Page 3 - Vision Benefits Plan Document

TEXAS MUTUAL INSURANCE COMPANY VISION PLAN

TABLE OF CONTENTS

SECTION 1 - WELCOME ................................................................................................................. 1

SECTION 2 - INTRODUCTION ......................................................................................................... 3
Eligibility ....................................................................................................................................... 3

Cost of Coverage ......................................................................................................................... 3
How to Enroll .............................................................................................................................. 4

When Coverage Begins ............................................................................................................... 4
Changing Your Coverage ............................................................................................................ 4

SECTION 3 - HOW THE PLAN WORKS .......................................................................................... 6
Network and Non-Network Provider ...................................................................................... 6
Eligible Expenses ......................................................................................................................... 7

Maximum Non-Network Benefit .............................................................................................. 7
Copayment .................................................................................................................................... 7

SECTION 4 - PLAN HIGHLIGHTS ................................................................................................... 8

SECTION 5 - ADDITIONAL COVERAGE DETAILS ...................................................................... 11

Routine Vision Examination .................................................................................................... 11
Eyeglass Lenses .......................................................................................................................... 12
Eyeglass Frames ......................................................................................................................... 12

Optional Lens Extras ................................................................................................................ 12
Contact Lenses ........................................................................................................................... 12

Necessary Contact Lenses ........................................................................................................ 12

SECTION 6 - EXCLUSIONS: WHAT THE VISION PLAN WILL NOT COVER .............................. 13

SECTION 7 - CLAIMS PROCEDURES .......................................................................................... 15
Network Benefits ....................................................................................................................... 15

Non-Network Benefits ............................................................................................................. 15
How to File Your Claim ........................................................................................................... 15
Examination of Covered Persons ............................................................................................ 16

Explanation of Benefits (EOB) ............................................................................................... 16
Claim Denials and Appeals ....................................................................................................... 16

I TABLE OF CONTENTS