Page 26 - 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

Maternity Support – Refer to Clinical Programs and Resources section
Mental Health Care and Substance-Related and Addictive Disorders Services

Prior Authorization Requirement
For Out-of-Network Benefits for a scheduled admission for Mental Health Care and Substance-Related
and Addictive Disorders Services (including an admission for services at a Residential Treatment
facility) you must obtain prior authorization five business days before admission or as soon as is
reasonably possible for non-scheduled admissions (including Emergency admissions).
In addition, for Out-of-Network Benefits you must obtain prior authorization before the following
services are received. Services requiring prior authorization: Partial Hospitalization/Day Treatment;
Intensive Outpatient Treatment programs; outpatient electro-convulsive treatment; psychological
testing; transcranial magnetic stimulation; extended outpatient treatment visits with or without
medication management; Intensive Behavioral Therapy, including Applied Behavior Analysis (ABA).
If you do not obtain prior authorization as required, Benefits will be subject to a $250 reduction.

Inpatient Network 40% after you pay
$250 copayment per
What Is the 20% after you pay Inpatient Stay
Copayment or
Coinsurance You $250 copayment per
Pay? This May Inpatient Stay
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?
Yes
Outpatient Network 40%

What Is the $20 per visit
Copayment or
Coinsurance You
Pay? This May
Include a
Copayment,
Coinsurance or
Both.

Does the Amount Network Yes
You Pay Apply to

23 Schedule of Benefits Plan Set 008