Page 16 - Dental Benefit Plan Summary

TEXAS MUTUAL INSURANCE COMPANY DENTAL PPO PLAN

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.

Individual Periapical Radiographs
100% 100%
Intraoral Periapical Radiographs
Pulp Vitality Tests

Limited to one charge per visit, regardless 100% 100%
of how many teeth are tested.

Intraoral Occlusal Film
100% 100%

Periodic Oral Evaluation

Limited to two times per calendar year.
Covered as a separate benefit only if no 100% 100%
other service was done during the visit
other than X-rays.

Comprehensive Oral Evaluation

Limited to two times per calendar year. 100% 100%
Not Covered if done in conjunction with
other exams.

Limited or Detailed Oral Evaluation
Limited to two times per calendar year. 100% 100%

Comprehensive Periodontal Evaluation
- new or established patient 100% 100%

Limited to two times per calendar year.

Adjunctive Pre-Diagnostic Test that
aids in detection of mucosal
abnormalities including premalignant
and malignant lesions, not to include 100% 100%
cytology or biopsy procedures

Limited to two times per calendar year.

11 SECTION 4 - PLAN HIGHLIGHTS