Page 15 - Dental Benefit Plan Summary

TEXAS MUTUAL INSURANCE COMPANY DENTAL PPO PLAN

This table provides an overview of the Plan's coverage levels.

Percentage of Eligible Expenses

Benefit Description & Limitation Payable by the Plan:
Network Non-Network
*
*You must also pay the amount of the Dentist's fee, if any, which is greater than the
Eligible Expense.
DIAGNOSTIC SERVICES

Bacteriologic Cultures
100% 100%

Viral Cultures
100% 100%

Bite-Wing Radiographs
Limited to 2 series of films per calendar 100% 100%
year.

Complete Series or Panorex
Radiographs
100% 100%
Limited to one time per 36 consecutive
months.

Oral/Facial Photographic Images

Limited to one time per consecutive 36 100% 100%
months.

Diagnostic Casts

Limited to one time per 24 consecutive 100% 100%
months.

Extraoral Radiographs

Limited to two series of films per calendar 100% 100%
year.
Intraoral - Complete Series (including
bitewings)

Limited to one time per 36 consecutive 100% 100%
months. Vertical bitewings can not be
billed in conjunction with a complete
series.

10 SECTION 4 - PLAN HIGHLIGHTS