Page 50 - 2021 Medical Plan SPD

Texas Mutual Insurance Company Medical Plan

• Short-term grief counseling for immediate family members while you are receiving hospice care.
Benefits are available when you receive hospice care from a licensed hospice agency.

You can call the Claims Administrator at the telephone number on your ID card for information about the
Claims Administrator's guidelines for hospice care.

Hospital - Inpatient Stay
Services and supplies provided during an Inpatient Stay in a Hospital.

Benefits are available for:
• Supplies and non-Physician services received during the Inpatient Stay.

• Room and board in a Semi-private Room (a room with two or more beds).
• Physician services for radiologists, anesthesiologists, pathologists and Emergency room
Physicians. (Benefits for other Physician services are described under Physician Fees for Surgical
and Medical Services.)

Lab, X-Ray and Diagnostic - Outpatient
Services for Sickness and Injury-related diagnostic purposes, received on an outpatient basis at a
Hospital or Alternate Facility or in a Physician's office include:
• Lab and radiology/X-ray.

• Mammography.
Benefits include:

• The facility charge and the charge for supplies and equipment.
• Physician services for radiologists, anesthesiologists and pathologists. (Benefits for other Physician
services are described under Physician Fees for Surgical and Medical Services.)
• Genetic Testing ordered by a Physician which results in available medical treatment options
following Genetic Counseling.
• Presumptive Drug Tests and Definitive Drug Tests.
Lab, X-ray and diagnostic services for preventive care are described under Preventive Care Services.

CT scans, PET scans, MRI, MRA, nuclear medicine and major diagnostic services are described under
Major Diagnostic and Imaging - Outpatient.

Major Diagnostic and Imaging - Outpatient
Services for CT scans, PET scans, MRI, MRA, nuclear medicine and major diagnostic services received
on an outpatient basis at a Hospital or Alternate Facility or in a Physician's office.
Benefits include:

• The facility charge and the charge for supplies and equipment.
• Physician services for radiologists, anesthesiologists and pathologists. (Benefits for other Physician
services are described under Physician Fees for Surgical and Medical Services.)

47 Section 1: Covered Health Care Services