We’re proud to protect your smile. Dental Plan Summary

In collaboration with Contents Enroll in the Veterans Affairs Dental Program today. Get the Plan Highlights 3 benefits you’re looking for:

• More coverage  Overview 4 • More savings  • More dentists  • More satisfaction

Benefits Options 5 MetLife.com/VADIP 1-888-310-1681

Covered Dental Services 6

Rates 7

Enroll 8

Frequently Asked Questions (FAQs) 9

Exclusions and Limitations 10

2 This dental benefit program helps protect the smiles of Veterans and their families by offering comprehensive and The Veterans Affairs competitively priced dental coverage.

Participation in VADIP is open to Veterans enrolled in the Dental Insurance VA Health Care System and eligible family members who are beneficiaries of the VA’s Civilian Health and Medical Program (VADIP) Program (CHAMPVA). You must apply with the VA to be eligible for the VA health care benefits. Please visit www.va.gov/healthbenefits for makes coverage more information or call 1-877-222-VETS.

VADIP covers dental services provided in the , simple and the District of Columbia, Puerto Rico, Guam, the U.S. Virgin Islands, American Samoa, and the Commonwealth of the competitively priced. Northern Mariana Islands. Enrollment: MetLife manages To enroll: the dental enrollment process and enrollment in this program is MetLife.com/VADIP “evergreen” (open throughout the 1-888-310-1681 year and not limited to a specific enrollment period).

• Participants can enroll in a high option or standard plan option as they become eligible. • MetLife will verify an applicant’s eligibility through an eligibility verification process prior to informing the applicant of their eligibility for this dental program. MetLife will enroll eligible applicants within 5 calendar days from the date of receipt of a request to enroll. • If you have any questions or encounter an issue with your enrollment, we ask that you contact our customer service for assistance at 1-888-310-1681. • Lock-in Period: The initial enrollment period will be 12 calendar months. • The rates provided in this Plan Summary are valid until the end of the calendar year, unless specified otherwise.

3 • • More Satisfaction • • More Dentists • • More Savings • • • More Coverage benefits you want We it to make get easy the 4. 3. 2. 1.

MetLife data, 1Q2020 cost of servicesrendered. various factors, including the costof the plan,how often participants visit the dentist and the Savings from enrolling in the Veterans Affairs Dental Insurance Program will dependon 19th birthday. There is no orthodontia coverage for adultsunder either planoption. Orthodontia coverage is for dependent children only, through the endof the month of their Except for Orthodontia inhighplan which hasa24-month waiting period. 97% of our members are satisfied with the plan 100% of our membersare satisfied with their dentist Over 490,000 participating dentist locations One of the nation’s largest networks Competitively priced Big discounts let you save even more with in Up to $3,500 annualplanmaximumbenefit Orthodontia Coverage for Dependent Children No waiting periods for major procedures 1  ‑ network dentists 2 4 4 3

4 Overview typically High Op selected option. **Orthodontia is for * T have agr change. For Allowable Charge isascheduled amountdeterminedby MetLife. Reimbursement forout-of-network servicesisbased on thelesserofdentist’s actualfeeorthe MaximumAllowable Charge(MAC).The out-of-networkMaximum services your your budget with We’ve madeitsimple to choose the right plan to fit You choose can In-Network Out-of-Network he AnnualM Participatingdentistschargenegotiated fees for • • A • • • charges in Allowable Charge reach your Orthodontia —ClassD**comprehensive orthodontic treatment, fixed appliance Major —ClassCcrowns, bridges,root canal treatment anddentures Intermediate —ClassB X-rays (other than bitewing), fillings andperiodontal maintenance Annual Maximum Per Person Maximums &Deductibles Basic —Class A cleanings,bitewing X-rays andoralexaminations Coverage Type Annual DeductiblePer Person: Applies to Basic, Intermediate andMajor Services Dependent ChildOrtho:Lifetime Maximum Per Person You To Negotiated fees may Dental PlanSummary tion for 24 consecutive months before orthodon eed toaccept aspayment in 30% to45%less than average dental charges in the samecommunity based onMetLife data. Negotia non-participating dentistsetshisor find outif your in-network coveredservices, will beresponsible for the differencebetween your dental plan does not cover or servicesreceivedafter you’ve reached your dental plandoesnotcover annual planmaximum,depending on applicablelaw.3.OUT-OF-NETWORK: aximum willincrease by $200 in the Standard Option, andby $500 in the Highoption on January the samecommunity based onMetLifedata. plan’s annualmaximum 3 dentist isin

