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08-07-07 Item 8To: The Honorable Mayor & Members of the City Commission Via: Yvonne S. McKinley, City Manager From: Jeanette Enrizo, Human Resource Manager Human Resource Date: August 7, 2007 Agenda 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 HEALTHCARE TO PROVIDE GROUP HEALTH INSURANCE FOR CITY OF SOUTH MIAMI FULL TIME EMPLOYEES; PROVIDING FOR AN EFFECTIVE DATE. Reason/Need: We have received renewal rates from our current group health insurance carrier, AVMED, wherein they quoted a (16.9 %) percent increase in premiums from current rates. The reason for this increase was due to the claims. The City had $800,746 in claims and actually paid $579,960 in premiums. Although, the increase was much lower considering the claims ratio, 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 Declined to quote HUMANA Declined to quote NHP Submitted) proposal UNITED HEALTH CARE Submitted proposal VISTA Submitted) proposal Although AVMED presented the renewal rate, it was requested to provide the City with possible alternatives (changes in benefit plan design) that would reduce the premiums renewal rate. AVMED offered two options, the current plan design and an alternative plan design with reduced benefits. The City Commission reviewed in detail both alternatives and recommended that the Triple Option Plan be offered to the employees. This Triple Option rates are stated below: Page; 3 of 4 Page,2 Health Cover Memo (HMO) $347.57 (City portion) $615.20 $684.71 $1025.33 (RENEWAL ENHANCED HMO) $403.32 $713.87 $794.54 $1189.79 (POS) $469.25 $830.57 $924.41 $1384.28 With the Triple Option, the City would cover the employee rate of $347.57 which is a 1.008 % ($4,170) increase annually instead of the 16.9 % ($87,795) increase annually. Changing the Benefit Plan Design would be a reduced cost savings to the City from the renewal rate. Cost: Funding Source: As budgeted for each department. Backup Documentation: U Proposed Resolution U Proposals from Insurance Vendors U AVMED Contract Page 4 of 4 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 RESOLUTION NO.: 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 HEALTHCARE TO PROVIDE GROUP HEALTH INSURANCE FOR CITY OF SOUTH MIAMI FULL TIME EMPLOYEES; PROVIDING AN EFFECTIVE DATE. WHEREAS, the City's Agent of Record received the health insurance renewal rates for Av Med wherein the carrier proposed a (16.9 %) increase in premiums; and WHEREAS, the Agent of Record recommended that we review all insurance carriers that are currently on the market to ensure that we are being offered the most competitive rates; and WHEREAS, the Agent of Record also requested changes in current plan design that would reduce benefits as well as reduce premium rate for the upcoming year; and WHEREAS, the City Commission compared the insurance rates, benefit plan designs, provider network as well as our previous claims experience /ratio; and WHEREAS, after careful review, the City Commission recommended renewing with Av Med offering an alternative to the current plan (Triple Option Plan); and WHEREAS, the Triple Option Plan included an HMO plan with a change in the plan design which reduced the renewal increase from (16.9 %) to (1.08 %); and, WHEREAS, with the selection of Av Med Health Care, 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, 2007 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. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 Section 3. This resolution shall take effect immediately upon approval. PASSED AND ADOPTED this _ day of , 2007. ATTEST: CITY CLERK READ AND APPROVED AS TO FORM: CITY ATTORNEY .APPROVED: ZE _•� COMMISSION VOTE: Mayor Horace Feliu: Vice Mayor Randy G. Wiscombe: Commissioner Marie Birts: Commissioner Velma Palmer: Commissioner Jay Beckman: Page 2 of 4 4' TABLE OF CONTENTS Executive Summary II. Proposed Medical Rates III. HMO Benefit Comparison IV. POS Benefit Comparison V. AvMed — Triple Option 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 The renewal increase with AvMed is 16.9% (without any plan design changes). From 2/1/06- 1/31/07 the City of South Miami had a 138% loss ratio with AvMed (i.e. for every $1.00 of premium AvMed paid $1.38 in claims). During this time period the City had $800,746 in claims vs. $579,960 in premium. Four plan participants had claims in excess of $50,000 ($125,077, $69,661, $57,871, and $55,214). From a plan design standpoint we are recommending a Triple Option plan with AvMed: ■ HMO ■ Enhanced HMO ■ Point -of- Service Under this scenario the City could base their contribution amount on the HMO "employee" rate. Employees would pay the entire premium amount for any additional coverage beyond the HMO "employee" rate. Aetna and Neighborhood Health Partnership submitted proposals that warrant further consideration. 