How HMOs Work

What Is Covered

The table below briefly describes what is covered by each HMO. For specific covered services, see your HMO’s materials.

Covered Service	UCHP	Humana Premier HMO	HMO Illinois
Ambulance Transportation	Provided in full for an emergency	Provided in full	Provided in full
Chiropractic and Naprapathy Services	Not covered.	Short-term therapy and rehabilitation is provided in full, if prescribed by Humana Premier HMO Plan physician.	Provided in full if referred by PCP.
Physical, Occupational and Speech Therapy	Provided in full up to 60 treatments combined per calendar year	Short-term therapy and rehabilitation is provided in full, if prescribed by Humana Premier HMO Plan physician.	Provided in full if referred by PCP up to 60 treatments combined per calendar year.
Drug and Alcoholism Services	Contact UCHP for available benefit information.	Contact Humana Premier HMO Plan for available benefit information at 1-800-448-6262.	Contact HMO Illinois at 1-800-346-3986 for available benefit information.
Emergency Care	$75 Copayment for emergency care provided in the emergency room, waived if admitted within 24 hours. See In an Emergency for procedures.	Provided in full. See In an Emergency for procedures.	$75 Copayment for emergency care provided in the emergency room, waived if immediately admitted. See In an Emergency for procedures.
Hearing Services	Exam provided in full. No coverage for hearing aids.	Exam provided in full. No coverage for hearing aids.	Exam provided in full. No coverage for hearing aids.
Hospitalization - Inpatient Includes room and board, X-rays, lab tests, medications, physician and surgical care, and private-duty nursing.	You pay $250 copayment per admission; Plan covers the remainder	You pay $100 copayment per day for the first three days of the hospital stay; after reaching $300, Plan covers the remainder.	You pay $250 copayment per admission; Plan covers the remainder
Infertility Services	Services and procedures necessary to diagnose and treat infertility are provided in full (generally up to four oocyte per person per lifetime). Prescription drugs used to treat infertility are covered at 75% up to a Lifetime Maximum of $6,750.	Services and procedures for the diagnosis and treatment of infertility are provided in full (generally up to four oocyte per person per lifetime). Coverage is provided only under certain conditions for in-vitro fertilization and gamete or zygote intrafallopian tube transfer.	Artificial insemination, sperm washings and in-vitro fertilization (generally up to four oocyte per person per lifetime) are provided in full after $10 Copayment. All laboratory blood work, ultrasound testing and prescription drugs approved and referred by the PCP as they relate to infertility services are covered at 100%.
Maternity Care	Provided in full	Provided in full	Provided in full
Mental Health Care
Inpatient	Limited to 30 days per person per calendar year.	Limited to 30 days per person per calendar year.	Limited to 20 days per person per calendar year.
Outpatient	Limited to 20 visits per person per calendar year. $20 Copayment each visit (waived for first visit each calendar year).	Limited to 20 visits per person per calendar year. $20 Copayment each visit.	Limited to 20 visits per calendar year. $20 Copayment each visit.
Outpatient Diagnostic Services Covers x-rays and lab tests.	Provided in full	Provided in full	Provided in full
Physical Exams	Provided in full	Provided in full once each calendar year	Provided in full

While this Summary Plan Description summarizes the major provisions of this plan, it does not provide you with every plan detail. The plan documents, which govern this plan, provide full details. If there are any discrepancies between this Summary Plan Description and the legal plan documents, the legal plan documents control.