Page 38 - 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?
telephone number on your
ID card.

Does the Amount Network Out-of-Network
You Pay Apply to Benefits are not
the Out-of-Pocket Yes available.
Limit?

Does the Annual Network Out-of-Network
Deductible Apply? Benefits are not
No available.

Wigs

What Is the Network None Limited to $500 per year.
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

Allowed Amounts

Allowed Amounts are the amount the Claims Administrator determines that the Plan will pay for Benefits.
For Network Benefits for Covered Health Care Services provided by a Network provider, you are not
responsible for anything except your cost sharing obligations. For Benefits for Covered Health Care
Services provided by an out-of-Network provider (other than Emergency Health Care Services or services
otherwise arranged by the Claims Administrator), you are responsible to work with the out-of-network
physician or provider to resolve any amount billed to you that is greater than the amount the Claims
Administrator determines to be an Allowed Amount as described below. Allowed Amounts are determined
solely in accordance with the Claims Administrator's reimbursement policy guidelines, as described in the
SPD.
When Covered Health Care Services are received from an out-of-Network provider, Allowed Amounts are
an amount negotiated by the Claims Administrator, a specific amount required by law (when required by
law), or an amount the Claims Administrator has determined is typically accepted by a healthcare provider
for the same or similar service. Please contact the Claims Administrator if you are billed for amounts in
excess of your applicable Coinsurance, Copayment or any deductible. The Plan will not pay excessive
charges or amounts you are not legally obligated to pay.

35 Schedule of Benefits Plan Set 008