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<br />e e. _. <br />Hum a n a' cov~ ~~'~Z;~'~s~~~;~6's~~~::~'~fB~rtefit.'. <br /> <br />, ~~ <br />~ ~ ~ <br /> <br /> <br />TEXAS CoverageFirst 1500 <br />Plan 35, Option 100 <br /> <br />Plan pays for services from <br />PARTICIPATING providers <br /> <br />Plan pays for services from <br />NONPARTICIPATING providers <br /> <br />Up-Front Benefit · Annual member benefit (Applies <br />Allowance to medical services received from <br />participating providers only. Does <br />. not apply to member <br />copayments, mental health <br />services or Rx benefits.) <br /> <br />$500 per calendar year <br />per member <br /> <br />Not applicable <br /> <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 70% 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 70% 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 70% 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 70% after deductible <br /> visit <br /> <br />Coverage First 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 />