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. 1 Employee Benefits Consulting Group Proposal Responses Vendor Name Response Aetna Submitted a proposal. AvMed Submitted a proposal. Blue Cross /Blue Shield Declined to quote. CIGNA HealthCare Declined to quote. Humana Declined to quote. Neighborhood Health Partnership Submitted a proposal. United HealthCare Submitted a proposal. Vista Submitted a proposal. 1111r,"MNINIElb lap=" 2 Employee Benefits Consulting Group AvMed Health Plan Large Group Financial Review Comparison City of South Miami - Statewide Incurred: Paid: Member Months Premium Revenue Primary Care FFS Specialist FFS Total Physician Expense February 01, 2006 through January 31,2007 April 30, 2007 % Of Total PMPM Revenue Z, "I y "I 579,960 $264.70 100.00% 26,480 $12.09 4.57% 201,834 $92.12 34.80% 228,314 $104.21 39.37% Hospital Inpatient 1156,825 $71.58 27.04% Hospital Outpatient 237,301 $108.31 40.92% Emergency Room 59,132 $26.99 10.20% DME 6,209 $2.83 1.07% Home Health 730 $0.33 0.13% Prescription Drugs 76,279 $34.81 13.15% Extended Care Facilities 14,703 $6.71 2.54% Laboratory Capitation 2,872 $1.31 0.50% Reinsurance Premium 6,792 $3.10 1.17% Other Medical 11,589 $5.29 2.00% Total Medical Expenses 1 800,7461 365.47 138.07% 'O N CO CD C�1 b r O A A A p A rr n O p m p K p 04 O p b 3 m � Z o '�* -o mmmml O mmmmll_ = o D mmmmo m mmmmlK -�O W N W -0 S as y m'< aaaa aaaa OCD asaa aaaa O O. 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O c co co m cc N A 69 CD M X ffl -69 CA N cn EA Efl ffl W 0 4A lw w ffl v CA W -4 O AO 0 0 0 W U1 m CT O O UI A 0 0 0 00 00 Z CD l< A A A A o 0 0 0 a -0 o (D CD A Di d d w w m 0 1 <• CL w w CD C O a° 3 << 3 T N N O -h CL UJ c CD N Efl Z) O 0 w �� O O O 0 0 0 0 O Ut A A A A A < ° ° 0 V O O O O O p CD C Z a -a o a CD CD CD C0D 0 N 0 aaaa �G » * * * N lD 3.0 N CD 3 0 Cl) 0 0 0 AvMED HEALTH PLAINS Benefit Summary LARGE GROUP SCHEDULE OF BENEFITS COST TO MEMBER $1 5/$250/$1,500/20% Annual gynecological examination when performed by a 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 $1,50013,000 annually Per Calendar Year The Out -of- Pocket Maximum includes Co payments and Co- • _ insurance amounts unless otherwiise excluded AVMED PRIMARY CARE Services at Participating Physicians' offices include, but are not $15 per visit PHYSICIAN limited to: duty nursing ■ Routine office visits /annual gynecological examination when • Laboratory and diagnostic imaging performed by Primary Care Physician • Required special diets ■ Pediatric care and well -child care • Radiation and inhalation therapies ■ Periodic health evaluation and immunizations OUTPATIENT SERVICES ■ Outpatient surgeries, including cardiac catheterizations and ■ Diagnostic imaging, laboratory or other diagnostic services angioplasty ■ Minor surgical procedures • Outpatient therapeutic services, including: ■ 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 m Annual gynecological examination when performed by a participating Specialty Health Care Physician 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 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 URGENT /IMMEDIATE 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 Care $60 Co- payment r _:i_- A V -LG- 15/250/ 1500/20 % -06 MP- 3990(10/06) Benefit Summary, continued FAMILY PLANNING ■ Voluntary family planning services $15 per visit _ 0 Sterilization $250 Co- payment MENTAL HEALTH • 20 outpatient visits _ $25 per visit ALLERGY TREATMENTS ■ Injections $15 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 to $1,500 per medically trained personnel is required and the Member cannot Calendar