Insurance issued by Principal Life Insurance Company, 711 High Street, Des Moines, IA 50392 GP62509-21 1156118 - 10001 Page 3 of 5 02/2026 Major Crowns Each 60 months per tooth if tooth cannot be restored by a filling Core buildup Each 60 months per tooth Bridges 60 months old (initial placement / replacement) Dentures 60 months old (initial placement / replacement) Repairs Partial denture, bridge, crown, relines, rebasing, tissue conditioning and adjustment to bridge/denture, within policy limitations Orthodontia Coverage For your dependent children. Bands that are placed on a dependent child's teeth before age 19 may be covered. Additional benefits Prevailing charge When you receive care from an out-of-network-provider, benefits will be based on the 99 th percentile of the usual and customary charges. 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 Periodontal program If you’re pregnant, have diabetes or heart disease, or are menopausal, 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. General anesthesia program If you have autism, Down syndrome, cerebral palsy, muscular dystrophy, or spina bifida you may receive general anesthesia or intravenous sedation coverage. Services must be administered in a dental office. All other contractual limitations apply.