Page 45 - 2021 Medical Plan SPD
P. 45
Texas Mutual Insurance Company Medical Plan
• Treatment must be completed within 12 months of the accident, or if not a Covered Person at the
time of the accident, within the first 12 months of coverage under the Plan.
Benefits for treatment of accidental Injury are limited to the following:
• Emergency exam.
• Diagnostic X-rays.
• Endodontic (root canal) treatment.
• Temporary splinting of teeth.
• Prefabricated post and core.
• Simple minimal restorative procedures (fillings).
• Extractions.
• Post-traumatic crowns if such are the only clinically acceptable treatment.
• Replacement of lost teeth due to Injury with implant, dentures or bridges.
Diabetes Services
Diabetes Self-Management and Training/Diabetic Eye Exams/Foot Care
Outpatient self-management training for the treatment of diabetes, education and medical nutrition
therapy services. Services must be ordered by a Physician and provided by appropriately licensed or
registered health care professionals.
Benefits also include medical eye exams (dilated retinal exams) and preventive foot care for diabetes.
Diabetic Self-Management Items
Insulin pumps and supplies for the management and treatment of diabetes, based upon your medical
needs include:
• Insulin pumps are subject to all the conditions of coverage stated under Durable Medical
Equipment (DME), Orthotics and Supplies.
• Blood glucose meters including continuous glucose monitors.
• Insulin syringes with needles.
• Blood glucose and urine test strips.
• Ketone test strips and tablets.
• Lancets and lancet devices.
Durable Medical Equipment (DME), Orthotics and Supplies
Benefits are provided for DME and certain orthotics and supplies. If more than one item can meet your
functional needs, Benefits are available only for the item that meets the minimum specifications for your
needs. If you purchase an item that exceeds these minimum specifications, the Plan will pay only the
amount that the Plan would have paid for the item that meets the minimum specifications, and you will be
responsible for paying any difference in cost.
42 Section 1: Covered Health Care Services
