Page 17 - 2021 Medical Plan SPD

Texas Mutual Insurance Company Medical Plan

Covered Health The Amount You Pay The Amount You Pay What are the Limitations
Care Service Network Out-of-Network & Exceptions?
Clinical Trials

Prior Authorization Requirement
For Out-of-Network Benefits, you must obtain prior authorization as soon as the possibility of
participation in a clinical trial arises. If you do not obtain prior authorization as required, Benefits will be
subject to a $250 reduction.

Network Depending upon where
the Covered Health
Depending upon where Care Service is
the Covered Health provided, Benefits will
Care Service is be the same as those
provided, Benefits will stated under each
be the same as those Covered Health Care
stated under each Service category in this
Covered Health Care Schedule of Benefits.
Service category in this
Schedule of Benefits.
Congenital Heart Disease (CHD) Surgeries

Prior Authorization Requirement
For Out-of-Network Benefits, you must obtain prior authorization as soon as the possibility of a
congenital heart disease (CHD) surgery arises. If you do not obtain prior authorization as required,
Benefits will be subject to a $250 reduction.
It is important that you notify the Claims Administrator regarding your intention to have
surgery. Your notification will open the opportunity to become enrolled in programs that are
designed to achieve the best outcomes for you.

What Is the Network 40% Benefits under this section
Copayment or include only the inpatient
Coinsurance You 20% and facility charges for the
Pay? This May and $250 copayment per congenital heart disease
Include a Inpatient Stay (CHD) surgery. Depending
Copayment, $250 copayment per upon where the Covered
Coinsurance or Inpatient Stay Health Care Service is
Both. provided, Benefits for
diagnostic services, cardiac
catheterization and non-
surgical management of
CHD will be the same as
those stated under each
Covered Health Care
Service category in this
Schedule of Benefits.
Does the Amount Network Yes
You Pay Apply to
the Out-of-Pocket Yes
Limit?

14 Schedule of Benefits Plan Set 008