Page 25 - 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.

Consultation (diagnostic service
provided by dentists or physician other 80% after you meet 80% after you meet
than practitioner providing treatment.) the Annual the Annual

Not Covered if done with exams or Deductible Deductible
professional visit.

MAJOR RESTORATIVE SERVICES
Replacement of complete dentures, fixed or removable partial dentures, crowns, inlays or
onlays previously submitted for payment under the plan is limited to one time per 60
consecutive months from initial or supplemental placement.

Coping

Limited to one per tooth per 60 50% after you meet 50% after you meet
consecutive months. Not Covered if done the Annual the Annual
at the same time as a crown on same Deductible Deductible
tooth.

Crowns – Retainers/Abutments
Not Covered if done in conjunction with 50% after you meet 50% after you meet
any other inlay, onlay and crown codes the Annual the Annual
except post and core buildup codes. Deductible Deductible

Crowns - Restorations
Covered only when a filling cannot restore 50% after you meet 50% after you meet
the tooth. Not Covered if done in the Annual the Annual
conjunction with any other inlay, onlay and Deductible Deductible
crown codes except post and core buildup
codes.

Temporary Crowns - Restorations
Covered only when a filling cannot restore 50% after you meet 50% after you meet
the tooth. Not Covered if done in the Annual the Annual
conjunction with any other inlay, onlay and Deductible Deductible
crown codes except post and core buildup
codes.

20 SECTION 4 - PLAN HIGHLIGHTS