Principal Dental
Eligibility:
First day of the month after 30 days of employment. Full-time staff only (minimum of 30 hours a week)
PPO LOW
PPO HIGH
In-Network
Out-of-Network*
In-Network
Out-of-Network*
$0
$300
$50
$50
Annual Individual Deductible
$0
$300
$150
$150
Annual Family Deductible
100% Coinsurance
50% Coinsurance after deductible
100% Coinsurance no deductible
100% Coinsurance no deductible 80% Coinsurance after deductible 50% Coinsurance after deductible
Preventative Care
30% Coinsurance after deductible
80% Coinsurance after deductible
80% Coinsurance
Basic Procedures
50% Coinsurance after deductible
40% Coinsurance
25% Coinsurance after deductible
Major Procedures
$1,000 per person
$2,000 per person
Calendar Year Max Benefit
N/A
N/A
$1,500 lifetime maximum for dependents up to age 19
Orthodontia
* Additional employee payment responsibility known as ‘Balance Billing’ applies to all out of network services
PPOLOW PRE-TAXCOSTS
PPOHIGHPRE-TAXCOSTS
Monthly Cost
Per Pay Period
Monthly Cost
Per Pay Period
$14.20
$6.55
$39.63
$18.29
Employee
$27.92
$12.89
$73.17
$33.77
Employee + Spouse
$39.37
$18.17
$106.43
$49.12
Employee + Child(ren)
$53.21
$24.56
$147.97
$68.29
Family
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