Res. No. 126-09-12935RESOLUTION NO.: 126 -09 -12935
A RESOLUTION OF THE MAYOR AND CITY COMMISSION OF THE CITY OF
SOUTH MIAMI, FLORIDA, AUTHORIZING THE CITY MANAGER TO RENEW
THE CONTRACT WITH AVMED TO PROVIDE GROUP HEALTH INSURANCE
FOR CITY OF SOUTH MIAMI FULL TIME EMPLOYEES TO BE CHARGED TO
DEPARTMENTAL ACCOUNT NUMBERS RESPECTIVELY; PROVIDING FOR
AN EFFECTIVE DATE.
WHEREAS, the Agent of Record (Employee Benefits Consulting Group) secured 8 bids
for the City's Group Health Insurance and recommended AVMED as the lowest responsive
bidder; and
WHEREAS, the Insurance Committee compared the insurance rates, benefit plan
designs, provider network as well as our previous claims experience /ratio; and
WHEREAS, the Insurance Committee unanimously voted to renew with AVMED for
another year; and
WHEREAS, the City Commission wishes to renew Group Health Insurance with
AVMED to all full -time employees; and
WHEREAS, with the selection of AVMED, the designated Agent of Record is
Employee Benefits Consulting Group until contract expiration or until otherwise determined by
either party.
NOW THEREFORE BE IT RESOLVED BY THE MAYOR AND CITY
COMMISSION OF THE CITY OF SOUTH MIAMI, FLORIDA, THAT;
Section 1. The contract shall be effective October 1, 2009 and shall be renewable on an
annual basis.
Section 2. This engagement is at will and shall continue until either party terminates the
engagement by giving written notice to the other party. The City shall not be charged for agent
of record services; Employee Benefits Consulting Group shall be compensated by the insurer.
Pg. 2 of Res. No. 126 -09 -12935
Section 3. This resolution shall take effect immediately upon approval.
PASSED AND ADOPTED this 4th day of Auqust 2009.
ATTEST:
C
Y CLERK
READ AND APPROVED AS TO FORM:
Commission Votes
5 -0
Mayor Horace Feliu:
Yea
Vice Mayor Brian Beasley:
Yea
Commissioner Velma Palmer:
Yea
Commissioner Valerie Newman:
Yea
Commissioner Lew Sellars:
Yea
South Miami
NI- AmericaCilp
CITY OF SOUTH MIAMI r hr
OFFICE OF THE CITY MANAGER
INTER- OFFICE MEMORANDUM 2 °0t
To: The Honorable Mayor & Members o e City Commission
Via: W. Ajibola Balogun, City Manager
From: Jeanette Earizo, Human Resource M n ARM
Date: July 28, 2009 nda Item No.:
Subject: Authorizing One Year Contract Renewal with AVMED Health Care
REQUEST: A RESOLUTION OF THE MAYOR AND CITY COMMISSION OF
THE CITY OF SOUTH MIAMI, FLORIDA, AUTHORIZING THE
CITY MANAGER TO RENEW THE CONTRACT WITH AVMED TO
PROVIDE GROUP HEALTH INSURANCE FOR CITY OF SOUTH
MIAMI FULL TIME EMPLOYEES TO BE CHARGED TO
DEPARTMENTAL ACCOUNT NUMBERS RESPECTIVELY;
PROVIDING FOR AN EFFECTIVE DATE.
Reason/Need: We have received renewal rates from our current group health insurance
carrier, AVMED. AVMED initially proposed 'a 10.6 % increase; however, we were
successful in negotiating the rate increase to 4.2 %. The City had $515,689 in claims vs.
$683,602 in premium. Although, renewal rates were received from AVMED, the Agent
of Record recommended that we seek out bids from other carriers to ensure that we are
being offered competitive rates. Our Agent of Record solicited bids from eight
companies. Bids were received from the following companies:
AETNA
Submitted proposal
AVMED
Submitted proposal
BCBS
Declined to quote
CIGNA HEALTHCARE
Submitted proposal
HUMANA
Submitted proposal
NHP
Submitted proposal
UNITED HEALTH CARE
Submitted proposal
VISTA
Submitted proposal
The Insurance Committee met to review and compare all the different alternatives. The
Committee Members that participated were as follows:
Maria Garcia — City Manager's Office
Maria Virguez — Finance
Carol Bynum — Code Enforcement (AFSCME)
George Greene — Motor Pool (AFSMCE)
Captain Lisa Morton — Police (PBA)
James McCants — South Miami Community Redevelopment Agency
Maria Stout -Tate- Planning
Lorenzo Woodley — Parks and Recreation
Michelle Egues — Human Resources
Slaven Kobola — Public Works and Engineering Department
The Insurance Committee made a recommendation to the City Commission to renew with
AVMED for another year without any changes to the current benefit plan design.
LOW HMO
EE $372.84 (City portion)
EC $659.93
ES $734.50
FAM $1099.88
HIGH HMO POS
$432.52 $502.01
$765.56 $888.55
$852.06 $988.95
$1275.93 $1480.91
With the Triple Option, the City would cover the employee rate of $372.84 which is a
(42 %) increase. Based on current enrollment assumptions (134 FTE), the annual
increase from this year to next year would be approximately $ 24,184.48. Current staffing
levels are at 151 full time employees.
Cost:
Funding Source: Departmental Account Numbers
Backup Documentation:
❑ Proposed Resolution
❑ Proposals from Insurance Vendors
❑ AVMED Contract
CITY COMM1551UN
Insurance Workshop
Workshop date: July 21, 2009 Time: 6:30 p.m.
Next Regular Meeting 'date: July 21, 2009; Time: 7:30 p.m.
6130 Sunset Drive, South Miami, FL Phone: (305) 663 -6340
1. Employees' Health Insurance Workshop - Benefit /Price
Comparison Overview
2, Adjournment: 7:30 P.M.
CITY COMMISSION WORKSHOP Z
AGENDA - July 21, 2009
CITY OF SOUTH MIAMI
OFFICE OF THE CITY MANAGER
INTER - OFFICE MEMORANDUM
To: The Honorable Mayor &
Via: W. Ajibola Balogun, City
From: Jeanette Emizo, Human
Date: July 17, 2009
Subject: Insurance Workshop
of the City Commission
Item No.:
South Miami
NI- AmedcaCity
2001
On Friday, July 17, 2009, the Insurance Committee met to discuss and finalize
recommendation/selection of health insurance carrier. The following employees were
present:
Maria Garcia — City Manager's Office
Maria V irguez — Finance
Carol Bynum — Code Enforcement (AFSCME)
George Greene — Motor Pool (AFSMCE)
Captain Lisa Morton — Police (PBA)
James McCants — South Miami Community Redevelopment Agency
Maria Stout -Tate- Planning
Michelle Egues — Human Resources
Slaven Kobola— Public Works
Upon further discussion and review, the Insurance Committee voted to renew with
AVMED with a 3 Tier Option (Low Option HMO, High Option HMO and POS). The
increase to the City for fiscal year 2009/2010 would be 4.2 %. The Insurance Committee
will be presenting their recommendations next Tuesday, July 21, 2009 at the Workshop.
I am forwarding all information that was provided to the Committee for your review and
consideration.
MEDICAL PROPOSAL ANALYSIS
JULY 2009
f�_a rc
. Employee Benefits Consulting Group
TABLE OF CONTENTS
I. Executive Summary
II. Proposed Medical Rates
III. HMO Benefit Comparison
IV. POS Benefit Comparison
V. Survey Results
sip
�Tc
Employee Benefits Consulting Group
Executive Summary
Attached is our analysis of the medical proposals that we received on behalf of the City
of South Miami. We approached the following vendors in regards to this project:
Aetna
Humana
Av Med (incumbent)
Neighborhood Health Partnership
Blue Cross/Blue Shield
United HealthCare
CIGNA
Vista
AvMed initially proposed a 10.6% rate increase. We were successful in negotiating the
rate increase to 4.2 %.
From 2/1/08 - 1/31/09 the City of South Miami had a 75.4% loss ratio with AvMed (i.e.
for every $1.00 of premium AvMed paid $35 in claims). During this time period the City
had $515,689 in claims vs. $683,602 in premium.
The rates and benefits for Standard Insurance and Humana (formerly CompBenefits) will
not change for the 10/1/09- 9/30/10 plan year.
We appreciate the opportunity the City of South Miami has given us in regards to this
project. Employee Benefits Consulting Group is prepared to assist the City of South
Miami in managing healthcare costs while still maintaining the integrity of the benefits
package.
Ma Mao Co 4G�
Employee Benefits Consulting Group
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Comparison of Employer Contributions
July 2009
Municipality
1) City of Doral
2
2) Village of Pinecrest
3) City of Aventura
4) Town of Bay Harbor Islands
5) City of Homestead
6) City of Miami Springs
7) Town of Surfside
8) Village of Key Biscayne
$750 allowance /month
$700 allowance /month
100% - Employee
70% - Dependent
100% - Employee
65% - Dependent
90 %- Employee
70% - Dependent
100% - Employee
50% - Dependent
100% - Employee
47% - Dependent
$450 allowance( *)
t9) City of South Miami 100% - Employee
0% - Dependent
1:9) City of Florida City 100 % - Employee
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( *) Police and Fire receive 100% employer contribution toward employee
and dependent coverage.
Page 1 Employee Benefits Consulting Group
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Comparison of Employer Contributions
July 2009
Municipality
1) City of Doral $750 allowance /month
2) Village of Pinecrest $700 allowance /month
3) City of Aventura 100% - Employee
70% - Dependent
4) Town of Bay Harbor Islands 100 % - Employee
65% - Dependent
.5) City of Homestead 90% - Employee
70% - Dependent
6) City of Miami Springs 100% - Employee
50% - Dependent
7) Town of Surfside 100 % - Employee
47% - Dependent
8) Village of Key Biscayne $450 allowance(`)
t9) City of South Miami 100% - Employee
0% -Dependent
t9) City of Florida City 100 % - Employee
0% - Dependent
(`) Police and Fire receive 100% employer contribution toward employee
and dependent coverage.
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Page 1 Employee Benefits Consulting Group
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How much does continuation
coverage cost?
Generally, each qualified beneficiary may be required to pay 102 percent
of the cost of group health coverage. For Healthcare FSAs, the cost for
continuation of coverage is a monthly amount calculated and based on
the amount you were paying via pre -tax salary reductions before the
qualifying event.
When and how must payment for
continuation of coverage be made?
First payment for continuation coverage
If you elect continuation of coverage, you do not have to send any
payment for continuation coverage with the COBRA Election Form.
However, you must make your first payment for continuation coverage
within 45 days after the date of your election. (This is the date the
Election Notice is post - marked, if mailed.) if you do not make your first
payment for continuation coverage within that 45 days, you will lose all
continuation coverage rights under the Plan.
Your first payment must cover the cost of continuation coverage from the
time your coverage under the Plan would have otherwise terminated up to
the time you make the first payment. You are responsible for making sure
that the amount of your first payment is enough to cover this entire period,
You may contact FBMC to confine the correct amount of your first payment
(for FSAs). Your health plan will notify you of the exact premium payable.
Instructions for sending your first payment for continuation coverage will
be shown on your COBRA Election Notice /Form.
Periodic Payments for Continuation Coverage:
After you make your first payment for continuation coverage, you will be
required to pay for continuation coverage for each subsequent month of
coverage. Under the Plan, these periodic payments for continuation
coverage are due on the first day of each month. If you make a periodic
payment on or before its due date, your coverage under the Plan will
continue for that coverage period without any break.
MEDICAL
2009 COBRA Monthly Rates
Instructions for sending your periodic payments for continuation
coverage will be shown on your COBRA Election Notice /Form.
Grace Periods for Periodic Payments:
Although periodic payments are due on the dates shown above, you
will be given a grace period of 30 days to make each periodic
payment. Your continuation coverage will be provided for each coverage
period as long as payment for that coverage period is made before the
end of the grace period for that payment. If you pay a periodic payment
later than its due date but during its grace period, your coverage under
the Plan will be suspended as of the due date and then retroactively
reinstated (going back to the due date) when the periodic payment is
made. This means that any claim you submit for benefits while your
coverage is suspended may be denied and may have to be resubmitted
once your coverage is reinstated.
If you fail to make a periodic payment before the end of the grace
period for that payment, you will lose all rights to continuation
coverage under the Plan.
For More Information
This COBRA Q &A section does not fully describe continuation coverage
or other rights under the Plan. More information about continuation
coverage and your rights under the Plan is available in your summary
plan description or certificate of coverage. You can get a copy of your
summary plan description or certificate of coverage from FBMC (for
FSAs) or your health plan.
Keep Your Address Updated
In order to protect your family's rights and to receive useful benefits
information, you must keep your Departmental Personnel Representative
informed of any change in your address, You should also keep a copy, for
your records, of any notices you send to FBMC or your health plan,
t/1�I A-A
2009 COBRA Monthly Rates
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Member Satisfaction for Adults - Ratings
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Flan Type: Commercial HMO / PPO / Indemnity
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Plan information for Miami -Dade County
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7/13/200
FloridaHealthFinder.gov ( Comparing Florida Health Plans
Page 2 of
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- Three checkmarks represent the highest rank and one checkmark represents the lowest rank.
Scores or Ratings may not have been collected for all available Health Plans in this county. To see a complete list of
available Health Plans in the selected county, please select this link: "Health Plans Available ".
Source: The results shown are posted as reported and certified by health plans to the Agency for Health Care
Administration (AHCA), Florida Center for Health Information and Policy Analysis.
http:// www. floridahealthfinder ,gov/HealthPlans /Compare.aspx 7/13/200
Please select an insurance carrier for FY 2009 -2010.
AvMed (Renewal) `
Aetna
Cigna
Humana
Neighborhood Health Partnership
United Health Care
Vista
Co r1c) P A nu n1_
Employee Print Name
CAA
Please select an insurance carrier for FY 2009 -2010.
AvMed (Renewal)
Aetna
Cigna
Humana
Neighborhood Health Partnership
United Health Care
Vista
Stows
Employee Print Name
t/
Employee Signature
Please select an insurance carrier for FY 2009 -2010.
AvMed (Renewal)
Aetna
Cigna
Humana
Neighborhood Health Partnership
United Health Care
Vista
Employee Print Name
Employee Signature
x
Please select an insurance carrier for FY 2009 -2010.
AvMed (Renewal)
Aetna
Cigna
Humana
Neighborhood Health Partnership
United Health Care
Vista
Employee Print Name
20
Employee Signature
LVAVA
11
Please select an insurance carrier for FY 2009-2010.
AvMed (Renewal)
Aetna
Cigna
Humana
Neighborhood Health Partnership
United Health Care
Vista
J
11,17,� A
Employee Print Name
Employee Signature
w
Please select an insurance carrier for FY 2009 -2010.
AvMed (Renewal)
Aetna
Cigna
Humana
Neighborhood Health Partnership
United Health Care
Vista
Employee Print Name
V
Am Eto a Signature
Please select an insurance carrier for FY 2009 -2010.
Renewal
A vMed (Renewal)
Aetna
Cigna
Humana
Neighborhood Health Partnership
United Health Care
Vista
Employee Print Name
1J
Y
Please select an insurance carrier for FY 2009 -2010.
AvMed (Renewal)
Aetna
Cigna
Humana
Neighborhood Health Partnership
United Health Care
Vista
Employee Print Name
Employee Signature
C!W
❑c
Please select an insurance carrier for FY 2009 -2010.
AvMed (Renewal)
Aetna
Cigna
Humana
Neighborhood Health Partnership
United Health Care
Vista
J
--
Employee Print NanW Employe Signature
ORKSHOP _JULY
Which option from the AvMed (Renewal) are you recommending for FY
2009 -2010?
1. AvMed Renewal (3 — Tier)
2. AvMed (2 — Tier)
1m �ti �i di71
Employee Print Na/ me
VA
Which option from the AvMed (Renewal) are you recommending for FY
2009 -2010?
1. AvMed Renewal (3 — Tier)
2. AvMed (2 —Tier)
Employee Print Name - Employee Signature
7
Which option from the AvMed (Renewal) are you recommending for FY
2009 -2010?
1. AvMed Renewal (3 — Tier)
2. AvMed (2 — Tier)
Employee Print Name
mployee Signature
17
Which option from the AvMed (Renewal) are you recommending for FY
2009 -2010?
1. AvMed Renewal (3 — Tier)
2. AvMed (2 —Tier)
l�
Employee Print Name
s�
Employee Signature
A
Which option from the AvMed (Renewal) are you recommending for FY
2009 -2010? ,
1. AvMed Renewal (3 —
2. AvMed (2 —Tier)
Employee Print Name
LN-9
OP JULY 17, 20
Which option from the AvMed (Renewal) are you recommending for FY
2009 - 2010 ?.
1. AvMed Renewal (3 — Tier)
2. AvMed (2 —Tier)
612 rin e
Employee Print Name
Signature
���
4P JULY 17, 2009
Which option from the AvMed (Renewal) are you recommending for FY
2009 -2010?
1
AvMed Renewal (3 — Tier)
2. AvMed (2 —Tier)
/yqR /t4 f /. V l,2GVGZ
Employee Print Name Employee Sig a ore
P JULY 17.
Which option from the AvMed (Renewal) are you recommending for FY
2009 -2010?
1. A, Med Renewal (3 — Tier)
2. AvMed (2 —Tier)
Ls'u! 1 9,,dcU�
Employee Print Name
Employee Signature
IM
P JULY 17
Which option from the AvMed (Renewal) are you recommending for FY
2009 -2010?
1. AvMed Renewal (3 — Tier)
2. AvMed (2 —Tier)
Employee Print Na de
1
Employ Signature
AvMed Health Plans
Group Medical
and
Hospital
Service
Contract
AV -G100 -2008
M&5241(10-08)
AVMED CORPORATE OFFICE
9400 S. DADELAND BLVD.
MIAMI, FL 33156 -9004
AVMED MEMBER SERVICES - ALL AREAS
1- 800 -88 AVMED
(1 -800- 882 -8633)
SERVICE AREAS
MIAMI GAINESVILLE ORLANDO
9400 South Dadeland Boulevard 4300 N.W. 89h Boulevard 1800 Pembroke Drive
Miami, Florida 33156 -9004 Post Office Box 749 Suite 190
Gainesville, Florida 32606 -0749 Orlando, Florida 32810
(305) 671 -5437
(800) 432 -6676
Miami -Dade
FT. LAUDERDALE,
13450 W. Sunrise Boulevard
Suite 370
Sunrise, Florida 33323 -2947
(954) 462 -2520
(800) 368 -9189
Broward
Palm Beach
JACKSONVILLE
1300 Riverplace Boulevard
Suite 640
Jacksonville, Florida 32207
(904) 858 -1300
(800) 227 -4184
Baker
Clay
Duval
Nassau
St. Johns
(352) 372 -8400
(407) 539 -0007
(800) 346 -0231
(800) 227 -4848
Alachua
Lake*
Bradford
Orange
Osceola
Citrus
Seminole
Columbia
Dixie
TAMPA BAY/ SOUTHWEST
Gilchrist
FLORIDA
Hamilton
1511 North Westshore Boulevard
Levy
Suite 450
Marion
Tampa, Florida 33607
Suwannee
Union
(813) 281 -5650
(800) 257 -2273
Hernando
Hillsboro
Lee
Pasco
Pinellas
Polk
Sarasota
* Coverage available in the following Lake County zip codes: 34736, 34711, 34712, 34713, 34714, 34715 and 34756
AV -G100 -2008
W -5241 (10 -08)
III. DEFINITIONS
As used in this Contract, each of the following terms shall have the meaning indicated:
3.01 "Adverse Benefit Determination" means a denial, reduction, or termination of, or a failure to
provide or make payment, in whole or in part, for a benefit, including any such denial, reduction,
termination, or failure to provide or make payment that is based on a determination of a
Member's eligibility to participate in the Plan, a denial, reduction, or termination of, or a failure
to provide or make payment (in whole or in part) of, a benefit resulting from the application of
any Utilization Management Program, as well as a failure to cover an item or service for which
benefits are otherwise provided because it is determined to be experimental and/or investigational
or not Medically Necessary.
