Skip to main content

2019 Basic Option PPO Plan

Plan Type
Dental

The Basic Option Preferred Provider Organization (PPO) Plan provides in and out-of-network coverage. Costs are less if participants use providers in the plan’s network. Individuals can access out-of-network providers without a referral for an additional cost.

Features
  • Lowest contribution cost offered
  • Preventive and diagnostic services, e.g., examinations, visits, x-rays, cleanings, covered in-network at 100% before deductible
  • Basic services, e.g. amalgam fillings and uncomplicated extractions, covered at 50% of the in-network charge
  • Major services, e.g., crowns and implants, are not covered
  • Orthodontia not covered
  • Members pay the full cost of the premium for dental coverage
Coverage Options
In-Network
Out-of-Network
Plan Design
Employee
$20.69
Employee & Children
$48.16
Employee & Spouse
$44.19
Family
$72.62
In-Network
Individual
None
Family
None
Out-of-Network
Individual
$50
Family
$150
In- or Out-of-Network
Individual
$2,000.00
Preventive & Diagnostic Services

Examinations & Visits

In- or Out-of-Network
Reimbursement based on 100% of in-network charge

X-Ray Services

In- or Out-of-Network
Reimbursement based on 100% of in-network charge

Cleanings

In- or Out-of-Network
Reimbursement based on 100% of in-network charge

Flouride Treatments

In- or Out-of-Network
Reimbursement based on 100% of in-network charge
Basic Services

Amalgam (Silver) Fillings

In- or Out-of-Network
Reimbursement based on 50% of in-network charge

Root Canal Therapy (Anterior Teeth)

In- or Out-of-Network
Reimbursement based on 50% of in-network charge

Root Canal Therapy (Molars)

In- or Out-of-Network
Reimbursement based on 50% of in-network charge

Composite Fillings (Anterior Teeth)

In- or Out-of-Network
Reimbursement based on 50% of in-network charge

Stainless Steel Crowns

In- or Out-of-Network
Reimbursement based on 50% of in-network charge

Uncomplicated Extractions

In- or Out-of-Network
Reimbursement based on 50% of in-network charge
Major Services

High Noble Metal & Porcelain Inlays

In- or Out-of-Network
Not covered / May receive up to 35% discount from in-network provider / Check with the provider prior to receiving treatment

High Noble Metal Restorations

In- or Out-of-Network
Not covered / May receive up to 35% discount from in-network provider / Check with the provider prior to receiving treatment

Crowns

In- or Out-of-Network
Not covered / May receive up to 35% discount from in-network provider / Check with the provider prior to receiving treatment

Implants

In- or Out-of-Network
Not covered / May receive up to 35% discount from in-network provider / Check with the provider prior to receiving treatment
Orthodontia

Orthodontics

In- or Out-of-Network
Not covered / May receive up to 35% discount from in-network provider / Check with the provider prior to receiving treatment
Basis of Reimbursement

Reimbursement

In- or Out-of-Network
Maximum allowable charge
Additional Information

All benefits-eligible employees can elect coverage under the Basic Option PPO Plan except Visiting Fellows.

ID cards will be mailed to home addresses within three to four weeks following enrollment in or changes to medical coverage. ID cards can also be viewed on the provider’s website or app.

Disclaimer

If there are any discrepancies between the information in this publication, verbal representations, and the plan documents, the plan documents always govern. Although Princeton intends to continue these benefits, the University reserves the right to amend or terminate these plans at any time.