Page 20 - 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.

Osseous Graft 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

Osseous Surgery 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

Guided Tissue Regeneration 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

Soft Tissue Surgery 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

Periodontal Maintenance
80% after you meet 80% after you meet
the Annual the Annual
Deductible Deductible

Full Mouth Debridement 80% after you meet 80% after you meet

the Annual the Annual
Deductible Deductible

Provisional Splinting

Cannot be used to restore vertical
dimension or as part of full mouth
rehabilitation, should not include use of 80% after you meet 80% after you meet
laboratory based crowns and/or fixed the Annual the Annual
partial dentures (bridges). Deductible Deductible
Exclusion of laboratory based crowns or
bridges for the purposes of provisional
splinting.

15 SECTION 4 - PLAN HIGHLIGHTS