3.02 "AvMed, Inc." otherwise known as "AvMed," means a private not for profit Florida corporation,
state licensed as a health maintenance organization under Chapter 641, Florida Statutes, for the
purpose of arranging for prepaid health care services to its Members under the terms and
conditions set forth in this Contract.
3.03 "Claim" means a request for benefits under this Contract made by a Member in accordance with
AvMed's procedures for filing benefit claims, including Pre- Service Claims and Post - Service
Claims.
3.04 "Claimant" means a Member or a Member's authorized representative acting on behalf of the
Member. AvMed may establish procedures for determining whether an individual is authorized
to act on behalf of the Member. If the Claim is an Urgent Care or Pre - Service Claim, a Health
Professional, with knowledge of the Member's medical condition, shall be permitted to act as the
Member's authorized representative and will be notified of all approvals on the Claimant's
behalf. In the event of an Adverse Benefit Determination, AvMed will notify both the Member
and the Heath Professional.
3.05 "Concurrent Care" means an ongoing course of treatment to be provided over a period of time
or number of treatments that was previously approved by AvMed.
3.06 "Contract" means this Group Medical and Hospital Service Contract which may at times be
referred to as "Group Contract" or "Subscribing Group Contract" and all applications, rate
letters, face sheets, riders, amendments, addenda, exhibits, supplemental agreements, and
schedules which are or may be incorporated in this Contract from time to time.
3.07 "Contract Term" means the period of consecutive months agreed to by the Subscribing Group
and AvMed on the Master Application, commencing on the effective date of this Contract. May
also be referred to as "Contract Year"
3.08 "Conversion Contract" means an individual Member or Subscriber contract which shall be
available to continue coverage (as provided for therein) of the Subscriber or the Dependent of the
Subscriber upon termination of the Subscribing Group Contract as provided in Part VIII of this
Contract, and shall at times be referred to as the "Individual Conversion Contract."
3.09 "Co- payment" means the charge, in addition to the prepaid premium charges, which the
Subscriber is required to pay at the time certain health services are provided under this Contract.
The Co- payment may be a specific dollar amount or a percentage of the cost. The Member is
Av -Gi00 -2008
MR5241(10/08)
3.15 "Emergency Medical Services and Care" means medical screening, examination, and
evaluation by a physician, or, to the extent permitted by applicable law, by other appropriate
personnel under the supervision of a physician, to determine if an Emergency Medical Condition
exists and, if it does, the care, treatment, or surgery for a covered service by,a physician necessary
to relieve or eliminate the Emergency Medical Condition within the service capability of the
Hospital.
3.15.01 In -area emergency does not include elective or routine care, care of minor illness, or
care that can reasonably be sought and obtained from the Member's Primary Care
Physician. The determination as to whether or not an illness or injury constitutes an
emergency shall be made by AvMed and may be made retrospectively based upon all
information known at the time the patient was present for treatment.
3.15.02 Out -of -area emergency does not include care for conditions for which a Member
could reasonably have foreseen the need of such care before leaving the Service Area
or care that could safely be delayed until prompt return to the Service Area. The
determination as to whether or not an illness or injury constitutes an emergency shall
be made by AvMed and may be made retrospectively based upon all information
known at the time the patient was present for treatment.
3.16 "Exclusion" means any provision of this Contract whereby coverage for a specific hazard or
condition is entirely eliminated.
3.17 "Full -Time Student or Part Time Student" means one who is attending a recognized and/or
accredited college, university, vocational, or secondary school and is carrying sufficient credits to
qualify as a full -time or part time student in accordance with the requirements of the school. (See
Subsection 4.02.02(f))
3.18 "Group Health Insurance" (for purposes of Part XIH) means that form of health insurance
covering groups of persons under a master Group Health Insurance policy issued to any one of
the groups listed in Sections 627.552 (employee groups), 627.553 (debtor groups), 627.554 (labor
union and association groups), and 627.5565 (additional groups), Florida Statutes.
3.18.01 The terms "amount of insurance" and "insurance" include the benefits provided under
a plan of self - insurance.
3.18.02 The term "insurer" includes any person, entity, or governmental unit providing a plan
of self-insurance.
3.18.03 The terms "policy," "insurance policy," "health insurance policy," and "Group Health
Insurance policy" include plans of self - insurance providing health insurance benefits.
3.19 "Health Professionals" means physicians, osteopaths, podiatrists, chiropractors, physician
assistants, nurses, social workers, pharmacists, optometrists, clinical psychologists, nutritionists,
occupational therapists, physical therapists, and other professionals engaged in the delivery of
health care services who are licensed and practice under an institutional license, individual
practice association, or other authority consistent with State law and who are Participating
Providers of AvMed Health Plans.
3.20 "Home Health Care Services (Skilled Home Health Care)" means services that are provided
for a Member who does not require confinement in a Hospital or Other Health Care Facility. Such
AV-Gtoo -2008
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e) Approved by the appropriate medical body or health care specialty involved as
effective, appropriate, and essential for the care and treatment of the Member's
condition;
f) Not experimental or investigational.
3.29 "Medical Office" means any outpatient facility or physician's office in the Service Area utilized
by a Participating Provider.
3.30 "Medical Services" (except as limited or excluded by this Contract) means those professional
services of physicians and other Health Professionals, including medical, surgical, diagnostic,
therapeutic, and preventive services that are:
a) Generally and customarily provided in the Service Area;
b) Performed, prescribed, or directed by Participating Providers; and
C) Medically Necessary (except for preventive services as stated herein) for the
diagnosis and treatment of injury or illness.
3.31 "Member" means any Subscriber or Dependent, as described in Part III, Sections 3.12 and 3.43,
of this Contract.
3.32 "Non- participating Provider" means any Health Professional or group of Health Professionals
or Hospital, Medical Office, or Other Health Care Facility with whom AvMed has neither made
arrangements nor contracted to render the professional health services set forth herein as a
Participating Provider.
3.33 "Other Health Care Facility(ies)" means any licensed facility, other than acute care Hospitals
and those facilities providing services to ventilator dependent patients, which provides inpatient
services such as skilled.nursing care or rehabilitative services for which AvMed has contracted or
established arrangements for providing these services to Members. Coverage is limited to 20
days per calendar year.
3.34 "Participating Provider" means any Health Professional or group of Health Professionals or
Hospital, Medical Office, or Other Health Care Facility with whom AvMed has made
arrangements or contracted to render the professional health services set forth herein.
3.35 "Participating Physician" means any Participating Provider licensed under Chapter 458
(physician), 459 (osteopath), 460 (chiropractor) or 461 (podiatrist), Florida Statutes. "Attending
Physician" means the Participating Physician primarily responsible for the care of a Member
with respect to any particular injury or illness.
3.36 "Post- Service Claim" means any Claim for benefits under the Plan that is not a Pre- Service
Claim.
3.37 "Pre- Service Claim" means any Claim for benefits under the Plan with respect to which, in
whole or in part, a Member must obtain authorization from AvMed in advance of such services
being provided to or received by the Member.
3.38 "Primary Care Physician" means a Participating Provider physician engaged in family practice,
pediatrics, internal medicine, obstetrics /gynecology, or any specialty physician from time to time
designated by AvMed as a "Primary Care Physician" in AvMed's current list of physicians and
Hospitals.
AV- 01000.2008
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Physician's office after -hours and the covered services for those conditions which, although not
life - threatening, could result in serious injury or disability if left untreated.
3.48 "Utilization Management Program" means those comprehensive initiatives that are designed to
validate medical appropriateness and to coordinate covered services and supplies. These include,
but are not limited to: (1) concurrent review of all patients hospitalized in acute care, psychiatric,
rehabilitation, and skilled nursing facilities, including on -site review when appropriate; (2) case
management and discharge planning for all inpatients and those requiring continued care in an
alternative setting (such as home care or a skilled nursing facility) and for outpatients when
deemed appropriate; and (3) the Benefit Coordination Program which is designed to conduct
prospective reviews for select medical services to ensure that services are covered and Medically
Necessary. The Benefit Coordination Program may also advocate alternative cost - effective
settings for the delivery of prescribed care and may identify other options for non - covered health
care needs.
3.49 "Ventilator Dependent Care Unit" means care received in any facility which provides services
to ventilator dependent patients other than acute Hospital care, including all types of facilities
known as sub -acute care units, ventilator dependent units, alternative care units, sub -acute care
centers, and all other like facilities whether maintained in a free standing facility or maintained in
a Hospital or skilled nursing facility setting. Coverage is limited to 100 days lifetime maximum.
IV. ELIGIBILITY
4.01 To be eligible to enroll as a Subscriber, a person must be:
4.01.01 An employee of the Subscribing Group who works the required number of hours per
week asset forth in the Master Application for this Contract. The employee must
either work or reside in the Service Area. Except as provided for Emergency
Medical Services and Care, the covered services and benefits are available only
from Participating Providers.
4.01.02 Employed for the period of time required for eligibility as set forth in the Master
Application; and
4.01.03 Entitled on his own behalf to participate in the medical and Hospital care benefits
arranged by the Subscribing Group under this Contract.
4.02 To be eligible to enroll as a Dependent, a person must be:
4.02.01 The spouse of the Subscriber; a new spouse must be enrolled within 31 days after
marriage in order to be covered; or
4.02.02 A child of the Subscriber, or a child of a covered Dependent of the Subscriber,
provided that all of the following conditions apply:
a) The child is the natural child or stepchild of the Subscriber; a legally adopted
child in the custody of the Subscriber from the time of placement in the home
(written evidence of adoption must be famished to AvMed upon request); a child
for whom the Subscriber has been appointed legal guardian, pursuant to a valid
court order; or a newborn child of a covered Dependent of the Subscriber (such
coverage terminates 18 months after the birth of the newborn child);
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4.02.03 In the event that the Subscriber has a child who meets the following requirements,
extended coverage may be available for that child until the end of the Calendar Year in
which the child reaches age 30, if the child meets the following requirements:
a) Is unmarried and does not have a Dependent of his or her own;
b) Is a resident of Florida or a Full -time or Part-time Student; and
c) Is not provided coverage as a named Subscriber, insured, enrollee or covered person
under any other group, blanket, or franchise health insurance policy or individual
health benefits plan, or is not entitled to benefits under Title XVIII of the Social
Security Act.
The child is not eligible to be covered unless the child was continuously covered by other
creditable coverage without a gap in coverage of more than 63 days.
In addition, until April 1, 2009, the Subscriber of a child who qualifies for coverage
under the dependent age extension, but whose coverage as a Dependent child terminated
under the terms of the plan before October 1, 2008 may make a written election to
reinstate coverage, without proof of insurability for that child.
4.03 No person is eligible to enroll hereunder who has had his coverage previously terminated under
Part IX, Subsection 9.01.05, except with the written approval of AvMed.
4.04 Attainment of the limiting age by a Dependent child shall not operate to exclude from or
terminate the coverage of such child nor shall coverage prevent the enrollment of a child while
such child is and continues to be both:
a) Incapable of self - sustaining employment by reason of mental retardation or
physical handicap; and
b) Chiefly dependent upon the Subscriber for support and maintenance, provided
proof of such incapacity and dependency is famished to AvMed by Subscriber
within 31 days of the child's attainment of the limiting age and subsequently as
may be required by AvMed, but not more frequently than annually after the two -
year period following the child's attainment of the limiting age.
4.05 During the term of this Contract, no changes in the Subscribing Group eligibility or requirements
of participation shall be permitted to effect eligibility or enrollment under this Contract unless
such change is agreed to by AvMed.
4.06 Eligible persons must reside within the continental United States, excluding Alaska and Hawaii.
V. ENROLLMENT
5.01 Prior to the effective date of this Contract and at a proper time prior to each anniversary thereof,
AvMed may allow an open enrollment period of 31 days, in which any eligible Subscriber on
behalf of himself and his Dependents may elect to enroll in the Plan.
5.02 Except as provided for newborns, eligible Subscribers and Dependents who meet the
requirements of Part IV, Sections 4.01 and 4.02 must enroll within 31 days after becoming
eligible by submitting application forms acceptable to or provided by AvMed; otherwise, the
eligible Subscribers and Dependents may not enroll until the next open enrollment period of
Subscribing Group.
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predetermined minimum enrollment as established by AvMed. The required minimum group
enrollment is included in the rate letter submitted to Subscribing Group.
VI. EFFECTIVE DATE OF MEMBERSHIP
Subject to the payment of applicable monthly premium charges set forth in Part VII and to the provisions
of this Contract, coverage under this Plan shall become effective on the following dates:
6.01 Eligible Subscribers and Dependents who enroll during the open enrollment period will be
covered Members as of the effective date of this Contract or subsequent anniversary thereof.
6.02 If a Subscriber acquires an eligible Dependent through birth, adoption, placement for adoption or
marriage, such Dependent shall be treated as covered under the Plan if, within 31 days (or as
otherwise provided for newborns in Part IV) of acquiring the new Dependent, you complete and
submit an enrollment form on behalf of such Dependent. If received by AvMed within the 31
day time period (or 60 days as permitted for newborns), the enrollment for such Dependent shall
become effective on the date of the birth, adoption or placement for adoption, or in the case of
marriage, on the first day of the month following the date of marriage. During this period, you
and your eligible spouse may also enroll for medical coverage under the Plan if not already
covered. However, if an enrollment request is not received by AvMed within the required time
frame, you and your eligible Dependents will be required to wait until the next open enrollment
period to apply for coverage.
6.03 If you or your Dependents originally declined medical coverage under the Plan due to other
health coverage, and that coverage is subsequently terminated as a result of either a loss of
eligibility for such coverage or the termination of any employer contributions for such coverage,
you and your Dependents will be eligible to enroll in the Plan. To enroll, you must properly
complete an enrollment form within 31 days of the loss of such other coverage or the termination
of employer contributions. The effective date of any coverage provided by AvMed will be the
first day of the month following the date you enroll. If you fail to enroll within 31 days after the
loss of other coverage, you must wait until the next open enrollment period to apply for coverage.
6.04 Coverage for the newborn child of the Subscriber or the newborn child of the Subscriber's
covered Dependent is effective at birth if Subsection 4.02.02(i) and Section 6.02 are complied
with.
VII. MONTHLY PAYMENTS AND CO- PAYMENTS
7.01 On or before the first day of each month for which coverage is sought, Subscribing Group or its
designated agent shall remit to AvMed, on behalf of each Subscriber and his Dependents, the
monthly premium based on the rate letter and Master Application. Only Members for whom the
stipulated payment is actually received by AvMed shall be entitled to the health services covered
under this Contract and then only for the period for which such payment is applicable. Failure of
the Subscribing Group to pay the premium due by the first of the month and not later than the end
of the grace period (as provided in Section 7.02) shall result in retroactive termination of the
Subscribing Group, effective at 12:00 a.m. (midnight) on the last day of the month for which the
premium was paid, unless the payment of premiums has otherwise been contractually adjusted
and specified by the parties in a fully executed addendum to this Contract. An additional charge
will apply to all late premium payments. (See Section 17.14)
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coverage terminates under this Group Contract, and all such Subscribers and
Dependents, after complying with Subsection 8.01.02 below, shall be covered under
the Individual Conversion Contract.
8.01.02 A completed status change form requesting conversion shall be sent to AvMed or its
designated administrator with the first applicable premium and shall be received by
AvMed or its designated administrator not later than 63 days after the date of
termination of this Group Contract.
8.01.03 Dependents may not convert without the Subscriber except:
a) In the event of the death of the Subscriber, Dependents are permitted an
automatic conversion privilege and must comply with Subsection 8.01.02 above.
b) A spouse whose coverage would terminate, or a spouse and children whose
coverage would otherwise terminate at the same time, or a child with respect to
himself, by reason of ceasing to be a qualified family member, may convert and
must comply with Subsection 8.01.02 above.
c) A former spouse whose coverage would otherwise terminate because of
annulment or dissolution of marriage may convert if the former spouse is
dependent for financial support. The former spouse must comply with
Subsection 8.01.02 above and must provide written evidence of financial
dependence upon request of AvMed.
8.01.04 Payment for health care services rendered to a Member after termination and prior to
conversion shall be the responsibility of the Member. When the conversion
application has been timely completed (within 63 days after termination of the Group
Contract) and the first premium due has been paid, AvMed shall reimburse the
Subscriber for any payment made by the Subscriber for covered Medical Services
under the converted Contract.
8.01.05 A new Conversion Contract is established upon application and payment of the
premium on the day following the Member's termination from group coverage (due
to ineligibility under the Group Contract) and continues through the end of the
calendar year. The Contract Term, upon renewal, shall be the calendar year.
8.02 Individual Conversion Contracts may not include supplemental benefits, notwithstanding the
supplemental benefits included under this Subscribing Group Contract, and may in other respects,
as determined by AvMed, differ from this Group C6ntract.
8.03 The conversion privilege will not apply to a Subscriber or covered Dependent if termination of
his coverage under this Contract occurred for any of the following reasons:
a) Failure to pay any required premium or contribution unless such nonpayment of
premium was due to acts of an employer or person other than the individual;
b) Replacement of any discontinued group coverage by similar group coverage within 31
days;
C) Fraud or material misrepresentation in applying for any benefits under this Contract;
(See Subsection 9.01.05)
d) Willful and knowing misuse of AvMed's identification card by the Subscriber;
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9.01.02 Failure to Make Premium Payment - Upon failure of the Subscribing Group to make
payment of the monthly premium provided in Part VII within ten days following the
due date specified herein, benefits hereunder shall terminate, for all Subscribers and
any Dependents for whom such payment has not been received, at 12:00 a.m.
(midnight) on the last day of the month for which the monthly premium was paid.
AvMed, regarding cancellation or non - renewal of this coverage, may retroactively
cancel the policy to the date for which the Subscribing Group's premiums have been
paid when AvMed provides notice of cancellation or non - renewal to the Subscribing
Group prior to 45 days after the date the premium was due. AvMed will include a
reason for the Contract termination in its written notification to the Subscribing
Group. The Subscribing Group will forward such notification to all Subscribers
when AvMed has notified the Subscribing Group of the cancellation or non - renewal,
and AvMed is deemed to have complied with its notification requirements by
providing said notice to the Subscribing Group.
9.01.03 Termination of Group Contract by Subscribing Group — Subscribing Group may
terminate this Group Contract on the anniversary date by giving written notice to
AvMed 15 days prior to Contract anniversary date. In such event, benefits hereunder
shall terminate for all Members at 12:00 a.m. (midnight) on Contract expiration date.
9.01.04 Early Termination of Group Contract by Subscribing Group - Subscribing Group
may terminate this Group Contract by giving at least 60 days written notice to
AvMed. [In such event, benefits hereunder shall terminate for all Members at 12:00
a.m. (midnight) on the last day of the month for which monthly premium was paid.]
[In such event, benefits hereunder shall terminate for all Members at 12:00a.m.
(midnight) on the date specified by the Group in their written notice to AvMed ].
