Page 27 - 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.

Sedative Filling

Covered as a separate benefit only if no 50% after you meet 50% after you meet
other service, other than x-rays and exam, the Annual the Annual
were done on the same tooth during the Deductible Deductible
visit.

FIXED PROSTHETICS
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.

Fixed Partial Dentures (Bridges) 50% after you meet 50% after you meet

There are no additional allowances for the Annual the Annual
precision or semi precision attachments. Deductible Deductible

REMOVABLE PROSTHETICS

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.

Full Dentures
50% after you meet 50% after you meet
No additional allowances for over- the Annual the Annual
dentures or customized dentures. Deductible Deductible

Partial Dentures 50% after you meet 50% after you meet

No additional allowances for precision or the Annual the Annual
semi-precision attachments. Deductible Deductible

Relining Dentures and Rebasing
Dentures
80% after you meet 80% after you meet
Limited to relining/rebasing performed the Annual the Annual
more than 6 months after the initial Deductible Deductible
insertion. Limited to one time per 36
consecutive months.

22 SECTION 4 - PLAN HIGHLIGHTS