Page 24 - 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.

Local Anesthesia 80% after you meet 80% after you meet

Covered only when clinically Necessary. the Annual the Annual
Deductible Deductible

Intravenous Sedation and Analegsia 80% after you meet 80% after you meet

the Annual the Annual
Deductible Deductible

Therapeutic Drug Injection, by
report/Other Drugs and/or 80% after you meet 80% after you meet
Medicaments, by report the Annual the Annual
Deductible Deductible
Limited to one per visit.

Occlusal Adjustment 80% after you meet 80% after you meet
the Annual the Annual
Deductible Deductible

Occlusal Guards
80% after you meet 80% after you meet
Limited to one guard every 60 consecutive the Annual the Annual
months and only covered if prescribed to Deductible Deductible
control habitual grinding.

Occlusal Guard Reline and Repair

Limited to relining and repair performed 80% after you meet 80% after you meet
more than 6 months after the initial the Annual the Annual
insertion. Limited to one guard every 60 Deductible Deductible
consecutive months.

Occlusion Analysis - Mounted Case 80% after you meet 80% after you meet
Limited to one time per 60 consecutive the Annual the Annual
months. Deductible Deductible

Palliative Treatment
Covered as a separate benefit only if no 80% after you meet 80% after you meet
other services, other than exam and the Annual the Annual
radiographs, were done on the same tooth Deductible Deductible
during the visit.

19 SECTION 4 - PLAN HIGHLIGHTS