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e e -. '. '-, ::~.'~ ~' :;;: ~'.'-~~;;~~;~ ;:~~~~'~~~f~;J~~f~~Hrf%;:~~{rt::!:t!~:~.)~t~{l:fi:,;:::::~{;;;:~:':: Hum a n. a P:P 0:. Sl!:I!J;~aj!:y.':'Q:t!te.r:t.~~f~IJ$,'.':\<:-r6.~:. .... :; >:'~.';=... :'~':'~"l ::. .;:.":' .'. .: .... :.;. . ..... . . . '. '. .. I ~ '.:' ~ . :": :., ~:~~t;.r. ..~ :~. ~~~ ':~:;: .?~_'~::.1<.~": j-. '.~ '~: :~;:' .;~ i" I:~':[~. :,'t:o'~ ':~"~;"~:: .. :'..": ~: ~-.,,~~ 7;.~" ":: J'~' . '. . .~ ~ . '.' =. . ~. : ",: - . ~.. i;A:~i~l:~~-~ ;:,,_:lJ -~= _:-~.:~-~:' :~;~'. :~:/~-." _~,~,:~ ::.~~,-~~:~~'::~. J:';i~~~~~ri~~Efil~~~t~~~ TEXAS PPO 500 Plan pays for services at Plan pays for services at Plan 44, Option 3 PARTICIPATING providers NONPARTICIPATING providers 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 mammogram · Annual routine Pap smear · Routine adult lab and X-ray · Annual routine adult physical 100% after $25 copayment per 70% after deductible examinations (16 years and visit to a Level One participating above; excludes lab and X-ray) physician or $40 copayment per · Routine child physical visit to a Level Two participating examinations (up to age 76; physician* includes lab and X-ray) Physician Services · Office visits (includes diagnostic 100% after $25 copayment per 70% after deductible lab/X-ray, allergy testing) (excludes visit to a Level One participating outpatient surgery) physician or $40 copayment per · Prenatal care (office visit visit to a Level Two participating copayment applies to first visit physician * only) ( · Allergy serum 80% after deductible 50% after deductible · Inpatient services · Outpatient services (includes surgery) · Physician visits to emergency room (1) · Allergy injections 100% after $5 copayment per 70% after deductible visit Hospital Services · Inpatient care (semiprivate room 100% after $250 copayment per 70% after deductible and board, nursing care, leU) (2) day for first five days per admission. and after deductible · Outpatient surgery - facility (2) 100% after $1 00 copayment per 70% after deductible procedure after deductible · Outpatient nonsurgical (including 80% after deductible 50% after deductible diagnostic lab and X-ray) · Emergency room (1) 100% after $150 copayment per 70% after deductible visit after deductible (copayment waived if admitted) Prescription · Rx4 See attached rider, if applicable Drugs Other Medical · Skilled nursing facility (up to 60 80% after deductible SO% after deductible Services days per calendar year) (, - HumanaPPO combines the cost-saving incentives of a modern health plan with freedom of choice. 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-1 041 O-HH 1/04