Page 37 - 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?
Procedures -
Outpatient Diagnostic
and Therapeutic.
• Outpatient surgery
procedures described
under Surgery -
Outpatient.
Outpatient therapeutic
procedures described under
Therapeutic Treatments -
Outpatient.
Does the Amount Network Yes
You Pay Apply to
the Out-of-Pocket Yes
Limit?

Does the Annual Network Yes
Deductible Apply?
No

Urinary Catheters
What Is the Network 40%
Copayment or
Coinsurance You 20%
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

Virtual Visits
What Is the Network Out-of-Network Network Benefits are
Copayment or Benefits are not available only when
Coinsurance You $0 available. services are delivered
Pay? This May through a Designated
Include a Virtual Network Provider.
Copayment, You can find a Designated
Coinsurance or Virtual Network Provider by
Both. contacting the Claims
Administrator at
www.myuhc.com or the

34 Schedule of Benefits Plan Set 008