for a givenservice.  Standard andHighOptions. full for dependen even apply the percentagesshown are the percentageof the negotiated fee that iscovered by the plan. Negotiated fees may also apply to co vered servicesrendered by them, subject to any deductibles, costsharingand benefits maximums.Negotia t children only. Orthodontia coverage isav the network, visit MetLife.com/VADIP and useour to services your plan doesn’tcover,includingany you’ve received after you . tia willbecovered. 1.S her standard covered services ubject tofrequency fee, which is typically dentist’s chargeand ailable for limita dependen that are typically 30–45% less than average tions. 2.IN-NETWORK: Negotia ted fees refer ts up to age19and the dependent mustbecovered under the • • Both plansprovide savings for you and your family. You’ll receive: higher 1st has a24-month waiting period) No waiting periods(except for Orthodontia inhighplan which Competitive pricing following completion of 12 months of the coveredpercentageof the Maximum than “Find aDentist” to thef the negotiated fee. ees that participating (in-network) dentists ted f ees withparticipating dentists are tool. enr ted fees are subject to ollmen t in $1,300/$1,500* the Not Covered Not Covered In-Network In-Network $50.00 100% 30% 50% Standard Option 2 2 Out-of-Network Out-of-Network $1,000/$1,200* Not Covered Not Covered $50.00 60% 40% 20% Standard Option: • • • • unforeseen dentalcosts: High Option provides you with additionalprotection from • No annualdeductible for in-network services Orthodontia coverage for children up to age19** $3,000/$3,500* annualmaximumbenefit per person No cost for in-network cleanings, X-rays andexams $1,300/$1,500* in-network annualmaximumbenefit per person 3 3 $3,000/$3,500* In-Network In-Network $3,000 $0.00 100% 50% 50% 70% 2 2 High Option Out-of-Network Out-of-Network $3,000/$3,500* $3,000 $50.00 60% 90% 40% 50% 1 3 3

5 Benefits Options it couldn’t beeasier to get the coverage you need. With the Veterans Affairs Dental InsuranceProgram, coverage More Covered Dental Services • • • • • • dental servicesineachcategory: Here isasummary of covered • • • • • • • • • •

Class B-Intermediate Class A -Basic 6 months every once prophylaxis) (oral teeth of Cleaning months 12 every 1set X-rays Bitewing months 60 every once X-rays Panoramic 6months every once than more no but treatment), and diagnosis for referral for need potential the or systemic or malformation, disease, injury, and oral of signs possible identify to performed is that inspection (limited clinical Patient assessments 6months every once than more no but diagnosis, for adentist by seen be to need screenings, to determine an individual’s includingScreenings, state or federally mandated 6months every exam one than more no Oral exams and problem-focused exams, but than once per quadrant in any 24 month period 24month any in quadrant per once than Periodontal scaling and root planing, but not more Protective (sedative) fillings tooth that on identified is decay of surface – anew or placed; was filling existing the since passed have 24months least – at but only if: Replacement of an existing resin-based composite filling, Initial placement of resin-based composite fillings tooth that on identified is decay of surface – anew or placed; was filling existing the since passed have 24months least – at but only if: filling, amalgam existing an of Replacement fillings amalgam of placement Initial pain tooth relieve to treatment palliative Emergency months 60 every once X-rays mouth Full elsewhere mentioned as except X-rays, Intraoral-periapical X-rays

• • • • • • • • • • • • • • • • •

Class C-Major Apexification/ recalcification Apexification/ extractions Surgical Pulp therapy months 60 every tooth per once molars, permanent second and first non-decayed non-restored, to applied are which 16, age under aChild for Sealants Diagnostic casts determination of agents bacteriologic for studies andPulp bacteriological vitality months 36 every tooth per once molars, permanent second and first non-restored to Preventive which are resin restorations, applied pulpotomyTherapeutic (excluding final restoration) Pulp capping (excluding final restoration) Year such during received cleanings teeth of number the Year any less in times four to limited is maintenance osseous surgery) has been performed. Periodontal surgery, such as gingivectomy, and gingivoplasty (including scaling, root planing, and periodontal Periodontal maintenance, where periodontal treatment Simple extractions lifetime per once to limited debridement, mouth Full immediate, temporary, full Denture. 1 in 10 years 10 1in Denture. full temporary, immediate, the of installation the of months 12 within done be made permanent and such replacement is immediate, temporary, full Denture cannot the if Denture, full apermanent, with Denture full temporary, immediate, an of Replacement years 10 1in replacement. to prior years 10 than more installed was Denture such if Denture Replacement of a non-serviceable removable years 10 1in replacement. to prior years 10 than more installed was Denture such if Denture fixed anon-serviceable of Replacement are that teeth natural replace to needed – when missing congenitally replace to needed – when implant supported prosthetics): (other ofInitial Dentures full installation or partial than of drugs Injections therapeutic i lost while the person receiving such benefits was benefits such receiving person the while lost or teeth; nsured for Insurance nsured Dental

