Page 69 - 2021 Medical Plan SPD

Texas Mutual Insurance Company Medical Plan

Providers
1. Services performed by a provider who is a family member by birth or marriage. Examples include a
spouse, brother, sister, parent or child. This includes any service the provider may perform on
himself or herself.
2. Services performed by a provider with your same legal address.

3. Services provided at a Freestanding Facility or diagnostic Hospital-based Facility without an order
written by a Physician or other provider. Services which are self-directed to a Freestanding Facility
or diagnostic Hospital-based Facility. Services ordered by a Physician or other provider who is an
employee or representative of a Freestanding Facility or diagnostic Hospital-based Facility, when
that Physician or other provider:
 Has not been involved in your medical care prior to ordering the service, or

 Is not involved in your medical care after the service is received.
This exclusion does not apply to mammography.

Reproduction
1. The following services related to a Gestational Carrier or Surrogate:
 All costs related to reproductive techniques including:

♦ Assistive reproductive technology.

♦ Artificial insemination.
♦ Intrauterine insemination.
♦ Obtaining and transferring embryo(s).

 Health care services including:
♦ Inpatient or outpatient prenatal care and/or preventive care.

♦ Screenings and/or diagnostic testing.
♦ Delivery and post-natal care.
The exclusion for the health care services listed above does not apply when the Gestational
Carrier or Surrogate is a Covered Person.
 All fees including:

♦ Screening, hiring and compensation of a Gestational Carrier or Surrogate including
surrogacy agency fees.

♦ Surrogate insurance premiums.
♦ Travel or transportation fees.

2. The following services related to donor services for donor sperm, ovum (egg cell) or oocytes
(eggs), or embryos (fertilized eggs):
 Donor eggs – The cost of donor eggs, including medical costs related to donor stimulation
and egg retrieval. This exclusion may not apply to certain procedures related to Assisted
Reproductive Technologies (ART) as described under Infertility Services including the cost
for fertilization (in vitro fertilization or intracytoplasmic sperm injection), embryo culture, and
embryo transfer.

66 Section 2: Exclusions and Limitations