Page 21 - Pampa Benefit Guide 4-1-24a

Dental Option:

Principal Life Insurance

Semi Monthly Option 1 Option 2 Dependent Information
24 Pay Periods (Base) (Buy-Up)
SkyBlue Healthcare offers our employees the opportunity to cover
Employee Only $16.48 $23.76 their spouse or dependent children. Children can join or remain on
a parent’s vision plan until age 26. When a child turns 26, they will
Employee + Spouse $31.52 $43.73
lose vision coverage on the last day of their birth month. This is an
Employee + Child(ren) $36.31 $58.76 automated process.
Employee + Family $53.73 $82.93 Principal Plan Dental Network

Option 1 (Base) Option 2 (Buy-Up)
Type of Service Non-Network Dentists Non-Network Dentists

90th % Usual & Customary (U&C ) Fees 95th % Usual & Customary (U&C ) Fees
Preventive Services Covered at 100%; CYD Waived Covered at 100%; CYD Waived

Basic Services Covered at 80% after CYD Covered at 80% after CYD

Major Services Covered at 50% after CYD Covered at 50% after CYD
Annual Maximum $1,000 $2,000

Maximum Rollover Limit $1,000 $2,000

Rollover Amount $250 $500
Claims Threshold $500 $1,000

Annual Deductible (CYD) $50 Individual / $150 Family $50 Individual / $150 Family
Orthodontics Lifetime Max Not Covered $1,500 (Adults & Children)

Type of Service Benefit Description

Routine cleanings, oral exams, bitewing Routine cleanings, oral exams, bitewing
Preventive Services and full mouth x-rays, fluoride, sealants, and full mouth x-rays, fluoride, sealants,
space maintainers. space maintainers.

Fillings, simple extractions, oral surgery, Fillings, simple extractions, oral surgery,
Basic Services endodontics (root canals), periodontics, endodontics (root canals), periodontics,
complex extractions and anesthesia. complex extractions and anesthesia.

Crowns, bridges, dentures, inlays, Crowns, bridges, dentures, inlays,
onlays, labial veneers, dentures crown/ onlays, labial veneers, dentures crown/
Major Services
bridges repair and implants bridges repair and implants

Orthodontia Services Not Available Included (Adult & Children)

NOTE: This is only a brief overview. Please see Benefit Summary and policy for more details.

Website: Visit www.principal.com/dentist to find a dentist or call Customer Service: 800-247-4695. Our Principle Plan Dental Network in-
cludes more than 117,000 dentists nationwide. .
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