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• <br />Available with HumanaPPO Plan 57 <br />This rider is made a part of the Group Policy to which it is attached. <br />Benefits <br />If you or your covered dependent(s) incur expenses for a routine exam or annual physical <br />exam, the associated routine laboratory and x -ray charges will be covered at 100 percent; <br />benefit payable up to a two hundred dollar ($200) maximum per calendar year. <br />Exclusions <br />Expense incurred will not be payable under this provision for the following: <br />1. Medical examination and related expenses for treatment or diagnosis of a bodily <br />injury or sickness <br />2. Medical examination or associated diagnostic laboratory charges caused by or <br />resulting from pregnancy <br />3. Eye examination for the purpose of prescribing corrective lenses <br />4. Hearing tests <br />5. Dental examinations <br />6. Expenses incurred under this benefit while you are confined in a Hospital or <br />Ambulatory Surgical Center <br />7. Expenses incurred for an employment physical or exams for the purpose of <br />obtaining insurance; and <br />8. Immunizations <br />Offered by Humana Health Insurance Company of Florida, Inc. <br />FL- 64701 -HH 01998 Humana Inc. <br />5/98 <br />