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<br />e <br /> <br />e <br /> <br />. ~.. - ._~ . ...---,_..... - -.--.. <br />-. .. - .;" . '" "."... , <br /> <br />....... .... -- <br />,.. <br /> <br />--" .~..---- . . ". . <br />... . <br /> <br />. .. <.. <br /> <br />0" -: "': <br /> <br />Humana Co.v~'rag:e~.j:rs~~ _'PPO.:s'u'~~~r~ ~f B~"nefits- <br /> <br />w~~ <br />- > - ~4li1i <br /> <br /> <br />TEXAS CoverageFirst 1500 Plan pays for services from Plan pays for services from <br /> Plan 35. Option 100 PARTICIPATING providers NONPARTICIPATING providers <br />Up-Front Benefit . Annual member benefit (Applies $500 per calendar year Not applicable <br />Allowance to medical services received from per member <br /> participating providers only. Does <br /> not apply to member <br /> copayments, mental health <br /> services or Rx benefits.) <br />Annual Deductible · Individual $1.500 $3,000 <br />(per calendar year) <br />(copayments do · Family $4,500 $9,000 <br />not apply) <br />Preventive Care · Routine immunizations (birth to 100% 100% <br /> age 7) <br /> · Routine immunizations (age 7 to 100% after deductible 10% after deductible <br /> age 18) <br /> . Annual routine mammography <br /> . Annual routine Pap smears <br /> · Routine adult lab and X-rays <br /> · Annual routine adult physical 100% after $20 copayment per 10% after deductible <br /> examinations (16 years and visit to a Level One participating <br /> above: excludes lab and X-ray) physician or $35 copayment per <br /> · Routine child physical visit to a Level Two participating <br /> examinations (up to age 16: physician * <br /> includes lab and X-ray) <br />Physician Services . Office visits (excludes diagnostic 100% after $20 copayment per 10% after deductible <br /> lab and X-ray, outpatient surgery) visit to a Level One participating <br /> · Prenatal benefit (office visit physician or $35 copayment per <br /> copayment applies to first visit visit to a Level Two participating <br /> only) physician * <br /> · Allergy testing (covered as part of <br /> office visit) <br /> · Diagnostic tests, lab and X-rays 80% after deductible 60% after deductible <br /> · Allergy serum <br /> · Inpatient services <br /> · Outpatient services (includes <br /> surgery) <br /> · Physician visits to emergency <br /> room (1) <br /> · Allergy injections 100% after $5 copayment per 10% after deductible <br /> visit <br /> <br />CoverageFirst PPO combines the cost-saving incentives of a modern health plan with freedom of choice <br />and an annual benefit allowance. When you see participating providers, you receive the highest level <br />of benefits available under your plan. At the same time, you retain the flexibility to see any physician. <br /> <br />TX-23441-HH 1/04 <br />