9.01.05 Termination of Group Contract by AvMed - AvMed may non -renew or discontinue
this Group Contract based on one or more of the conditions listed below. In such
event, benefits hereunder shall terminate for all Members at 12:00 a.m. (midnight) on
the Contract expiration date as described below.
a) Subscribing Group has failed to pay premiums or contributions in accordance
with the terms of this Contract or AvMed has not received timely premium
payments (See Part VII, Monthly Payments and Co- payments and Subsection
9.01.02). Termination of coverage will be effective on the last day of the month
for which payments were received by AvMed.
b) Subscribing Group has performed an act or practice that constitutes fraud or
made an intentional misrepresentation of material fact under the terms of this
Contract. This will result in immediate termination of Subscribing Group.
c) Subscribing Group has failed to comply with a material provision of the Contract
that relates to rules for employer contributions or group participation.
Termination will be effective upon 45 days written notice from AvMed to
Subscribing Group.
d) There is no longer any enrollee in connection with the Plan who lives, resides, or
works in the Service Area. Termination of coverage will be effective on the last
day of the month for which payments were received by AvMed.
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9.03 Certificates of Coverage. If your coverage under the Plan ends, you will automatically receive a
Certificate of Group Health Plan Coverage. You may take this certificate to another health care
plan to receive credit for your coverage under the Plan. You will only need to do this if the other
health care plan has a pre- existing condition limit. You can request a Certificate of Group Health
Plan Coverage anytime during the 24 -month period after the date your coverage under the Plan
has ended.
9.04 Continuation Coverage under COBRA.. Under certain provisions of COBRA., the Subscriber or
his Dependents may elect continued coverage under the Plan if coverage is lost due to a
qualifying event.
9.04.01 Eligibility. You or your covered Dependents will become eligible for continuation
coverage under COBRA after any of the following qualifying events result in the loss of
Plan coverage:
a) loss of benefits due to a reduction in your hours of employment;
b) termination of your employment, including retirement but excluding termination for
gross misconduct;
e) termination of employment following leave under the Family and Medical Leave Act
of 1993 (FMLA), in which case the qualifying event will occur on the earlier of the
date you indicated you were not returning to work or the last day of the FMLA leave;
or
d) you or a Dependent first become entitled to Medicare or covered under another group
health plan prior to your loss of coverage due to termination of employment or
reduction in hours.
9.04.02 In addition, your Dependents will become eligible for COBRA continuation coverage
after any of the following qualifying events occur to cause a loss of Plan coverage:
a) your death;
b) your divorce or legal separation;
c) you first become entitled to Medicare after your loss of coverage due to
termination of employment or reduction in hours; or
d) your Dependent child no longer qualifies as a Dependent under the Plan.
A child who is born to or placed for adoption with a covered former employee
during the continuation coverage period has the same continuation coverage rights as
a Dependent child described above.
9.04.03 Notification. If a qualifying event other than divorce, legal separation, loss of
Dependent status or entitlement to Medicare occurs, the Plan Administrator will be
notified of the qualifying event by your employer and will send you an election form.
To continue Plan coverage, you must return the election form within 60 days from
the later of the date you receive the form, or the date your coverage ends due to a
qualifying event.
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To be eligible for extended coverage due to Social Security disability, you must notify the Plan
Administrator of the disability before the end of the initial 18 months of COBRA continuation coverage
and within 60 days following the date you or a covered Dependent is determined to be disabled by the
Social Security Administration. If the disabled individual should no longer be considered to be disabled
by the Social Security Administration, you must notify the Plan Administrator within 30 days following
the end of the disability. Coverage that has exceeded the original 18 -month continuation period will end
when the individual is no longer Social Security disabled.
If more than one qualifying event occurs, no more than 36 months total of COBRA continuation coverage
will be available. The COBRA beneficiary must experience the second qualifying event during the first
18 months of COBRA continuation, and must provide notice to the Plan Administrator within the
required time period. COBRA. continuation coverage will end sooner if the Plan terminates and the
employer does not provide replacement medical coverage, or if a person covered under COBRA.:
a) first becomes covered under another group health plan after the loss of coverage
due to your termination or reduction in hours, unless the new group coverage is
limited due to a pre- existing condition exclusion; this Plan will be primary for the
pre - existing condition and secondary for all other eligible health care expenses,
provided contributions for COBRA coverage continue to be paid. Coverage may
only continue for the remainder of thei original COBRA period;
b) fails to make required contributions when due;
c) first becomes entitled to Medicare benefits after the initial COBRA qualifying
event; or
d) is extending the 18 -month coverage period because of disability and is no longer
disabled as defined by the Social Security Act.
9.05 Continuation Coverage During Leaves of Absence.
9.05.01 Family and Medical Leaves of Absence (FMLA). Under FMLA, you may be entitled
to up to a total of 12 weeks of unpaid, job- protected leave during each calendar year
for the following:
a) the birth of your child, to care for your newborn child, or for placement of a child
in your home for adoption or foster care;
b) to care for your spouse, child or parent with a serious health condition; or
c) for your own serious health condition.
If your FMLA leave is a paid leave, your pay will be reduced by your before -tax contributions as usual
for the coverage level in effect on the date your FMLA leave begins. If your FMLA leave is unpaid, you
will be required to pay your contributions directly to the employer until you return to active pay status.
20
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a) Fraud or intentional misrepresentation in applying for any benefits under this
Contract;
b) Disemollment for cause; or
c) The Subscriber has left the geographic Service Area of AvMed with the intent to
relocate or establish a new residence outside AvMed's Service Area.
X. SCHEDULE OF BASIC BENEFITS
AvMed is committed to arranging for comprehensive prepaid health care services rendered to its
Subscribers through AvMed's network of contracted independent physicians and Hospitals and other
independent health care providers, under reasonable standards of quality health care. The professional
judgment of a physician licensed under Chapters 458 (physician), 459 (osteopath), 460 (chiropractor) or
461 (podiatrist), Florida Statutes, concerning the proper course of treatment of a Subscriber shall not be
subject to modification by AvMed or its Board of Directors, Officers, or Administrators. However, this
subsection is not intended to and shall not restrict any Utilization Management Program established by
AvMed.
Only services and benefits in conformity with Part III (Definitions), Part X (Schedule of Basic Benefits),
Part XI (Limitations of Basic Benefits), Part XIl (Exclusions from Basic Benefits) and the Schedule of
Benefits, which by reference is incorporated herein, are covered by AvMed. It is the Member's
responsibility when seeking benefits under this Contract to identify himself as a Member of AvMed and
to assure that the services received by the Member are being rendered by Participating Providers. Any
covered service for which the member is seeking reimbursement, must be submitted to the plan within
one year from the date of service to be considered.
Members should remember that services that are provided or received without advance authorization from
AvMed, or when the service is beyond the scope of practice authorized for that provider under State law
are not covered unless such services otherwise have been expressly authorized under the terms of this
Contract or when required to treat an Emergency Medical Condition. Except for Emergency Medical
Services and Care, all services must be received from Participating Providers. If a Member does not
follow the access rules, he risks having the services and supplies received not covered under this Contract.
In such a circumstance, the Member will be responsible for reimbursing AvMed for the reasonable cost of
the services and supplies received. The following services require authorization from AvMed Health
Plans:
• inpatient admissions
• All Home Health Care Services
• Complex diagnostic procedures
• Surgical procedures or services performed in an outpatient Hospital, Hospital - affiliated
ambulatory surgery center, or free - standing ambulatory surgery center
• All medications administered in an outpatient Hospital or infusion therapy setting
• Select medications administered in a physician's office
• Care rendered by Non - participating Providers (except for Emergency Medical Services and
Care)
• Transplant services
• Dialysis services
"For more information about which services require prior authorization, contact AvMed at 1- 800 - 882 - 8633,"
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10.05 Hospital Care: Inpatient. All Hospital inpatient services received at Participating Hospitals for
non - mental illness or injury are provided when prescribed by Participating Physicians and pre -
authorized by AvMed. Inpatient services include semi- private room and board, birthing rooms,
newborn nursery care, nursing care, meals and special diets when Medically Necessary, use of
operating rooms and related facilities, the intensive care unit and services, diagnostic imaging,
laboratory and other diagnostic tests, medications, biologicals, anesthesia and oxygen supplies,
physical therapy, radiation therapy, respiratory therapy, and administration of blood or blood
plasma. See Section 10.12 with regard to inpatient admission following Emergency Medical
Services and Care.
Pre - authorization from AvMed is required for inpatient Hospital Services for substance abuse and
these services are subject to the conditions set forth in the optional coverage selected. (Also see
Section 11.05)
10.06 Physician Care: Inpatient. All Medical Services rendered by Participating Physicians and other
Health Professionals when requested or directed by the Attending Physician, including surgical
procedures, anesthesia, consultation and treatment by Specialty Health Care Physicians,
laboratory and diagnostic imaging services, and physical therapy (See Section 10.08) are covered
while the Member is admitted to a Participating Hospital as a registered bed patient. When
available and requested by the Member, AvMed covers the services of a certified nurse
anesthetist licensed under Chapter 464, Florida Statutes.
10.07 Physician Care: Outpatient
10.07.01 Diagnosis and Treatment. All Medical Services rendered by Participating Physicians
and other Health Professionals, as requested or directed by the Primary Care
Physician, are !covered when provided at Medical Offices, including surgical
procedures, routine hearing examinations and vision examinations for glasses for
children under age 18 (such examinations may be provided by optometrists licensed
pursuant to Chapter 463, Florida Statutes or by ophthalmologists licensed pursuant
to Chapter 458 or 459, Florida Statutes) and consultation and treatment by Specialty
Health Care Physicians. Also included are non - reusable materials and surgical
supplies. These services and materials are subject to the Limitations outlined in Part
XI (Limitations of Basic Benefits). See Part XII for Exclusions.
10.07.02 Preventive and Health Maintenance Services. The services of the Member's Primary
Care Physician for illness prevention and health maintenance, including child health
supervision services and immunizations provided in accordance with prevailing
medical standards consistent with the Recommendations for Preventive Pediatric
Health Care of the American Academy of Pediatrics and/or the Advisory Committee
on Immunization Practices; sterilization (See Schedule of Benefits), periodic health
assessment, physical examinations, and voluntary family planning services are also
covered. These services are subject to Limitations as outlined in Part XI (Limitations
of Basic Benefits). See Part XII for Exclusions.
10.07.03 Outpatient Mental Health Services are covered only for diagnostic evaluation and
crisis intervention. These services are limited to a total of 20 outpatient visits per
calendar year. Referral for outpatient mental health services must be arranged by the
Member's Participating Physician, and each visit requires a Co- payment. (See
Schedule of Benefits)
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10.13 Urgent Care Services. All necessary and covered services received in Urgent Care or Immediate
Care Centers or rendered in your Primary Care Physician's office after -hours for conditions as
described in Section 3.47 will be covered by AvMed. See Schedule of Benefits for details. In
addition, any Member requests for reimbursement (of payment made by the Member for services
rendered) must be filed within 90 days after the emergency or as soon as reasonably possible but
not later than one year unless the Claimant was legally incapacitated.
10.14 Ambulance Services as follows: (i) local professional air /ground ambulance transport for
emergency services to the nearest emergency department appropriately staffed and equipped to
treat a medical condition; (ii) ground transportation to an alternative level of care when associated
with an approved Hospital confinement; and (iii) ground transportation to a Member's home, will
be covered when associated with an approved hospitalization or other confinement and the
Member's condition requires the skill of medically trained personnel. Transportation is not
covered when the skill of medically trained personnel is not required and the Member can be
safely transferred (or transported) by other means. Air ambulance transportation is covered only
when the point of pick -up is inaccessible by land or when distance or other obstacles are involved
in transporting the Member to the nearest emergency department equipped to adequately treat the
medical condition. See Part XII for Exclusions.
10.15 Other Health Care Facility(ies). All routine services of Other Health Care Facilities (see Section
3.33), including physician visits, physiotherapy, diagnostic imaging and laboratory work, are
covered for a maximum of 20 days per calendar year when a Member is admitted to such a
facility, following discharge from a Hospital, for a condition that cannot be adequately treated
with Skilled Home Health Care Services or on an ambulatory basis.
10.16 Diagnostic Imaging and Laboratory. All prescribed diagnostic imaging and laboratory tests and
services including diagnostic imaging, fluoroscopy, electrocardiograms, blood and urine and
other laboratory tests, and diagnostic clinical isotope services are covered when Medically
Necessary and ordered by a Participating Physician as part of the diagnosis and/or treatment of a
covered illness or injury or as preventive health care services.
10.17 Skilled Home Health Care Services. Home Health Care Services (as defined in Section 3.20) are
covered as outlined on the Schedule of Benefits when ordered by and under the direction of the
Member's Attending Physician. Physical, occupational or speech therapy services provided in the
home are limited as noted in Section 10.08. Home Health Care Services that do not include a
medical, diagnostic, therapeutic or rehabilitative component, or that do not require the skill of a
registered nurse, licensed practical (vocational) nurse or other healthcare personnel are not
covered. Homemaker or other Custodial Care services are not covered.
10.18 Hospice Services. Services are available from a participating Hospice organization for a Member
whose Participating Physician has determined the Member's illness will result in a remaining life
span of six months or less.
10.19 Second Medical Opinions. The Member is entitled to a second medical opinion when he disputes
the appropriateness or necessity of a surgical procedure or is subject to a serious injury or illness.
The Member may obtain a second medical opinion from any physician who is within AvMed's
Service Area. If you chose a Participating Physician, there is no prior authorization requirement.
You pay only the applicable Co- payment or Deductible and Co- insurance. If you choose a non-
participating physician, the service is subject to prior authorization requirements. You are also
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Medical Director, payment not to exceed usual, customary and reasonable charges for such
covered services rendered by a Non - participating Provider will be made by AvMed. Charges for
non - participating Hospital Services will be reimbursed in accordance with the covered benefits
the Member would be entitled to receive in a Participating Hospital.
10.24 Prescription Drug Benefits. Allergy serums and chemotherapy for cancer patients are covered.
Coverage for insulin and other diabetic supplies is described in Section 10.27 below. Other retail
Prescription Drugs are a covered benefit only when the Subscribing Group Contract includes
supplemental Prescription Drug Benefits.
10.25 Ventilator Dependent Care. with prior authorization by AvMed, Ventilator Dependent Care (See
Section 3.49) is covered up to a total of 100 days lifetime maximum benefit.
10.26 Major organ transplants at a facility deemed appropriate and authorized by AvMed, as well as
associated immunosuppressam medications are covered except those deemed experimental. (See
Section 12.15)
10.27 Diabetes treatment includes all Medically Necessary equipment, supplies, and services to treat
diabetes. This includes outpatient self- management training and educational services, if the
Member's Primary Care Physician or the physician to whom the Member has been referred who
specializes in diabetes treatment, certifies the equipment, supplies or services are Medically
Necessary. Insulin pumps are covered under Section 10.20. Diabetes outpatient self -
management training and educational services must be provided under the direct supervision of a
certified diabetes educator or a board certified endocrinologist under contract with AvMed. In
accordance with Florida Statutes, coverage of insulin pumps for the treatment of diabetes will not
apply toward or be subject to the annual DME maximum limitation.
Insulin, insulin syringes, lancets, and test strips are covered under the Subscribing Group's
supplemental Prescription Drug Benefits. In the event that a Subscribing Group does not purchase
supplemental Prescription Drug Benefits, insulin, insulin syringes, lancets, and test strips are
covered subject to a $25 Co- payment per item for a 30 -day supply.
10.28 Mammograms are covered in accordance with Florida Statutes. One baseline mammogram is
covered for female Members between the ages of 35 and 39. A mammogram is available every
two years for female Members between the ages of 40 and 49 and a mammograrn is available
every year for female Members aged 50 and older.
In addition, one or more mammograms a year are available when based upon a physician's
recommendation for any woman who is at risk for breast cancer because of a personal or family
history of breast cancer, because of having a history of biopsy - proven benign breast disease,
because of having a mother, sister, or daughter who has had breast cancer, or because a woman
has not given birth before the age of 30.
10.29 Osteoporosis Diagnosis and Treatment when Medically Necessary for high -risk individuals, e.g.
estrogen- deficient individuals, individuals with vertebral abnormalities, individuals on long -term
glucocorticoid (steroid) therapy, individuals with primary hyperparathyroidism, and individuals
with a family history of osteoporosis.
10.30 Dermatological Services. AvMed will cover office visits to a participating dermatologist for
Medically Necessary covered services subject to Sections 3.28. No prior referral is required for
these services.
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The rights of Members and obligations of Participating Providers hereunder are subject to the
following Limitations:
11.01 In the event of any major disaster, Participating Providers shall render Hospital and Medical
Services provided under this Contract insofar as practical, according to their best judgment,
within the limitations of such facilities and personnel as are then available, but AvMed and
Participating Providers shall have no liability or obligation for delay or failure to provide or
arrange for such services due to lack of available facilities or personnel if such lack is the result of
any major disaster.
11.02 In the event of circumstances not reasonably within the control of AvMed, such as complete or
partial destruction of facilities, an act of God, war, riot, civil insurrection, disability of a
significant part of Hospital or participating medical personnel or similar causes, if the rendition of
Medical Services and Hospital Services provided under this Contract is delayed or rendered
impractical, neither AvMed, Participating Providers, nor any physician shall have any liability or
obligation on account of such delay or failure to provide services; however, AvMed shall make a
good faith effort to arrange for the timely provision of covered services during such event.
11.03 Periodic physical examinations are limited to those that, in the judgment of the Member's Primary
Care Physician, are essential to the maintenance of the Member's good health.
11.04 A Member shall select one Primary Care Physician upon enrollment. If you do not select a
Primary Care Physician upon enrollment, a Primary Care Physician will be assigned to you by
AvMed. You may obtain assistance in making a selection by contacting AvMed.
11.05 Substance Abuse - Hospital Limitation. Inpatient services for alcohol and drug abuse shall be
provided but only for acute detoxification and the treatment of other medical sequelae of such
abuse. Inpatient alcohol or drug rehabilitation services are not covered.
11.06 Visits to licensed dietitians /nutritionists for treatment of diabetes, renal disease or obesity control
shall be limited to three outpatient visits per calendar year and each visit requires a Co- payment.
(See Schedule of Benefits and also Section 12.21)
11.07 Spinal manipulations will be covered only when Medically Necessary and prescribed by a
Participating Physician or by self - referral to a Participating Physician.
11.08 The total benefit for Ventilator Dependent Care is limited to 100 calendar days lifetime
maximum.
11.09 In the event that a Member is confined in a participating or Non - participating facility after
receiving Emergency Medical Services and Care, AvMed must be notified by the Hospital,
Member or designee, within 24 hours following the day of admission if reasonably possible. (See
Section 10.12 with regard to Emergency Services).
11.10 Other Health Care Facility(ies). All routine inpatient services of Other Health Care Facilities
(See Section 3.33), including physician visits, physiotherapy, diagnostic imaging and laboratory
work, are covered for a maximum of 20 days per calendar year when a Member is admitted to
such a facility, following discharge from a Hospital, for a condition that cannot be adequately
treated with Home Health Care Services or on an ambulatory basis.
11.11 Physical, Occupational or Speech Therapy. Physical, occupational or speech therapies shall be
limited as explained in Sections 10.08 and 10.17.
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a) When such services are for the treatment of trauma related fractures of the jaw or
facial bones or for the treatment of tumors;
b) Reconstructive jaw surgery for the treatment of deformities that are present and
apparent at birth; or
C) Full mouth extraction when required before radiation therapy.
