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<br /> <br />TEXAS PPO 500 Plan pays for services at Plan pays for services at <br /> Plan 44. Option 3 PARnCIPAnNG providers NONPARnCIPAnNG providers <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 78) <br /> · Annual routine mammogram <br /> · Annual routine Pap smear <br /> · Routine adult lab and X-ray <br /> · Annual routine adult physical 100% after $25 copayment per 70% after deductible <br /> examinations (76 years and visit to a Level One participating <br /> above; excludes lab and X-ray) physician or $40 copayment per <br /> · Routine child physical visit to a Level Two participating <br /> examinations (up to age 76; physician * <br /> includes lab and X-ray) <br />Physician Services · Office visits (includes diagnostic 100% after $25copayment per 70% after deductible <br /> lab/X-ray, allergy testing) (excludes visit to a Level One participating <br /> outpatient surgery) physician or $40 copayment per <br /> · Prenatal care (office visit visit to a Level Two participating <br /> copayment applies to first visit physician * <br /> only) <br /> · Allergy serum 80% after deductible SO% after deductible <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 />Hospital Services · Inpatient care (semiprivate room 100% after $250 copayment per 70% after deductible <br /> and board, nursing care, leU) (2) day for first five days per <br /> admission, and after deductible <br /> · Outpatient surgery - facility (2) 100% after $100 copayment per 70% after deductible <br /> procedure after deductible <br /> · Outpatient nonsurgical (including 80% after deductible 50% after deductible <br /> diagnostic lab and X-ray) <br /> · Emergency room (1) 100% after $150 copayment per 70% after deductible <br /> visit after deductible (copayment <br /> waived if admitted) . <br />Prescription · Rx4 See attached rider, if applicable <br />Drugs <br />Other Medical · Skilled nursing facility (up to 60 80% after deductible 50% after deductible <br />Services days per calendar year) <br /> <br />HumanaPPO combines the cost-saving incentives of a modern health plan with freedom of choice. <br />When you see participating providers, you receive the highest level of benefits available under your plan. <br />At the same time. you retain the flexibility to see any physician. <br /> <br />TX-1 041 O-HH 1/04 <br />