MetLife Schedule of Benefits 2021 Platinum DHMO California

Plan Overview

The MetLife Platinum Dental Health Maintenance Organization (DHMO) plan offers California residents comprehensive dental coverage with an emphasis on preventive care and predictable out-of-pocket costs. The Platinum DHMO provides access to an extensive network of dentists who have agreed to provide services at discounted rates.

Enrollment Requirements

To enroll in the MetLife Platinum DHMO plan, members must:

• Select a primary care dentist from the MetLife DHMO California network
• Designate a general dentist who will coordinate all dental care
• Obtain referrals from the primary care dentist before seeing specialists
• Pay any required copayments at the time of service

Schedule of Benefits

Category I: Preventive and Diagnostic Services

Service	Member Cost
Periodic oral evaluation (limited to 2 per year)	$0
Comprehensive oral evaluation (once per 3 years)	$0
Dental prophylaxis (cleaning) - 2 per year	$0
Fluoride treatment - adults (once per year)	$15
Fluoride treatment - children under 14 (2 per year)	$0
Bitewing radiographs - 4 films (once per year)	$0
Full mouth series or panoramic radiographs (every 3 years)	$0
Sealants (permanent teeth up to age 14)	$15

Category II: Basic Restorative Services

Service	Member Cost
Amalgam (silver) fillings - 1 surface	$10
Amalgam (silver) fillings - 2 surfaces	$15
Amalgam (silver) fillings - 3 or more surfaces	$25
Composite (tooth-colored) fillings - anterior	$25
Composite (tooth-colored) fillings - posterior	$45
Extraction - simple	$20
Extraction - surgical	$45
Removal of impacted teeth - soft tissue	$75
Removal of impacted teeth - partial bony	$95
Removal of impacted teeth - complete bony	$120
Palliative treatment (emergency relief of pain)	$15

Category III: Major Restorative Services

Service	Member Cost
Core buildup	$35
Endodontic therapy - anterior tooth	$110
Endodontic therapy - bicuspid	$140
Endodontic therapy - molar	$190
Periodontal scaling and root planing - per quadrant	$45
Periodontal maintenance - per visit	$20
Periodontal surgery - flap procedure - per quadrant	$165
Full metal crown - noble metal	$175
Porcelain-fused-to-metal crown	$195
All-ceramic/ceramic-substrate crown	$235
Fixed bridge - per unit	$235
Partial denture - cast metal framework - upper or lower	$295
Complete denture - upper or lower	$345
Surgical placement of implant body	$395
Abutment placement for implant	$195
Implant-supported crown	$495

Category IV: Orthodontic Services

Service	Member Cost
Orthodontic treatment - children under 19	$2,200
Orthodontic treatment - adults 19 and over	$2,500

Important Plan Information

Pre-authorization Requirements

Certain services require pre-authorization before treatment can be provided. These include:

• Periodontal surgery
• Crowns and bridges
• Dental implants
• Oral surgery procedures
• Orthodontic treatment
• Dentures and partials
• Endodontic procedures

Specialist Referrals

Referrals from the member's primary care dentist are required to see specialists, including endodontists, periodontists, oral surgeons, orthodontists, and prosthodontists.

Limitations and Exclusions

Services not covered under the plan include but are not limited to:

• Cosmetic procedures (including tooth whitening)
• Services for teeth that are not functional chewing units
• Experimental or investigational procedures
• Appliances for the treatment of temporomandibular joint (TMJ) disorders

Additional Resources

For more information about the MetLife Platinum DHMO plan or to locate a network dentist, members can visit the MetLife website at www.metlife.com/dental or contact MetLife customer service directly.