Page 19 - 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.

Therapeutic Pulpotomy 80% after you meet 80% after you meet

the Annual the Annual
Deductible Deductible

Pulpal Therapy (resorbable filling) -
Anterior or Posterior, Primary Tooth
(excluding final restoration) 80% after you meet 80% after you meet
the Annual the Annual
Limited to one time per tooth per lifetime. Deductible Deductible
Covered for anterior or posterior teeth
only.
Pulp Caps - Direct/Indirect –
excluding final restoration 80% after you meet 80% after you meet
the Annual the Annual
Not covered if utilized solely as a liner or Deductible Deductible
base underneath a restoration.

Pulpal Debridement, Primary and
Permanent Teeth 80% after you meet 80% after you meet

This procedure is not to be used when the Annual the Annual
endodontic services are done on same date Deductible Deductible
of service.

PERIODONTICS

Crown Lengthening 80% after you meet 80% after you meet
Limited to one per quadrant or site per 36 the Annual the Annual
consecutive months. Deductible Deductible

Gingivectomy/Gingivoplasty 80% after you meet 80% after you meet
Limited to one per quadrant or site per 36 the Annual the Annual
consecutive months. Deductible Deductible

Gingival Flap Procedure 80% after you meet 80% after you meet

Limited to one per quadrant or site per 36 the Annual the Annual
consecutive months. Deductible Deductible

14 SECTION 4 - PLAN HIGHLIGHTS