Page 37 - Vision Benefits Plan Document

TEXAS MUTUAL INSURANCE COMPANY VISION PLAN

■ included in Sections 4 and 5, Plan Highlights and Additional Coverage Details; and

■ provided to a Covered Person who meets the Plan's eligibility requirements, as described
under Eligibility in Section 2, Introduction.

Covered Contact Lens Selection – a selection of available contact lenses that may be
obtained from a Network Provider on a covered-in-full basis, subject to payment of any
applicable Copayment.

Dependent – an individual who meets the eligibility requirements specified in the Plan, as
described under Eligibility in Section 2, Introduction. A Dependent does not include anyone
who is also enrolled as a Participant. No one can be a Dependent of more than one
Participant.

Eligible Expenses – charges for Covered Vision Services that are provided while the Plan
is in effect, determined as follows:

For: Eligible Expenses are Based On:

Network Benefits ■ contracted rates with the provider.
■ billed amounts up to the Maximum Non-Network
Non-Network Benefits Benefit.

For certain Covered Vision Services, you are required to pay a percentage of Eligible
Expenses in the form of a Copay.

Eligible Expenses are subject to the Claims Administrator's reimbursement policy guidelines.

Employee Retirement Income Security Act of 1974 (ERISA) – the federal legislation
that regulates retirement and employee welfare benefit programs maintained by employers
and unions.

Employer – Texas Mutual Insurance Company.

EOB – see Explanation of Benefits (EOB).

ERISA – see Employee Retirement Income Security Act of 1974 (ERISA).

Explanation of Benefits (EOB) – a statement provided by UnitedHealthcare Vision to
you, your Provider, or another health care professional that explains:

■ the Benefits provided (if any);

■ the allowable reimbursement amounts;

■ any other reductions taken;
■ the net amount paid by the Plan; and

■ the reason(s) why the service or supply was not covered by the Plan.

33 SECTION 10 - GLOSSARY