2023 MetLife Dental Insurance Summary

Metropolitan Life Insurance Company | 200 Park Avenue | New York, NY 10166

DN-ANY-PPO-DUAL

PLAN SUMMARY

Dental Insurance

Coverage that helps makes it easier to visit a dentist and helps lower your

dental costs.

Princeton University

Network: PDP Plus

Deductible

†

Individual N/A $50 $50 $50

Family N/A $150 $150 $150

Annual Maximum Benefit

Per Person $2,000 $2,000 $2,000 $1,500

Orthodontia Lifetime Maximum

Per Person

***

N/A N/A $2,000 $1,500

“In-Network Benefits" refers to benefits provided under this plan for covered dental services that are provided by a participating dentist. "Out-of-Network Benefits" refers to benefits

provided under this plan for covered dental services that are not provided by a participating dentist.

Negotiated fees refer to the fees that participating dentists have agreed to accept as payment in full for covered services, subject to any copayments, deductibles, cost sharing and benefits

maximums. Negotiated fees are subject to change.

*Reimbursement for out-of-network services is based on the lesser of the dentist’s actual fee or the Maximum Allowable Charge (MAC). The out-of-network Maximum Allowable Charge is a

scheduled amount determined by MetLife.

**R&C fee refers to the Reasonable and Customary (R&C) charge, which is based on the lowest of (1) the dentist’s actual charge, (2) the dentist’s usual charge for the same or similar

services, or (3) the charge of most dentists in the same geographic area for the same or similar services as determined by MetLife.

†Applies to Type B Services (Basic Plan; Non-PDP). Applies only to Type B & C Services (High Plan).

*** Orthodontia included for adults. Available for dependent children up to age 26 (High Plan).

Plan option 1

Basic Plan

Plan option 2

High Plan

In-Network

% of Negotiated

Fee

Out-of-Network

% of Maximum

Allowable Charge*

In-Network

% of Negotiated

Fee

Out-of-Network

% of R&C Fee**

Coverage Type

Type A: Preventive

(cleanings, exams, X-rays)

100% 100% 100% 100%

Type B: Basic Restorative

(fillings, extractions)

50% 50% 80% 70%

Type C: Major Restorative

(bridges, dentures)

N/A N/A 60% 50%

Type D: Orthodontia N/A N/A 50% 50%

Metropolitan Life Insurance Company | 200 Park Avenue | New York, NY 10166

DN-ANY-PPO-DUAL

PLAN SUMMARY

Dental Insurance

Coverage that helps makes it easier to visit a dentist and helps lower your

dental costs.

Princeton University

List of Primary Covered Services & Limitations*

The service categories and plan limitations shown represent an overview of your Plan Benefits. This

document presents the majority of services within each category but is not a complete description of the Plan.

Plan Type

Plan Option 1: Basic Plan

How Many/How Often

Plan Option 2: High Plan

How Many/How Often

Type A — Preventive

Prophylaxis (cleanings) Two per calendar year Two per calendar year

Oral Examinations Two exams per calendar year Two exams per calendar year

Topical Fluoride Applications

One fluoride treatment per calendar

year for dependent children up to

his/her 16th birthday

One fluoride treatment per calendar

year for dependent children up to

his/her 16th birthday

X-rays

 Full mouth X-rays; one per 3

calendar years

 Bitewings X-rays; one set per

calendar year

 Full mouth X-rays; one per 3

calendar years

 Bitewing X-rays; one set per

calendar year

Space Maintainers Once per tooth area, per lifetime Once per tooth area, per lifetime

Sealants

One application of sealant material every

3 years for each non-restored, non-

decayed 1st and 2nd molar of a

dependent child up to his/her 16th

birthday

One application of sealant material every

3 years for each non-restored, non-

decayed 1st and 2nd molar of a

dependent child up to his/her 16th

birthday

Type B — Basic Restorative

Fillings

Simple Extractions

Crown, Denture and Bridge Repair/

Recementations

 Repairs; once per 12 months

 Recementations; once per 12 months

N/A

Oral Surgery Includes removal of bony impacted tooth Excludes removal of bony impacted tooth

Endodontics

General Anesthesia

When dentally necessary in connection

with oral surgery, extractions or other

covered dental services

N/A

Periodontics

 Periodontal scaling and root

planing once per quadrant, every

24 months

 Total number of periodontal

maintenance treatments and

prophylaxis cannot exceed four

treatments in a calendar year

 Periodontal scaling and root

planing once per quadrant, every

24 months

 Total number of periodontal

maintenance treatments and

prophylaxis cannot exceed four

treatments in a calendar year

Metropolitan Life Insurance Company | 200 Park Avenue | New York, NY 10166

DN-ANY-PPO-DUAL

PLAN SUMMARY

Dental Insurance

Coverage that helps makes it easier to visit a dentist and helps lower your

dental costs.

