Glacier Jet Center

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8 UNDERSTANDING
YOUR DENTAL PLAN
Dental Questions? Need to Locate a Provider?
Contact Principal
1-800-986-3343 or
Type of Plan
In-Network
Out-of-Network
(*Subject to 90th Percentile of Reasonable and
Customary)
Deductible
Single: $25
Family: $75
Single: $25
Family: $75
Annual Maximum Benefit
(per member enrolled)
Unit 1-Preventive Services
(oral exam, cleaning, x-rays)
100% 100%*
Unit 2-Basic Services
(fillings, root canal, oral surgery, periodontics)
80% after Deductible 80% after Deductible*
Unit 3-Major Services
(crowns, dentures, bridges)
50% after Deductible 50% after Deductible*
Orthodontia Services
Contribution
Employee $35.07 $17.54
Employee + Spouse $72.94 $36.47
Employee + Child(ren) $75.56 $37.78
Employee + Family $117.48 $58.74
Type of Plan
In-Network
Out-of-Network
(*Subject to 90th Percentile of Reasonable and
Customary)
Deductible
Single: $25
Family: $75
Single: $25
Family: $75
Annual Maximum Benefit
(per member enrolled)
Unit 1-Preventive Services
(oral exam, cleaning, x-rays)
100% 100%*
Unit 2-Basic Services
(fillings, root canal, oral surgery, periodontics)
80% after Deductible 80% after Deductible*
Unit 3-Major Services
(crowns, dentures, bridges)
50% after Deductible 50% after Deductible*
Unit 4-Orthodontia Services
(child and adult)
Contribution
Employee $37.72 $18.86
Employee + Spouse $78.46 $39.23
Employee + Child(ren) $81.27 $40.64
Employee + Family $126.36 $63.18
Late Entrant Waiting Period
Dental Coverage
Principal - Low Option PPO
$1,000
Not Covered
Monthly Semi-Monthly
Limitations and Exclusions
Late entrants (those enroling more than 31 days after becoming eligible) will be subject to an
individual benefit waiting period, subject to plan guidelines.
Principal - High Option PPO
$1,000
Plan pays 50%, $1,000 Lifetime Benefit
Monthly Semi-Monthly