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2019 High Option PPO Plan

Plan Type
Dental

The High 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
  • Highest 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 in-network at 80% after deductible
  • Major services, e.g. crowns and implants, covered in-network at 60% after deductible
  • Orthodontia covered in-network at 50% with a lifetime maximum benefit of $2,000
  • Members pay the full cost of the premium for dental coverage
Coverage Options
In-Network
Out-of-Network
Plan Design
Employee
$67.79
Employee & Children
$132.84
Employee & Spouse
$136.80
Family
$188.96
In- or Out-of-Network
Individual
$50.00 (basic and major services)
Family
$150.00 (basic and major services)
In-Network
Individual
$2,000.00
Out-of-Network
Individual
$1,500.00
Preventive & Diagnostic Services

Examinations & Visits

In-Network
$0
Out-of-Network
$0

X-Ray Services

In-Network
$0
Out-of-Network
$0

Cleanings

In-Network
$0
Out-of-Network
$0

Flouride Treatments

In-Network
$0
Out-of-Network
$0
Basic Services

Amalgam (Silver) Fillings

In-Network
20%
Out-of-Network
30%

Root Canal Therapy (Anterior Teeth)

In-Network
20%
Out-of-Network
30%

Root Canal Therapy (Molars)

In-Network
20%
Out-of-Network
30%

Composite Fillings (Anterior Teeth)

In-Network
20%
Out-of-Network
30%

Stainless Steel Crowns

In-Network
20%
Out-of-Network
30%

Uncomplicated Extractions

In-Network
20%
Out-of-Network
30%
Major Services

High Noble Metal & Porcelain Inlays

In-Network
40%
Out-of-Network
50%

High Noble Metal Restorations

In-Network
40%
Out-of-Network
50%

Crowns

In-Network
40%
Out-of-Network
50%

Implants

In-Network
40%
Out-of-Network
50%
Orthodontia

Orthodontics

In-Network
50% / Lifetime maximum benefit of $2,000 / Covers children and adults
Out-of-Network
50% / Lifetime maximum benefit of $1,500 / Covers children and adults
Basis of Reimbursement

Reimbursement

In-Network
Negotiated fee
Out-of-Network
80th percentile of reasonable and customary charges
Additional Information

All benefits-eligible employees can elect coverage under the High 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.