Page 14 - 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
Limit has been reached, you still will be
required to pay the following:
• Any charges for non-Covered Health
Care Services.
• The amount you are required to pay if
you do not obtain prior authorization as
required.

• Charges that exceed Allowed Amounts.
• Copayments or Coinsurance for any
Covered Health Care Service shown in
the Schedule of Benefits table that
does not apply to the Out-of-Pocket
Limit.

Copayment
Copayment is the amount you pay (calculated as a set dollar amount) each time you receive certain
Covered Health Care Services. When Copayments apply, the amount is listed on the following pages
next to the description for each Covered Health Care Service.

Copayments do not count towards the annual deductible.
Copayments do count towards the Out-of-Pocket Maximum.
Please note that for Covered Health Care Services, you are responsible for paying the lesser of:

• The applicable Copayment.
• The Allowed Amount.

Details about the way in which Allowed Amounts are determined appear at the end of the Schedule of
Benefits table.

Coinsurance
Coinsurance is the amount you pay (calculated as a percentage of the Allowed Amount) each time you
receive certain Covered Health Care Services.
Details about the way in which Allowed Amounts are determined appear at the end of the Schedule of
Benefits table.

11 Schedule of Benefits Plan Set 008