• • • • • • • • • • • • • • •

10 years 10 Restorations) Cast implant supported (except Restorations Cast of installation Initial – n the since passed have 6months least at – if Dentures: removable existing of rebasings and Relinings once for the same tooth position in a 10 year period year a10 in position tooth same the for once than more no but Dentures, fixed supported Implant 1 no but Restorations, Cast supported Implant period month 12 a in once than more no but implants, of Repair are that teeth natural replace to needed – when missing congenitally replace to needed – when replacement and for graft ridge preservation): (including sinusImplant augmentation and services bone period month 36 any in quadrant per procedure surgical one than more no but surgery, osseous and gingivoplasty Periodontal surgery, including gingivectomy, tooth same the for period 24month any in once than more not but treatment, canal Root period month a12 in twice Other consultations, but not more than period month a12 in twice than more not but image, the of capture the with associated not aDentist by Consultations for interpretation of diagnostic image years 10 of aperiod in tooth per once than more no but veneers, Labial years 10 of aperiod in tooth per once than more no but cores, and Posts years 10 of aperiod in tooth per once than more no but buildup, Core within for the tooth same surface Prefabricated crown, but no more than one replacement replacement aprior of months 120 within surface tooth same the for replacement one than more no but Restoration, Cast of type adifferent or same the with Restoration) Cast supported implant an (except Restoration Cast any of Replacement more than once for the same tooth position in a in position tooth same the for once than more 0 year period 0 year i installation of the existing removable Denture; and, Denture; removable existing the of installation lost while the person receiving such benefits was benefits such receiving person the while lost or teeth; 10 year period year 10 a in position tooth same the for once nsured for Dental Insurance; but no more than more no but Insurance; Dental for nsured ot more than once in any 36 month period month 36 any in once than more ot

to dental review and the alternate benefit. of the plan.Pleasenote certainserviceslistedare subject plan benefits. This document isnot acomplete description The details in this document represent anoverview of your • • • • • • • • • • • • • • •

Class D-Orthodontia There is a 24 month waiting period for services for period waiting a24month is There 19 of age the under achild for Orthodontia, Plan Standard the in covered not Option Plan High the in covered Only months 84 1in document, this in elsewhere Other fixed Denture prosthetic not services described B Aand Classes Under mentioned as except surgery, Oral and other removable services prosthetic of removableModification prosthodontic period month a12 in once than more not but recementing, than other Dentures or Restorations Cast of Repairs Simple period month a36 in once Tissue conditioning, but not more than the receiving such person services for effect in was Insurance Dental this while removed teeth natural replace to Denture removable apartial to teeth of Addition period month 12 any in once than more not and Denture the of installation the since passed have 6months least at if Dentures, of Adjustments period month a12 in once than more not but Dentures, or Restorations Cast of Re-cementing with generally accepted dental standards such in anesthesia is accordance necessary We determine when Services, Covered other connection with oral surgery, or extractions anesthesiaGeneral or intravenous sedation in certificate this in elsewhere mentioned as except surgery, Oral months. Limited: No frequency limitation 12 1in Complete: adjustments, Occlusal as osseous surgery) has been performed root planing, and surgery, periodontal such where treatment (including periodontal scaling, ofApplication desensitizing medicaments

6 Covered Dental Services atch that Rating Area to your enrollment type andplanoption ind your state below 2. 1. Finding your monthly rate issimple. bystate areas rating Premium Find your personalized rate onlineby visiting usat MetLife.com/VADIP

