Page 18 - 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.

Space Maintainers

Limited to Covered Persons under the age 80% after you meet 80% after you meet
of 19 years, once per lifetime. Benefit the Annual the Annual
includes all adjustments within 6 months Deductible Deductible
of installation.

Pin Retention 80% after you meet 80% after you meet
the Annual the Annual
Deductible Deductible

ENDODONTICS

Apexification 80% after you meet 80% after you meet
the Annual the Annual
Deductible Deductible

Apicoectomy and Retrograde filling 80% after you meet 80% after you meet
the Annual the Annual
Deductible Deductible

Hemisection 80% after you meet 80% after you meet
the Annual the Annual
Deductible Deductible

Root Canal Therapy 80% after you meet 80% after you meet
the Annual the Annual
Deductible Deductible

Retreatment of Previous Root Canal
Therapy 80% after you meet 80% after you meet
Dentist who performed the original root the Annual the Annual
canal should not be reimbursed for the Deductible Deductible
retreatment for the first 12 months.

Root Resection/Amputation 80% after you meet 80% after you meet
the Annual the Annual
Deductible Deductible

13 SECTION 4 - PLAN HIGHLIGHTS