Year be safely transported by other means PHYSICAL, SPEECH, AND Short-term physical, speech or occupational therapy for acute $15 per visit OCCUPATIONAL THERAPIES conditions 20% of the contracted Coverage is limited to 30 visits per calendar year for all services combined SKILLED NURSING 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: 20% of the contracted EQUIPMENT AND w Hospital beds rate after Deductible ORTHOTIC APPLIANCES • Walkers ■ Crutches Benefits limited • Wheelchairs to $2,000 per Orthotic appliances are limited to: Calendar Year ■ Leg, arm, back, and neck custom -made braces PROSTHETIC DEVICES Prosthetic devices are limited to: 20% of the contracted ■ Artificial limbs rate after Deductible ■ 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 CONSULT YOUR AVMED GROUP MEDICAL AND HOSPITAL SERVICE CONTRACT. A V -LG- 15/250/ 1500/20 % -06 MP- 3990(10/06) ,jroup Medical & Hospital Service Contract THE RIGHT 1 o your employees AvMED H E A L T 11 P i A N S Contract Number(s): Subscribing Group Name. Effective Date: Group Contract AVIVIED, INC. d /b /a AVIVIED Health Plans Group Medical and Hospital Service Contract Group Master Application new # City Of South Miami 10101107 This Group Contract provides the benefits listed .below. Identifier AV LG- 1.5/25011500/20 % -06 AV- Deductible/Co- insurance Amendment-06. AV- LG- RX- 2x- 15/30/50f75/50% -OC -06 AV- G'100 -MH /PH -$250 per day -04 AV -SA -9B AV -G I OO -DM E- 2000) -R -0.6 AV-STUDENT ELIGIBILITY -R -02 AV- DP- 6 -R -02 AV- G'100- ETP -R -97 AV- Mammogram -05 i_Ilaiblllty Description Summary of Benefits Dad & Co -ins Prescription Drug I Mental Health Substance Abuse Durable Mad, Equip. Student Eligibility Domestic Partner ETOP Mammogram `& Active Employees (Class 1) are required to work 25 hours.per weekto become eligible forcoverage under this Contract. Employees will become eligible for coverage on the first of the month following the first day of employment. Active Employees (Class 2) are required to work 25 hours'per week to becorne eligible for coverage under this Contract. Employees will become eligible for coverage on the first of the month following the first day of employment. Termination For Active Employees (Class 1), termination of coverage .under this Contract shall become effective End of Month. For Active Employees (Class 2), termination of coverage under this Contract shall become effective End of Month. Monthlv Membershlp Charaes SubscriberOnly ....... :........ ............. :.............. :.:...._ .....:...... .... : ....... .................. Subscriberplus Spouse :...... .......:........... .....:....:........ ............ ............. .....:.... ........... : , :......::.... Subscriber plus One Dependent (No Spouse)........ ................. .... ....... ....... .................... .................. Subscriber plus Two or More Dependents ...... .. ....................................... .............. ... ................. ___ Subscriber plus Spouse and One or More Dependents .................................... ............................... AV MasterAppficatian -07 MP-2027(110T) $347.57 $684.71 $615.20 $615.20 $1,025.33 AVMED, INC. d /b /a AVMED Health Plans Group Medical and Hospital Service Contract Group Master Application, continuer) Agreement This Contract is issued in consideration of the Master Application of the Subscribing Group for group medical and hospital services and the monthly prepayment subscription charges and the mutual promises and benefits between AVMED; Inc. d /b /a AVMED Health Plans and the Subscribing Group. This Contract shall remain in effect for a period of twelve (12) months from the effective date of October 1, 2007 and may be renewed annually, not later than the anniversary date, upon mutual agreement of the parties. This. Contract period begins at 12;01 a.m. Eastern Standard Time on the effective date or on the anniversary date; if a renewal. The Contract shail be governed by Chapter 641, Florida Statutes, and other applicable State and Federal laves: The first monthly .payment is due on October 1, 2007. Subsequent payments are due on the 1st day of each month thereafter. 