Page 14 - Vision Benefits Plan Document

TEXAS MUTUAL INSURANCE COMPANY VISION PLAN

Network Maximum
Service Frequency of Service Provider Non-Network
Copayment Benefit
■ Scratch Warranty $10

Materials

■ High Index less
than or equal to $53
1.66

■ High Index
greater than 1.67 $63

■ Polycarbonate
Adults $33

■ Polycarbonate for
Children up to No Charge
age 19

Plan includes a second exam for children under age 13 (after applicable copay).
Additionally, Participants age 0-12 who have a prescription change of 0.5 diopter or
more are eligible for a replacement frame and lenses. The replacement glasses benefit
will include the same copay (lenses) and allowance (frame) that applied toward the
initial frame and lenses.

Plan includes maternity benefit for pregnant and breastfeeding women that covers an
additional eye exam and material benefit with vision charges during pregnancy. The
same exam and materials copayments for the first eye exam will apply and the frame
and lens benefits will replicate the plan’s core coverage level.

1 You are eligible to select only one of either eyeglasses (Eyeglass Lenses and/or Eyeglass
Frames) or Contact Lenses. If you select more than one of these Services, only one Service will
be covered.

2 If you purchase Eyeglass Lenses and Eyeglass Frames at the same time from the same
Network Provider, only one Copay will apply to those Eyeglass Lenses and Eyeglass Frames
together.

3 Eyeglass Frames will receive an allowance up to $130.

4 You may purchase from your Network Provider Contact Lenses that are outside of the
Covered Contact Lens Selection. Non-selection Contact Lenses will receive an allowance of
$105. No Copay will apply to non-selection Contact Lenses.

10 SECTION 4 - PLAN HIGHLIGHTS