Page 23 - 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.

Excision of Hyperplastic Tissue or
Pericoronal Gingiva 80% after you meet 80% after you meet
the Annual the Annual
Limited to one per site per 36 consecutive Deductible Deductible
months.

Appliance Removal (not by dentist who 80% after you meet 80% after you meet
placed appliance) includes removal of the Annual the Annual
arch bar Deductible Deductible

Tooth Reimplantation and/or 80% after you meet 80% after you meet
Transplantation Services the Annual the Annual

Limited to one per site per lifetime. Deductible Deductible

Oroantral Fistula Closure 80% after you meet 80% after you meet
Limited to one per site per visit. the Annual the Annual
Deductible Deductible

ADJUNCTIVE SERVICES

Analgesia

Covered when Necessary in conjunction
with Covered Dental Services. If required 80% after you meet 80% after you meet
for patients under 6 years of age or the Annual the Annual
patients with behavioral problems or Deductible Deductible
physical disabilities or if it is clinically
Necessary. Covered for patients over age
of 6 if it is clinically Necessary.

Desensitizing Medicament 80% after you meet 80% after you meet
the Annual the Annual
Covered only when clinically Necessary. Deductible Deductible

General Anesthesia

Covered only when clinically Necessary. 80% after you meet 80% after you meet
the Annual the Annual
Deductible Deductible

18 SECTION 4 - PLAN HIGHLIGHTS