© Principal’ policyholder: LA MAR CEBICHERIA PERUANO Voluntary Dental POS Benefit Summary Predetermination of Benefits: Before treatment begins for inlays, onlays, single crowns, prosthetics, periodontics and oral surgery, you may file a dental treatment plan with Principal Life Insurance Company. Principal Lie will provide a written response indicating benefits that may be payable for the proposed treatment. “The Principal Point of Service (POS) benefit design has three levels of benefits available - Exclusive Provider ‘organization (EPO) level, Preferred Provider Organization (PPO) level and non-network level. Your level of coverage varles by the provider you see for services. This chart provides you a brief summary of the key benefits of the dental coverage available from Principal Life Insurance Company. Following the chart, you will find additional information to answer questions you may have. Fora complete list ofall your dental coverage benefits and restrictions, please reer to your booklet or contact your employer. Le es ‘Active Members oes a PPO | neswork | f° PPO | Network niet = Preventive 30 3 30 700% 1008 500% Unit 2 = Basie 350 $50 350 809% 20% 80% nit 3 Major 350 355 150 3% 30% 30% Family Deduible Maximum Times the pev person deductible amount ‘Combined Dedudible TPO Deduatbies for basic and major procedures are combined, PPO Deductibis for Basie and major procedures are combined. Non-network deductibles for basic and major procedures are combined, Combined Waximums ‘Maximum for preventive, bole, and major procedures ae combined for EPO, PPO and NonNetwork. Calender year €20 maximums are $1,500 per person. Calendar year PPO ‘maximums ae 51,500 per person. Calendar year nonnetwork maximums are $1,000 per person, Prevailing Charge When using nor-netwark provides, you pay any amount over he allowable charge, ‘Maximum Accurnulation “This allows fora portion of unused maximum benef to cary over to next year's maximum beneftamount. To qualiy, you musthave had a dental serie performed within the Calendar year and used less than the maximum threshold. The threshold is equal to the Tesser of 30% ofthe maximum benefit or $1000. tf qualification i met, 50% of the threshold is carted ove to next year's maximum benefit. Individuals with fourth quarter electives wil Start qualifying for rollover atthe begining of the next calendar year. You can accumulate rho more then four times the carty over amount. The ene accumblation amount will be forfeited if no dental service is submited within a calendar yeae dotsThe list of common procedures shows what unit the procedure is included in and how often they are covered. EPO Schedule Of Dental Procedures Unit 1— Routine exams - wo per calendar year Preventive {Routine cleaning (praphyass)- two per calendar year (Expectant mothers, diabetics and Procedures those with heart ceease receive one adeiional routine or periodontal cleaning within a calendar year) ‘+ Second Opinion Consuitation 1 Fluoride—one treatment each calendar year (covered only for dependent children under age 4) ‘+ Space maintainers - covered only for dependent children under age 14; repairs not covered + _Sealants—an fst and second permanent molars for dependent children underage 14; ‘one each tooth each 36 months ‘+ Harmful Habie Appliance - covered only for dependent ciléren under age 14 2 erays-Bitewing (one st every calendar year), occlusal, periapical + rays Full mouth survey (one every 60 months), exrzorl ‘Unit 2— {Periodontal prophylans three months have elapsed ater active surgical periodontal Basie treatment subject to Routine ceaning frequency limit (Expectant mothers, dlabetics and Procedures those with heat disease recive one additional routine or periodontal cleaning within 2 calendar year) ‘+ Emergency exams ~ subject to Routine exam frequency iit + Filings and stainless steal crowns + General Anesthesia (covered only for speci procedures)/V Sedation 2 Simple Oral Surgery + Complex Oral Surgical Procedures 1 Nonsurgial Periodontics, including scaling and ret planing -once each quadrant each 24 mont (For expectant mothers, dabetis and those with heat seas, this procedure is provided with no deductible and 100% coinsurance) Periodontal Surgical Procedures ~one each quadrant each 36 months {Simple Endodontics (oot canal therapy for antrior teeth) {Complex Endodontics (oot canal Uerapy for malar teeth) Unit 3— + Repairs to Paral Denture, Bridge, Crown Reine, Rebasing, Tissue Conditioning and Major ‘Adjustment to Bridge/Denture, within policy imitations Procedures + Crowns each 60 months per tooth tooth cannot be restored by ailing, 2 nlaye, Onlays, Cast Post and Core, Core Bulkup - each 60 months per tooth Implants —each 60 months {Bridges nial placement / Replacement of bridges 60 months old 1 Dentures- Initial placement of complete or patio dentures / Replacement of complete oF partial dentures over 60 months old “There is Coordination of Benefits, which is a pracedure for limiting benefits from two or more carters to 100% of the claimant's covered expenses. 