurance,

including a certified self-insurance plan;

Treatment of services for injuries resulting from war

or act of war, whether declared or undeclared, or from

police or military service for any country or organization;

Hospital costs or any additional fees that the dentist

or hospital charges for treatment at the hospital

(inpatient or outpatient);

Charges by the provider for completing dental forms;

Adjustment of a denture or bridgework which is made

within 6 months after installation by the same dentist

who installed it;

Use of material or home health aids to prevent decay,

such as toothpaste, fluoride gels, dental floss and

teeth whiteners;

Sealants for teeth other than permanent molars;

Precision attachments, personalization, precious

metal bases, and other specialized techniques;

Replacement of dentures that have been lost,

stolen or misplaced;

Orthodontic care for dependent children age

22 and over for Federal civilian enrollees;

Orthodontic care for dependent children age

21 and over or full time students age 23 and

over for TRICARE eligible enrollees;

Repair of damaged orthodontic appliances;

Replacement of lost or missing appliances;

Fabrication of athletic mouth guard;

Internal bleaching;

Nitrous oxide;

Oral sedation;

Services arising out of accidental injury to the

teeth and supporting structures, except for injuries

to the teeth due to chewing or biting of food;

When two or more services are submitted and the

services are considered part of the same service to

one another, the Plan will pay the most comprehensive

service (the service that includes the other non-benefited

service) as determined by MetLife;

When two or more services are submitted on the same

day and the services are considered mutually exclusive

(when one service contradicts the need for the other

service), the Plan will pay for the service that represents

the final treatment as determined by MetLife;

The details in this document represent an overview of

your plan benefits. This document is not a complete

description of the plan. Please note certain services

listed are subject to dental review and the alternate

benefit. Please visit MetLife.com/FEDVIP-Dental for a

full explanation of plan benefits including exclusions

and limitations. The MetLife 2022 Federal Dental

Plan Brochure will govern if any discrepancies

exist between this Plan Summary as well as these

exclusions and limitations and the actual MetLife

Federal Dental Plan. The MetLife 2022 Federal

Dental Plan Summary is available for viewing and

printing at our website, MetLife.com/FEDVIP-Dental.

Enroll now

Metropolitan Life Insurance Company

200 Park Avenue

New York, NY 10166

Like most group benefits programs, benefit programs offered

by MetLife contain certain exclusions, exceptions, waiting

periods, reductions, limitations and terms for keeping them

in force. For more information please view the Federal Dental

Plan Brochure, which will govern these plan options and

can be viewed by visiting MetLife.com/FEDVIP-Dental.

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