What The Plans Cover

The benefits provided under the Dental Plans are intended to cover treatment that is customarily provided by dentists throughout the country to prevent and eliminate oral disease, and to repair or replace damaged or missing teeth. As noted under Benefit Payments , benefits for the Dental Plans are generally based on eligible charges for the services and supplies listed below.

If you use dentists who are members of the HDS or MetLife networks, these dentists agree to charge a certain amount; you are only responsible for your percentage share of this amount (and any applicable tax), not for any amounts that exceed the agreed amount.*

*The "agreed" amount is referred to as the "UCR" amount under the HDS-administered Plans, and the "negotiated" amount under the MetLife-administered Plans.

Should you use a non-network dentist and the dentist's charges exceed the agreed amount, you will be required to pay the difference.

Remember, too, that alternative procedures as explained previously can affect how much the Plan will pay.

Lastly, you should know that while your dentist may recommend a particular dental service, this does not mean that...

  • The dental service will be deemed necessary under the provisions of the Dental Plan, or

  • Benefits will be paid for the service.

When determining benefit payments, the Claims Administrator will make a decision as to whether the dental service is necessary based on generally accepted dental services and is an eligible service with regard to Plan benefits.

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Preventive, Diagnostic And Certain Therapeutic Services

All three Dental Plan options pay 100% of the eligible charges for preventive, diagnostic and therapeutic services as described below:

Preventive Services And Supplies

  • Cleaning and scaling of teeth (oral prophylaxis) twice each calendar year.

  • Sealant material applied to a dependent child's* permanent molar tooth; this benefit, which is covered only under the MetLife-administered Plans for children up to age 16, is limited to two applications per tooth per lifetime.

  • Fluoride treatments for a dependent child* through age 17 (HDS) or age 18 (MetLife) once each calendar year.

  • Space maintainers and their fitting for a dependent child* through age 17 (HDS) or age 18 (MetLife). Space maintainers are appliances used to keep teeth from moving into the space remaining after a tooth is pulled or lost.

* For the purposes of these benefits, a child is one that meets the definition of child as outlined under Who Is Eligible.

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Diagnostic Services And Supplies

  • Oral exams; provided once each calendar year under HDS and twice each calendar year under MetLife;

  • X-rays and laboratory tests needed to diagnose a dental problem (as required);

  • Full mouth X-rays once every three years;

  • Bitewing X-rays available twice each calendar year.

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Therapeutic Services And Supplies

  • Emergency treatment for dental pain when no other treatment but x-rays is given; if other treatment is given, payment at this benefit level (i.e., 100%) will be made only for the palliative treatment—any other treatment will be paid at the applicable benefit level (i.e., 50%, 65% or 80%).

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General Services

All three Dental Plan options provide benefits for general or "basic" dental services. The actual percentage amount paid is based on the option you elected through FlexSolutions: 50% under Option 1, 65% under Option 2 and 80% under Option 3.

Therapeutic Services And Supplies

  • Pulling teeth (extractions) and cutting procedures in the mouth (oral surgery); extra charges for removing stitches and for exams after surgery are not covered.

  • Root canal work (endodontic treatment).

  • Treatment of gums and mouth tissues (periodontic treatment).

  • General anesthetics for oral surgery (local anesthetics are considered to be included in the treatment charges, so extra charges for local anesthetics are not covered).

  • Injections of antibiotic drugs (covered under the MetLife-administered Plan only).

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Restorative Services

  • Silver (amalgam), silicate, plastic, porcelain, and composite fillings. Note: If a tooth can be replaced by a less expensive method, then only that charge will be covered. (See Alternative Procedures for more details.)

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Prosthetic Services And Supplies (Repairs And Rebasing)

  • Repairs to broken crowns, inlays, bridgework, and dentures; however, this does not include adjustments made to new dentures or bridgework during the first six months after they are installed. These charges are considered to be included in the cost of the new denture or bridgework; extra charges are not covered.

  • Rebasing or relining dentures; this is a covered benefit if provided two years after the insertion of a denture (HDS) and not more than once in a 36-month period (MetLife).

  • Adding teeth to fixed bridgework or partial dentures to replace missing natural teeth.

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Major Services

All three Dental Plan options provide benefits for major dental services. The actual percentage amount paid is based on the option you elected through FlexSolutions: 50% under Option 1, 65% under Option 2 and 80% under Option 3.

Major services include the following:

Restorative Services And Supplies

  • Crowns and fillings* to repair a tooth broken down by decay or fracture, as long as:

    • the tooth cannot be repaired with a less-expensive type of filling; if the tooth can be repaired by a less-expensive method, then only that charge will be covered; and

    • the old crown or filling* is at least five years old.

  • Inlays and onlays, but not more than one such restoration to the same tooth within five years of the prior restoration.

* Under the HDS-administered Plan, benefits are limited to crowns and gold restorations.

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Prosthetic Services And Supplies (Dentures And Fixed Bridges)

  • Full or partial dentures and fixed bridgework to replace missing natural teeth; and

  • Full or partial dentures and fixed bridgework to replace an existing denture or bridge that cannot be made serviceable; if the existing denture or bridge was inserted while the individual was covered under this Plan, the existing denture or bridge must be over 5 years old.

Note that charges for special techniques or precision attachments are not covered nor are any charges for any special work that you ask to have done on a standard denture. Also, charges made for adjustments to new dentures or bridgework during the first six months after they are inserted are not covered as these are considered to be included in the new fee for the denture or bridgework.

A permanent denture may replace an existing temporary one. However, in this case, charges for both are limited to the charge for the permanent one.

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Orthodontic Services

All three Dental Plan options provide benefits for orthodontic services provided to covered dependent children. As with general and major services, the actual percentage amount paid is based on the option you elected through FlexSolutions: 50% under Option 1, 65% under Option 2 and 80% under Option 3. These benefits are limited to $1,500 per the covered individual's lifetime.

Eligible charges for orthodontic services include the customary charges made by a dentist for straightening teeth. This includes...

  • Diagnostic procedures, and

  • Appliances to realign the teeth.

Note that necessary space maintainers and teeth extractions are covered under the other portions of this Plan, not under the orthodontic benefit.

As with other dental charges, the Claims Administrator will compare the charge for orthodontic treatment with the charges for comparable treatment made by other dentists in the area. For details, see How The Plans Work.

Orthodontic services are not covered if...

Limitations Of Orthodontic Coverage

  • Orthodontic services are not covered if services were started prior to the date the patient became eligible under this Plan.

  • If a patient's eligibility ends prior to the completion of the orthodontic treatment, payments will not continue.

  • If A&B terminates orthodontic benefits from this Plan, coverage will end on the last day of the month that the change occurred. 

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Payment Sequence

Benefit payments for orthodontic treatment will be made in installments; the exact payment provisions will vary based on the determination of the applicable Claims Administrator (HDS in Hawaii and MetLife on the Mainland).

The following rules apply to benefit payments for orthodontic services...

  • The individual receiving the treatment must be covered under this Plan on the first day of the period in order to receive payment for that period.

  • If the orthodontic treatment is stopped for any reason before it is complete, benefits will be paid for only those services and supplies actually received.

  • Any benefits for orthodontic treatment stop when coverage for the individual receiving the treatment ends under this Plan—no benefits are payable for charges made after coverage ends.

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