Page 22 - 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.

Simple Extraction 80% after you meet 80% after you meet
the Annual the Annual
Deductible Deductible

Surgical Extraction of Erupted Teeth 80% after you meet 80% after you meet
or Roots the Annual the Annual
Deductible Deductible

Surgical Extraction of Impacted Teeth 80% after you meet 80% after you meet

Including extraction of impacted wisdom the Annual the Annual
teeth. Deductible Deductible

Surgical Access, Surgical Exposure, or 80% after you meet 80% after you meet
Immobilization of Unerupted Teeth the Annual the Annual

Limited to one time per tooth per lifetime. Deductible Deductible

Primary Closure of a Sinus Perforation 80% after you meet 80% after you meet
the Annual the Annual
Limited to one time per tooth per lifetime. Deductible Deductible

Placement of Device to Facilitate 80% after you meet 80% after you meet
Eruption of Impacted Tooth the Annual the Annual
Limited to one time per tooth per lifetime Deductible Deductible

Transseptal Fiberotomy/Supra Crestal 80% after you meet 80% after you meet
Fiberotomy, by report the Annual the Annual
Limited to one time per tooth per lifetime Deductible Deductible

Vestibuloplasty 80% after you meet 80% after you meet

Limited to one time per site per 60 the Annual the Annual
consecutive months. Deductible Deductible

Bone Replacement Graft for Ridge
Preservation - per site 80% after you meet 80% after you meet

Limited to one per site per lifetime Not the Annual the Annual
Covered if done in conjunction with other Deductible Deductible
bone graft replacement procedures.

17 SECTION 4 - PLAN HIGHLIGHTS