Page 21 - 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 Amount Yes Yes
You Pay Apply to
the Out-of-Pocket
Limit?
Does the Annual Yes, when Benefits are Emergency:
Deductible Apply? subject to Coinsurance
Yes, the Network
Annual Deductible
applies
Non-Emergency:

Yes, the Out-of-
Network Annual
Deductible applies
Enteral Nutrition

What Is the Network 40%
Copayment or
Coinsurance You None
Pay? This May
Include a
Copayment,
Coinsurance or
Both.
Does the Amount Network Yes
You Pay Apply to
the Out-of-Pocket Yes
Limit?
Does the Annual Network Yes
Deductible Apply?
No
Habilitative Services

Prior Authorization Requirement
For Out-of-Network Benefits for a scheduled admission, you must obtain prior authorization five
business days before admission, or as soon as is reasonably possible for non-scheduled admissions
(including Emergency admissions). If you do not obtain prior authorization as required, Benefits will be
subject to a $250 reduction.

In addition, for Out-of-Network Benefits you must contact us 24 hours before admission for scheduled
admissions or as soon as is reasonably possible for non-scheduled admissions (including Emergency
admissions).
Inpatient Network Depending upon where Inpatient services limited
the Covered Health per year as follows:
Depending upon where Care Service is
the Covered Health provided, Benefits will Limit will be the same as,
Care Service is be the same as those and combined with, those

18 Schedule of Benefits Plan Set 008