Page 59 - 2021 Medical Plan SPD

Texas Mutual Insurance Company Medical Plan

Transplantation Services
Organ and tissue transplants including CAR-T cell therapy when ordered by a Physician. Benefits are
available for transplants when the transplant meets the definition of a Covered Health Care Service, and
is not an Experimental or Investigational or Unproven Service.
Examples of transplants for which Benefits are available include:

• Bone marrow including CAR-T cell therapy.

• Heart.
• Heart/lung.

• Lung.
• Kidney.

• Kidney/pancreas.
• Liver.

• Liver/small bowel.
• Pancreas.

• Small bowel.
• Cornea.

Donor costs that are directly related to organ removal are Covered Health Care Services for which
Benefits are payable through the organ recipient's coverage under the Plan.

You can call the Claims Administrator at the telephone number on your ID card for information about the
Claims Administrator's specific guidelines regarding Benefits for transplant services.

Urgent Care Center Services
Covered Health Care Services received at an Urgent Care Center. When services to treat urgent health
care needs are provided in a Physician's office, Benefits are available as described under Physician's
Office Services - Sickness and Injury.

Urinary Catheters
Benefits for indwelling and intermittent urinary catheters for incontinence or retention.
Benefits include related urologic supplies for indwelling catheters limited to:

• Urinary drainage bag and insertion tray (kit).
• Anchoring device.

• Irrigation tubing set.

Virtual Visits
Virtual visits for Covered Health Care Services that include the diagnosis and treatment of less serious
medical conditions through live audio with video technology or audio only. Virtual visits provide
communication of medical information in real-time between the patient and a distant Physician or health

56 Section 1: Covered Health Care Services