12.05 Services related to the diagnosis /treatment of temporomandibular joint (TMJ) dysfunction except
when Medically Necessary; all dental treatment for TMJ.
12.06 Mandibular and maxillary osteotomies except when Medically Necessary to treat conditions
caused by congenital or developmental deformity, disease, or injury.
12.07 Except as provided in,Sections 10.35 and 10.36, medical supplies including, but not limited to:
pre- fabricated splints, Thromboemboletic /Support hose and all other bandages.
12.08 Home monitoring devices and measuring devices (other than apnea monitors), and any other
equipment or devices for use outside the Hospital.
12.09 Surgically implanted devices and any associated external devices, except for cardiac pacemakers,
intraocular lenses, cochlear implants, artificial joints, orthopedic hardware and vascular grafts
Dental appliances, other corrective lenses and hearing aids, including the professional fee for
fitting them, are not covered..
12.10 Over -the- counter medications, all contraceptives (including medications and devices),
hypodermic needles and syringes and Self - Administered Injectable Medications except insulin
and insulin syringes for the treatment of diabetes as outlined in Section 10.27.
12.11 Travel expenses including expenses for ambulance services to and from a physician or Hospital
except in accordance with Section 10.14.
12.12 Treatment for chronic alcoholism and chronic drug addiction, except those services offered as a
basic health service (See Section 11.05).
12.13 Treatment for armed forces service - connected medical care (for both sickness and injury).
12.14 Custodial Care (as defined in Part III, Section 3.10).
12.15 Experimental and/or investigational procedures, except for bone marrow transplants, as approved
per Florida Administrative Code, Section 59B- 12.001. For the purposes of this Contract, a
medication, treatment, device, surgery or procedure may be determined to be experimental and/or
investigational if any of the following applies:
a) The FDA has not granted the approval for general use;
b) There are insufficient outcomes data available from controlled clinical trials published in
peer- reviewed literature to substantiate its safety and effectiveness for the disease of injury
involved;
c) There is no consensus among practicing physicians that the medication, treatment, therapy,
procedure or device is safe or effective for the treatment in question or such medication,
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surrogacy, as defined under Chapter 63, Florida Statutes. Medications for the treatment of
infertility are not covered.
1225 Reversal of sterilization procedures.
12.26 Immunizations and medications for the purpose of foreign travel or employment.
12.27 Acupuncture, biofeedback, hypnotherapy, massage therapy, sleep therapy, sex therapy,
behavioral training, cognitive therapy, and vocational rehabilitation.
12.28 Foot supports are not covered. These include orthopedic or specialty shoes, shoe build -ups, shoe
orthotics, shoe braces, and shoe supports. Also excluded is routine foot care, including trimming
of corns, calluses, and nails.
12.29 The Medical Services and Hospital Services for a donor or prospective donor who is an AvMed
Member when the recipient of an organ transplant is not an AvMed Member. Coverage is
provided for costs associated with the bone marrow donor - patients to the same extent as the
insured recipient. The reasonable costs of searching for the bone marrow donor is limited to
family members and the National Bone Marrow Donor Program. Post - transplant donor
complications will not be covered.
12.30 Diagnostic testing and treatment related to mental retardation or deficiency, learning disabilities,
behavioral problems, developmental delays or Autism Spectrum Disorder. Expenses for remedial
or special education, counseling, or therapy including evaluation and treatment of the above -
listed conditions or behavioral training whether or not associated with manifest mental disorders
or other disturbances.
12.31 Emergency room services for non- emergency purposes. (See Sections 3.14 and 3.15)
12.32 Hospital Services that are associated with excluded surgery or Dental Care.
12.33 Any treatment or service from a Non - participating Provider, except in the case of an emergency
or when specifically pre- authorized by AvMed. (See Sections 3.14 and 3.15)
12.34 Speech therapy for delayed or abnormal speech pathology.
12.35 Alcohol or substance abuse rehabilitation, vocational rehabilitation, pulmonary rehabilitation,
long term rehabilitation, or any other rehabilitation program.
12.36 Surgery for the reduction or augmentation of the size of the breasts except as required for the
comprehensive treatment of breast cancer.
12.37 Termination of pregnancy unless deemed Medically Necessary by the Medical Director, subject
to applicable State and Federal laws or as specified in the Elective Termination of Pregnancy
amendment to the Subscribing Group Contract.
12.38 Hospital Exclusion. If a Member elects to receive Hospital care from a non - participating
Attending Physician or a non - participating Hospital, then coverage is excluded for the entire
episode of care, except when the admission was due to an emergency or with the prior written
authorization of AvMed.
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13.03 The standards governing the coordination of benefits are the following, pursuant to the provisions
of Section 627.423 5, Florida Statutes:
13.03.01 The benefits of a policy or plan that covers the person as an employee, member, or
subscriber, other than as a dependent, are determined before those of the policy or
plan which covers the person as a dependent.
13.03.02 Except as stated in Subsection 13.03.03, when two or more policies or plans cover the
same child as a dependent of different parents:
a) The benefits of the policy or plan of the parent whose birthday, excluding year of
birth, falls earlier in a year are determined before the benefits of the policy or
plan of the parent whose birthday, excluding year of birth, falls later in the year;
but
b) If both parents have the same birthday, the benefits of the policy or plan which
covered the parent for a longer period of time are determined before those of the
policy or plan which covered the parent for a shorter period of time.
However, if a policy or plan subject to the rule based on the birthday of the parents as
stated above coordinates with an out -of -state policy or plan which contains
provisions under which the benefits of a policy or plan which covers a person as a
dependent of a male are determined before those of a policy or plan which covers the
person as a dependent of a female and if, as a result, the policies or plans do not agree
on the order of benefits, the provisions of the other policy or plan shall determine the
order of benefits.
13.03.03 If two or more policies or plans cover a dependent child of divorced or separated
parents, benefits for the child are determined in this order:
a) First, the policy or plan of the parent with custody of the child;
b) Second, the policy or plan of the spouse of the parent with custody of the child;
and
c) Third, the policy or plan of the parent not having custody of the child.
However, if the specific terms of a court order state that one of the parents is
responsible for the health care expenses of the child and if the entity obliged to pay or
provide the benefits of the policy or plan of that parent has actual knowledge of those
terms, the benefits of that policy or plan are determined first. This does not apply
with respect to any claim determination period or plan or policy year during which
any benefits are actually paid or provided before that entity has that actual
knowledge.
13.03.04 The benefits of a policy or plan which covers a person as an employee who is neither
laid off nor retired, or as that employee's dependent, are determined before those of a
policy or plan which covers that person as a laid off or retired employee or as that
employee's dependent. If the other policy or plan is not subject to this rule, and if, as
a result, the policies or plans do not agree on the order of benefits, this Subsection
shall not apply.
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benefits or services provided for the Member. The "amount of the payments made" includes the
reasonable cash value of any benefits provided in the form of services.
13.08 In the event the Subscribing Group offers Health Reimbursement Arrangements (HRA) in
connection with this Plan, the HRA is intended to pay solely for otherwise un- reimbursed medical
expenses. Accordingly, it shall not be considered a group health plan for coordination of benefits
purposes, and its benefits shall not be taken into account when determining benefits payable
under any other plan.
XIV. SUBROGATION AND RIGHT OF RECOVERY
If AvMed provides health care benefits under this Contract to a Member for injuries or illness for which
another party is or may be responsible, then AvMed retains the right to repayment of the full cost of all
benefits provided by AvMed on behalf of the Member that are associated with the injury or illness for
which another party is or may be responsible. AvMed's rights of recovery apply to any recoveries made
by or on behalf of the Member from the following third -party sources, as allowed by law, including but
not limited to: payments made by a third -party tortfeasor or any insurance company on behalf of the
third -party tortfeasor; any payments or awards under an uninsured or underinsured motorist coverage
policy; any worker's compensation or disability award or settlement; medical payments coverage under
any automobile policy, premises or homeowners medical payments coverage or premises or homeowners
insurance coverage; any other payments from a source intended to compensate a Member for injuries
resulting from an accident or alleged negligence. For purposes of this Contract, a tortfeasor is any party
who has committed injury, or wrongful act done willingly, negligently or in circumstances involving
strict liability, but not including breach of contract for which a civil suit can be brought.
Member specifically acknowledges AvMed's right of subrogation. When AvMed provides health care
benefits for injuries or illnesses for which a third parry is or may be responsible, AvMed shall be
subrogated to the Member's rights of recovery against any party to the extent of the full cost of all
benefits provided by AvMed, to the fullest extent permitted by law. AvMed may proceed against any
party with or without the Member's consent.
Member also specifically acknowledges AvMed's right of reimbursement. This right of reimbursement
attaches, to the fullest extent permitted by law, when AvMed has provided health care benefits for injuries
or illness for which another party is or may be responsible and the Member and/or the Member's
representative has recovered any amounts from the third party or any party making payments on the third
party's behalf. By providing any benefit under this Contract, AvMed is granted an assignment of the
proceeds of any settlement, judgment or other payment received by the Member to the extent of the full
cost of all benefits provided by AvMed. AvMed's right of reimbursement is cumulative with and not
exclusive of AvMed's subrogation right and AvMed may choose to exercise either or both rights of
recovery.
Member and the Member's representatives further agree to:
a) Notify AvMed promptly and in writing when notice is given to any third party of the intention to
investigate or pursue a claim to recover damages or obtain compensation due to injuries or illness
sustained by the Member that may be the legal responsibility of a third parry; and
b) Cooperate with AvMed and do whatever is necessary to secure AvMed's rights of subrogation
and/or reimbursement under this Contract; and
C) Give AvMed a first- priority lien on any recovery, settlement or judgment or other source of
compensation which may be had from a third party to the extent of the full cost of all benefits
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15.05 Certain Members may, for personal reasons, refuse to accept procedures or treatment
recommended by Participating Physicians. Participating Physicians may regard such refusal to
accept their recommendations as incompatible with the continuance of the physician/patient
relationship and as obstructing the provision of proper medical care. If a Member refuses to
accept the medical treatment or procedure recommended by the Participating Physician and if, in
the judgment of the Participating Physician, no professionally acceptable alternative exists or if
an alternative treatment does exist but is not recommended by the Participating Physician, the
Member shall be so advised.
If the Member continues to refuse the recommended treatment or procedure, AvMed may
terminate the Member's coverage under this Contract as set forth in Part IX, Subsection 9.01.05.
XVI. GRIEVANCE PROCEDURE
16.01 Urgent Care Claims.
16.01.01 Initial Claim. An Urgent Care Claim shall be deemed to be filed on the date received
by AvMed. AvMed shall notify the Claimant of AvMed's benefit determination
(whether adverse or not) as soon as possible, taking into account the medical
exigencies, but not later than 72 hours after AvMed receives, either orally or in
writing, the Urgent Care Claim, unless the Claimant fails to provide sufficient
information to determine whether, or to what extent, benefits are covered or payable
under the Plan. If such information is not provided, AvMed shall notify the Claimant
as soon as possible, but not later than 24 hours after AvMed receives the Claim, of the
specific information necessary to complete the Claim. The Claimant shall be afforded
a reasonable amount of time, taking into account the circumstances, but not less than
48 hours, to provide the specified information. AvMed shall notify the Claimant of
the benefit determination as soon as possible, but in no case later than 48 hours after
the earlier of:
1) AvMed's receipt of the specified information; or
2) The end of the period afforded the Claimant to provide the specified additional
information.
If the Claimant fails to supply the requested information within the 48 -hour period, the Claim
shall be denied. AvMed may notify the Claimant of the benefit determination orally or in writing.
If the notification is provided orally, a written or electronic notification, meeting the requirements
of Section 16.05, shall be provided to the Claimant no later than three days after the oral
notification.
16.01.02 Appeal. A Claimant may appeal an Adverse Benefit Determination with respect to an
Urgent Care Claim within 180 days of receiving the Adverse Benefit Determination.
AvMed shall notify the Claimant, in accordance with Section 16.07, of AvMed's
benefit determination on review as soon as possible, taking into account the medical
exigencies, but not later than 72 hours after AvMed receives the Claimant's request
for review of an Adverse Benefit Determination.
You may submit an appeal to:
AvMed Member Services —North AvMed Member Services — South
P.O. Box 823 P.O. Box 569008
Gainesville, Florida 32602 -0823 Miami, Florida 33156 -9906
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AvMed shall notify the Claimant, in accordance with Section 16.07, of its
determination on review within a reasonable period of time. Such notification shall be
provided not later than 30 days after AvMed receives the Claimant's request for review
of the Adverse Benefit Determination.
You may submit an appeal to:
AvMed Member Services —North AvMed Member Services — South
P.O. Box 823 P.O. Box 569008
Gainesville, Florida 32602 -0823 Miami, Florida 33156 -9906
Telephone: 1-800-882-8633 Telephone: 1-800-882-8633
Fax: (352) 337-8612 Fax: (305) 671-4736
If you are not satisfied with AvMed's final decision, you may contact AHCA or DFS in writing
within 365 days of receipt of the final decision letter. If you appeal AvMed's decision, your
grievance will be reviewed by the Subscriber Assistance Program. You also have the right to
contact AHCA or DFS at any time to inform them of an unresolved grievance.
The Subscriber Assistance Program will not hear a grievance if you have not completed the entire
AvMed grievance process nor if you have instituted an action pending in State or Federal court.
If you need further assistance, you may contact:
Subscriber Assistance Panel (SAP)
Agency for Health Care Administration
HMO Section
2727 Mahan Drive, Mail Stop 26
Tallahassee, Florida 32308
Telephone 1- 888- 419 -3456 or 850 -921 -5458
Florida Department of Financial Services
200 East Gaines Street
Tallahassee, Florida 32399
Telephone 1 -800- 342 -2762
16.03 Post - Service Claims.
16.03.01 Initial Claim — A Post - Service Claim shall be deemed to be filed on the date received
by AvMed. AvMed shall notify the Claimant, in accordance with Section 16.05 of
AvMed's Adverse Benefit Determination within a reasonable period of time, but not
later than 30 days after AvMed receives the Post- Service Claim. AvMed may extend
this period one time for up to 15 days, provided that AvMed determines that such an
extension is necessary due to matters beyond AvMed's control and notifies the
Claimant, before the expiration of the initial 30 -day period, of the circumstances
requiring the extension of time and the date by which AvMed expects to render a
decision. If such an extension is necessary because the Claimant failed to submit the
information necessary to decide the Post - Service Claim, the notice of extension shall
specifically describe the required information, and the Claimant shall be afforded at
least 45 days from receipt of the notice within which to provide the specified
information. AvMed's period for making the benefit determination shall be tolled from
the date on which the notification of the extension is sent to the Claimant until the date
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appeal and obtain a determination on review of the Adverse Benefit Determination
before the benefit is reduced or terminated.
16.04.02 Any request by a Claimant to extend the course of treatment beyond the period of time
or number of treatments that relates to an Urgent Care Claim shall be decided as soon
as possible, taking into account the medical exigencies, and AvMed shall notify the
Claimant of the benefit determination, whether adverse or not, within 24 hours after
AvMed receives the Claim, provided that any such Claim is made to AvMed at least 24
hours before the expiration of the prescribed period of time or number of treatments.
Notification and appeal of any Adverse Benefit Determination concerning a request to
extend the course of treatment, whether involving an Urgent Care Claim or not, shall be
made in accordance with the remainder of Part XVL
16.05 Manner and.Content of Initial Claims Determination Notification. AvMed shall provide a Claimant
with written or electronic notification of any Adverse Benefit Determination. The notification shall
set forth, in a manner calculated to be understood by the Claimant, the following:
a) The specific reasons for the Adverse Benefit Determination.
b) Reference to the specific Plan provisions on which the determination is based.
c) A description of any additional material or information necessary for the Claimant to
perfect the Claim and an explanation of why such material or information is necessary.
d) A description of AvMed's review procedures and the time limits applicable to such
procedures, including, when applicable, a statement of the Claimant's right to bring a
civil action under Section 502(a) of the Employee Retirement Income Security Act of
1974, as amended (ERISA), following an Adverse Benefit Determination on final
review.
e) If an internal rule, guideline, protocol, or other similar criterion was relied upon in
making the Adverse Benefit Determination, either the specific rule, guideline, protocol,
or other similar criterion or a statement that such rule, guideline, protocol or other
similar criterion was relied upon in making the Adverse Benefit Determination and that
a copy shall be provided free of charge to the Claimant upon request.
i) If the Adverse Benefit Determination is based on whether the treatment or service is
experimental and/or investigational or not Medically Necessary, either an explanation of
the scientific or clinical judgment for the determination, applying the terms of the Plan
to the Claimant's medical circumstances, or a statement that such explanation shall be
provided free of charge upon request.
g) In the case of an Adverse Benefit Determination involving an Urgent Care Claim, a
description of the expedited review process applicable to such Claim.
16.06 Review Procedure Upon Appeal. AvMed's appeal procedures shall include the following.
substantive procedures and safeguards:
a) Claimant may submit written comments, documents, records, and other information relating
to the Claim.
b) Upon request and free of charge, the Claimant shall have reasonable access to and copies of
any Relevant Documents.
c) The appeal shall take into account all comments, documents, records, and other information
the Claimant submitted relating to the Claim, without regard to whether such information was
submitted or considered in the initial Adverse Benefit Determination.
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the Claimant's medical circumstances, or a statement that such explanation shall be
provided free of charge upon request.
XVIL MISCELLANEOUS
17.01 Contracting Parties. By executing this Contract, Subscribing Group and AvMed agree to make
the Medical Services and Hospital Services specified herein available to persons who are eligible
under the provisions of Part IV. However, the delivery of benefits and services covered in this
Contract shall be subject to the provisions, Limitations, and Exclusions set forth herein and any
amendments, modifications, and Contract termination provisions specified herein and by the
mutual agreement between AvMed and Subscribing Group, without the consent or concurrence of
the Members. By electing or accepting Medical Services and Hospital or other benefits
hereunder, all Members legally capable of contracting and the legal representatives of all
Members incapable of contracting, agree to all terms, conditions, and provisions hereof.
No changes or amendments to this Contract shall be valid unless approved by an executive officer
of AvMed and endorsed herein or attached hereto. No agent has authority to change this Contract
or to waive any of its provisions.
17.02 Certificate of Coverage. AvMed shall provide a copy of the Certificate of Coverage for each
Subscriber.
17.03 Membership Application. Members or applicants for membership shall complete and submit to
AvMed such applications or other forms or statements as AvMed may reasonably request. If
Member or applicant fails to provide accurate information which AvMed deems material then,
upon ten days written notice, AvMed may deny coverage and/or membership to such individual.
Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a
statement of Claim or an application containing any false, incomplete, or misleading information
is guilty of a felony, punishable as provided by the Florida Statutes.
17.04 Identification Cards. Cards issued by AvMed to Members pursuant to this Contract are for
purposes of identification only. Possession of an AvMed identification card confers no right to
health services or other benefits under this Contract. To be entitled to such services or benefits
the holder of the card must, in fact, be a Member on whose behalf all applicable charges under
this Contract have actually been paid and accepted by AvMed.
17.05 Waiver. A Claim that has not been timely filed with AvMed within one year of date of service
shall be considered waived.
17.06 Non- Waiver. The failure of AvMed to enforce any of the provisions of this Contract or to
exercise any options herein provided or to require timely performance by any Member or
Subscribing Group of any of the provisions herein, shall not be construed to be a waiver of such
provisions nor shall it affect the validity of this Contract or any part thereof or the right of AvMed
to thereafter enforce each and every such provision.
