Dental coverage for you,
commitment
from us.
2024 Dental Plan Summary
Contents
Enroll in the MetLife
Federal Dental Plan today.
Get the benefits you’re
looking for:
•
More Savings
•
More Coverage
•
More Choice
Enroll November 13, 2023 –
December 11, 2023, midnight EST
BENEFEDS.com
1-877-888-FEDS (3337)
Plan Highlights 4
Covered Dental Services 5
Benefits Options 7
Rates 8
Enroll 9
Exclusions and Limitations 10
2
Open Season
November 13, 2023 –
December 11, 2023,
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
Choose the support and
comprehensive
coverage of MetLife
Federal Dental.
3
More Savings
1. 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.
2. Subject to frequency limitations.
3. As of March 2023.
4. As a component of becoming an Aura Plan member, Consumers receive identity theft insurance through a group
policy issued to Aura which is underwritten and administered by American Bankers Insurance Company of Florida,
an Assurant company, which is not an affiliate or subsidiary of MetLife. Checking & Savings Cash Recovery and
401(K) & HSA Cash Recovery are part of and not in addition to the Expense Reimbursement limit of liability. The
description herein is a summary and intended for informational purposes only and does not include all terms‚
conditions and exclusions of the policies described. Please refer to the actual policies for terms, conditions, and
exclusions of coverage. Coverage may not be available in all jurisdictions.
Committed to you and your health.
4
•
Savings up to 50% for in-network services such as fillings and crowns
1
•
100% coverage for in-network cleanings, X-rays, and exams
2
•
Competitively priced premiums
More Coverage
•
Orthodontic coverage for adults and children in both plan options
•
An unlimited annual benefit in our High option
•
Benefits available on day one of your coverage
More Choice
•
A network of over 427,000 dentist locations nationwide
3
•
Find out if your dentist is in our network by using our "Find a Dentist"
tool at MetLife.com/FEDVIP-Dental
•
Two plan options to choose from
NEW! MetLife + Aura Identity & Fraud Protection included at no cost
•
Award-winning and powerful online protection for your personal info, credit,
finances, and devices, plus a $5M
4
insurance policy.
•
This 24/7 digital security solution is available for all FEDVIP dental members
starting January 1, 2024.
Comprehensive dental benefits
for Federal employees and retired
uniformed service members include:
Class A - Basic
Class B - Intermediate
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
Minor Restorative Services
Coverage for resin-based composite
fillings on molar teeth
Resin-based anterior composites
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
Nitrous Oxide
When medically or dentally necessary,
similar to coverage for general anesthesia
and intravenous conscious sedation
Enroll now
5
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 2024 Federal Dental Plan Brochure will govern if
any discrepancies exist between that Brochure and this Plan Summary or any other document. The MetLife 2024 Federal Dental Plan
Brochure and 2024 Federal Dental Plan Summary are available for viewing and printing at our website, MetLife.com/FEDVIP-Dental.
Your comprehensive
dental benefits continued:
Class C - Major
Class D - Orthodontia
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 resinbonded fixed
prosthesis; one every 60 months
Implant Services
Implant services subject to the
guidelines of the plan
Enroll now
6
Choose the option that best fits
the needs of you and your family.
Both options are competitively priced and provide these ways to save:
•
Participating dentists charge negotiated fees that are typically 35-50% less than average
charges in the same community.
3
•
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.
4
•
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.
4
Your out-of-pocket cost will generally be higher when you visit an out-of-network dentist.
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
High Option for additional protection
from unexpected 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
In-Network Out-of-Network
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 2024 MetLife Federal Dental Plan Brochure will govern these plan options
and can be viewed by visiting MetLife.com/FEDVIP-Dental.
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 llings and periodontal maintenance 55% 40% 70% 60%
Major crowns, bridges, root canal treatment and dentures 35% 20% 50% 40%
Orthodontia comprehensive orthodontic treatment, xed appliance 50% 50% 70% 70%
Annual Deductible Per Person
2
$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
Enroll now
7
•
Competitively priced
•
100% coverage for in-network cleanings, X-rays and exams
1
•
No annual deductible for in-network services
•
Benefits available on day one of your coverage
You can easily find your rates online by visiting fedvip.metlife.com/dental/rates/
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
TX
733, 739, 750-
754, 760-762,
770, 772-775,
786-787
2
TX
Rest of State 1
UT
Entire State 1
VA
201, 205, 220-
227
4
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
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
MN
550-551, 553-
555, 563
4
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
Standard Option High Option
Rating Area Self Self + One Self + Family Self Self + One Self + Family
1 $10.23 $20.47 $30.70 $18.43 $36.85 $55.28
2 $10.88 $21.75 $32.63 $19.44 $38.88 $58.31
3 $12.13 $24.26 $36.39 $21.59 $43.19 $64.78
4 $13.38 $26.77 $40.15 $23.49 $46.98 $70.46
5 $14.16 $28.33 $42.49 $26.14 $52.29 $78.43
State State/Zip (first 3) Rating
AK
Entire State 5
AL
Entire State 1
AR
Entire State 1
AZ
856-857 1
AZ
850-853,
855, 859-860,
863, 865
2
AZ
864 3
CA
919-921, 942,
956-959
4
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
FL
320-328, 335-
339, 341-342,
344, 346, 347
2
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
Enroll now
8
Your bi-weekly rates
Competitively priced. Find the Rating Area for your State and Zip
Code below. Then, find the associated rate for your coverage level
in each plan option.
Dental coverage for you,
commitment from us.
Enroll in the MetLife Federal
Dental Plan today.
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
Key plan highlights include:
•
More Savings — up to 50% for in-network services such as fillings and crowns
1
•
More Coverage — Orthodontic coverage for adults and children in both plan options
•
More Choice — A network of over 427,000 dentist locations nationwide
2
1. 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.
2. As of March 2023.
Enroll now
9
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 2024 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 2024 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.
No one can prevent all identity theft or monitor all
transactions effectively.
Aura is a product of Aura Sub, LLC. Aura Sub, LLC. is not
affiliated with MetLife, and the services and benefits they
provide are separate and apart from any MetLife product.
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10
