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Principal Life Dental – Plan 1 PPO 100/80/50; 80/80/50 $1500-PFG
| Benefit Summary * |
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In Network |
Out-of-Network |
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| General |
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| Deductible |
$25 (waived for Preventive); $50 for Ortho |
$50; $100 for Ortho |
| Maximum |
$1,500 |
$1,500 |
| Waiting Period |
N/A |
N/A |
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| Diagnostic |
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| Office Visit |
100% |
80% |
| X-rays - complete set |
100% |
80% |
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| Preventive |
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| Prophylaxis |
100% |
80% |
| Space maintainer |
100% |
80% |
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| Restorative |
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| Amalgam - primary |
80% |
80% |
| Amalgam - permanent |
80% |
80% |
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| Endodontics |
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| Root canal - anterior |
80% |
80% |
| Root canal - molar |
80% |
80% |
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| Periodontics |
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| Gingivectomy - per quadrant |
50% |
50% |
| Periodontal scaling - per quadrant |
80% |
80% |
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| Oral Surgery |
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| Extraction - single tooth |
80% |
80% |
| Extraction impacted |
80% |
80% |
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| Adjunctive |
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| Local anesthesia |
80% |
80% |
| Broken appt. fee |
N/A |
N/A |
| General anesthesia |
80% |
80% |
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| Crown/Bridge |
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| Porcelain/Ceramic |
50% |
50% |
| Inlay - metallic 1 surface |
50% |
50% |
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| Prosthodontics |
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| Upper or lower partial |
50% |
50% |
| Upper or lower complete |
50% |
50% |
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| Orthodontics |
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| Plan, x rays, study model |
50% (Available as a rider) |
50% (Available as a rider) |
| Limited treatment |
50% (Available as a rider) |
50% (Available as a rider) |
| Full treatment |
50% (Available as a rider) |
50% (Available as a rider) |
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| Notes: |
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| This summary of group insurance from Principal Life Insurance Company is not an insurance contract or a complete statement of its provisions. There are limitations, restrictions, and exclusions to the policy summarized here. There are also certain restrictions involving payment of premium, termination, fraud, eligibility, and participation. Before making any purchase decision, be sure to review a complete proposal. Acceptance of a group, the final premium rates, and actual benefits cannot be offered until all necessary information about the group has been received, reviewed, and approved by an underwriter of Principal Life. Rates will be recalculated based on actual enrollment under the policy. Changes in assumptions, group demographics, policy design and policy effective date are likely to affect your rates. In case of a conflict between a policy provision and federal or state law, the policy provision will be applied to comply with federal or state law. The group policy determines all rights, benefits, exclusions and limitations of the insurance. |
| * Please refer to certificate for full benefit descriptions and limitations |
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