Region Region Rating Rating State M F CO DC GU GA CA AK AZ AR CT DE AS 3 3 4 4 AL 2 2 5 5 FL 1 1 HI 1 Veteran 1 Veteran Rating $33.80 $60.52 $59.49 $28.89 $28.59 $58.32 $27.55 $71.53 $28.12 $61.14 4 4 5 5 5 5 5 5 2 2 2 1 1 1 Veteran Veteran Standard Option –Monthly Premium Rates State MO MN MD MA 2 Veterans 2 Veterans ME MP KY MI LA KS High Option –Monthly Premium Rates IN ID IA IL $135.92 $115.00 $113.04 $54.90 $64.23 $54.33 $53.42 $52.37 $110.81 $116.17 Rating 4 3 3 3 3 3 3 3 5 5 2 1 1 1 1 Beneficiary 1 Beneficiary $33.80 $60.52 $59.49 $28.89 $28.59 $58.32 $27.55 $71.53 $28.12 $61.14 State NM OH MS MT NC NH ND OK OR NV NY NE NJ PA 2 Beneficiaries 2 Beneficiaries Rating CHAMPVA CHAMPVA 4 4 4 3 3 3 5 5 5 $135.92 $115.00 1 1 1 1 1 $113.04 $54.90 $64.23 $54.33 $53.42 $52.37 $110.81 $116.17 State WV WA WY TN SC SD VA WI UT VT PR TX VI RI 3+ Beneficiaries 3+ Beneficiaries $160.64 $165.09 $163.42 $157.47 $193.15 $91.29 $78.01 $75.91 $74.41 $77.21 Rating 4 4 4 3 3 5 2 2 2 2 1 1 1 1

7 Rates Every year, we provide benefits for more than 20million people Dental Insurance Program now. Program Insurance Dental Enroll MetLife in the Veterans Affairs moreGet to smile about. And that meansmore choices for you. country. You’ll have access to oneof the largest networks in the dentists More 2. 1. MetLife is the largest commercial dental carrier in the U.S.

MetLife data asof October 2020. LIMRA data, basedonenrolled lives as of December 2019.  M etLife.com/VADIP Online 1-888-310-1681 Phone 1

2

8 Enroll • • • If you are anon-CHAMPVA Dependent: in the VADIP, even if the Veteran doesnot. If your dependents are eligible for VADIP coverage under CHAMPVA, they canenroll What doIneed to doif I want to addafamily member to my coverage? By Mail: Pleasedownload, andprint the enrollment form from M By Phone:call1-888-310-1681 TDD 888-638-48638:00amEST to 11:00pmEST M Online: visit You may enroll in the VADIP using the below options: How doIenroll? time of enrollment are valid until the endof the calendar year. dependents mustremain in the plan for aperiodof 12months. The rates quoted at the Once you enroll in the VADIP dental program offered by MetLife, you and your eligible Questions sectionof our website at M be lower. For further information about the VADIP, please visit the Frequently Asked to make the mostof your benefit planbecause your out-of-pocket expenses may for specialty care. But, when you visit anin-network dentist, you have the opportunity or eacheligibledependent visit anin-network dentist, plusreferrals are not necessary With the MetLife VADIP you receive a wide rangeof benefits whether or not you and/ How does the Veteran Affairs Dental InsuranceProgram (VADIP) work? FAQs VADIP

of 19, dependents mustprovide proof that they are full-time students. coverage for children of Veterans isavailable up to the ageof 23. Also, after the age Please note that unless they meet certaindisability requirements, comparable at the number above to addbeneficiaries to hisor her plan. If the eligible Veteran hasalready completed enrollment, heor shemustcontact us 8:00am EST to 11:00pmEST. Veteran. For more information call1-888-310-1681, TDD 888-638-4863, hours: comparable plan you may beable to enroll in. You mustenroll along with aneligible While non-CHAMPVA dependents are not eligible for the MetLife VADIP, there isa etLife.com/VADIP etLife.com/VADIP. etLife.com/VADIP

9 Frequently Asked Questions (FAQs) Exclusions and limitations

Under the VADIP plan, we will not pay dental more natural teeth which were missing before such standard option; • When two or more services are submitted and insurance benefits for charges incurred for: person was insured for Dental Insurance, except for • Orthodontic services and appliances for adults; the services are considered part of the same • Services and treatment not prescribed by or under congenitally missing natural teeth. service to one another the Plan will pay the most • Orthodontic services and appliances for dependent the direct supervision of a dentist, except in those comprehensive service (the service that includes • Charges for copies of your records, charts or X-rays, children under the age of 19 that have not been states where dental hygienists are permitted to the other non-benefited service) as determined by or any costs associated with forwarding/mailing enrolled in the high plan option for the entire 24 practice without supervision by a dentist. In these MetLife; copies of your records, charts or X-rays; month waiting period. states, we will pay for eligible covered services • When two or more services are submitted on the • State or territorial taxes on dental services • Replacement of an orthodontic device under the provided by an authorized dental hygienist same day and the services are considered mutually performed; standard option; performing within the scope of his or her license and exclusive (when one service contradicts the need for • Any charge submitted by a dentist, which is for the applicable state law; • Repair or replacement of an orthodontic device for the other service), the Plan will pay for the service same services performed on the same date for the • Services and treatment which are experimental or adults; that represents the final treatment as determined by