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 OF THE THIRD DEGREE. The provisions contained in the Schedule of Benefits applicable to this Contract and all Exhibits and Amendments executed. bythe parties and attached hereto are, by reference, made a part of this Contract. AGREED TO AND ACCEPTED BY the parties the day and. year hereinafter written. The Effective Date of this Contract is October 1, 2007. Subscribing Group: Ctty Of South Miami By: Signature Name Title Date: AV- Master Apprication -07 MP -2027 6107) AVMED, Inc. d /b /A AVMED Health Plans (ff~ ! c� By: Signat . iEvis Clavareza, Name J;ii- ec;tor, Client Service Date: Title Id AVNIED Benefit Summary ffi-i�i T11- FT —A-N--S LARGEGROUP SCHEOULE OF BENEFITS COST TO MEMBER $1164250111500/20% CALENDAR YEAR INDIVIDUAL /FAMILY $21-90/$750 annually DEDUCTIBLE The Deductible does not apply toward the Out-qf-Pocket. Aftwinfum OUT-OF-POCKET MAXIMUM INDIVIDUAL / FAMILY $1,500/3,000 annually Per Calendar Year 71ze Qut-qf-Pocket Alwimurn. j lchgje�s, Co.-pqnzents and :Co- insurance amounts unless other4ise excluded AVM ED PRIMARY CARE Services at Participating Physicians' offices include, but are not $15 per visit PHYSICIAN lim ited to: Routine office visits/annual gynecological examination when performed by Primary Care Physician ■ Pediatric care and wellmmchild care ■ Periodic health evaluation and immunizations ■ Diagnostic im aging. laboratory or other diagnostic services ■ Minot surgical procedures ■ Vision and hoaring examinations for children under IS MATERNITY CARE ■ Initial visit $15 Co- payment ■ Subsequent visits NO CHARGE AVM ED SPECIALISTS' ■ Office visits $15 per visit SERVICES ■ Amual gynecological ex=ination ,hen performed by a 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. surgeon,;' 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 d-Uty nursing • Laboratory and diamostic imaging angioplasty ■ 04atient therapeutic services, including: • Drug infusion therapy $400 Co- payment • Injectable Drugs (Co-payment foil Injectable Drug An emergency is the sudden and unexpected onset of 'a condition requiring immediate medical or surgical care. (Co-payment waived it adm itted) ■ Flberg�ncy services at Participating -.[-IospitaN ■ Emergency services at non participating Hospitals, facilities, and/or physicians AvMed must be notified within 2:4 hours of inpatient admission following emergency services or as soon as reasonably possible. $75 Co-payment $100 Co,7p ayment URGENT /IMMEDIATE UARE • Medical ServIces at 9 participating, Urgentliffirnediate Care $40 Co-payment facility or services rendered after hours in your Primary Care PhysiciaWs office ■ Medical Services at a non-participating Urgent/immediate Care -p, $60Co ayme nt facility AV-LG- 1517-5 0115 0 0/2 M -06 NIP-3990.(10106) FAMILY PLANNING ■ Voluntary family planning services $15 per visit 20 outpatient visits $25 per v ALLERGY TREATMENTS ■ injections $15 per visit ■ Skin testing $50 per course of testing AMBULANCE ■ Ambulance transport for emergency services $,100 Co- payment N Non - emergent ambulance services are, covered; when the skill of medically trained personnel is required and the :Ivlember'cannot be safely transported 'by other means 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 . 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 Cardiac rehabilitation is covered for the following conditions, S15 per visit • Acute. myocardial infarction • Percutaneous transluminal coronary angioplasty (PTC,A) Benefits limited • Repair or replacement of heart valves to $1,500 per • Coronary artery bypass graft (CA13% or Calendar Year • Heart transplant Coverage is limited to 18 visits per Calendar Year HOME HEALTH CARE ■ Limited to Eo skilled visits per calendaryear 20% of the contracted :rate after Deductible DURABLE MEDICAL Equipment includes: 260r5 of the contracted EQUIPMENT AND ■ Hospital beds rate after Deductible ORTHOTIC APPLIANCES " Walkers • Crutches Benefits limited 0 Wheelchairs to $2,000 per Calendar Year W.hotic applsanees.are.1imitedto: ■ Leg, arms back;, and neck custom-made Braces PROSTHETIC DEVICES Prosthetic devices are limited to: 20% of the. contracted ■ Artificial limbs rate after Deductible ■ Artificial joints Ocular prostheses FOR ADDITIONAL INFORMATION, PLEASE CALL: 1. 