Page 15 - Vision Benefits Plan Document

TEXAS MUTUAL INSURANCE COMPANY VISION PLAN

SECTION 5 - ADDITIONAL COVERAGE DETAILS

What this section includes:
■ Covered Vision Services for which the Plan pays Benefits.

This section supplements the table in Section 4, Plan Highlights.

While the table provides you with Benefit limitations along with Copayment information for
each Covered Vision Service, this section includes descriptions of the Benefits. These
descriptions include any additional limitations that may apply. The Covered Vision Services
in this section appear in the same order as they do in the table for easy reference. Services
that are not covered are described in Section 6, Exclusions.

Routine Vision Examination

The Plan pays Benefits for a routine vision examination of the condition of the eyes and
principal vision functions according to the standards of care in the jurisdiction in which the
Covered Person resides, to include:

■ a case history, including chief complaint and/or reason for examination, patient
medical/eye history, current medications, etc.;

■ recording of monocular and binocular visual acuity, far and near, with and without
present correction (20/20, 20/40, etc.);

■ cover test at 20 feet and 16 inches (checks eye alignment);
■ ocular motility including versions (how well eyes track) near point convergence (how
well eyes move together for near vision tasks, such as reading), and depth perception;

■ pupil responses (neurological integrity);
■ external exam;

■ internal exam;
■ retinoscopy (when applicable) - objective refraction to determine lens power of
corrective subjective refraction — to determine lens power of corrective lenses;

■ phorometry/Binocular testing - far and near: how well eyes work as a team;
■ tests of accommodation and/or near point refraction: how well Covered Person sees at
near point (reading, etc.);
■ tonometry, when indicated: test pressure in eye (glaucoma check);

■ ophthalmoscopic examination of the internal eye;
■ confrontation visual fields;

■ biomicroscopy;
■ color vision testing;

■ diagnosis/prognosis; and

11 SECTION 5 - ADDITIONAL COVERAGE DETAILS