Page 115 - 2021 Medical Plan SPD

Texas Mutual Insurance Company Medical Plan

maintaining a level of function, as opposed to improving that function to an extent that might allow
for a more independent existence.

Definitive Drug Test - test to identify specific medications, illicit substances and metabolites and is
qualitative or quantitative to identify possible use or non-use of a drug.

Dependent – an individual who meets the eligibility requirements specified in the Plan, as described
under Dependent in Section 3: When Coverage Begins. A Dependent does not include anyone who is
also enrolled as a Participant. No one can be a Dependent of more than one Participant.
Designated Dispensing Entity - a pharmacy or other provider that has entered into an agreement with
the Claims Administrator, or with an organization contracting on the Claims Administrator's behalf, to
provide Pharmaceutical Products for the treatment of specified diseases or conditions. Not all Network
pharmacies or Network providers are Designated Dispensing Entities.

Designated Network Benefits - the description of how Benefits are paid for certain Covered Health Care
Services provided by a provider or facility that has been identified as a Designated Provider. The
Schedule of Benefits will tell you if your plan offers Designated Network Benefits and how they apply.
Designated Provider - a provider and/or facility that:
• Has entered into an agreement with the Claims Administrator, or with an organization contracting
on the Claims Administrator's behalf, to provide Covered Health Care Service for the treatment of
specific diseases or condition; or

• The Claims Administrator has identified through the Claims Administrator's designation programs
as a Designated Provider. Such designation may apply to specific treatments, conditions and/or
procedures.
A Designated Provider may or may not be located within your geographic area. Not all Network Hospitals
or Network Physicians are Designated Providers.
You can find out if your provider is a Designated Provider by contacting the Claims Administrator at
www.myuhc.com or the telephone number on your ID card.

Designated Virtual Network Provider - a provider or facility that has entered into an agreement with the
Claims Administrator, or with an organization contracting on the Claims Administrator's behalf, to deliver
Covered Health Care Services through live audio and video technology.
Durable Medical Equipment (DME) - medical equipment that is all of the following:

• Ordered or provided by a Physician for outpatient use primarily in a home setting.
• Used for medical purposes.

• Not consumable or disposable except as needed for the effective use of covered DME.
• Not of use to a person in the absence of a disease or disability.

• Serves a medical purpose for the treatment of a Sickness or Injury.

• Primarily used within the home.
Eligible Person - an employee of the Plan Sponsor or other person connected to the Plan Sponsor who
meets the eligibility requirements specified in the Plan, as described under Eligible Person in Section 3:
When Coverage Begins.

112 Section 9: Defined Terms