000 -RR -AV ED (1- 800 - 002 - 3.633) THIS SCHEDULE OF BENEFITS 19 NOT A CONTRACT. FOR SPFCMC INFORMATION ON BENEFITS, EXCLUSIONS AND LIMITATIONS, PLEASE CONSULT YOUR AVINIE-D GROUP MEDICAL AND HOSPITAL SERCTIC:=E CONTRACT. AV - LG- 15J250/1500/2VA -0G. XIP- 3990(106) AMMED, H EA i.,rii PLANS Amendrnent 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 I and ending December 31. • "Co-insurance" means the amount acovered 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-paymentg, 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; and o the Can- ion: any expense; incurred by a Member while covered under the prior yover provis' coverage will be credited toward satisfaction of the Deductible under this Plan if, • The expenses were incurred during the 90-day period be-fore 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. How-ever, in order to receive credit, you must supply evidence of satisfaction of the Deductible under the prior coverage by providing Av'Med written proof of what has been paid by prior coverage, Under Part VIE[. MONTHLY PAYMENTS AND C0_PAYIN4ENTS,. 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 bear are accumulated toward your annual maximum out-of-pocket limit. once you meet your indi-%idual or family annual maximum out-of-pocket limit in any Calendar Year,, AvMed will pay 100°18 of the allowable charges for all covered services for the remainder of that Calendar Year. Expenses that do not count toward the twitual maximum out-bf-pockbt limit are expenses used to satisfy the individual or family Deductible and any services provided under the Prescription Diu,& 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 m(med 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 alur 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 doer, 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-DedudiblclCo-insurance Athendment-06 AQ-3647 (9106) AvMED Prescrtp*tion Drug Benefits $16/30/50/75/50% CO-PAYMENT with Contraceptives "Brand" medication ineariA 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 Gerieric/13rand 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 ffie applicable Brand Co-payment. (Referred or NoriPreferre4). "Cost-sharing Medications" are those medications, as desigmted by AvMed, which were designed to improve the quality of life by treAting, relatively minor non- life threatening conditions. Suchinedications are subject to Co- insurance and coverage: islinritec . t as outlined below. "Dental- specific Mecbcation- is medication used for dental- specific purposes, including but not. limited to fluoride medicatiots and medications packaged .and labeled for-dentdi-specitio purposes. "Oonctio" medication means a mediodtion that has die same active ipgredient as a Brand indclication or is identified as a Generic medication by AvMeWs, Pharmacy Benefits Manager. `, Injectable Medication" is a medication that bas' been approved by the Food and Drug Administration (FDA) for administration by one or more of the following routes: intramuscular injecfion,.intravenoii.-.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. "Pari.icipating 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 listin of preferred medications as determined by AvMed';s Pharmacy and Therapeutics Committee based .9 ;a on clinical efficacy, relative sgety and cost in comparison to similar medications within q therapeutic class. 71iis.multi-tiered list esfabliffies difTerentlevels of co-payment for Medications within therapeutic classes. As now medications become available, they may be considered excluded until they have been reviewed by AvMed's Pharmacy And Therapeutics Committee. "Prescription Drug" mews 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 -tAuthorization" means the process of obtaining approval for certain Prescription Drugs (prior to dispensing) according, to AvMedls guidelines. The ,prescribing physician must obtain approval from AvMed. The list of Prescription Drugs requiring PreAutlwfizafion 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-Adininistered. Injectable Me-died&v".is a medication that has been approved by the FDA fbi self-injection and is administered by subcutaneous injection ora medicatitm for which