Page 40 - 2021 Medical Plan SPD

Texas Mutual Insurance Company Medical Plan

You or your Network Physician must notify the Claims Administrator of special service needs (such as
transplants or cancer treatment) that might warrant referral to a Designated Provider. If you do not notify
the Claims Administrator in advance, and if you receive services from an out-of-Network facility
(regardless of whether it is a Designated Provider) or other out-of-Network provider, Network Benefits will
not be paid. Out-of-Network Benefits may be available if the special needs services you receive are
Covered Health Care Services for which Benefits are provided under the Plan.

Health Care Services from Out-of-Network Providers Paid as Network
Benefits
If specific Covered Health Care Services are not available from a Network provider, you may be eligible
for Network Benefits when Covered Health Care Services are received from out-of-Network providers. In
this situation, your Network Physician will notify the Claims Administrator and, if the Claims Administrator
confirms that care is not available from a Network provider, the Claims Administrator will work with you
and your Network Physician to coordinate care through an out-of-Network provider.

Limitations on Selection of Providers
If the Claims Administrator determines that you are using health care services in a harmful or abusive
manner, or with harmful frequency, your selection of Network providers may be limited. If this happens,
the Claims Administrator may require you to select a single Network Physician to provide and coordinate
all future Covered Health Care Services.
If you don't make a selection within 31 days of the date the Claims Administrator notifies you, the Claims
Administrator will select a single Network Physician for you.
If you do not use the selected Network Physician, Covered Health Care Services will be paid as Out-of-
Network Benefits.

37 Schedule of Benefits Plan Set 008