Page 34 - 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 Network Yes
You Pay Apply to
the Out-of-Pocket Yes
Limit?
Does the Annual Network Yes
Deductible Apply?
Yes

Spine and Joint Surgery – Refer to Clinical Programs and Resources section
Spine and Joint Surgeries

What Is the Designated Network Not Covered Depending upon where the
Copayment or Covered Health Care
Coinsurance You 10% Service is provided,
Pay? This May Network Benefits for diagnostic
Include a services, implant fees, DME
Copayment, 20% and supplies and non-
Coinsurance or surgical management of
Both. spine and joint services will
be the same as those stated
under each Covered Health
Care Service category in
this Schedule of Benefits.

For eligible Participants 18
and older.

Does the Amount Network Not Covered
You Pay Apply to
the Out-of-Pocket Yes
Limit?

Does the Annual Network Not Covered
Deductible Apply?
Yes

Surgery - Outpatient
Prior Authorization Requirement

For Out-of-Network Benefits for orthognathic surgery or sleep apnea surgery you must obtain prior
authorization five business days before scheduled services are received or, for non-scheduled
services, within one business day or as soon as is reasonably possible. If you do not obtain prior
authorization as required, Benefits will be subject to a $250 reduction.
What Is the Network 40%
Copayment or
Coinsurance You 20%
Pay? This May
Include a
Copayment,
Coinsurance or
Both.

31 Schedule of Benefits Plan Set 008