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Payments - Plan benefits are paid based on reasonable charges. as defined in your r:ertificate. Participating providers agree to .:cept reasonable charges. as listed in negotiated payment schedules. as payment in full. For seNlces rendered by nonparticipating physicians. the member is responsible for charges exceeding a fee schedule selected by your employer and defined in your Certificate. For seNices 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 e 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 seNice 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 seNices 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. Tht~ amr)l4nr of heruifits providt'd depends llJ1tlll dIe plan selected. Premiums will lIar)' accordit(~ to the selection made. Ftlr ~~e/leml questions about the plan, Cl.llltOa )/our benefits odmi/listrmor. limitations and This is a partial and summarized list of limitations and exclusions. Your group may have specific limitations and exclusions not included on this list. Please check your Certificate for 'Us complete listing. The Certificate is .le document upon which benefit payment will be determined. Unless stated orhenvise, no coverage will be provided tor the followi.ng situations. I. A sickness or injury which is coven:d under any Workers' Compensation or similar law. 2. Sicknes.~ or injury tor which the insured person is in any w:lY paid or emided co paymem or care and treacment by or through a governmem program. other than Medicaid or as othen\.>ise provided by Texas law: 3. Education or training; medical services provided by the insured person"s parent, spouse, brother, sister or child. {. Investigational or experimental drugs or substances not approved by Humana or by the Food and Dl'l1gAdminisrration. 5. Treaunent, services, supplies or surgery that is noc medically necessary. 6. Purchase or fitting of hearing aids, implanClble hearing devices or advice on their care, unless provided by rider. 7. Weekend nonemergency hospica.l admissions. TX-23443-HH 1/04 Exclusions 8. In-vitl'O fertilization, unless our In- Vio"O Fertilization Rider is included in che Group Policy; any medical or surgical t:re:ltment of infertility; infertility evaluations; sex change services or reversal of elective the certificate. 9. Plastic, cosmetic or reconstructive surgery, unless a timctional impairment is present or if required to correct a congenit::ll defect, birth abnomlality of a newborn or for breast reconstruction or as odlenvise stated in the certificace. 10. Services and supplies for dental care, treatment of teeth or periodontiwn or oral surgery, unless the expenses a. are medically necessary diagnostic andlor surgical t:re:louent of the cempol'Omandibular Gaw or cr:miomandibular) joint: b. are fOl' che surgical remoV'dl of a nlmor 01" lesions in the mouth; or c. are incurred in connection "vith an injury to sound namral 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 treannent mUSt be provided within the 12 month period t.~~- Insured by Humana Insurance Company @2004 Humana Inc. beginning on the date of the iI1iury. Also. the insured person must remain covered under the Group Policy dming the 'J 2 month period while the care and O'eaonent is being received. We will not cover any treannent related to the preparation or the fitting of denmres, including dental imp.lants. 11. Any service, supply oi' treaunent connected with custodial care. 12. Sickness or injury caused by dle insured person's: a. engaging in an megal occupation; or b. commission of or an attempt to commit a criminal act. '13. Any treaOnem to reduce obesity, including, but nO[ limiced to, surgical procedures. 14. Elective abortion unless: a. the physician certifies in writing that dle pregnancy \vouJd endanger the life of the mother; 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 eyt:'g1asses or contact lenses. 16. Care and treamlent of complications of non covered procedures, wuess required by state law;