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e e ... -.~~-". -;--. . :":.-:.~_.. } ~~:::r::-r ;;'~ff~~'~.J~?~?t~:~~~;~~~;:f~~f.!.~;~~t~~;:~;B.~.~~F"~'Jf?-4r:::~:}:~;'~:~ ..},:.~ -:~:'~/..:.-':.'~~ .~~ .~ u.:~:~'.n. ~', :~':~:v~~'t~~-.~-:':~.lt;:$~~--~' :~J.!~~P\:~~~.-~:~:~:'~:~ ._~~~..:,~hef:~.t.s ::':. .~. ..,.:.......,... :'..'.~' "~'...~ .:~ ", ...~.;.:.;:..:. .:!~.;~'::.~...,;:~.~ --i' h..:..... .: ...........;.,:,.~...;_. ".:.<J .;." 0' -:'" ...."r ' :-----:-r . . I ( r - ~ ~.. ~~,:;;'E~~~.~~;-"!~ ~~r-;lTe:;~:; 71~~."7'"U~~;;~j~<:~: .~~J ~ '~r 7i:'7;.f~';?~2:---:,-~ "'i3'~ ~~'l'j't.~j.1'..~r;;~F~71T~~4 !"_ .[1 ~ ~i lli~~~~ni:~j~1?i1i!filll~b~i~?0~~1t:~:~~;l~l,-;:~:,.:~~~ry~~t:~~~~!:k;;i~~~~~~Si~1~~~fe.:~irti~1 TEXAS CoverageFirst 1500 Plan pays for services from Plan pays for services from Plan 35, Option 100 PARTICIPATING providers NONPARTICIPATING providers Up-Front Benefit · Annual member benefit (Applies $500 per calendar year Not applicable Allowance to medical services received from per member participating providers only. Does not apply to member copayments, mental health services or Rx benefits.) Annual Deductible · Individual $1,500 $3,000 (per calendar year) (copayments do · Family $4,500 $9,000 not apply) Preventive Care · Routine immunizations (birth to 100% 100% age 7) · Routine immunizations (age 7 to 100% after deductible 70% after deductible age 18) · Annual routine mam.mography · Annual routine Pap smears · Routine adult lab and X-rays · Annual routine adult physical 100% after $20 copayment per 70% after deductible r' examinations (16 years and visit to a Level One participating " above; excludes lab and X-ray) physician or $35 copayment per · Routine child physical visit to a Level Two participating examinations (up to age 16; physician * includes lab and ~-ray) Physician Services · Office visits (excludes diagnostic 100% after $20 copayment per 70% after deductible lab and X-ray, outpatient surgery) visit to a Level One participating · Prenatal benefit (office visit physician or $35 copayment per copayment applies to first visit visit to a Level Two participating only) physician * · Allergy testing (covered as part of office visit) · Diagnostic tests, lab and X-rays 80% after deductible 60% after deductible · Allergy serum · Inpatient services · Outpatient services (includes surgery) · Physician visits to emergency room (1) · Allergy injections 100% after $5 copayment per 70% after deductible visit (, '-. CoverageFirst PPO combines the cost-saving incentives of a modern health plan with freedom of choice and an annual benefit allowance. When you see participating providers, you receive the highest level of benefits available under your plan. At the same time, you retain the flexibility to see any physician. TX-23441-HH 1/04