there are instructions to the patient for self-irjection in the manufactur is prescribing information (pac1mge insert). Pre - Author ization.isrequired for All Self-Administered Injectable Medications. HOW DOB YOUR RETAIL PRESCRIPTION COVERAGE WORK? To obtain your Prescription Dru& take your prescription to, or have your physician c4 an AvMed PartLcipating Pharmacy. Your physician should s sabinit prescriptions for Self-Admidistered Injectable Medications to AvMeWs specialty pharmacy. Weserrit your prescription along with your .AvMed identification card. Pay the follow >g Co-payrrient (as well w the Brand Additional Cliarge if you or your physician choose a Brand product when a Generic equivalent isavailable). Tier I Preferred Generic Medications: $ 15.- 00 Co-payment Tier '2 Preferred Brand Medications: $ 30.00 Co-payment Tier 3 Nair - Preferred .Brand or Generic Medications: $ 50.00 Co payment Tier 4 Self-Administered Injectable Medications: $ 75.00 Co payment Tier 5 Cost - sharing Medications 50% Cb. m.suranct ORDERING YOUR PRESCRIPTIONS THROUGH THE MAIL Mail service :is q benefit -option formainfcnance. medications needed for chronic or long-tenn health condition-,. It is best, to get an initial prescription filled at your retail pharmacy. Ask your physiciari for an additional prescription for up to a 90-day supply of your medication to be ordered through mail service. Up to 3 ieffib are -allowed per prescription. Pay the following Co-payment (as well as die Brand Additional Charge if you or your physician choose a Brand product when a Generic equivalent is available). Tier I Preferred Gene-Tic Medicatiom: $ 36-00 Co-payment Tier 2 Preferred Bt rTd Medications: $ 60.00 Cc-paymen .. t Tier 3 Non-Preferred Brand or 0 enericMedications: $ 100.00 COpayment Tier 4 Self-Adninistered Injectable Medications are not available thwugh mail service Tier 5 Cost Sharing Medications are not available through mail service AV-LO- RX-U4 5/30)50/73/5 00/.-OC-06 W-3859 (10/06.) _Vrescriphon.Drug Benejtts, 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 detemtine payment ofproducts 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 mimum ax 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 asthina, 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-payinent. ■ 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 ineans that you are responsible for the appropriate co- payment whether you receive your Self - Admitristered 14 actable Medication from the pharmacy, at the physician's office:.or during bonne health visits, Self Administered injectable Medications are limited to a 30 -day supply. ■ Your Tier 5 coverage is limited to Terb riafine (I ami.sily) and It acorrawle (Sporanokft in oral form, when prescribed by your physician for the treatment of documented fungal infections: Pv authotization is not required, • 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 udth the injection, there will be sit additional iii payment required for the office 6§it. • Quantity limits are set in accordance with FDA approved prescribing; Iimitations, 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 - spetific quantity :limit may apply for medications that have an increased potential for over-utilization or an inoreazed potential fora Member to experience an adverse effect at higher doses. QUESTIONS? Call your AvMed Member Services Department at 1-800-99-AvMed (1-800-882-413633) EXCLUSIONS AND LIMITATIONS ■ Medications which do not require aprescriptiori (.e. over=the>cou nteritledications) or- when:a non-prescription alternative is available Medical supplies, including therapeutic: device% dressings, appliances, and support: garments ■ Replacement Prescription Drugs products resulting from a lost, stolen, expired, broken, or destroyed' prescription order or rehhl ■ Diaphragms-and other contraceptive devices ■ Fertility drugs ■ Medications, or devices for the diagnosis or tieatr ieitt of sexual .dysfunction • Dental - specific Medications for dental purposes, including fluoride medications ■ Prescription and non -pregm ption vitamins and minerals except prenatal vitamins ■ Nutritional. supplements ■ Immunizations ■ Allergy smiths, medications administered by the Attending