Maximum accumulation Some of your unused annual benefit maximum can be carried over to the next year. To qualify, you must have had a dental service performed within the calendar year and used less than the maximum threshold. The threshold is equal to the lesser of 50% of the out-of-network maximum benefit or $1,000. If the qualification is met, 50% of the threshold is carried over to next year's maximum benefit. Individuals with fourth quarter effective dates will start qualifying for rollover at the beginning of the next calendar year. You can accumulate no more than four times the carry over amount. The entire accumulation amount will be forfeited if no dental service is submitted within a calendar year Emergency services If you have a dental emergency and you can't see an in-network provider in a reasonable amount of time, your claim may be paid if you see an out-of-network provider. Participating provider services If you require treatment and you can’t see an in-network provider in a reasonable amount of time, your claim may be paid if you see an out-of-network provider. Periodontal program If you’re pregnant or have diabetes or heart disease, you may receive scaling and root planing covered at 100% (if dentally necessary), or one additional cleaning (routine or periodontal) subject to deductible and coinsurance. Second opinion program You may be eligible for second opinions from dental providers at 100%. This program makes sure you get the best advice to make an informed decision about your care. Cancer treatment oral health program If you have cancer and are undergoing chemotherapy or head/neck radiation therapy, you may receive up to three fluoride treatments every 12 months covered at 100% plus one additional routine cleaning. How do I find a network dentist? When you receive services from a dentist in our network, your cost may be lower. Network dentists agree to lower their fees for dental services and not charge you the difference. You’ll have access to the Principal Plan Dental network, with more than 117,000 dentists nationwide. Visit principal.com/dentist to find a dentist or call 800-247-4695. What if my dentist isn't in the network? You can refer your dentist to our network. Please submit the dentist’s name and information by calling 800-247-4695, or submitting a form at principal.com/refer-dental-provider. What are the limitations and exclusions of my coverage? • Missing tooth –The initial placement of bridges, partials, and dentures to replace teeth missing before this coverage starts won’t be covered. If this policy replaces coverage with another carrier, continuous coverage under the prior plan may be applied to the missing tooth provision requirement. This doesn’t apply to pediatric essential benefits. • Frequency limitations for services are calculated to the month and exact date from the last date of service or placement date. There are additional limitations to your coverage. Please review your booklet for more information.
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Insurance issued by Principal Life Insurance Company, 711 High Street, Des Moines, IA 50392 04052210597 - 6 Page 3 of 4
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