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Payments - Plan benefits are paid based on reasonable charges, as defined in your '"":ertificate. Participating providers agree to .:cept reasonable charges, as listed in negotiated payment schedules. as payment in full. For services rendered by nonparticipating physicians, the member is responsible for charges exceeding a fee schedule selected by your employer and defined in your Certificate. For services from other nonparticipating providers. the member is responsible for amounts exceeding reasonable charges, as defined in your Certificate. Participating primary care and specialist physicians and other providers in Humana's networks are not the agents, employees or partners of Humana or any of its affiliates or subsidiaries. They are independent - contractors. Humana is not a provider of medical services. Humana does not endorse or control the clinical judgement or treatment recommendations made by the physicians or other providers listed in network directories or otherwise selected by you. Emergency services received while out of the service area are covered at participating provider level. To be covered, expenses must be medically necessary and specified as covered. Please see your Certificate for more information on medical necessity and other specific plan benefits. (1) Emergency care provided by a nonparticipating provider will be covered at the participating provider level. e (2) Prior authorization required in order to receive these benefits. (3) Transplant services do not apply toward the maximum out-of-pocket expense limit. (4) Any out-of-pocket expense for the treatment of mental health services does not apply towards any out-of-pocket expense limits except for serious mental illness. (5) Subject to certain limitations and exclusions. Refer to the Certificate for additional information. TIll! amount of berrefirs provided depe/lds Ilpon the plern selected. Premiums will lIar)' aa:ordi/lg to the selection made. Fllf gelreml questions erbout the pler/l, COllterct )'OUI" bL~lifit.~ admi/listrator. limitations and This is a partial and summarized list of lim.itations and exclusions. Your group may have specific limitations and exclusions not included on this list. Please check your Certificate for ( ',is complete listing. The Certificate is \ .Ie document upon which benefit payment will be determined. Unless stated otherwise, no coverage will be provided for the following situations. 1. A sickness or injury which is covered under any Workers' Compensation or similar law. 2. Sickness 0\' injury tor which the insured person is in any way paid or emided to paymem or care and treatm.ent by or through a government program. other than Medicaid or as otherwise provided by Texas law; 3. Education or training; medical services provided by the insured person S parent, spouse, brother, sister or child. -l-. Investigational or experimental drugs or substances not approved by Hwnana or by the Food and DrugAdministration. 5. Treaunent, services. supplies or surgery that is not medically necessary. 6. Purchase or fitting of hearing aids, implantable hearing devices or advice on their care, unless provided by rider. 7. Weekend nonemergency hospital admissions. '..~ . TX-23443-HH 1/04 Exclusions 8. In-vitro fertilization, unless our In-Vitro Fertilization Rider is included in the Group Policy; any medical or surgical treatment of infertility; infertility evaluations; se.'C change services or reversal of elective the certificate. 9. Plastic. cosmetic or reconstructive surgery, unless a nmctional impairmenc is present or if required to correCt a congenital defect, birth abnormality of a newborn or for breast reconstruction or as othel"\vise stated in the certificate. 10. Services and supplies for dental care, treatment of teeth or periodontium or oral surgery, unless the expenses a. are medically necessary diagnostic and/or sUl"gical treatment of the temporomandibular Gaw or craniomandibular) joint: b. are for the surgical removal of a nJmor or lesions in the mouth; or c. are incurred in connection \vith an injury to sound nantral teeth or jaw. except injuries resulting from biting or chewing, sust.:uned while the person is covered by the Group Policy. For an injury, the care and treatment must be provided within the 12 mondl period ~ Ff2-~_ Insured by Humana Insurance Company @2004 Humana Inc. beginning on the date of the injury. Also, the insured person must remain covered under the Group Policy during the 'J 2 month period while the care and trearment is being received. We will not cover any trearment related to the preparation or the fitting of dennu:es, including dental implants. 11. Any service, supply or treaonem connected with custodial care. 12. Sickness or injury caused by dle insured person's: a. engJging in an illegal occupation; or b. commission of or an attempt to commit a criminal act. 13. Any trearment to redl.lce obesity, including, but not limited to, surgical procedures. 14. Elective abortion unless: a. the physician certifies in writing that the pregnancy wouJd endanger the life of the modler; or b. the pregnancy is a result of rape or incest; or c. the services are received to treat medical complications due to dle abortion. 15. Vision analysis, testing or orthoptic training or the purchase of eyeglasses or contact lenses. 16. Care and treatment of complications of non covered procedures, unless required by state law;