17.07 Plan Administration. AvMed may from time to time adopt reasonable policies, procedures,
rules, and interpretations to promote the orderly and efficient administration of this Contract.
M.-
AV -G100 -2008
MT-5241 (10/08)
17.16 Assignment. This Contract, and all rights and benefits related thereto, may not be assigned by
the Subscribing Group or the Members without written consent of AvMed.
17.17 he plartiel
s,and shall beinterp e o interpreted, as to l comply with he laws and regulations of the State of
Florida and the United States.
17.18 ERISA. When this Contract is purchased by the Subscribing Group to provide benefits under a
welfare plan governed by ERISA, AvMed shall be considered a fiduciary to the extent that it
performs any discretionary functions on behalf of the Plan. If a Member has questions about the
group's welfare plan, the Member should contact the Subscribing Group.
In
AV-G100 -2008
NT-5241 (10/08)
This page has been left blank intentionally.
ABenefit Summary
LTli P4ANS
BASIC OPTION
SCHEDULE OF BENEFITS
COST TO MEMBER
250 -ADMIT
• Room and board - unlimited days (semi - private)
100% coverage
OUT -OF- POCKET MAXIMUM
• Physicians', specialists' and surgeons' services
$1,500 INDIVIDUAL
Per Calendar Year
• Anesthesia, use of operating and recovery rooms, oxygen,
$3,000 FAMILY
AVMED PRIMARY CARE
Services at participating Physicians' offices include, but are not
$15 per visit
PHYSICIAN
limited to:
• Routine office visits / annual gynecological examination
when performed by Primary Care Physician
• Pediatric care and well -child care
• Periodic health evaluation and immunizations
OUTPATIENT SERVICES
• Diagnostic imaging, laboratory or other diagnostic
$250 Co- payment
services
• Minor surgical procedures
• Vision and hearing examinations for children under 18
$100 Co- payment
MATERNITY CARE
• Initial visit
$15 Co- payment
• Subse went visits
NO CHARGE
AVMED SPECIALISTS'
• Office visits
$25 per visit
SERVICES
• Annual gynecological examination when performed by a
$25 per test
TESTS
participating Specialty Health Care Physician
$10 per test
Additional Co- payments will apply if Outpatient Diagnostic Test
are performed in the Specialist office.
HOSPITAL
Inpatient care at Participating Hospitals includes:
$250 per admission;
• Room and board - unlimited days (semi - private)
100% coverage
• Physicians', specialists' and surgeons' services
thereafter
• Anesthesia, use of operating and recovery rooms, oxygen,
drugs and medication
• Intensive care unit and other special units, general and
special duty nursing
• Laboratory and diagnostic imaging
• Required special diets
• Radiation and inhalation therapies,_
OUTPATIENT SERVICES
• Outpatient surgeries, including cardiac catheterization
$250 Co- payment
and angioplasty
• Outpatient therapeutic services, including:
• Drug infusion therapy
$100 Co- payment
• Injectable Drugs (Co- payment for Injectable
$75 Co- payment
Drug waived if incidental to same -day drug
infusion therapy)
OUTPATIENT DIAGNOSTIC
CAT Scan, PET Scan, MRI
$25 per test
TESTS
Other diagnostic imaging tests
$10 per test
Co- payments for office visits will also apply if services are
performed in a Specialist office.
EMERGENCY SERVICES
An emergency is the sudden and unexpected onset of a condition
requiring immediate medical or surgical care. (Co- payment
waived if admitted)
• Emergency services at Participating Hospitals
$75 Co- payment
• Emergency services at non - participating Hospitals,
$100 Co- payment
facilities and/or physicians
AvMed must be notified within 24 hours of inpatient
admission following emergency services or as soon as
reasonably possible
AV- BASIC- 250A -07
W- 3422(10/07)
Benefit Summary, continued
URGENTAMMEDIATE CARE • Medical Services at a participating Urgent/Immediate Care $40 Co- payment
facility or services rendered after hours in your Primary
Care Physician's office
• Medical Services at a non - participating Urgent/Immediate $60 Co- payment
Care facility
MENTAL HEALTH • 20 outpatient visits $25 per visit
FAMILY PLANNING • Voluntary family planning services ylz) per VIJll
• Sterilization (In addition to any Outpatient Facility Co- $250 Co- payment
payment)
ALLERGY TREATMENTS • Injections $10 per visit
• Ambulance transport for emergency services
• Non - emergent ambulance services are covered when the
skill of medically trained personnel is required and the
PHYSICAL, SPEECH AND Short-term physical, speech or occupational therapy
OCCUPATIONAL THERAPIES acute conditions
Coverage is limited to 30 visits per calendar year for all
services combined
$100 Co- payment
$15 per visit
SKILLED NURSING
Up to 20 days post - hospitalization care per calendar year
$50 per day
FACILITIES AND
when prescribed by physician and authorized by AvMed
$50 per episode of
REHABILITATION CENTERS
• Hospital beds
illness
CARDIAC REHABILITATION
Cardiac rehabilitation is covered for the following conditions:
$20 per visit
• Acute myocardial infarction
Benefits limited
• Percutaneous transluminal coronary angioplasty (PTCA)
Benefits limited
• Repair or replacement of heart valves
to $1,500 per
• Coronary artery bypass graft (CABO), or
calendar year
• Heart transplant
Coverage is limited to 18 visits per calendar year
HOME HEALTH CARE
Limited to 60 skilled visits per calendar year
NO CHARGE
DURABLE MEDICAL
Equipment includes:
$50 per episode of
EQUIPMENT AND
• Hospital beds
illness
ORTHOTIC APPLIANCES
• Walkers
• Crutches
Benefits limited
• Wheelchairs
to $500 per
Orthotic appliances are limited to:
calendar year
• Leg, arm, back and neck custom -made braces
PROSTHETIC DEVICES Prosthetic devices are limited to: NO CHARGE
• Artificial limbs
• Artificial joints
• Ocular prostheses
FOR ADDITIONAL INFORMATION, PLEASE CALL: 1- 800 -88 -AVMED (1- 800. 882 -8633)
THIS SCHEDULE OF BENEFITS IS NOT A CONTRACT.
FOR SPECIFIC INFORMATION ON BENEFITS, EXCLUSIONS AND LIMITATIONS, PLEASE SEE YOUR AVMED GROUP
MEDICAL AND HOSPITAL SERVICE CONTRACT.
AV- 3ASIC- 250A -07
MP -3422 (10/07)
Hy�D Prescription Drug Benefits
H E A L T H P L AN S
s2ol40f60/75150% CO- PAYMENT with Contraceptives
"Brand" medication means a Prescription Drug that is usually manufactured and sold under a name or trademark by a pharmaceutical manufacturer or a
medication that is identified as a Brand medication by AvMed. AvMed delegates determination of Generic/Brand status to our Pharmacy Benefits
Manager.
"Brand Additional Charge' means the additional charge that must be paid if you or your physician choose a Brand medication when a Generic equivalent
is available. The charge is the difference between the cost of the Brand medication and the Generic medication. This charge must be paid in addition to
the applicable Non- Prefered Brand Co- payment.
"Cost- sharing Medications" are those medications, as designated by AvMed, which were designed to improve the quality of life by treating relatively
minor non -life threatcning conditions. Such medications are subject to Co- insurance and coverage is limited as outlined below.
"Dental- specific Medication" is medication used for dental - specific purposes, including but not limited to fluoride medications and medications packaged
and labeled for dental- specific purposes.
"Generic" medication means a medication that has the same active ingredient as a Brand medication or is identified as a Generic medication by AvMed's
Pharmacy Benefits Manager.
"Injectable Medication" is a medication that has been approved by the Food and Drug Administration (FDA) for administration by one or more of the
following routes: intramuscular injection, intravenous injection, intravenous infusion, subcutaneous injection, intrathecal injection, intrarticular injection,
intracavemous injection or intraocular injection. Pre - Authorization is required for all Injectable Medications.
"Maintenance Medication" is a medication that has been approved by the FDA, for which the duration of therapy can reasonably be expected to exceed
one year.
"Participating Pharmacy" means a pharmacy (either retail, mail order or specialty pharmacy) that has entered into an agreement with AvMed to provide
Prescription Drugs to AvMed Members and has been designated by AvMed as a Participating Pharmacy.
"Preferred Medication List" means the listing of preferred medications as determined by AvMed's Pharmacy and Therapeutics Committee based on
clinical efficacy, relative safety and cost in comparison to similar medications within a therapeutic class. This multi - tiered list establishes different levels
of Co- payment for medications within therapeutic classes. As new medications become available, they may be considered excluded until they have been
reviewed by AvMed's Pharmacy and Therapeutics Committee.
"Prescription Drug" means a medication that has been approved by the FDA and that can only be dispensed pursuant to a prescription according to state
and federal law.
"Pre- Authorization" means the process of obtaining approval for certain Prescription Drugs (prior to dispensing) according to AvMed's guidelines. The
prescribing physician must obtain approval from AvMed. The list of Prescription Drugs requiring Pre - Authorization is subject to periodic review and
modification by AvMed. A copy of the list of medications requiring Pre- Authorization and the applicable criteria are available from Member Services or
from the AvMed website.
"Self- Administered Injectable Medication" is a medication that has been approved by the FDA for self - injection and is administered by subcutaneous
injection or a medication for which there are instructions to the patient for self- injection in the manufacturer's prescribing information (package insert).
Pre - Authorization is required for all Self- Administered Injectable Medications.
HOW DOES YOUR RETAIL PRESCRIPTION euvMnnut wunna
To obtain your Prescription Drug, take your prescription to, or have your physician call, an AvMed Participating Pharmacy. Your physician should
submit prescriptions for Self - Administered Injectable Drugs to AvMed's specialty pharmacy. Present your prescription along with your AvMed
identification card. Pay the following Co- payment (as well as the Brand Additional Charge if you or your physician choose a Brand product when a
Generic equivalent is available).
Tier I Preferred Generic Medications: $ 20.00 Co- payment
Tier 2 Preferred Brand Medications: $ 40.00 Co- payment
Tier 3 Non-Preferred Brand or Generic Medications: $ 60.00 Co- payment
Tier 4 Self - Administered Injectable Medications: $ 75.00 Co- payment
Tier 5 Cost - sharing Medications 50% Co- insurance
Mail service is a benefit option for maintenance medications needed for chronic or long -term health conditions. It is best to get an initial prescription
filled at your retail pharmacy. Ask your physician for an additional prescription for up to a 90 -day supply of your medication to be ordered through mail
service. Up to 3 refills are allowed per prescription. Pay the following Co- payment (as well as the Brand Additional Charge if you or your physician
choose a Brand product when a Generic equivalent is available).
Tier 1 Preferred Generic Medications: $ 40.00 Co- payment
Tier 2 Preferred Brand Medications: $ 80.00 Co- payment
Tier 3 Non-Preferred Brand or Generic Medications: $120.00 Co- payment
Tier 4 Self - Administered Injectable Medications are not available through mail service
Tier 5 Cost - sharing Medications are not available through mail service
A V -G 100- RX -2x- 20/40/60/75/50 %OC -07
MP -3855 (10/07)
Prescription Drug .Benefits, continued
WHAT IS COVERED?
• - Your Prescription Drug coverage includes outpatient medications (including contraceptives) that require a prescription and are prescribed by
your AvMed physician in accordance with AvMed's coverage criteria. AvMed reserves the right to make changes in coverage criteria for
covered products and services. Coverage criteria are medical and pharmaceutical protocols used to determine payment of products and services
and are based on independent clinical practice guidelines and standards of cue established by government agencies and medicaVpharmaceutical
societies.
• Your retail Prescription Drug coverage includes up to a 30 -day supply of a medication for the listed Co- payment. Your prescription may be
refilled via retail or mail order after 75% of your previous fill has been used and subject to a maximum of 13 refills per year. You also have
the opportunity to obtain a 90 -day supply of medications used for chronic conditions including, but not limited to asthma, cardiovascular
disease, and diabetes from the retail pharmacy for the applicable Co- payment per 30 -day supply. However, Pre - Authorization may be,
required for covered medications.
• Your mail -order Prescription Drug coverage includes up to a 90 -day supply of a routine maintenance medication for the listed Co- payment. If
the amount of medication is less than a 90-day supply, you will still be charged the listed mail order Co- payment.
• Your Self - Administered Injectable Medication coverage extends to many injectable medications approved by the FDA. These medications must
be prescribed by a physician and dispensed by a retail or specialty pharmacy. The Co- payment levels for Self-Administered Injectable
Medications apply regardless of provider. This means that you are responsible for the appropriate Co- payment whether you receive your Self -
Administered Injectable Medication from the pharmacy, at the physician's office or during home health visits. Self- Administered Injectable
Medications are limited to a 30 -day supply.
• Your Prescription Drug coverage includes coverage for injectable contraceptives. There is a Co- payment of $30 for each injection. If there is
an office visit associated with the injection, there will be an additional Co- payment required for the office visit.
• Your Tier 5 coverage is limited to Terbinafmc (Lamisil®) and Itraconazole (Sporanox®), in oral fort, when prescribed by your physician for
the treatment of documented fungal infections. Pre - authorization is not required.
• Quantity limits are set in accordance with FDA approved prescribing limitations, general practice guidelines supported by medical specialty
organizations, and/or evidence - based, statistically valid clinical studies without published conflicting data This means that a medication -
specific quantity limit may apply for medications that have an increased potential for over - utilization or an increased potential for a Member to
experience an adverse effect at higher doses.
ONESTIONS? Call your AvMed Member Services Department at: 1- 800 -88 -AvMed (1- 800 - 882 -8633)
EXCLUSIONS AND LIMITATIONS
• Medications which do not require a prescription (i.e. over - the - counter medications) or when a non - prescription alternative is available
• Medical supplies, including therapeutic devices, dressings, appliances, and support garments
• Replacement Prescription Drug products resulting from a lost, stolen, expired, broken, or destroyed prescription order or refill
• Diaphragms and other contraceptive devices
• Fertility drugs
• Medications or devices for the diagnosis or treatment of sexual dysfunction
• Dental- specific Medications for dental purposes, including fluoride medications
• Prescription and non - prescription vitamins and minerals except prenatal vitamins
• Nutritional supplements
• Immunizations
• Allergy serums, medications administered by the Attending Physician to treat the acute phase of an illness and chemotherapy for cancer patients
are covered in accordance with the Group Medical and Hospital Service Contract and may be subject to Co- payments or Co- insurance as
outlined on the Schedule of Benefits
• Investigational and experimental drugs (except as required by Florida statute)
• Cosmetic products, including, but not limited to, hair growth, skin bleaching, sun damage and anti - wrinkle medications
• Nicotine suppressants and smoking cessation products and services
• Prescription and non - prescription appetite suppressants and products for the purpose of weight loss
• Compounded prescriptions, except pediatric preparations
• Medications and immunizations for non - business related travel, including Transdermal Scopolamine
Filling a prescription at a pharmacy is not a claim for benefits and is not subject to the Claims and Appeals procedures under ERISA. However, any
medicines that require Pre - Authorization will be treated as a claim for benefits subject to the Claims and Appeals Procedures, as outlined in the
Group Medical and Hospital Service Contract.
A V-G 100- RX -2x- 20/40/60/75/50 %OC -07
W -3855 (10/07)
A .Amendment
Inpatient Mental Health and Partial Hospitalization Benefits
As of the effective date, Inpatient Mental Health and Partial Hospitalization Benefits are being provided for an additional
premium.
Inpatient treatment of mental/nervous disorders for up to 30 days per patient, subject to a member copayment of $250
per admit, shall be provided by the Plan when a member is admitted to a Participating Hospital or Participating Health
Care Facility as a registered bed patient.
Partial Hospitalization for mental health services is a Covered Service when it is provided in lieu of inpatient
hospitalization and is combined with the inpatient hospital benefit. Two days of Partial Hospitalization will count as
one day toward the inpatient Mental Health Benefit subject to member copayment as noted above.
AV- 0100 -MH/PH -$250 per admit -04
MP -3522 (10/04)
AV�
H a A L i H PLAN S
Amendment
Substance Abuse Benefits
As of the effective date, the following Substance Abuse Benefits have been added for an additional
premium.
INPATIENT Inpatient treatment of alcohol and drug abuse is not provided except for acute
detoxification.
OUTPATIENT An intensive treatment program(s) of one or more weeks by Plan Physicians,
• subject to a member copayment of $50 per week. Coverage is limited to a
maximum of six weeks per contract year.
AV- SA -R -98
W -1527 (1/04)
A V�D Addendum L S H PLAN S
Coverage for Mammograms — Waiver of Co- payment
If selected, the following provision is hereby modified for an additional premium:
Section 10.28 of the AvMed Health Plans Group Medical and Hospital Service Contract is amended to state:
Mammograms are covered in accordance with Florida Statutes: one baseline mammogram is covered for female
Members between the ages of 35 and 39; a mammogram is available every two years for female Members between
the ages of 40 and 49; and a mammogram is available every year for female Members aged 50 and older.
In addition, one or more mammograms a year are available when based upon a physician's recommendation for any
woman who is at risk for breast cancer because of a personal or family history of breast cancer, because of having a
history of biopsy - proven benign breast disease, because of having a mother, sister, or daughter who has had breast
cancer, or because a woman has not given birth before the age of 30. This coverage will not be subject to
diagnostic imaging Co- payments.
" -Ma ogmm -05
MP -3228 (12105)
AVMED Amendment
HEALTH PLANS
Durable Medical Equipment
If selected, the following coverage is hereby modified, for an additional premium.
DURABLE MEDICAL EQUIPMENT
• Benefits are limited to a maximum of $2,000 per contract year *.
All other coverage provisions, including co- payment, limitations and exclusions remain
as stated in the Certificate of Coverage or Schedule of Co- Payments.
*For the treatment of diabetes, coverage for an infusion pump will not apply toward the
annual maximum limitation and shall not be subject to the durable medical equipment
benefit limitation.
AV- 0100 -DW- 2000 -R -06
MP -2149 (4 -06)
DNS Amendment
DOMESTIC PARTNER
As of the Effective Date, Part IV. ELIGIBILITY, of the Group Medical and Hospital Service Contract is
amended by the addition of the following provision:
Dependent Eligibility will be added for a Domestic Partner and his or her children.
Definition of Domestic Partner:
A Domestic Partner means an unmarried adult who:
• Cohabits with you in an emotionally committed and affectional relationship that is meant to be of
lasting duration;
• Is not related by blood or marriage;
• Is at least eighteen years of age;
• Is mentally competent to consent to a contract;
• Has filed a Domestic Partnership agreement or registration with the Employer, if available, in the state
(and/or city) of residence;
• Has shared financial obligations including basic living expenses for the six month period prior to
enrollment in the plan;
• Will provide documentation that will be satisfactory to the Employer as evidence of a Domestic
Partner relationship; and
• Meets the dependents eligibility requirements of the Employer's health benefits plan.