same member by another dentist; and Limitations Exclusions investigational; • Repair or replacement of an orthodontic device for MetLife; • Services provided free of charge by any • Services and treatment which are for any illness dependent children under the age of 19 that have not • All out of network services are subject to the governmental unit, except where this exclusion is or bodily injury which occurs in the course of been enrolled in the high plan option for the entire 24 Maximum Allowable Charge (MAC) as determined prohibited by law; employment if a benefit or compensation is available, month waiting period; by MetLife. The member is responsible for all in whole or in part, under the provision of any law • Services for which the member would have no • Replacement of lost or missing appliances; remaining charges that exceed the MAC; obligation to pay in the absence of this or any similar or regulation or any government unit. This exclusion • Fabrication of athletic mouth guard; • Space maintainers; applies whether or not you claim the benefits or coverage; • Internal and external bleaching; • Fixed and removable appliances for correction of compensation; • Services which are for specialized procedures and • Nitrous oxide; harmful habits; • Services and treatment received from a dental or techniques; • Oral sedation; • Appliances or treatment for bruxism (grinding teeth), medical department maintained by or on behalf of • Services performed by a dentist who is compensated including but not limited to occlusal guards and night an employer, mutual benefit association, labor union, by a facility for similar covered services performed • Topical medicament center; guards; trust, VA hospital or similar person or group; for members; • Bone grafts when done in connection with • Local chemotherapeutic agents; • Services and treatment performed prior to your • Duplicate, provisional and temporary devices, extractions, apicoetomies or non-covered/ effective date of coverage; appliances, and services; non-eligible implants; • Topical fluoride treatment for patients age 14 & older. • Services and treatment incurred after the termination • Plaque control programs, oral hygiene instruction, date of your coverage unless otherwise indicated; and dietary instructions; • Services and treatment which are not dentally • Gold foil restorations; necessary or which do not meet generally accepted • Treatment or services for injuries resulting from standards of dental practice; the maintenance or use of a motor vehicle if such • Services and treatment limited by Plan frequency treatment or service is paid or payable under a plan limitations; or policy of motor , including a • Services and treatment resulting from your failure to certified self-insurance plan; comply with professionally prescribed treatment; • Hospital costs or any additional fees that the dentist • Telephone consultations; or hospital charges for treatment at the hospital (inpatient or outpatient); • Any charges for failure to keep a scheduled appointment; • Charges by the provider for completing dental forms; • Any services that are considered strictly cosmetic • Adjustment of a denture or bridgework which is in nature including, but not limited to, charges for made within 6 months after installation by the same personalization or characterization of prosthetic Dentist who installed it; appliances; • Use of material or home health aids to prevent decay, • Services related to the diagnosis and treatment of such as toothpaste, fluoride gels, dental floss and Temporomandibular Joint Disorder (TMJ); teeth whiteners; • Services or treatment provided as a result of • Sealants for teeth other than non-restored, non- intentionally self-inflicted injury or illness; decayed first and second permanent molars; • Services or treatment provided as a result of injuries • Sealants for patients age 16 and over. suffered while committing or attempting to commit • Precision attachments, personalization, precious a felony, engaging in an illegal occupation, or metal bases and other specialized techniques; participating in a riot, rebellion or insurrection; • Replacement of dentures that have been lost, stolen • Office infection control charges; or misplaced; • Initial installation of a denture to replace one or • Orthodontic services and appliances under the

10 Enroll in the Veterans Affairs Dental Insurance Program today. Get the benefits you’re looking for:

• More coverage • More savings • More dentists • More satisfaction

MetLife.com/VADIP 1-888-310-1681

Metropolitan Company 200 , NY 10166 © 2020 MetLife Services and Solutions LLC L1120009051[exp1121][All States][DC,GU,MP,PR,VI]

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