Page 120 - 2021 Medical Plan SPD

Texas Mutual Insurance Company Medical Plan

Out-of-Network Benefits - the description of how Benefits are paid for Covered Health Care Services
provided by out-of-Network providers. The Schedule of Benefits will tell you if your plan offers Out-of-
Network Benefits and how Out-of-Network Benefits apply.
Out-of-Pocket Limit - the maximum amount you pay every year. The Schedule of Benefits will tell you if
your plan is subject to an Out-of-Pocket Limit and how the Out-of-Pocket Limit applies.
Partial Hospitalization/Day Treatment - a structured ambulatory program. The program may be
freestanding or Hospital-based and provides services for at least 20 hours per week.
Participant - a Participant of the Employer who meets the eligibility requirements specified in the Plan. A
Participant must live and/or work in the United States.

Pharmaceutical Product(s) - U.S. Food and Drug Administration (FDA)-approved prescription
medications, products or devices administered in connection with a Covered Health Care Service by a
Physician.
Physician - any Doctor of Medicine or Doctor of Osteopathy who is properly licensed and qualified by
law.
Please Note: Any podiatrist, dentist, psychologist, chiropractor, optometrist, or other provider who acts
within the scope of his or her license will be considered on the same basis as a Physician. The fact that
the Claims Administrator describes a provider as a Physician does not mean that Benefits for services
from that provider are available to you under the Plan.

Plan - the Plan Sponsor’s self-funded group health benefit plan, which is referred to as the Texas Mutual
Insurance Company Medical Plan and also by its formal name as the Texas Mutual Insurance Company
Employee Benefit Plan.
Plan Administrator – Texas Mutual Insurance Company or its designee.

Plan Sponsor – Texas Mutual Insurance Company.
Pregnancy - includes all of the following:
• Prenatal care.

• Postnatal care.

• Childbirth.
• Any complications associated with Pregnancy.
Prescription Drug List (PDL) Management Committee - the committee that the Claims Administrator
designates for, among other responsibilities, placing Pharmaceutical Products into specific tiers.
Presumptive Drug Test - test to determine the presence or absence of drugs or a drug class in which
the results are indicated as negative or positive result.
Primary Care Physician - a Physician who has a majority of his or her practice in general pediatrics,
internal medicine, obstetrics/gynecology, family practice or general medicine.
Private Duty Nursing - nursing care that is provided to a patient on a one-to-one basis by licensed
nurses in an inpatient or home setting when any of the following are true:
• Services exceed the scope of Intermittent Care in the home.

• Skilled nursing resources are available in the facility.
• The Skilled Care can be provided by a Home Health Agency on a per visit basis for a specific
purpose.

117 Section 9: Defined Terms