Page 36 - 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?
Transplantation Services

Network Out-of-Network For Network Benefits,
Benefits are not transplantation services
Depending upon where available. must be received from a
the Covered Health Designated Provider. The
Care Service is Claims Administrator does
provided, Benefits will not require that cornea
be the same as those transplants be received
stated under each from a Designated Provider
Covered Health Care in order for you to receive
Service category in this Network Benefits.
Schedule of Benefits.

Travel and Lodging – Refer to the Clinical Programs and Resources section

Urgent Care Center Services
What Is the Network 40% In addition to the
Copayment or Copayment stated in this
Coinsurance You $45 per visit section, the
Pay? This May Copayments/Coinsurance
Include a and any deductible for the
Copayment, following services apply
Coinsurance or when the Covered Health
Both. Care Service is performed
at an Urgent Care Center:
• Lab, radiology/X-rays
and other diagnostic
services described
under Lab, X-Ray
and Diagnostic -
Outpatient.
• Major diagnostic and
nuclear medicine
described under
Major Diagnostic and
Imaging - Outpatient.
• Outpatient
Pharmaceutical
Products described
under
Pharmaceutical
Products -
Outpatient.

• Diagnostic and
therapeutic scopic
procedures described
under Scopic

33 Schedule of Benefits Plan Set 008