Page 26 - 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.

Stainless Steel Crowns

Limited to one time per tooth per 60
consecutive months. Covered only when a 80% after you meet 80% after you meet
filling cannot restore the tooth. the Annual the Annual
Prefabricated esthetic coated stainless steel Deductible Deductible
crown - primary tooth, are limited to
primary anterior teeth.

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

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

Retainer-Cast Metal for Resin Bonded
Fixed Prosthesis 50% after you meet 50% after you meet
the Annual the Annual
Limited to one time per tooth per 60 Deductible Deductible
consecutive months.

Post and Cores 50% after you meet 50% after you meet
Covered only for teeth that have had root the Annual the Annual
canal therapy. Deductible Deductible

Re-cement Bridges
Re-Cement Inlays/Onlays, Crowns, 80% after you meet 80% after you meet
Bridges and Post and Core the Annual the Annual

Limited to those performed more than 12 Deductible Deductible
months after the initial insertion.

21 SECTION 4 - PLAN HIGHLIGHTS