Page 18 - 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?
Does the Annual Network Yes
Deductible Apply?
Yes
Dental Services - Accident Only

What Is the Network Same as Network
Copayment or
Coinsurance You 20%
Pay? This May
Include a
Copayment,
Coinsurance or
Both.
Does the Amount Network Same as Network
You Pay Apply to
the Out-of-Pocket Yes
Limit?
Does the Annual Network Same as Network
Deductible Apply?
Yes
Diabetes Services

Prior Authorization Requirement
For Out-of-Network Benefits you must obtain prior authorization before obtaining any DME for the
management and treatment of diabetes that costs more than $1,000 (either retail purchase cost or
cumulative retail rental cost of a single item). If you do not obtain prior authorization as required,
Benefits will be subject to a $250 reduction.

Diabetes Self- Network Depending upon where
Management and the Covered Health
Training/Diabetic Depending upon where Care Service is
Eye Exams/Foot the Covered Health provided, Benefits for
Care Care Service is diabetes self-
provided, Benefits for management and
diabetes self- training/diabetic eye
management and exams/foot care will be
training/diabetic eye the same as those
exams/foot care will be stated under each
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.
Diabetes Self- Network For diabetes Benefits for diabetes
Management equipment, Benefits equipment that meets the
Items For diabetes will be the same as definition of DME are
equipment, Benefits those stated under subject to the limit stated
will be the same as Durable Medical under Durable Medical
those stated under
Durable Medical

15 Schedule of Benefits Plan Set 008