Page 27 - 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?
the Out-of-Pocket Yes
Limit?

Does the Annual Network Yes
Deductible Apply?
No

Obesity Surgery – Refer to Bariatric Resource Services program in the Clinical Programs and
Resources section

Obesity – Weight Loss Surgery

You must enroll in and participate in the Bariatric Resource Service (BRS) program for obesity -
weight loss surgery services to be considered Covered Health Care Services.

What Is the Designated Network Out-of-Network For Network Benefits,
Copayment or Benefits are not obesity - weight loss
Coinsurance You 20% available. surgery must be received
Pay? This May from a Designated Provider
Include a and you must be enrolled in
Copayment, the BRS program.
Coinsurance or
Both.
Does the Amount Designated Network Out-of-Network
You Pay Apply to Benefits are not
the Out-of-Pocket Yes available.
Limit?
Does the Annual Designated Network Out-of-Network
Deductible Apply? Benefits are not
Yes available.

Ostomy Supplies
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?
Yes

24 Schedule of Benefits Plan Set 008