Page 19 - 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?
Equipment (DME), Equipment (DME), Equipment (DME), Orthotics
Orthotics and Supplies. Orthotics and Supplies. and Supplies.

For diabetes supplies, For diabetes supplies,
you pay none of the you pay 40% of the
Allowed Amount. Allowed Amount.
Does the Amount Network For diabetes
You Pay Apply to equipment, Benefits
the Out-of-Pocket For diabetes will be the same as
Limit? equipment, Benefits those stated under
will be the same as Durable Medical
those stated under Equipment (DME),
Durable Medical Orthotics and Supplies.
Equipment (DME),
Orthotics and Supplies. For diabetes supplies,
Yes Coinsurance
For diabetes supplies, applies to the Out-of-
Yes Coinsurance Pocket Limit.
applies to the Out-of-
Pocket Limit.
Does the Annual Network For diabetes
Deductible Apply? equipment, Benefits
For diabetes will be the same as
equipment, Benefits those stated under
will be the same as Durable Medical
those stated under Equipment (DME),
Durable Medical Orthotics and Supplies.
Equipment (DME),
Orthotics and Supplies. For diabetes supplies,
No.
For diabetes supplies,
No.

Durable Medical Equipment (DME), Orthotics and Supplies
Prior Authorization Requirement

For Out-of-Network Benefits you must obtain prior authorization before obtaining any DME 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.
What Is the Network 40%, after you meet Benefits are limited to a
Copayment or the Annual Deductible single purchase of a type of
Coinsurance You None, after you meet DME or orthotic every three
Pay? This May the Annual Deductible years. Repair and/or
Include a replacement of DME or
Copayment, orthotics would apply to this
Coinsurance or limit in the same manner as
Both. a purchase. This limit does
not apply to wound
vacuums.

To receive Network
Benefits, you must

16 Schedule of Benefits Plan Set 008