Physician to treat the acute phase of an illness and chemotherrapy for cancer patients awe covered in accordance with the Group Medical and Hospital Service Contract and may be subject to Co- payruents or Co- insurance as outlined 6n &a 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 v nrikle medications ■ Nicotine suppressants and smoking cessationprodueW and services: ■ Prescription and non - prescription appetite suppressants and products for the purpose of weight loss ■ Compounded prescriptions, exceptpediatiic preparations ■ Medications and immunizations for non-business related travel, including Transdermal Scopolarnine Filling n. prescription at it pharmacy is not a claim for benefits and is not subject to the Clahns and Appeals pp dcedu,es under l*Rl94_ However, tart,}., medicines that require Pre- R4u #horisatiorx will be tt eatecl its a claim for lnertef ts,suNect to the Claims and AppeakProcedures as outlined in the CnoupMedical and Hvspttul.Service Conp -act. AV- LG= R.K- 2x-15/30150/ 5/- )00o- CSC -Q6 MP -385Q (1.0106] .. AvMED n i r ri P H Amendment Inpatient Mental Hea th and partial If��zet n 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, sutliect 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 clays of Partial Hospitalization will cowit as one day toward the inpatient Mental Health Benefit subj ect to member copayment as noted above. AV -G100 I 4H/PH .$2 -';O per day-04 MP -3523 (10/04) AvMED H .E a r .1-,.. P L A -.. —N, -'S Substance Abuse Benefits .r ,� i� j �► �. 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. ■ OUTPATEENT 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 (1104) AvMED ff"F-A T-T 1-4-"-PL-A-N -S Amendment Minable Xledical Eqidpinent If selected, the following coverage is hereby modified, for an additional premium. DURABLE MEDICAL EQUIPMENT • Benefits are limited to a maximum of $2jOOO per contract year*. All other coverage provisions, iacludiii g co-paynent, linYitatiQias and exclusions remain its stated in the Certificate of Coverage or Schedule of Co-Payments. *For the treatment of diabetes, coverage for an infusion pump will not apply to-ward the annual maximum limitation and shall not be subject to the durable medical equipment benefit limitation. AV-G1O0-D1\ffi- 2000-R-06 XV-22 149 (4-06) AvMED ff -E -A" -LT " -H-, -PL A---N-ii STUDENT EUCIBIUTV Amendmenc-'L As of the Effective Date, and in spite of anything in the Certificate, to the contrary, the following benefit is revised for an additional premium. Coverage of dependents under the age of 19, or to the age of 25 if dependent is a full time student. AV-MIDENT ELIGIBILITY! R-02 MP-3122 (1/0+) AvNlED 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 Doin estic Partner and his or her cNidren. Definition of DomesticPailner. 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 ej&eenyears of age; • Is -mentAlly competent to consent to a contract. • Has. filed 'a Domestic- Partnership agreeiffent or registration with the Employek, if available, in the state (and/or city) of residence; ■ Has shared financial obligations including basic li Vmg expenses for the six, mdnth period prior to enrollment in the plan; • will provide docum ent?Ltiori that will be satisfactory to the Employer wevidence of a Dom estic Partner relationship; and • Meets the dependents eligibility requirements of the Eimpjoyer'g health benefits plan. AV-DP-6-R-02 W-3149 (1/04) A �f W-E-A-I-T-1-1" Amendment 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 AvXled participating provider in an AvMed participating facility. There shall be a physician copayment of $100.00 in addition to the applicable facility copayment. AV-G140 -ETP R 97 MP -1321 (1/04) AvMED Coverage for Mommograms — Waiver of Co-payment If selected, the following provision is hereby modified for an additional premium: Section 10.28 of AvMed Health Plans Group _Medical and Hospital Service Contract is amended to state: Mammograms are covered in accordance with Flodda Statutes: one baseline mammogram is -covered for female Members between the ages of 35 and 39; a mammograjaj is available every ttvo years for female Members between the ages of 40 and 49; and aniammogram 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 