2otsKees o PPO & Non-Network Schedule Of Dental Procedures Unit 1— : Preventive : Procedures Routine exams two per calendar year Routine cleaning (prophylaxis) - two per calendar year (Expectant mothers, diabetic and those with heart disease receive one additonal routine or periodontal deaning within a calendar year) Second Opinion Consultation Fluoride ~ one treatment each calendar year (covered only for dependent cilren under ‘age 14) Space maintainer- covered only for dependent children under age 14; repairs not ‘covered Sealants — on fist and second permanent molars fer dependent children underage 14; ‘one ech toath each 36 months Harmful Habit Appiance - covered only fr dependent children under age 14 Xcrays- Bitewing (one per calendar year), occlusal, periapical X-rays = Full mouth survey (one every 60 months), extraorl Unit 2— 5 Basie Procedures Periodontal prophylavis-if three months have lapsed after ative surgical periodontal ‘treatment; subject to Routine cleaning frequency limit Expectant mothers, clabetis and ‘those with heart liease receive one aditéonal routine or periodontal cleaning within 2 ‘calendar year.) “Emergency exams — subject to Routine exam frequency limit Filings and stainless steel crowns General Anesthesia (covered only for specie proceduresyIV Sedation Simple Ora Surgery Complex Oral Surgical Procedures "Non-sueglal Periodontics, including scaling and root planing - once each quadrant each 24 months (For expectant mothers, diabetis and those with hear clkeas, this procedure Is provided wlth no deductible and 100% coinsurance.) Periodontal Surgical Procedures —one each quadrant each 36 months ‘Simple Endodonis (root canal therapy for anterior teeth) Complex Endodontics (root canal therapy for mola teeth) Unit 3— . Major Procedures Repairs to Partial Denture, Bridge, Crown, lines, Rebasing, Tissue Conditoning and Adjustment to Beidge/Denture, within policy imitations ‘Crowns ~each 60 months pe tooth if tooth cannat be restored by ailing. Inlays, Onlay, Cast Post and Core, Core Buildup -each 60 months per tooth Implants each 60 months ‘Bridges nial placement / Replacement of bridges 60 months old. ‘Dentures ital placement of complete or paral dentures / Replacement of complete or partll dentures over 60 months old “There is Coordination of Benefits, whichis a pracedure for limiting benefits from two or more carriers to 100% of the claimant's covered expenses.Understanding Your Dental Benefits ett nse ee To be eligible for coverage, you must qualify as an eligible member and be considered actively at work. You must be enrolled for dental coverage before it can be offered to your dependents, Eligible dependents include your spouse, state registered ar nonregistered domestic partner, and children, including those of your state registered or nonregistered domestic partner. Additional eligibility requirements may apply. {An annual enrollment applies. Members can enroll for dental coverage during the annwal enrollment period and not be subject to the late entrant waiting period. Certain restrictions apply: How Do I Find A Participating Provider? Use the Provider Directory on www.principal.com to locate nearby PPO & EPO dentists or see if your dentist participates in one ofthese networks. Vise www princlpal.comidentist. 2 ‘Begin your search by picking the state where you would like to find a provider. For Pont of Service (POS) plans, the state selected should be California, After selecting Calfornia, spect the Principal POS Plan, Enter the name ofthe provider you are looking fr (Fknown). Ifyou are ooking fora nearby dents, enter the city And state and/or ZIP cade. Be sure to indicate how far you are willing to travel, Select the desired specialty or use the No Specialty Preference default. Click Continue TPO providers willbe listed fist. For addtional dentists not contracted with the EPO, select Show PPO Providers. The PO network sa subset of the PPO network and all EPO providers are also contracted 2s PPO providers. The EPO network provides the greatest clcount and prefered benefit design coverage. Selecta language f your preferences other than English. Click Continue. You may nominate your dentist for inclusion in our network. Please submit the dentist's name, address, phone and specialty by calling 1-800-832-4450, or submit through www.principal.com/refer-dental-provider. What Are The Restrictions Of My Coverage? ‘This Benefit Summary is a summary only. For a complete lst of benefit restrictions, please refer to your booklet. 40s owasLate Entrant Provision ‘Those members enrolling more than 31 days after becoming eligible vl be subject to an individual benefit wating perio, subject to policy guidelines Missing Tooth Benefits forthe ial placement of bridges, partials and dentures are not covered if those teeth ‘were mising prior to becoming insured under the Principal Life policy. When the policy replaces coverage under a prior pan, continuous coverage under te pier plan may be applied tothe missing toth provision requirement Other Limitations ‘There are addlonal imitations to your coverage. A complete Ist sincluded in your booklet. © Principal’ Principle nsurance Company, Des Moines, low 503920002, ww principal om “Tie a summary of dental covergeunderuten by or with administrate services provided by Pinal Li Insurance Company. Tit benef summary for adminis purpose ands nat complet statement of benefits nd estctons You recive abet boot wth deta about your coverage theres ascrepancy between this summary and your bene bookle th brat bolle peal onzieanse-1 Sofs wane