Page 52 - 2021 Medical Plan SPD

Texas Mutual Insurance Company Medical Plan

Obesity - Weight Loss Surgery
Surgical treatment of obesity when provided by or under the direction of a Physician when either of the
following criteria is met:
You have a body mass index (BMI) of greater than 35 with complicating coexisting medical conditions or
diseases (such as sleep apnea or diabetes) directly related to, or made worse by, obesity.

Ostomy Supplies

Benefits for ostomy supplies are limited to the following:
• Pouches, face plates and belts.

• Irrigation sleeves, bags and ostomy irrigation catheters.
• Skin barriers.
Benefits are not available for deodorants, filters, lubricants, tape, appliance cleaners, adhesive, adhesive
remover, or other items not listed above.

Pharmaceutical Products - Outpatient
Pharmaceutical Products for Covered Health Care Services administered on an outpatient basis in a
Hospital, Alternate Facility, Physician's office, or in your home.
Benefits are provided for Pharmaceutical Products which, due to their traits (as determined by the Claims
Administrator), are administered or directly supervised by a qualified provider or licensed/certified health
professional. Depending on where the Pharmaceutical Product is administered, Benefits will be provided
for administration of the Pharmaceutical Product under the corresponding Benefit category in this SPD.

If you require certain Pharmaceutical Products, including specialty Pharmaceutical Products, the Claims
Administrator may direct you to a Designated Dispensing Entity. Such Dispensing Entities may include an
outpatient pharmacy, specialty pharmacy, Home Health Agency provider, Hospital-affiliated pharmacy or
hemophilia treatment center contracted pharmacy.
If you/your provider are directed to a Designated Dispensing Entity and you/your provider choose not to
get your Pharmaceutical Product from a Designated Dispensing Entity, Network Benefits are not available
for that Pharmaceutical Product.

Certain Pharmaceutical Products are subject to step therapy requirements. This means that in order to
receive Benefits for such Pharmaceutical Products, you must use a different Pharmaceutical Product
and/or prescription drug product first. You may find out whether a particular Pharmaceutical Product is
subject to step therapy requirements by contacting the Claims Administrator at www.myuhc.com or the
telephone number on your ID card.

The Claims Administrator may have certain programs in which you may receive an enhanced or reduced
Benefit based on your actions such as adherence/compliance to medication or treatment regimens and/or
participation in health management programs. You may access information on these programs by
contacting the Claims Administrator at www.myuhc.com or the telephone number on your ID card.

Physician Fees for Surgical and Medical Services
Physician fees for surgical procedures and other medical services received on an outpatient or inpatient
basis in a Hospital, Skilled Nursing Facility, Inpatient Rehabilitation Facility or Alternate Facility, or for
Physician house calls.

49 Section 1: Covered Health Care Services