Princeton University

The service categories and plan limitations shown above represent an overview of your plan benefits. This document presents the majority of services

within each category, but is not a complete description of the plan.

 Periodontal surgery once per

quadrant, every 36 months

Type C — Major Restorative

Crown, Denture and Bridge Repair/

Recementations

Not a covered service

 Repairs; once per 12 months

 Recementations; once per 12

months

Implants Not a covered service Replacement once every 60 months

Bridges and Dentures

Not a covered service

 Initial placement to replace one or

more natural teeth, which are lost

while covered by the plan

 Dentures and bridgework replacement;

one every 60 months

 Replacement of an existing

temporary full denture if the temporary

denture cannot be repaired and the

permanent denture is installed within

12 months after the temporary denture

was installed

Crowns, Inlays and Onlays Not a covered service Replacement once every 60 months

General Anesthesia Not a covered service

When dentally necessary in connection

with oral surgery, extractions or other

covered dental services

Periodontics N/A

Periodontal surgery once per quadrant,

every 36 months

Type D — Orthodontia

Not a covered service

 You, your spouse and your

children, up to age 26, are

covered while Dental insurance

is in effect

 All dental procedures performed

in connection with orthodontic

treatment are payable as

Orthodontia

 Payments are on a repetitive

basis

 20% of the amount charged by

the dentist will be considered at

initial placement of the appliance

and paid based on the plan

benefit’s coinsurance level for

Orthodontia as defined in the

plan summary

 Orthodontic benefits end at

cancellation of coverage

Metropolitan Life Insurance Company | 200 Park Avenue | New York, NY 10166

DN-ANY-PPO-DUAL

PLAN SUMMARY

Dental Insurance

Coverage that helps makes it easier to visit a dentist and helps lower your

dental costs.

Princeton University

Exclusions

This plan does not cover the following services, treatments and supplies:

 Services which are not Dentally Necessary, those which do not meet generally accepted standards of care for treating the

particular dental condition, or which we deem experimental in nature;

 Services for which you would not be required to pay in the absence of Dental Insurance;

 Services or supplies received by you or your Dependent before the Dental Insurance starts for that person;

 Services which are primarily cosmetic (for Texas residents, see notice page section in Certificate);

 Services which are neither performed nor prescribed by a Dentist except for those services of a licensed dental hygienist

which are supervised and billed by a Dentist and which are for:

o Scaling and polishing of teeth; or

o Fluoride treatments;

 Services or appliances which restore or alter occlusion or vertical dimension;

 Restoration of tooth structure damaged by attrition, abrasion or erosion;

 Restorations or appliances used for the purpose of periodontal splinting;

 Counseling or instruction about oral hygiene, plaque control, nutrition and tobacco;

 Personal supplies or devices including, but not limited to: water picks, toothbrushes, or dental floss;

 Decoration, personalization or inscription of any tooth, device, appliance, crown or other dental work;

 Missed appointments;

 Services:

o Covered under any workers’ compensation or occupational disease law;

o Covered under any employer liability law;

o For which the employer of the person receiving such services is not required to pay; or

o Received at a facility maintained by the Employer, labor union, mutual benefit association, or VA hospital;

 Services covered under other coverage provided by the Employer;

 Temporary or provisional restorations;

 Temporary or provisional appliances;

 Prescription drugs;

 Services for which the submitted documentation indicates a poor prognosis;

 The following when charged by the Dentist on a separate basis:

o Claim form completion;

o Infection control such as gloves, masks, and sterilization of supplies; or

o Local anesthesia, non-intravenous conscious sedation or analgesia such as nitrous oxide.

