Page 12 - Vision Benefits Plan Document

TEXAS MUTUAL INSURANCE COMPANY VISION PLAN

SECTION 4 - PLAN HIGHLIGHTS

The table below provides an overview of Copays that apply when you receive certain
Covered Vision Services and outlines the Plan's frequency of service and Maximum Non-
Network Benefit.

Network Maximum
Service Frequency of Service Provider Non-Network
Copayment Benefit

Vision Exam Once every 12 months $15 $40
2
$15 from the
Covered
Frames Once every 12 months Eyeglass $45
1
Frames
Selection
3
Lenses (Any one Once every 12 months
1
type)
■ Single Vision $15 $40
2
■ Bifocal Vision $15 $60
2
■ Trifocal Vision $15 $80
2

■ Lenticular Vision $15 $80
2
Contact Lenses Once every 12 months

$15 from the
■ Elective Contact Covered
Lenses Contact Lens $150
4
Selection
■ Necessary
Contact Lenses $15 $210

Lenses

■ Faceted 20%

■ Oversize Lens 20%

■ Polarized 20%

■ Roll & Polish
Edges $13

8 SECTION 4 - PLAN HIGHLIGHTS