Page 54 - 2021 Medical Plan SPD

Texas Mutual Insurance Company Medical Plan

• Immunizations that have in effect a recommendation from the Advisory Committee on
Immunization Practices of the Centers for Disease Control and Prevention.

• With respect to infants, children and adolescents, evidence-informed preventive care and
screenings provided for in the comprehensive guidelines supported by the Health Resources and
Services Administration.
• With respect to women, such additional preventive care and screenings as provided for in
comprehensive guidelines supported by the Health Resources and Services Administration.
Benefits defined under the Health Resources and Services Administration (HRSA) requirement
include the cost of renting or purchasing one breast pump per Pregnancy in conjunction with
childbirth. Breast pumps must be ordered by or provided by a Physician. You can find more
information on how to access Benefits for breast pumps by contacting the Claims Administrator at
www.myuhc.com or the telephone number on your ID card.
The Claims Administrator will determine the following:

 Which pump is the most cost effective.
 Whether the pump should be purchased or rented.

 Duration of a rental.
 Timing of purchase or rental.
 If more than one breast pump can meet your needs, Benefits are available only for the most
cost effective pump.

Prosthetic Devices
External prosthetic devices that replace a limb or a body part, limited to:

• Artificial arms, legs, feet and hands.
• Artificial face, eyes, ears and nose.

• Breast prosthesis as required by the Women's Health and Cancer Rights Act of 1998. Benefits
include mastectomy bras. Benefits for lymphedema stockings for the arm are provided as
described under Durable Medical Equipment (DME), Orthotics and Supplies.

Benefits are provided only for external prosthetic devices and do not include any device that is fully
implanted into the body. Internal prosthetics are a Covered Health Care Service for which Benefits are
available under the applicable medical/surgical Covered Health Care Service categories in this SPD.
If more than one prosthetic device can meet your functional needs, Benefits are available only for the
prosthetic device that meets the minimum specifications for your needs. If you purchase a prosthetic
device that exceeds these minimum specifications, the Plan will pay only the amount that the Plan would
have paid for the prosthetic that meets the minimum specifications, and you will be responsible for paying
any difference in cost.
The prosthetic device must be ordered or provided by, or under the direction of a Physician.

Benefits are available for repairs and replacement, except as described in Section 2: Exclusions and
Limitations, under Devices, Appliances and Prosthetics.

51 Section 1: Covered Health Care Services