 Dental 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;

 Caries susceptibility tests;

 Initial installation of a fixed and permanent Denture to replace one or more natural teeth which were missing before such

person was insured for Dental Insurance, except for congenitally missing natural teeth;

 Other fixed Denture prosthetic services not described elsewhere in the certificate;

 Precision attachments, except when the precision attachment is related to implant prosthetics;

 Initial installation of a full or removable Denture to replace one or more natural teeth which were missing before such person

was insured for Dental Insurance, except for congenitally missing natural teeth;

 Addition of teeth to a partial removable Denture to replace one or more natural teeth which were missing before such person

was insured for Dental Insurance, except for congenitally missing natural teeth;

 Adjustment of a Denture made within 6 months after installation by the same Dentist who installed it;

 Implants including, but not limited to any related surgery, placement, restorations, maintenance, and removal (Basic Plan

Only);

 Repair of implants (Basic Plan Only);

Metropolitan Life Insurance Company | 200 Park Avenue | New York, NY 10166

DN-ANY-PPO-DUAL

PLAN SUMMARY

Dental Insurance

Coverage that helps makes it easier to visit a dentist and helps lower your

dental costs.

Princeton University

 Implants supported prosthetics to replace one or more natural teeth which were missing before such person was insured for

Dental Insurance, except for congenitally missing natural teeth;

 Diagnosis and treatment of temporomandibular joint (TMJ) disorders;

 Repair or replacement of an orthodontic device;

 Duplicate prosthetic devices or appliances;

 Replacement of a lost or stolen appliance, Cast Restoration, or Denture;

 Intra and extraoral photographic images; and

 The following under the Basic Plan:

o Crowns, Inlays and Onlays;

o Fixed and removable appliances for correction of harmful habits;

o Appliances or treatment for bruxism (grinding teeth), including but not limited to occlusal guards and night guards;

o Bridges and Dentures;

o Orthodontia.

Limitations

Alternate Benefits: Where two or more professionally acceptable dental treatments for a dental condition exist, payment is

based on the least costly treatment alternative. If you and your dentist have agreed on a treatment that is more costly than the

treatment upon which the plan benefit is based, you will be responsible for any additional payment responsibility. To avoid any

misunderstandings, we suggest you discuss treatment options with your dentist before services are rendered, and obtain a pre-

treatment estimate of benefits prior to receiving certain high cost services such as crowns, bridges or dentures. You and your

dentist will each receive an Explanation of Benefits (EOB) outlining the services provided, your plan’s payment for those

services, and your out-of-pocket expense. Actual payments may vary from the pretreatment estimate depending upon annual

maximums, plan frequency limits, deductibles and other limits applicable at time of payment.

Cancellation/Termination of Benefits: Coverage is provided under a group insurance policy (Policy form GPNP99) issued by

Metropolitan Life Insurance Company (MetLife). Coverage terminates when your participation ceases, when your dental

contributions cease or upon termination of the group policy by the Policyholder or MetLife. The group policy terminates for non-

payment of premium and may terminate if participation requirements are not met or if the Policyholder fails to perform any

obligations under the policy. The following services that are in progress while coverage is in effect will be paid after the

coverage ends, if the applicable installment or the treatment is finished within 31 days after individual termination of coverage:

Completion of a prosthetic device, crown or root canal therapy.

Group dental insurance policies featuring the Preferred Dentist Program are underwritten by Metropolitan Life Insurance Company, New

York, NY 10166.

Questions & Answers

Q. Who is a participating dentist?

A. A participating dentist is a general dentist or specialist who has agreed to accept negotiated fees as payment in full for

covered services provided to plan members. Negotiated fees typically range from 30% – 45% below the average fees

charged in a dentist’s community for the same or substantially similar services.

†

Q. How do I find a participating dentist?

A. There are thousands of general dentists and specialists to choose from nationwide --so you are sure to find one that meets

your needs. You can receive a list of these participating dentists online at www.metlife.com/mybenefits or call 1-800-942-

0854 to have a list faxed or mailed to you.

Q. What services are covered under this plan?

A. The Plan documents set forth the services covered by your plan. The List of Primary Covered Services & Limitations herein contains a

summary of covered services. In the event of a conflict between the Plan documents and this summary, the terms of the Plan

documents shall govern. Please review the enclosed plan benefits to learn more.

Metropolitan Life Insurance Company | 200 Park Avenue | New York, NY 10166

DN-ANY-PPO-DUAL

PLAN SUMMARY

Dental Insurance

Coverage that helps makes it easier to visit a dentist and helps lower your

dental costs.

