Page 28 - 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.

Tissue Conditioning - Maxillary or
Mandibular 50% after you meet 50% after you meet
the Annual the Annual
Limited to one time per 12 consecutive Deductible Deductible
months.

Repairs to Full Dentures, Partial
Dentures, Bridges 80% after you meet 80% after you meet
Repairs or Adjustments to Full Dentures, the Annual the Annual
Partial Dentures, Bridges or Crowns. Deductible Deductible

ORTHODONTICS

Orthodontic Services
Services or supplies furnished by a Dentist
to a Dependent under age 19 in order to
diagnose or correct misalignment of the 50% 50%
teeth or the bite. The extended coverage
provision does not apply to orthodontic
services.
Appliance Therapy, Fixed or
Removable

Limited to one time per 60 consecutive 50% 50%
months. This includes retainers, habit
appliances, and any fixed or removable
interceptive orthodontic appliances.

Cephalometric Film
Limited to one per 12 consecutive months. 50% 50%
Can only be billed for orthodontics.

23 SECTION 4 - PLAN HIGHLIGHTS