Page 15 - 2021 Medical Plan SPD

Texas Mutual Insurance Company Medical Plan

Schedule of Benefits Table

Covered Health The Amount You Pay The Amount You Pay What are the Limitations
Care Service Network Out-of-Network & Exceptions?
Ambulance Services

Prior Authorization Requirement
In most cases, the Claims Administrator will initiate and direct non-Emergency ambulance
transportation. For Out-of-Network Benefits, if you are requesting non-Emergency air ambulance
services (including any affiliated non-Emergency ground ambulance transport in conjunction with non-
Emergency air ambulance transport), you must obtain authorization as soon as possible before
transport. If you do not obtain prior authorization as required, Benefits will be subject to a $250
reduction.

Emergency Ground Ambulance: Same as Network Allowed Amounts for
Ambulance Emergency ambulance
20% transport provided by an
What Is the out-of-Network provider will
Copayment or Air Ambulance: be determined as described
Coinsurance You 20% below under Allowed
Pay? This May Amounts in this Schedule of
Include a Benefits. As a result, you
Copayment, will be responsible for the
Coinsurance or difference between the
Both. amount billed by the out-
of-Network provider and
the amount the Claims
Administrator determines
to be the Allowed Amount
for reimbursement.
Does the Amount Ground Ambulance: Same as Network
You Pay Apply to
the Out-of-Pocket Yes
Limit? Air Ambulance:

Yes

Does the Annual Ground Ambulance: Same as Network
Deductible Apply?
Yes

Air Ambulance:
Yes

Non-Emergency Ground Ambulance: Ground Ambulance: Ground ambulance, as the
Ambulance Claims Administrator
20% 40% determines appropriate.
What Is the
Copayment or Air or Water Air or Water
Coinsurance You Ambulance: Ambulance:
Pay? This May Not Covered Not Covered
Include a
Copayment,

12 Schedule of Benefits Plan Set 008