AV- DP- 6 -R -02
MP -3149 (1/04)
AVMED Benefit Summary
HEALTH PLANS
LARGE GROUP SCHEDULE OF BENEFITS COST TO MEMBER
$15/$2501$1,500 /20%
CALENDAR YEAR INDIVIDUAL / FAMILY $250/$750 annually
DEDUCTIBLE The Deductible does not apply toward the Out -of- Pocket Maximum
OUT -OF- POCKET MAXIMUM
INDIVIDUAL / FAMILY
$1,500/$3,000 annually
Per Calendar Year
The Out -of- Pocket Maximum includes Co payments and Co-
first 5 days, per admission;
insurance amounts unless otherwise excluded
100% coverage thereafter
AVMED PRIMARY CARE
Services at Participating Physicians' offices include, but are not
$15 per visit
PHYSICIAN
limited to:
• Routine office visits /annual gynecological examination when
performed by Primary Care Physician
• Pediatric care and well -child care
• Periodic health evaluation and immunizations
• Diagnostic imaging, laboratory or other diagnostic services
OUTPATIENT SERVICES
• Minor surgical procedures
$250 Co- payment
• Vision and hearing examinations for children under 18
MATERNITY CARE
• Initial visit
$15 Co- payment
Subsequent visits
NO CHARGE
AVMED SPECIALISTS'
• Office visits
$25 per visit
SERVICES
• Annual gynecological examination when performed by a
OUTPATIENT DIAGNOSTIC
participating Specialty Health Care Physician
20% of the contracted
TESTS
Additional Co- payments will apply if Outpatient Diagnostic Test are
rate after Deductible
HOSPITAL
Inpatient care at Participating Hospitals includes:
$250 per day for the
• Room and board — unlimited days (semi - private)
first 5 days, per admission;
• Physicians', specialists' and surgeons' services
100% coverage thereafter
• Anesthesia, use of operating and recovery rooms, oxygen, drugs
and medication
• Intensive care unit and other special units, general and special
duty nursing
• Laboratory and diagnostic imaging
• Required special diets
• Radiation and inhalation therapies
OUTPATIENT SERVICES
Outpatient surgeries, including cardiac catheterizations and
$250 Co- payment
angioplasty
• Outpatient therapeutic services, including:
• Drug infusion therapy
$100 Co- payment
• Injectable Drugs (Co- payment for Injectable Drug
$75 Co- payment
waived if incidental to same -day drug infusion therapy)
OUTPATIENT DIAGNOSTIC
• CAT Scan, PET Scan, MRI
20% of the contracted
TESTS
• Other diagnostic imaging tests
rate after Deductible
Co- payments for office visits will also apply if services are
performed in a Specialist's office.
EMERGENCY SERVICES
An emergency is the sudden and unexpected onset of a condition
$100 Co- payment
requiring immediate medical or surgical care. (Co- payment waived
if admitted)
• Emergency services at Participating Hospitals
• Emergency services at non - participating Hospitals, facilities
and/or physicians
AvMed must be notified within 24 hours of inpatient admission
following emergency services or as soon as reasonably possible
A V -LG- 15/250/1500/20 %07
MP -3990 (10 /07)
Benefit Summary, continued
URGENTAMMEDIATE CARE • Medical Services at a participating Urgent/Immediate Care
s4o co- paymem
facility or services rendered after hours in your Primary Care
FACILITIES AND
Physician's office
rate after Deductible
• Medical Services at a non - participating Urgenulmmediate Care
$60 Co- payment
facility
CARDIAC REHABILITATION
FAMILY PLANNING • Voluntary family planning services
$15 per visit
. ctPrili7atinn (in addition to any Outpatient Facility Co- payment)
_ $250 Co- payment
20 outpatient visits $25 per visit
ALLERGY TREATMENTS Inject ons $15 per visit
• Ambulance transport for emergency services $100 Co- payment
• Non - emergent ambulance services are covered when the skill of
medically trained personnel is required and the Member cannot
PHYSICAL, SPEECH AND • Short-term physical, speech or occupational therapy for acute $15 per visit
OCCUPATIONAL THERAPIES conditions
Coverage is limited to 30 visits per calendar year for all services
combined
SKILLED NURSING
x Up to 20 days post - hospitalization care per calendar year when
20% of the contracted
FACILITIES AND
prescribed by physician and authorized by AvMed
rate after Deductible
REHABILITATION CENTERS
CARDIAC REHABILITATION
Cardiac rehabilitation is covered for the following conditions:
$15 per visit
• Acute myocardial infarction
• Percutaneous transluminal coronary angioplasty (PTCA)
Benefits limited
• Repair or replacement of heart valves
to $1,500 per
• Coronary artery bypass graft (CABG), or
calendar year
• Heart transplant
Coverage is limited to 18 visits per calendar year
HOME HEALTH CARE Limited to 60 skilled visits per calendar year 20% of the contracted
rate after Deductible
DURABLE MEDICAL Equipment includes:
EQUIPMENT AND • Hospital beds
ORTHOTIC APPLIANCES • Walkers
• Crutches
• Wheelchairs
Orthotic appliances are limited to:
• Leg, arm, back and neck custom -made braces
20% of the contracted
rate after Deductible
Benefits limited
to $2,000 per
calendar year
PROSTHETIC DEVICES Prosthetic devices are limited to: 20% of the contracted
• Artificial limbs rate after Deductible
• Artificial joints
FOR ADDITIONAL INFORMATION, PLEASE CALL: 1. 800.88 -AVMED (1 -800- 882 -8633)
THIS SCHEDULE OF BENEFITS IS NOT A CONTRACT. FOR SPECIFIC INFORMATION ON
BENEFITS, EXCLUSIONS AND LIMITATIONS, PLEASE CONSULT YOUR AVMED GROUP
MEDICAL AND HOSPITAL SERVICE CONTRACT.
AV -L& 15/250/1500/20'/,07
MP -3990 (10/07)
VMT ED Amendment
HEALTH 'P L A N S
Large Group - Deductible and Co- insurance
These provisions of the policy are amended as follows:
Part III. DEFINITIONS, has been amended to add the following definitions:
"Calendar Year" means the twelve -month period beginning January 1 and ending December 31.
"Co- insurance" means the amount a covered Member must pay, once the Deductible has been met, and is
expressed as a percentage of the allowed amount for the covered benefit.
"Deductible" means the first payments up to a specified dollar amount, excluding Co- payments, that a
Member must make in the applicable Calendar Year for covered benefits. The Deductible applies to each
Member, subject to any family Deductible listed on the Schedule of Benefits. For purposes of the
Deductible, "family" means the Subscriber and Covered Dependents. The Deductible must be satisfied once
each Calendar Year, except for:
o the Common Accident Provision: if the Deductible applies to accident expenses and if 2 or more
Members of any family receive covered benefits because of disabilities resulting from injuries
sustained in any one accident, the Deductible will be applied only once with respect to all covered
benefits received as a result of the accident.
o the Deductible Credit Provision: any expense incurred by a Member while covered under the
group's prior carrier will be credited toward satisfaction of the Deductible under this Plan if.
• the expenses were incurred during the 90 -day period before the effective date of the Group
Plan;
• the expenses were applied toward satisfaction of the Deductible under the prior coverage
during the 90 -day period before the effective date of this Group Plan; and
• the expenses would be considered eligible expenses under this Group Plan.
However, in order to receive credit, you must supply evidence of satisfaction of the Deductible
under the prior coverage by providing AvMed Health Plans written proof of what has been paid by
prior carrier.
o the Carryover Provision: if any part or all of the Deductible has been satisfied during the last 3
months of the preceding Calendar Year, the Deductible for the next Calendar year will be reduced
by the amount satisfied.
Under Part VII. MONTHLY PAYMENTS AND CO- PAYMENTS, has been amended as follows:
7.03 Annual Maximum Out -of- Pocket Limits (as described in your Schedule of Benefits). Co- insurance and Co- payments
you pay for benefits received during any Calendar Year are accumulated toward your annual maximum out -of- pocket
limit. Once you meet your individual or family annual maximum out -of- pocket limit in any Calendar Year, AvMed will
pay 100% of the allowable charges for all covered services for the remainder of that Calendar Year. Expenses that do
not count toward the annual maximum out -of- pocket limit are expenses used to satisfy the individual or family
Deductible and any services provided under the Prescription Drug, Mental Health, Substance Abuse, Vision and other
supplemental riders.
7.04 Member shall pay premiums, applicable supplemental charges, Deductibles, Co- payments and/or Co- insurance as
provided in this Contract. If the Member fails to do so, upon ten (10) days written notice from AvMed to Member, the
Member's rights hereunder shall be terminated. Consideration for reinstatement with AvMed shall require a new
application, and any re- enrollment shall be at the sole discretion of AvMed and shall not be retroactive.
7.07 A Member will be entitled to covered benefits after the Member has satisfied the Deductible amount, if any, specified on
the Schedule of Benefits. After satisfying the Deductible, the Member must pay any applicable Co- insurance for
covered benefits. Covered benefits to which the Deductible applies are shown in the Schedule of Benefits. The
Deductible does not apply to certain covered benefits. In those instances, the Member must pay any applicable Co-
payments for covered benefits to which the Deductible does not apply.
AV- Deductible/Co- insurance Amendment -08
MP -3647 (3/08)
AVM prescription Drug Benefits
H E A L T H P L AN S
$20/40/60(75/50% CO- PAYMENT with Contraceptives
`Brand" medication means a Prescription Drug that is usually manufactured and sold under a name or trademark by a pharmaceutical manufacturer or a
medication that is identified as a Brand medication by AvMed. AvMed delegates determination of Generic/Brand status to our Pharmacy Benefits
Manager.
"Brand Additional Charge" means the additional charge that must be paid if you or your physician choose a Brand medication when a Generic equivalent
is available. The charge is the difference between the cost of the Brand medication and the Generic medication. This charge must be paid in addition to
the applicable Non - Preferred Brand Co- payment.
"Cost- sharing Medications" are those medications, as designated by AvMed, which were designed to improve the quality of life by treating relatively
minor non -life threatening conditions. Such medications are subject to Co- insurance and coverage is limited as outlined below.
"Dental- specific Medication" is medication used for dental- specific purposes, including but not limited to fluoride medications and medications packaged
and labeled for dental - specific purposes.
"Generic" medication means a medication that has the same active ingredient as a Brand medication or is identified as a Generic medication by AvMed's
Pharmacy Benefits Manager.
"Injeetable,Medieation" is a medication that has been approved by the Food and Drug Administration (FDA) for administration by one or more of the
following routes: intramuscular injection, intravenous injection, intravenous infusion, subcutaneous injection, intrathecal injection, intrarticular injection,
intracavemous injection or intraocular injection. Pre - Authorization is required for all Injectable Medications.
"Maintenance Medication" is a medication that has been approved by the FDA, for which the duration of therapy can reasonably be expected to exceed
one year.
"Participating Pharmacy" means a pharmacy (either retail, mail order or specialty pharmacy) that has entered into an agreement with AvMed to provide
Prescription Drags to AvMed Members and has been designated by AvMed as a Participating Pharmacy.
"Preferred Medication List" means the listing of preferred medications as determined by AvMed's Pharmacy and Therapeutics Committee based on
clinical efficacy, relative safety and cost in comparison to similar medications within a therapeutic class. This multi -tiered list establishes different levels
of Co- payment for medications within therapeutic classes. As new medications become available, they may be considered excluded until they have been
reviewed by AvMed's Pharmacy and Therapeutics Committee.
"Prescription Drug" means a medication that has been approved by the FDA and that can only be dispensed pursuant to a prescription according to state
and federal law.
"Pre- Authorization" means the process of obtaining approval for certain Prescription Drugs (prior to dispensing) according to AvMed's guidelines. The
prescribing physician must obtain approval from AvMed. The list of Prescription Drugs requiring Pre - Authorization is subject to periodic review and
modification by AvMed. A copy of the list of medications requiring Pre - Authorization and the applicable criteria are available from Member Services or
from the AvMed website.
"Self- Administered Injectable Medication" is a medication that has been approved by the FDA for self - injection and is administered by subcutaneous
injection or a medication for which there are instructions to the patient for self - injection in the manufacturer's prescribing information (package insert).
Pre - Authorization is required for all Self- Administered Injectable Medications.
HOW DOES YOUR RETAIL PRESCHIP7IUN eu111:11RUL wunn:
To obtain your Prescription Drug, take your prescription to, or have your physician call, an AvMed Participating Pharmacy. Your physician should
submit prescriptions for Self - Administered Injectable Drugs to AvMed's specialty pharmacy. Present your prescription along with your AvMed
identification card. Pay the following Co- payment (as well as the Brand Additional Charge if you or your physician choose a Brand product when a
Generic equivalent is available).
Tier I Preferred Generic Medications: $ 20.00 Co- payment
Tier 2 Preferred Brand Medications: $ 40.00 Co- payment
Tier 3 Non - Preferred Brand or Generic Medications: $ 60.00 Co- payment
Tier 4 Self - Administered Injectable Medications: $ 75.00 Co- payment
Tier 5 Cost - sharing Medications 50% Co- insurance
ORDERING YOUR PRESCRIPTIONS THROUGH THE MAIL
Mail service is a benefit option for maintenance medications needed for chronic or long -term health conditions. It is best to get an initial prescription
filled at your retail pharmacy. Ask your physician for an additional prescription for up to a 90 -day supply of your medication to be, ordered through mail
service. Up to 3 refills are allowed per prescription. Pay the following Co-payment (as well as the Brand Additional Charge if you or your physician
choose a Brand product when a Generic equivalent is available).
Tier 1 Preferred Generic Medications: $ 40.00 Co-payment
Tier 2 Preferred Brand Medications: $ 80.00 Co- payment
Tier 3 Non - Preferred Brand or Generic Medications: $ 120.00 Co- payment
Tier 4 Self - Administered Injectable Medications are not available through mail service
Tier 5 Cost - sharing Medications are not available through mail service
AV- G100- RX -2x- 20/40160/75/50 %OC -07
MP -3855 (10 /07)
Prescription Drug Benefits, continued
WHAT IS COVERED?
• Your Prescription Drug coverage includes outpatient medications (including contraceptives) that require a prescription and are prescribed by
your AvMed physician in accordance with AvMed's coverage criteria AvMed reserves the right to make changes in coverage criteria for
covered products and services. Coverage criteria are medical and pharmaceutical protocols used to determine payment of products and services
and are based on independent clinical practice guidelines and standards of care established by government agencies and medical/pharmaceutical
societies.
• Your retail Prescription Drug coverage includes up to a 30 -day supply of a medication for the listed Co- payment. Your prescription may be
refilled via retail or mail order after 75% of your previous fill has been used and subject to a maximum of 13 refills per year. You also have
the opportunity to obtain a 90 -day supply of medications used for chronic conditions including, but not limited to asthma, cardiovascular
disease, and diabetes from the retail pharmacy for the applicable Co- payment per 30 -day supply. However, Pre - Authorization may be
required for covered medications.
• Your mail -order Prescription Drug coverage includes up to a 90 -day supply of a routine maintenance medication for the listed Co-payment. If
the amount of medication is less than a 90 -day supply, you will still be charged the listed mail order Co- payment.
• Your Self- Administered Injectable Medication coverage extends to many injectable medications approved by the FDA. These medications must
be prescribed by a physician and dispensed by a retail or specialty pharmacy. The Co- payment levels for Self - Administered Injectable
Medications apply regardless of provider. This means that you are responsible for the appropriate Co- payment whether you receive your Self -
Administered Injectable Medication from the pharmacy, at the physician's office or during home health visits. Self - Administered Injectable
Medications are limited to a 30 -day supply.
• Your Prescription Drug coverage includes coverage for injectable contraceptives. There is a Co- payment of $30 for each injection. If there is
an office visit associated with the injection, there will be an additional Co- payment required for the office visit.
• Your Tier 5 coverage is limited to Terbinafine (Lamisil®) and Itraconazole (Sporanox®), in oral form, when prescribed by your physician for
the treatment of documented fungal infections. Pre- authorization is not required.
• Quantity limits are set in accordance with FDA approved prescribing limitations, general practice guidelines supported by medical specialty
organizations, and/or evidence - based, statistically valid clinical studies without published conflicting data This means that a medication-
specific quantity limit may apply for medications that have an increased potential for over - utilization or an increased potential for a Member to
experience an adverse effect at higher doses.
QUESTIONS? Cali your AvMed Member Services Department at: 1- 800 -88 -AvMed (1- 800 - 882 -8633)
EXCLUSIONS AND LIMITATIONS
• Medications which do not require a prescription (i.e. over - the - counter medications) or when a non - prescription alternative is available
• Medical supplies, including therapeutic devices, dressings, appliances, and support garments
• Replacement Prescription Drug products resulting from a lost, stolen, expired, broken, or destroyed prescription order or refill
• Diaphragms and other contraceptive devices
• Fertility drugs
• Medications or devices for the diagnosis or treatment of sexual dysfunction
• Dental - specific Medications for dental purposes, including fluoride medications
• Prescription and non - prescription vitamins and minerals except prenatal vitamins
• Nutritional supplements
• Immunizations
• Allergy serums, medications administered by the Attending Physician to treat the acute phase of an illness and chemotherapy for cancer patients
are covered in accordance with the Group Medical and Hospital Service Contract and may be subject to Co- payments or Co-insurance as
outlined on the Schedule of Benefits
• Investigational and experimental drugs (except as required by Florida statute)
• Cosmetic products, including, but not limited to, hair growth, skin bleaching, sun damage and anti - wrinkle medications
• Nicotine suppressants and smoking cessation products and services
• Prescription and non - prescription appetite suppressants and products for the purpose of weight loss
• Compounded prescriptions, except pediatric preparations
• Medications and immunizations for non - business related travel, including Transdermal Scopolamine
Filling a prescription at a pharmacy is not a claim for benefits and is not subject to the Claims and Appeals procedures under ERISA. However, any
medicines that require Pre - Authorization will be treated as a claim for benefits subject to the Claims and Appeals Procedures, as outlined in the
Group Medical and Hospital Service Contract.
AV- G100- RX -2x- 20/40/60/75/50 %OC -07
M2-3855 (10/07)
Amendment
H E A L T H P L A N S
Inpatient Mental Health and Partial Hospitalization Benefits
As of the effective date, Inpatient Mental Health and Partial Hospitalization Benefits are being provided for an additional
premium.
Inpatient treatment of mental/nervous disorders for up to 30 days per patient, subject to a member copayment of $250
per day for the first 5 days of each admission, shall be provided by the Plan when a member is admitted to a
Participating Hospital or Participating Health Care Facility as a registered bed patient.
Partial Hospitalization for mental health services is a Covered Service when it is provided in lieu of inpatient
hospitalization and is combined with the inpatient hospital benefit. Two days of Partial Hospitalization will count as
one day toward the inpatient Mental Health Benefit subject to member copayment as noted above.
AV- G100- M-1 /PH -$250 per day -04
MP -3523 (10/04)
AVMED
HE A L T H P L AN S
Substance Abuse Benefits
Amendment
As of the effective date, the following Substance Abuse Benefits have been added for an additional
premium.
. INPATIENT Inpatient treatment of alcohol and drug abuse is not provided except for acute
detoxification.
OUTPATIENT An intensive treatment program(s) of one or more weeks by Plan Physicians,
subject to a member copayment of $50 per week. Coverage is limited to a
maximum of six weeks per contract year.
AV- SA -R -98
NT- 1527 (1/04)
ANw Addendum
Coverage for Mammograms — Waiver of Co- payment
If selected, the following provision is hereby modified for an additional premium:
Section 10.28 of the AvMed Health Plans Group Medical and Hospital Service Contract is amended to state:
Mammograms are covered in accordance with Florida Statutes: one baseline mammogram is covered for female
Members between the ages of 35 and 39; a mammogram is available every two years for female Members between
the ages of 40 and 49; and a mammogram is available every year for female Members aged 50 and older.
