Page 21 - 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.

Scaling and Root Planning 80% after you meet 80% after you meet

Limited to one time per quadrant per 24 the Annual the Annual
consecutive months. Deductible Deductible

Localized Delivery of Antimicrobial
80% after you meet 80% after you meet
Agents via a controlled release vehicle into
diseased crevicular tissue, per tooth, by the Annual the Annual
Deductible
Deductible
report.
ORAL SURGERY

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

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

Frenectomy/Frenuloplasty 80% after you meet 80% after you meet
the Annual the Annual
Deductible Deductible

Incision and Drainage 80% after you meet 80% after you meet
the Annual the Annual
Deductible Deductible

Removal of a Benign Cyst/Lesions 80% after you meet 80% after you meet
the Annual the Annual
Limited to one per site per visit. Deductible Deductible

Removal of Torus 80% after you meet 80% after you meet
the Annual the Annual
Limited to one per site per visit. Deductible Deductible

Root Removal 80% after you meet 80% after you meet
the Annual the Annual
Deductible Deductible

16 SECTION 4 - PLAN HIGHLIGHTS