Page 21 - Lakeside Benefit Guide 4-1-24
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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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