In addition, one or more mammograms a year are available when based upon a physician's recommendation for any
woman who is at risk for breast cancer because of a personal or family history of breast cancer, because of having a
history of biopsy - proven benign breast disease, because of having a mother, sister, or daughter who has had breast
cancer, or because a woman has not given birth before the age of 30. This coverage will not be subject to
diagnostic imaging Co- payments.
AV- Mammogram -05
MP -3228 (12/05)
Amendment
nnMF1ZT1r PnRTMFR
As of the Effective Date, Part IV. ELIGIBILITY, of the Group Medical and Hospital Service Contract is
amended by the addition of the following provision:
Dependent Eligibility will be added for a Domestic Partner and his or her children.
Definition ojDomestic Partner:
A Domestic Partner means an unmarried adult who:
• Cohabits with you in an emotionally committed and affectional relationship that is meant to be of
lasting duration;
• Is not related by blood or marriage;
• Is at least eighteen years of age;
• Is mentally competent to consent to a contract;
• Has filed a Domestic Partnership agreement or registration with the Employer, if available, in the state
(and/or city) of residence;
• Has shared financial obligations including basic living expenses for the six month period prior to
enrollment in the plan;
• Will provide documentation that will be satisfactory to the Employer as evidence of a Domestic
Partner relationship; and
• Meets the dependents eligibility requirements of the Employer's health benefits plan.
AV- DP- 6 -R -02
MP -3149 (1 /04)
AyM D Amendment
H E A L T H P L A N 3
ELECTIVE TERMINATION OF PREGNANCY
If selected, the following optional coverage is hereby added:
The AvMed Health Plan Group Medical and Hospital Service Contract is amended to state:
Elective termination of pregnancy will be a covered benefit if the services and treatment are
provided by an AvMed participating provider in an AvMed participating facility. There shall be a
physician copayment of $100.00 in addition to the applicable facility copayment.
AV- G100- ETP -R -97
MR1321 (1/04)
.tE►VMED .Benefit Summar°y�
Hencrn r ,.ANS
STANDARD OPTION SCHEDULE OF BENEFITS COST TO MEMBER
250 -ADMIT
OUT -OF- POCKET MAXIMUM $1,500 INDIVIDUAL
Per Calendar Year $3,000 FAMILY
AARY CARE
PHYSICIAN
at Participating Physicians' offices include, but are not $10 per visit
limited to:
• Routine office visits / annual gynecological examination
when performed by Primary Care Physician
• Pediatric care and well -baby care
• Periodic health evaluation and immunizations
• Diagnostic imaging, laboratory or other diagnostic
services
• Minor surgical procedures
• Vision and hearing examinations for children under 18
MATERNITY CARE • Initial
Co- payment
AVMED SPECIALISTS'
• Office visits
$10 per visit
SERVICES
• Annual gynecological examination when performed by a
participating Specialty Health Care Physician
Additional Co- payments will apply if Outpatient Diagnostic
Test are performed in the Specialist Office,
HOSPITAL
Inpatient care at Participating Hospitals includes:
$250 per admission;
• Room and board - unlimited days (semi - private)
100% coverage thereafter
• Physicians', specialists' and surgeons' services
• Anesthesia, use of operating and recovery rooms,
oxygen, drugs and medication
• Intensive care unit and other special units, general and
special duty nursing
• Laboratory and diagnostic imaging
• Required special diets
• Radiation and inhalation therapies
OUTPATIENT SERVICES
Outpatient surgeries, including cardiac catheterization
$250 Co- payment
and angioplasty
• Outpatient therapeutic services, including:
• Drug infusion therapy
$100 Co- payment
• Injectable Drugs (Co- payment for Injectable $75 Co- payment
Drug waived if incidental to same -day drug
OUTPATIENT DIAGNOSTIC CAT Scan, PET Scan, MRI $25 per test
TESTS Other diagnostic imaging tests $10 per test
Co- payments for office visits will also apply if services are
performed in a Specialist's office.
EMERGENCY SERVICES An emergency is the sudden and unexpected onset of a
condition requiring immediate medical or surgical care. (Co-
payment waived if admitted)
• Emergency services at Participating Hospitals $75 Co- payment
• Emergency services at non - participating Hospitals, $100 Co- payment
facilities and/or physicians.
AvMed must be notified within 24 hours of inpatient
admission following emergency services or as soon as
reasonably possible.
AV- STD- 25OA -07
la -3411 (10 /07)
Benefit Summary, continued
URGENT/IMMEDIATE CARE • Medical Services at a participating Urgent/Immediate $40 Co- payment
Care facility or services rendered after hours in your
Primary Care Physician's office
• Medical Services at a non - participating $60 Co- payment
Ument/Immediate Care facility_
• 20 outpatient visits
$25 per visit
FAMILY PLANNING • voluntary family planning services
$ to per visit
• Sterilization (In addition to any Outpatient Facility Co-
$100 Co- payment
payment)
$25 per day
ALLERGY TREATMENTS • Injections
$10 per visit
• Skin testing
$50 per course of testing
AMBULANCE • Ambulance transport for emergency services $100 Co- payment
• Non - emergent ambulance services are covered when the
skill of medically trained personnel is required and the
Member cannot be safely transported by other means
PHYSICAL, SPEECH AND Short-term
OCCUPATIONAL THERAPIES acute cond
speech or
Coverage is limited to 30 visits per calendar year for all
for $10 per visit
Coverage is limited to 18 visits per calendar year
HOME HEALTH CARE
services combined
NO CHARGE
SKILLED NURSING
Up to 20 days post - hospitalization care per calendar year
$25 per day
FACILITIES AND
when prescribed by physician and authorized by AvMed
REHABILITATION CENTERS
• Walkers
CARDIAC REHABILITATION
Cardiac rehabilitation is covered for the following conditions:
$20 per visit
• Acute myocardial infarction
to $500 per
• Percutaneous transluminal coronary angioplasty (PTCA)
Benefits limited
• Repair or replacement of heart valves
to $1,500 per
• Coronary artery bypass graft (CABO), or
calendar year
• Heart transplant
Coverage is limited to 18 visits per calendar year
HOME HEALTH CARE
Limited to 60 skilled visits per calendar year
NO CHARGE
DURABLE MEDICAL
Equipment includes:
$50 per episode of illness
EQUIPMENT AND
• Hospital beds
ORTHOTIC APPLIANCES
• Walkers
• Crutches
Benefits limited
• Wheelchairs
to $500 per
Orthotic appliances are limited to: calendar year
• Leg, arm, back and neck custom -made braces
PROSTHETIC DEVICES Prosthetic devices are limited to: NO CHARGE
• Artificial limbs
• Artificial joints
• Ocular prostheses
FOR ADDITIONAL INFORMATION, PLEASE CALL: 1- 800 -88 -AVMED (1- 800 -882 -8633)
THIS SCHEDULE OF BENEFITS IS NOT A CONTRACT.
FOR SPECIFIC INFORMATION ON BENEFITS, EXCLUSIONS AND LIMITATIONS, PLEASE SEE YOUR AVMED GROUP
MEDICAL AND HOSPITAL SERVICE CONTRACT.
AV- STD- 250A -07
MP- 3411 (10/07)
H E A L T H PLAN 5
Classic
Point -of- Service Amendment
AvMed Health Plans Group Medical and Hospital Service Contract is hereby amended and
supplemented by the terms and conditions of this Amendment.
Nothing contained in this Amendment will be held to vary, alter, waive, or extend any of
the terms, conditions, provisions, Exclusions or Limitations of the HMO Contract to which
this Amendment is attached, other than as specifically stated herein. Furthermore, when
additional benefit riders are selected, those benefits are subject to the POS Amendment
Deductible and Co- insurance arrangements when using Non - participating Providers unless
services are specifically excluded herein.
Additionally, this. Amendment in no way extends benefits beyond what has been stated in
this Amendment and the Schedule of Point of Service Benefits or in the HMO Contract
and Schedule in terms of specific service limits or benefit maximums. This Amendment
does not create any duplication of coverage or coordination of benefits. contained in the
HMO Contract or any other riders or amendments the Subscribing Group may elect.
Point -of- Service Benefits
A Member is eligible to receive medical care and services including medical, surgical,
diagnostic, therapeutic and preventive services. Coverage is provided for health services
that are:
• Received while you are covered under this Group Plan;
• Performed, prescribed or directed by a physician;
• Medically Necessary (except for preventive services as stated herein) for the
diagnosis and treatment of injury or illness, as determined by AvMed Health
Plans; and
• Not excluded under Parts XI. and XII. or any other provision, rider or
amendment made a part of this Group Plan.
This Point -of- Service (POS) Amendment allows you to receive benefits for covered
services and supplies outside the AvMed HMO network. When medical services are
needed, you are free to obtain care from your HMO Primary Care Physician (PCP) or you
may also consult with a Health Professional of your choice. However, your
responsibilities for payment and claim filing will be greater when covered services and
supplies are accessed outside the TWO system.
You are free to choose any Health Professional when health care services are needed. By
using a Health Professional who has contracted with the AvMed Provider Network (a
Participating Provider), the benefit payment level will often be higher than that for
services or supplies provided by a Health Professional who has not contracted with the
AvMed Provider Network (a Non - participating Provider). See the HMO and POS
Schedules for more details on how these options can work best for you.
AV -POS amend- Clusic-05
MP -3530 (10105)
Classic Point -of- Service
Amendment, continued
This Point -of- Service Amendment does not eliminate the requirement that each Member
choose a PCP as outlined in the HMO Group Medical and Hospital Service Contract. If
you do not choose a PCP, one will be chosen for you at the time of enrollment. You must
continue to have certain HMO network services authorized by AvMed in order to obtain
maximum benefits under the HMO coverage. Under the POS Amendment, some services
will require your Non - participating Provider to request prior authorization as described
herein.
Benefit Payment Levels
This Point -of- Service Amendment has several special features that can influence how
much you pay out -of- pocket for medical care. Your choice of a Health Professional may
result in lower or higher costs and you will be required to follow certain procedures to
avoid additional costs. Your choice of a Health Professional and wise use of these
benefits can save you money.
This POS Amendment to the HMO Group Medical and Hospital Service Contract creates
two benefit payment levels; one for services provided by AvMed HMO Participating
Providers and a second for services provided by Non - participating Providers. The benefit
level this Group Plan will pay depends on the Health Professional you select to provide
covered health care services:
1. If the Health Professional used is part of the AvMed Health Plans Participating
Provider Network, benefits for covered services are payable at the Participating
Provider benefit level shown in the IWO Schedule of Co- payments.
2. If the Health Professional used is not part of AvMed Health Plans' Participating
Provider network, benefits for services covered under this POS Amendment are
payable at the Non - participating Provider benefit level specified in the POS
Amendment Schedule.
Services rendered by a Participating Provider are subject to the direction and
approval of AvMed or referral by an AvMed Primary Care Physician. I£ you
receive covered services through a Participating Provider which have not been
authorized by your PCP, benefits may not be payable under the HMO
Participating Provider benefit. A service may be payable under the POS
Amendment Non - participating Provider benefit if the service or supply
received is a covered service as specified in this POS Amendment and
Schedule.
AV -POS amend - Classic -05
W -3530 (10105)
Classic Point -of- Service
Amendment, continued
Cost - Sharing Information
Deductible. Before AvMed Health Plans will begin paying expenses for services covered
under this POS Amendment, you must satisfy the annual Deductible specified in the POS
Schedule. The Deductible means the amount a Member must pay each calendar year for
covered services from his or her own pocket before AvMed Health Plans will make
payment for eligible expenses. The individual Deductible or family Deductible must be
satisfied each calendar year before any payment will be made by AvMed Health Plans for
any claim.
If two or more covered members of a family incur injury due to the same accident, the
Deductible applies only once for all such expenses. If during a calendar year, the covered
members of a family incur eligible expenses for which no benefits are payable because of
the Deductible requirements and the amount of such eligible expense equals the family
Deductible limit, then no further Deductible will apply to the covered members of the
family during the remainder of such calendar year.
Any eligible expenses credited by AvMed Health Plans towards your Deductible
requirement during the last three months of this Group Plan's prior calendar year, will be
reduced to the extent of such application for the next ensuing calendar year.
Only those eligible expenses submitted on claims to AvMed Health Plans will be credited
toward the Deductible. Expenses that are not eligible will not be counted toward' the
satisfaction of the Deductible. Eligible expenses are only those expenses which are Usual,
Customary, and Reasonable as described below.
Co- insurance. Once the calendar year Deductible has been met, you are responsible for
paying a percentage of eligible expenses. The coverage percentage, hereinafter called "co-
insurance" is specified in the Schedule. You will be responsible for paying any charges
not considered an eligible expense.
Usual, Customary, and Reasonable means the usual charge made by a physician or
supplier of services, medicines, or supplies. The charge will not exceed the general level
of charges made by others rendering or furnishing such services, medicines, or supplies
within an area in which the charge is incurred for sickness or injuries comparable in
severity and nature to the sickness or injury being treated. The term "area" as it would
apply to any particular service, medicine, or supply means: a county or such greater areas
as is needed to obtain a representative cross section of level of charges.
Annual Co- insurance Maximum Out -of- Pocket Limits. Co- insurance and Co- payments
you pay for benefits received during any calendar year under this Amendment are
accumulated toward your annual Co- insurance maximum out -of- pocket limit. Once you
meet your individual or family Co- insurance maximum out -of- pocket in any calendar year,
the Plan will pay 100% of the Usual, Customary, and Reasonable charges for all covered
services for the remainder of that calendar year.
AV -POS amend - Classic -05
MP -3530 (10105)
Classic Point -of- ,service
Amendment, continued
Expenses that do not count toward the annual Co- insurance maximum out -of- pocket are
expenses related to charges for services not covered by this POS Amendment, additional
charges incurred for failure to pre- authorize a service requiring prior authorization,
expenses that relate to services that exceed any specific treatment limitations noted in the
Schedules, expenses used to satisfy the individual or family Deductible, and Co- payments
paid by you for services provided exclusively under the Group Medical and Hospital
Service Contract.
Lifetime Maximum Benefit. While this Group Plan stays in force, the eligible expenses
incurred by a Member are limited to the applicable maximum shown in the POS Schedule.
When benefits in such amount have been paid or are payable under this Amendment, all
coverage under this Amendment will terminate for the Member.
Effect of Prior Coverage. The following provision applies to Members who, on the day
before this Group Plan Effective Date, were covered under prior coverage. Prior coverage
means the policyholder's group medical plan that this Group Plan replaced. AvMed
Health Plans will automatically cover any such person under this Group Plan on its
Effective Date, subject to the following provision.
Those persons eligible according to the terms of this Group Plan will be covered at the
level of benefits of this Group Plan. This includes persons who were covered under a
continuation provision of the prior coverage to the extent it was required by state or federal
law. This continued coverage under this Group Plan will terminate on the date that
coverage would have terminated according to the law under the prior coverage, had the
prior coverage remained in force.
Deductible Carryover. Any expenses incurred by a Member while covered under the
prior coverage will be credited toward satisfaction of the Deductible under this Plan if-
The expenses were incurred during the 90 -day period before the Effective Date of
the Group Plan;
The expenses were applied toward satisfaction of the Deductible under the prior
coverage during the 90 -day period before the Effective Date of this Group Plan;
and
The expenses would be considered eligible expenses under this Group Plan.
However, in order to receive credit, you must supply evidence of satisfaction of the
Deductible under the prior coverage by providing AvMed Health Plans written proof of
what has been paid by prior coverage.
Prior Authorization of Covered Services
In order to determine whether services and supplies are Medically Necessary, certain
covered services require prior authorization from AvMed Health Plans. Prior authorization
ensures a Member of receiving the most appropriate medical care available, in the most
AV -POs amend - Classic -05
W -3530 (10 105)
Classic Point -of- Service
Amendment, continued
appropriate setting. If your physician is a Participating Provider, then he or she will handle
all authorizations, notifications and utilization reviews with AvMed Health Plans.
If your doctor is not a Participating Provider, you are responsible for making sure your
physician or Health Professional calls AvMed Health Plans to obtain prior authorization
for a covered service when it is required. Please refer to your Member ID card for the
telephone number where authorization may be obtained, or have your physician call 1 -800-
443 -4103.
Before the service is performed, you should verify with your Provider that the service has
received prior authorization. If you are unable to secure verification from your provider,
you may also call AvMed Health Plans. Please remember that failure to receive prior
authorization of a service will result in a reduction in coverage. The. amount of the
reduction can be found in the POS Schedule.
The following services require prior authorization:
Inpatient admissions (Hospital, Skilled Nursing Facility, and /or acute
rehabilitation).
Inpatient and outpatient surgery, including cardiac catheterization and
percutaneous transluminal coronary angioplasty (PTCA).
PET Scans.
It is important to remember that benefits for Hospital admissions not authorized in
advance will be reduced by the amount shown in the POS Schedule. This reduction will
occur regardless of whether such confinements are deemed Medically Necessary. If
hospitalization is extended without authorization beyond the number of days approved,
benefits for the extra days will be similarly reduced.
Exclusions and Limitations
The benefit Exclusions and Limitations specified in the Group Medical and Hospital
Service Contract are also applicable to the benefits specified in this POS Amendment.
Additionally, services not covered under this Point -of- Service Amendment include:
• Services provided exclusively under the Group Medical and Hospital Service
Contract.
• Second medical opinions are covered exclusively through the HMO portion of
the benefits and are not available as point -of- service benefits.
• Transplantation services must be authorized by AvMed and provided
exclusively through the HMO network. However, any follow -up care managed
by a Participating Provider outside of the AvMed Service Area will be subject
to the out -of- network benefit and reimbursement.
• Any applicable prescription benefits are available only under the HMO portion
of coverage. They are not available as out -of- network benefits.
Av -POS mend- Classic -05
W -3530 (10105)
Classic Point -of- Service
Amendment, continued
• Hospice services.
• Dialysis care.
• Ambulance services.
• Voluntary family planning services, sterilization, infertility evaluation and
medical treatment, surgery for the enhancement of fertility and genetic
counseling.
• Emergency Medical Services and Care for an Emergency Medical Condition.
Emergency services administered by any provider will be covered under
the HMO Contract benefits. In order for the care to be covered under the
HMO, AvMed must be notified as described in Section 10.12 of the Group
Medical and Hospital Service Contract. If notification is not provided as
specified under the HMO contract, services may be payable under the POS
Amendment if the service or supply received is a covered service as specified
in this POS Amendment and Schedule.
• Durable medical equipment, orthotic appliances and prosthetic devices are
limited to those items specified in the POS Schedule. In addition, custom
wheelchairs, electric wheelchairs and scooters must be authorized by AvMed
and provided by the HMO network.
Payment of Claims
When you receive services from a Non - participating Provider, the provider must bill
AvMed Health Plans directly for the services rendered, and you will pay the doctor
directly all or part of the annual Deductible, if not satisfied, and the required percentage of
Co- insurance. You must also comply with the following claim firing procedures when
receiving covered services from Non - participating Providers.
Notice of Claim. Notice of a claim for benefits must be given to AvMed Health Plans.
The notice must be in writing, and any claim will be based on that written notice. The
notice must be received by AvMed within six months after the start of the loss on which
the claim is based. If notice is not given in time, the claim may be reduced or invalidated.
If it can be shown that it was not reasonably possible to submit the notice within the six
month period and that notice was given as soon as possible, the claim will not be reduced
or invalidated.
When written notice is required under this Plan, it shall be mailed to:
AvMed Health Plans
P. O. Sox 560844
Miami, Florida 33156
You should call 1- 800 - 882 -8633 if assistance is needed regarding a claim or information
about coverage.
