Iris and Hector Guzman and their children are new patients covered by PPO Their copayment is $10 for office Visits. they have annual deductible of $500 for out of network charges as well as coinsurance of 80-20.

4- Iris takes her three children ages five months three years and eight years for routine well child visits to a network provider the infant and three year old receive immunization what amount will Guzmans be required to pay?

5- Iris, age thirty-five, also receives a physical and screening mammogram from a network provider. what amount will the Guzmans be required to pay?

6- While on vacation in another state, the eight-year-old fell. he was seen in a walk-in medical center; charges were$85. The physician felt that he could have broken wrist and also ordered ab X-ray; charges were $120. The X-ray shower a fracture and a cast was applied to the child's wrist; charges were $165. what is the total amount the Guzmans will be required to pay?

7- After they return home from vacation, the child's cast is removed . He goes to outpatient physical therapy with a network provider for right visits. what is the total amount the Guzmans will be required to pay?

8- Hector has had a persistent respiratory condition for serval months. He is seen by the physician for an office visit. The physician also orders a chest X-ray that is not clear enough. The physician then orders a CAT scan. what is the total amount the Guzmans will be required to pay?

9- Hector wishes to get a second opinion and so visits a physician who is bot in the PPO network. This physician also orders CAT Scan. Total charges were $70 for office visit and $535 for CAT scan. What is the total amount the Guzmans will be required to pay?

10- What is the total amount paid by the Guzmans for healthcare so far this year?

Standard Benefits This is a preferred provider organization (PPO) plan. That means members can receive the highest level of benefits when they I use any of the more than 5,000 physicians and other healthcare professionals in this network. When members receive covered in-network services, they simply pay a copayment. Members can also receive care from providers that are not part of the network; however, benefits are often lower and covered claims are subject to deductible, coinsurance and charges above the maximum allowable amount. Referrals are not needed from a Primary Care Physician to receive care from a specialist. PREVENTIVE CARE Well child care Birth through 12 years All others Periodic, routine health examinations Routine eye exams Routine OB/GYN visits Mammography Hearing Screening MEDICAL CARE PCP office visits Specialist office visits Outpatient mental health & substance abuse - prior authorization required Maternity care - initial visit subject to copayment, no charge thereafter Diagnostic lab, X-ray and testing High-cost outpatient diagnostics - prior authorization required. The following are subject to copayment: MRI, MRA, CAT, CTA, PET, SPECT scans Allergy Services Office visits/testing Injections - 80 visits in 3 years In-Network OV Copayment OV Copayment OV Copayment OV Copayment OV Copayment No Charge OV Copayment In-Network OV Copayment OV Copayment OV Copayment OV Copayment No Charge No Charge OR $200 Copayment OV Out-of-Network Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Out-of-Network Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance (CMH) enobasin ov Copayment Deductible & Coinsurance in th HOSPITAL CARE - Prior authorization required Semi-private room (General/Medical/Surgical/Maternity) Skilled nursing facility - up to 120 days per calendar year Rehabilitative services - up to 60 days per calendar year Outpatient surgery - in a hospital or surgical-center EMERGENCY CARE Walk-in centers Urgent care centers - at participating centers only Emergency care - copayment waived if admitted Ambulance OTHER HEALTHCARE Outpatient rehabilitative services - 30 visit maximum for PT, OT, and SLP per year. 20 visit maximum for Chiro. per year Durable medical equipment / Prosthetic devices - Unlimited maximum per calendar year Infertility Services (diagnosis and treatment) Home HealthCare KEY: Office Visit (OV) Copayment Hospital (HSP) Copayment PREVENTIVE CARE SCHEDULES Well Child Care (including immunizations) 6 exams, birth to age 1 6 exams, ages 1-5 1 exam every 2 years, ages 6-10 1 exam every year, ages 11-21 Emergency Room (ER) Copayment Outpatient Surgery (OS) Copayment Adult Exams $25 Copayment In-Network HSP Copayment HSP Copayment No Charge CT OS Copayment In-Network OV Copayment UR Copayment ER Copayment No Charge In-Network OV Copayment No Charge OR 20% Not Covered No Charge Deductible & Coinsurance Out-of-Network Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Deductible & Coinsurance Out-of-Network Deductible & Coinsurance Not Covered ER Copayment No Charge Out-of-Network Deductible & Coinsurance Deductible & Coinsurance Not Covered $50 Deductible & 20% Coinsurance Urgent Care (UR) Copayment 1 exam every 5 years, ages 22-29 1 exam every 3 years, ages 30-39 1 exam every 2 years, ages 40-49 .1 exam every year, ages 50+ Mammography 1 baseline screening, ages 35-39 1 screening per year, ages 40+ Vision Exams 1 exam every 2 calendar years Hearing Exams 1 exam per calendar year OB/GYN Exams 1 exam per calendar year