Page 17 - Dental Benefit Plan Summary
P. 17
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.
PREVENTIVE SERVICES
Dental Prophylaxis Cleanings
100% 100%
Limited to 2 times per calendar year.
Fluoride Treatments
Limited to Covered Persons under the age
of 19 years, and limited to 2 times per 100% 100%
calendar year.
Treatment should be done in conjunction
with dental prophylaxis.
Sealants
Limited to Covered Persons under the age 100% 100%
of 14 years of age and limited to 1
application per lifetime.
MINOR RESTORATIVE SERVICES
Amalgam Restorations Fillings 80% after you meet 80% after you meet
Multiple restorations on one surface will the Annual the Annual
be treated as a single filling. Deductible Deductible
Composite Resin Restorations Fillings
80% after you meet 80% after you meet
Composite Resin Restorations - Anterior
the Annual the Annual
Multiple restorations on one surface will Deductible Deductible
be treated as a single filling.
Gold Foil Restorations 80% after you meet 80% after you meet
Multiple restorations on one surface will the Annual the Annual
be treated as a single filling. Deductible Deductible
12 SECTION 4 - PLAN HIGHLIGHTS
