Page 3 - Dental Benefit Plan Summary

TEXAS MUTUAL INSURANCE COMPANY DENTAL PPO PLAN

TABLE OF CONTENTS

SECTION 1 - WELCOME ................................................................................................................. 1
How To Use This SPD ............................................................................................................... 1
Network and Non-Network Benefits ....................................................................................... 2

Dental Services Covered Under the Plan ................................................................................. 2
Important Information Regarding Medicare ........................................................................... 2

Identification ("ID") Card .......................................................................................................... 3
Contact the Plan Administrator ................................................................................................. 3

SECTION 2 - INTRODUCTION ......................................................................................................... 4
Eligibility ....................................................................................................................................... 4
Cost of Coverage ......................................................................................................................... 4

How to Enroll .............................................................................................................................. 5
When Coverage Begins ............................................................................................................... 5

Changing Your Coverage ............................................................................................................ 5

SECTION 3 - HOW THE PLAN WORKS .......................................................................................... 7

Network and Non-Network Benefits ....................................................................................... 7
Eligible Expenses ......................................................................................................................... 8

Annual Deductible ....................................................................................................................... 8
Annual Maximum Benefit .......................................................................................................... 8

Lifetime Maximum Benefit for Orthodontic Services ........................................................... 8
Coinsurance .................................................................................................................................. 8

SECTION 4 - PLAN HIGHLIGHTS ................................................................................................... 9

SECTION 5 - EXCLUSIONS: WHAT THE DENTAL PLAN WILL NOT COVER ............................ 24

SECTION 6 - CLAIMS PROCEDURES .......................................................................................... 27

Network Benefits ....................................................................................................................... 27
Non-Network Benefits ............................................................................................................. 27

If Your Dentist Does Not File Your Claim ........................................................................... 27
Explanation of Benefits (EOB) ............................................................................................... 28
Claim Denials and Appeals ....................................................................................................... 28

SECTION 7 - SUBROGATION AND REIMBURSEMENT .............................................................. 33

I TABLE OF CONTENTS