Page 13 - 2021 Medical Plan SPD

Texas Mutual Insurance Company Medical Plan

Payment Term And Description Amounts

The Amount You Pay The Amount You Pay
Network Out-of-Network

Coupons: The Plan may not permit certain $2,250 for all Covered $4,500 for all Covered
coupons or offers from pharmaceutical Persons in a family. Persons in a family.
manufacturers or an affiliate to apply to your
Annual Deductible.
Amounts paid toward the Annual Deductible
for Covered Health Care Services that are
subject to a visit or day limit will also be
calculated against that maximum Benefit limit.
As a result, the limited Benefit will be reduced
by the number of days/visits used toward
meeting the Annual Deductible.

Any amount you pay for medical expenses in
the last three months of the previous year that
is applied to the previous Annual Deductible
will be carried over and applied to the current
Annual Deductible. This carry-over feature
applies to the individual and family Annual
Deductible.
The amount that is applied to the Annual
Deductible is calculated on the basis of the
Allowed Amount. The Annual Deductible does
not include any amount that exceeds the
Allowed Amount. Details about the way in
which Allowed Amounts are determined
appear at the end of the Schedule of Benefits
table.
Out-of-Pocket Limit

The maximum you pay per year for the Network $7,500 per Covered
Annual Deductible, Copayments or Person, not to exceed
Coinsurance. Once you reach the Out-of- $3,000 per Covered $22,500 for all Covered
Pocket Limit, Benefits are payable at 100% of Person, not to exceed Persons in a family.
Allowed Amounts during the rest of that year. $7,000 for all Covered
The Out-of-Pocket Limit applies to Covered Persons in a family. The Out-of-Pocket Limit
Health Care Services under the Plan as The Out-of-Pocket Limit includes the Annual
indicated in this Schedule of Benefits. includes the Annual Deductible.
Coupons: The Plan may not permit certain Deductible. The Out-of-Network Out-
coupons or offers from pharmaceutical The Network Out-of- of-Pocket Maximum does
manufacturers or an affiliate to apply to your Pocket Maximum does apply to the Network Out-
Out-of-Pocket Limit. not apply to the Out-of- of-Pocket Maximum.

Details about the way in which Allowed Network Out-of-Pocket
Amounts are determined appear at the end of Maximum.
the Schedule of Benefits table.
The Out-of-Pocket Limit does not include any
of the following and, once the Out-of-Pocket

10 Schedule of Benefits Plan Set 008