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<br />TEXAS CoverageFirst 1000 Plan pays for services from Plan pays for services from
<br /> Plan 35, Option 84 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 $1,000 $2,000
<br />(per calendar year)
<br />(copayments do · Family $3,000 $6,000
<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-10434-HH 1/04
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