AV -POS amend- Classic -05
W -3530 (]0(05) 6
Classic Point -of-- .Service
Amendment, continued
Proof of Loss. Written proof of loss must be given to AvMed Health Plans within six
months after the date of injury or sickness for which claim is made. If it was not
reasonably possible to give written proof in the time required, we will not reduce or deny
the claim for this reason if the proof is filed as soon as reasonably possible.
Legal Actions. No legal action may be brought to recover under this Amendment until at
least 60 days after written proof of claim has been filed with AvMed Health Plans. if such
action is taken after the 60 -day period, it must be taken prior to the expiration of the statute
of limitations from the date written proof of claim was required to be filed.
overview — Member Responsibilities When Receiving Covered Services
Responsibilities when using Participating Providers. All paperwork is handled by
Participating Providers, so there are no bills for you to submit to AvMed Health Plans.
However, it is your responsibility to:
1. Verify the participation status of (a) the Health Professional who prescribes the
treatment, and (b) the Health Professional who provides the covered service.
2. Pay the applicable Co- payment or Co- insurance at the time of service.
Responsibilities whennsing Non - participating Providers:
i
1. Know which covered services require prior authorization and comply with all
requirements specified in this Amendment.
2. Pay eligible expenses applied toward satisfaction of the Deductible. The
Deductible must be satisfied before benefits begin.
3. Pay the Co- insurance amount required.
4. Pay any amount of eligible expense which exceeds the Usual, Customary, and
Reasonable charges.
5. Pay any increase in Co- insurance if prior authorization requirements are not
followed as stated in this Amendment.
6. Pay any charges for services and supplies not covered under this Amendment.
7. You must complete and submit claim forms and provider bills to AvMed Health
Plans.
AV -POS amend- Cimic -05
W -3530 (10 /05)
AvMED
H E A L T H PLANS
POINT -OF- SERVICE
BENEFITS
Benefit ,summary
SCHEDULE OF
OUT -OF- NETWORK BENEFITS
COST TO MEMBER
DEDUCTIBLE INDIVIDUAL/FAMILY $500 /$1,500 Annually
CO- INSURANCE OUT -OF- INDIVIDUAL/FAMILY $3,000/$6,000 Annually
POCKET MAXIMUM
LIFETIME MAXIMUM $2,000,000 PER MEMBER
PRIOR AUTHORIZATION Required for specific covered services. The penalty for not obtaining
prior authorization is a 20% reduction in benefits.
PHYSICIAN Services in physicians' offices include, but are not limited to: 30% of the UCR charge,
• Routine office visits /annual gynecological exam when subject to the Deductible
performed by Primary Care Physician
• Maternity- outpatient visits
• Pediatric care and well -child care
• Diagnostic imaging, laboratory or other diagnostic services
• Minor surgical procedures
• Vision and hearing examinations for children under 18
SPECIALISTS' SERVICES . Office visits 30% of the UCR charge,
• Annual gynecological examination when performed by a subject to the Deductible
participating Specialty Health Care Physician
Additional Co- payments will apply if Outpatient Diagnostic Test are
performed in the Specialist Office.
HOSPITAL Inpatient care at Hospitals includes: 30% of the UCR charge,
• Room and board — unlimited days (semi - private) subject to the Deductible
• Physicians', specialists' and surgeons' services
• Anesthesia, use of operating and recovery rooms, oxygen, drugs
and medication
• Intensive care unit and other special units, general and special
duty nursing
• Laboratory and diagnostic imaging
• Required special diets
OUTPATIENT SERVICES
. Outpatient surgeries, including cardiac catheterizations and
30% of the UCR charge,
angioplasty
subject to the Deductible
-
• Outpatient therapeutic services, including:
• Drug infusion therapy
• Injectable drugs (Co- payment for Injectable Drug
waived if incidental to same -day drug infusion therapy)
OUTPATIENT DIAGNOSTIC
. CAT Scan, PET Scan, MRI
30% of the UCR charge,
TESTS
. Other diagnostic imaging tests
subject to the Deductible
Co- payments for office visits will also apply if services are
performed in a Specialist's office.
MENTAL HEALTH
. 20 outpatient visits
30% of the UCR charge,
subject to the Deductible
If mental health/substance abuse benefit riders are elected, benefits
are subject to POS rider Deductible and Co- insurance arrangements
when using Non - participating Providers. Specified service limits are
the total number of covered visits for both in and out -of- network,
combined.
AV -POS- 500/30/3000 -07
MP- 3440 (10 /07)
Benefit Summary, continued
ALLERGY TREATMENTS . Iniections 30% of the UCR charge,
PHYSICAL, SPEECH AND . Short-term physical, speech or occupational therapy for acute 30% of the UCR charge,
OCCUPATIONAL THERAPIES conditions subject to the Deductible
Coverage is limited to 30 visits per calendar year for all services
combined
SKILLED NURSING FACILITIES . Up to 20 days per calendar year when prescribed by physician 30% of the UCR charge,
AND REHABILITATION and authorized by AvMed subject to the Deductible
CARDIAC REHABILITATION Cardiac Rehabilitation is covered for the following conditions:
$20 per visit
• Acute myocardial infarction
• Percutaneous transluminal coronary angioplasty (PTCA)
Benefits limited to $1,500 per
• Repair or replacement of heart valves
calendar year
• Coronary artery bypass graft (CABO), or
• Heart transplant
Coverage is limited to 18 visits per calendar year
HOME HEALTH CARE Limited to 60 skilled visits per calendar year
30% of the UCR charge,
subject to the Deductible
DURABLE MEDICAL Equipment includes:
EQUIPMENT AND . Hospital beds
ORTHOTIC APPLIANCES • Walkers
• Crutches
• Wheelchairs
Ortbotic appliances are limited to:
• Leg, arm, back and neck custom -made braces
$50 per episode of illness
Benefits limited to $500 per
calendar year
PROSTHETIC DEVICES Prosthetic devices are limited to: 30% of the UCR charge,
• Artificial limbs subjectto the Deductible
• Artificial joints
• Ocular prostheses
THIS SCHEDULE IS NOT A CONTRACT.
FOR SPECIFIC INFORMATION ON BENEFITS, EXCLUSIONS AND LIMITATIONS PLEASE CONSULT
YOUR GROUP MEDICAL AND HOSPITAL SERVICE CONTRACT AND POINT -OF- SERVICE AMENDMENT.
AV- POS- 500/30/3000 -07
MP- 3440 (10107)
AWprescription Drug Benefits
(k9ni 0/R0i75/50% CO- PAYMENT with Contraceptives
"Brand" medication means a Prescription Drug that is usually manufactured and sold under a name or trademark by a pharmaceutical manufacturer or a
medication that is identified as a Brand medication by AvMed AvMed delegates determination of Generic/Brand status to our Pharmacy Benefits
Manager.
"Brand Additional Charge" means the additional charge that must be paid if you or your physician choose a Brand medication when a Generic equivalent
is available. The charge is the difference between the cost of the Brand medication and the Generic medication. This charge must be paid in addition to
the applicable Non - Preferred Brand Co- payment.
"Cost- sbaring Medications'' are those medications, as designated by AvMed, which were designed to improve the quality of life by treating relatively
minor non -life threatening conditions. Such medications are subject to Co- insurance and coverage is limited as outlined below.
"Dental- specific Medication" is medication used for dental - specific purposes, including but not limited to fluoride medications and medications packaged
and labeled for dental- specific purposes.
"Generic" medication means a medication that has the same active ingredient as a Brand medication or is identified as a Generic medication by AvMed's
Pharmacy Benefits Manager.
"Injectable Medication" is a medication that has been approved by the Food and Drug Administration (FDA) for administration by one or more of the
following routes: intramuscular injection, intravenous injection, intravenous infusion, subcutaneous injection, intrathecal injection, intrarticular injection,
intraeavemous injection or intraocular injection. Pre - Authorization is required for all Injectable Medications.
"Maintenance Medication" is a medication that has been approved by the FDA, for which the duration of therapy can reasonably be expected to exceed
one year.
"Participating Pharmacy" means a pharmacy (either retail, mail order or specialty pharmacy) that has entered into an agreement with AvMed to provide
Prescription Drugs to AvMed Members and has been designated by AvMed as a Participating Pharmacy.
"Preferred Medication List" means the listing of preferred medications as determined by AvMed's Pharmacy and Therapeutics Committee based on
clinical efficacy, relative safety and cost in comparison to similar medications within a therapeutic class. This multi- tiered list establishes different levels
of Co- payment for medications within therapeutic classes. As new medications become available, they may be considered excluded until they have been
reviewed by AvMed's Pharmacy and Therapeutics Committee.
"Prescription Dmg" means a medication that has been approved by the FDA and that can only be dispensed pursuant to a prescription according to state
and federal law.
"Pre- Authorization" means the process of obtaining approval for certain Prescription Drags (prior to dispensing) according to AvMed's guidelines. The
prescribing physician must obtain approval from AvMed. The list of Prescription Drugs requiring Pre - Authorization is subject to periodic review and
modification by AvMed. A copy of the list of medications requiring Pre-Authorization and the applicable criteria are available from Member Services or
from the AvMed website.
"Self- Administered Injectable Medication" is a medication that has been approved by the FDA for self - injection and is administered by subcutaneous
injection or a medication for which there are instructions to the patient for self-injection in the manufacturer's prescribing information (package insert).
Pre- Authorization is required for all Self- Administered Injectable Medications.
HOW DOES YOUR RETAIL PRESCRIPTION WlItnnut Wunn:
To obtain your Prescription Drug, take your prescription to, or have your physician call, an AvMed Participating Pharmacy. Your physician should
submit prescriptions for Self- Administered Injectable Drugs to AvMed's specialty pharmacy. Present your prescription along with your AvMed
identification card. Pay the following Co- payment (as well as the Brand Additional Charge if you or your physician choose a Brand product when a
Generic equivalent is available).
Tier 1 Preferred Generic Medications: $ 20.00 Co- payment
Tier 2 Preferred Brand Medications: $ 40.00 Co- payment
Tier 3 Non - Preferred Brand or Generic Medications: $ 60.00 Co- payment
Tier 4 Self - Administered Injectable Medications: $ 75.00 Co- payment
Tier 5 Cost - sharing Medications 50% Co- insurance
ORDERING YOUR PRESCRIPTIONS THROUGH THE MAIL
Mail service is a benefit option for maintenance medications needed for chronic or long -term health conditions. It is best to get an initial prescription
filled at your retail pharmacy. Ask your physician for an additional prescription for up to a 90 -day supply of your medication to be ordered through mail
service. Up to 3 refills are allowed per prescription. Pay the following Co- payment (as well as the Brand Additional Charge if you or your physician
choose a Brand product when a Generic equivalent is available).
Tier I Preferred Generic Medications: $ 40.00 Co- payment
Tier 2 Preferred Brand Medications: $ 80.00 Co- payment
Tier 3 Non - Preferred Brand or Generic Medications: $ 120.00 Co- payment
Tier 4 Self- Administered Injectable Medications are not available through mail service
Tier 5 Cost- sharing Medications are not available through mail service
AV- GI00- RX -2x- 20/40/60/75/50" / OC -07
MP- 3855 (10/07)
Prescription Drug Benefits, continued
WHAT IS COVERED?
• Your Prescription Drug coverage includes outpatient medications (including contraceptives) that require a prescription and are prescribed by
your AvMed physician in accordance with AvMed's coverage criteria. AvMed reserves the right to make changes in coverage criteria for
covered products and services. Coverage criteria are medical and pharmaceutical protocols used to determine payment of products and services
and are based on independent clinical practice guidelines and standards of care established by government agencies and medical/pharmaceutical
societies.
• Your retail Prescription Drug coverage includes up to a 30 -day supply of a medication for the listed Co- payment. Your prescription may be
refilled via retail or mail order after 75% of your previous fill has been used and subject to a maximum of 13 refills per year. You also have
the opportunity to obtain a 90 -day supply of medications used for chronic conditions including, but not limited to asthma, cardiovascular
disease, and diabetes from the retail pharmacy for the applicable Co- payment per 30 -day supply. However, Pre - Authorization may be
required for covered medications.
• Your mail -order Prescription Drug coverage includes up to a 90 -day supply of a routine maintenance medication for the listed Co- payment. If
the amount of medication is less than a 90-day supply, you will still be charged the listed mail order Co- payment.
• Your Self - Administered Injectable Medication coverage extends to many injectable medications approved by the FDA. These medications must
be prescribed by a physician and dispensed by a retail or specialty pharmacy. The Co-payment levels for Self - Administered Injectable
Medications apply regardless of provider. This means that you are responsible for the appropriate Co- payment whether you receive your Self -
Administered Injectable Medication from the pharmacy, at the physician's office or during home health visits. Self- Administered Injectable
Medications are limited to a 30 -day supply.
• Your Prescription Drug coverage includes coverage for injectable contraceptives. There is a Co- payment of $30 for each injection. If there is
an office visit associated with the injection, there will be an additional Co- payment required for the office visit.
• Your Tier 5 coverage is limited to Terbinafine (Lamisil®) and Itraconazole (Sporanox®), in oral form, when prescribed by your physician for
the treatment of documented fungal infections. Pre - authorization is not required.
• Quantity limits are set in accordance with FDA approved prescribing limitations, general practice guidelines supported by medical specialty
organizations, and/or evidence-based, statistically valid clinical studies without published conflicting data. This means that a medication -
specific quantity limit may apply for medications that have an increased potential for over - utilization or an increased potential for a Member to
experience an adverse effect at higher doses.
QUESTIONS? Call your AvMed Member Services Department at: 1- 800 -88 -AvMed (1- 800 - 882 -8633)
EXCLUSIONS AND LIMITATIONS
• Medications which do not require a prescription (i.e. over - the - counter medications) or when a non - prescription alternative is available
• Medical supplies, including therapeutic devices, dressings, appliances, and support garments
• Replacement Prescription Drug products resulting from a lost, stolen, expired, broken, or destroyed prescription order or refill
• Diaphragms and other contraceptive devices
• Fertility drugs
• Medications or devices for the diagnosis or treatment of sexual dysfunction
• Dental- specific Medications for dental purposes, including fluoride medications
• Prescription and non- prescription vitamins and minerals except prenatal vitamins
• Nutritional supplements
• Immunizations
• Allergy serums, medications administered by the Attending Physician to treat the acute phase of an illness and chemotherapy for cancer patients
are covered in accordance with the Group Medical and Hospital Service Contract and may be subject to Co- payments or Co- insurance as
outlined on the Schedule of Benefits
• Investigational and experimental drugs (except as required by Florida statute)
• Cosmetic products, including, but not limited to, hair growth, skin bleaching, sun damage and and- wrinkle medications
• Nicotine suppressants and smoking cessation products and services
• Prescription and non - prescription appetite suppressants and products for the purpose of weight loss
• Compounded prescriptions, except pediatric preparations
• Medications and immunizations for non - business related travel, including Transdermal Scopolamine
Filling a prescription at a pharmacy is not a claim for benefits and is not subject to the Claims and Appeals procedures under ERISA. However, any
medicines that require Pre - Authorization will be treated as a claim for benefits subject to the Claims and Appeals Procedures, as outlined in the
Group Medical and Hospital Service Contract,
AV- G100- RX -2x- 20/40/60/75/50 %OC -07
W- 3855(10/07)
Ay ED Amendment
H E A L T H P L A N S
Inpatient Mental Health and Partial Hospitalization Benefits
As of the effective date, Inpatient Mental Health and Partial Hospitalization Benefits are being provided for an additional
premium.
Inpatient treatment of mental /nervous disorders for up to 30 days per patient, subject to a member copayment of $250
per admit, shall be provided by the Plan when a member is admitted to a Participating Hospital or Participating Health
Care Facility as a registered bed patient.
Partial Hospitalization for mental health services is a Covered Service when it is provided in lieu of inpatient
hospitalization and is combined with the inpatient hospital benefit. Two days of Partial Hospitalization will count as
one day toward the inpatient Mental Health Benefit subject to member copayment as noted above.
AV- G100 -MH/PH -$250 per admit -04
MP -3522 (10/04)
MMMED
HEALTH PLA fJs
Snhstanra Ahuse Benefits
Amendment
As of the effective date, the following Substance Abuse Benefits have been added for an additional
premium.
• INPATIENT Inpatient treatment of alcohol and drug abuse is not provided except for acute
detoxification.
• OUTPATIENT An intensive treatment Program(s) of one or more weeks by Plan Physicians,
subject to a member copayment of $50 per week. Coverage is limited to a
maximum of six weeks per contract year.
AV- SA -R -98
MP- 1527 (1/04)
AWAddendum
Coverage for Mammograms — Waiver of Co- payment
If selected, the following provision is hereby modified for an additional premium:
Section 10.28 of the AvMed Health Plans Group Medical and Hospital Service Contract is amended to state:
Mammograms are covered in accordance with Florida Statutes: one baseline mammogram is covered for female
Members between the ages of 35 and 39; a mammogram is available every two years for female Members between
the ages of 40 and 49; and a mammogram is available every year for female Members aged 50 and older.
In addition, one or more mammograms a year are available when based upon a physician's recommendation for any
woman who is at risk for breast cancer because of a personal or family history of breast cancer, because of having a
history of biopsy - proven benign breast disease, because of having a mother, sister, or daughter who has had breast
cancer, or because a woman has not given birth before the age of 30. This coverage will not be subject to
diagnostic imaging Co- payments.
AV- Mammogram -05
MP- 3228 (12/05)
AVED Amendment
Durable Medical Equipment
If selected, the following coverage is hereby modified, for an additional premium.
DURABLE MEDICAL EQUIPMENT
Benefits are limited to a maximum of $2,000 per contract year *.
All other coverage provisions, including co- payment, limitations and exclusions remain
as stated in the Certificate of Coverage or Schedule of Co- Payments.
*For the treatment of diabetes, coverage for an infusion pump will not apply toward the
annual maximum limitation and shall not be subject to the durable medical equipment
benefit limitation.
AV- G100 -DME- 2000 -R -06
MP -2149 (4 -06)
AV�I�IED
HEX LTn PLANS Amendment
nnmV4ZT1P PARTNER
As of the Effective Date, Part IV. ELIGIBILITY, of the Group Medical and Hospital Service Contract is
amended by the addition of the following provision:
Dependent Eligibility will be added for a Domestic Partner and his or her children.
Definition of Domestic Partner.
A Domestic Partner means an unmarried adult who:
• Cohabits with you in an emotionally committed and affectional relationship that is meant to be of
lasting duration;
• Is not related by blood or marriage;
• Is at least eighteen years of age;
• Is mentally competent to consent to a contract;
• Has filed a Domestic Partnership agreement or registration with the Employer, if available, in the state
(and/or city) of residence;
• Has shared financial obligations including basic living expenses for the six month period prior to
enrollment in the plan;
• Will provide documentation that will be satisfactory to the Employer as evidence of a Domestic
Partner relationship; and
• Meets the dependents eligibility requirements of the Employer's health benefits plan.
AV- DP- 6 -R -02
MP -3149 (1/04)
H EA LT rt PLAN$ Amendment
F1 MTRIF TFRMINATIGN OF PREGNANCY
If selected, the following optional coverage is hereby added:
The AvMed Health Plan Group Medical and Hospital Service Contract is amended to state:
Elective termination of pregnancy will be a covered benefit if the services
provided by an AvMed participating provider in an AvMed participating facility
physician copayment of $100.00 in addition to the applicable facility copayment.
AV- GI00- ETP -R -97
MP -1321 (1/04)
and treatment are
. There shall be a