Princeton University

Q. May I choose a non-participating dentist?

A. Yes. You are always free to select the dentist of your choice. However, if you choose a non-participating dentist your out-of-

pocket costs may be higher.

Q. Can my dentist apply for participation in the network?

A. Yes. If your current dentist does not participate in the network and you would like to encourage him/her to apply, ask your

dentist to visit www.metdental.com, or call 1-866-PDP-NTWK for an application.

††

The website and phone number are for

use by dental professionals only.

Q. How are claims processed?

A. Dentists may submit your claims for you which means you have little or no paperwork. You can track your claims online and

even receive email alerts when a claim has been processed. If you need a claim form, visit www.metlife.com/mybenefits or

request one by calling 1-800-942-0854

Q. Can I get an estimate of what my out-of-pocket expenses will be before receiving a service?

A. Yes. You can ask for a pretreatment estimate. Your general dentist or specialist usually sends MetLife a plan for your care

and requests an estimate of benefits. The estimate helps you prepare for the cost of dental services. We recommend that

you request a pre-treatment estimate for services in excess of $350. Simply have your dentist submit a request online at

www.metdental.com or call 1-877-MET-DDS9. You and your dentist will receive a benefit estimate for most procedures

while you are still in the office. Actual payments may vary depending upon plan maximums, deductibles, frequency limits

and other conditions at time of payment.

Q. Can MetLife help me find a dentist outside of the U.S. if I am traveling?

A. Yes. Through international dental travel assistance services

you can obtain a referral to a local dentist by calling +1-312-

356-5970 (collect) when outside the U.S. to receive immediate care until you can see your dentist. Coverage will be

considered under your out-of-network benefits.

Please remember to hold on to all receipts to submit a dental claim.

Q. How does MetLife coordinate benefits with other insurance plans?

A. Coordination of benefits provisions in dental benefits plans are a set of rules that are followed when a patient is covered by

more than one dental benefits plan. These rules determine the order in which the plans will pay benefits. If the MetLife

dental benefit plan is primary, MetLife will pay the full amount of benefits that would normally be available under the plan,

subject to applicable law. If the MetLife dental benefit plan is secondary, most coordination of benefits provisions require

MetLife to determine benefits after benefits have been determined under the primary plan. The amount of benefits payable

by MetLife may be reduced due to the benefits paid under the primary plan, subject to applicable law.

Q. Do I need an ID card?

A. No. You do not need to present an ID card to confirm that you are eligible. You should notify your dentist that you are

enrolled in the MetLife Preferred Dentist Program. Your dentist can easily verify information about your coverage through a

toll-free automated Computer Voice Response system.

†Based on internal analysis by MetLife. Negotiated fees refer to the fees that in-network dentists have agreed to accept as payment in full for covered services, subject to any co-payments,

deductibles, cost sharing and benefits maximums. Negotiated fees are subject to change.

††Due to contractual requirements, MetLife is prevented from soliciting certain providers.

*AXA Assistance USA, Inc. provides Dental referral services only. AXA Assistance is not affiliated with MetLife, and the services and benefits they provide are separate and apart from the

insurance provided by MetLife. Referral services are not available in all locations. Exclusions: The AXA Travel Assistance Program is available for participants in traveling status. Whenever

a trip exceeds 120 days, the participant is no longer considered to be in traveling status and is therefore no longer eligible for the services. Also, AXA Assistance USA will not evacuate or

repatriate participants without medical authorization; with mild lesions, simple injuries such as sprains, simple fractures or mild sickness which can be treated by local doctors and do not

prevent the member from continuing his/her trip or returning home; or with infections under treatment and not yet healed. Benefits will not be paid for any loss or injury that is caused by or is

the result from: pregnancy and childbirth except for complications of pregnancy, and mental and nervous disorders unless hospitalized. Reimbursements for non-medical services such as

hotel, restaurant, taxi expenses or baggage loss while traveling are not covered. The maximum benefit per person for costs associated with evacuations, repatriations or the return of mortal

remains is US$500,000. Treatment must be authorized and arranged by AXA Assistance’s designated personnel to be eligible for benefits under this program. All services must be provided

and arranged by AXA Assistance USA, Inc. No claims for reimbursement will be accepted.

**Refer to your dental benefits plan summary for your out-of-network dental coverage.