|
|
 |
Principal Life Dental – Plan 2 EPO 100/80/50
$1500-FDH
| Benefit Summary * |
| |
|
| General |
|
| Deductible |
$50 (waived for Preventive) |
| Maximum |
$1,500 |
| Waiting Period |
N/A |
| |
| Diagnostic |
| Office Visit |
100% |
| X-rays - complete set |
100% |
| |
|
| Preventive |
|
| Prophylaxis |
100% |
| Space maintainer |
100% |
| |
| Restorative |
| Amalgam - primary |
80% |
| Amalgam - permanent |
80% |
| |
|
| Endodontics |
|
| Root canal - anterior |
80% |
| Root canal - molar |
80% |
| |
| Periodontics |
| Gingivectomy - per quadrant |
50% |
| Periodontal scaling - per quadrant |
80% |
| |
| Oral Surgery |
| Extraction - single tooth |
80% |
| Extraction impacted |
80% |
| |
| Adjunctive |
| Local anesthesia |
80% |
| Broken appt. fee |
N/A |
| General anesthesia |
80% |
| |
| Crown/Bridge |
| Porcelain/Ceramic |
50% |
| Inlay - metallic 1 surface |
50% |
| |
|
| Prosthodontics |
|
| Upper or lower partial |
50% |
| Upper or lower complete |
50% |
| |
|
| Orthodontics |
|
| Plan, x rays, study model |
50% (Available as a rider) |
| Limited treatment |
50% (Available as a rider) |
| Full treatment |
50% (Available as a rider) |
| |
|
| Notes: |
|
| 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 |
|