be-fore the age of 30. This coverage will not be subject to diagnostic imaging Co-payments. AV-MwnmdSram-05 MP-3229,,(12105.) Contract Number(s): Subscribing Group Name Effective Date: Group Contract AVMED, INC. d /b/a AVMEID Health Plans Group Medical and Hospital Service Contract Group Master Application 105544 City Of South Miami 10101/07 This Group Contract provides the benefits listed below Identifier AV STD- 25OA -06 P:OS- 500 -30 -3000 AV =POS Classic -05 AV- LG- RX- 2x- 15/3.0150/75150% -OC -06 AV4G100 -MH /PH =$250 per admit-0.4 AV -SA -98 AV -G 100 -DME- 20100 -R -06 AV-STUDENT ELIGIBILITY -R -02 AV-DP-6-R-02 AV -G 100- ErP -R -97 AV-Mammogram-05 Ellalbility Descri tp ion Summary of Benefits POS Open >Access Prescription Drug IPMental Health Substance.Ab.use Durable Mod. Equip; Student Eligibility Domestic Partner ET'OP Mammogram man Active Employees.. (Class 1) are required to vvork 25 hours per week to .become eligible for coverage under this Contract. Employees WIl .become eligible for coverage on the first of the month fo.11owng the first day of employment. Active Employees {Glass 2) are required to work 25 hours,per weekto become eligible-for coverage under this Contract. Employees will become eligible for coverage on the first of the Month folloWng the first day of ernployrrx�nt. Termination For Active Employees .(Class 1), termination of coverage under this Contract shall become effective End of Month For Active Employees (Class 2), termination of coverage under this Contract shall become effective End of Month. Monthiv Membership Charges SubscriberOnly ............................ ......... .... ............................... ........ ,..........._...... — $469.:25 Subscriberplus Spouse ......... .. ................ ,........................ ............................ ..... ...........................,.,. $924.42 Subscriber plus One Dependent (No Spouse) :.................... .......... $830.57 Subscriber plus Two or More Dependents ........ .............................,..................... ............_.................. $$30.57 Subscriber plus Spouse and One or More Dependents ................. :........................................... ..:..... $1:,384.29 AV- Master Application -07 MP- 2027 (1 /07) AVMED, INC. d /b /a AVMED Health Plans Group Medical and Hospital Service Contract Group Master Application, continued Agreement This Contract is issued in consideration of the Master Application of the Subscribing Group for group medical and hospital services and the monthly prepayment subscription charges and the mutual promises and benefits between AVMED; Inc. d /b /a AVMED Health Plans and the Subscribing Group. This Contract shall remain in effect for a period of twelve (12) months from the effective date of October 1, 2007 and may be renewed annually, not later than the anniversary date, upon mutual agreement of the parties. This Contract period begins at 12:01 a.m. Eastern Standard Time on the :effective date or on the anniversary date, if a renewal. The Contract shall be governed by Chapter 641, Florida Statutes, and other applicable State and Federal laws. The first monthly payment is due on October 1, 2007. Subsequent payments are due on the 1st day of each month thereafter. 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 OF THE THIRD DEGREE. The provisions contained in the Schedule of Benefits applicable to this Contract and all Exhibits and Amendments executed . by the parties and attached hereto are; by reference, made a part, of this Contract. AGREED TO AND ACCEPTED BY the parties the day and year hereinafter written. The Effective Date of this Contract is October 1, 2007. Subscribing Group: City Of South Miami By: Signature Name Title date: AV- Master Application -07 MP -2027 (1/07) A IVIED, Inc. d /b /a AVMED: Health Plans By: Signature' [ ?ate: Evis Clavarem Name Director, Client Service Title Nk enefit Summary 1i E A L T f I P L A N 6 01� STANDARD OPTION 250- SCHEDULE OF BENEFITS COST TO MEMBER ADMIT OUT-OF•POCKET MAXIMUM $1,500 INDIVIDTjAL Per Calendar Year $3,,000 FAMILY AVMED PRIMARY CARE Services at Participating Physicians' offices 'include, but are not $10 per visit PHYSICIAN limited to: ■ Routine office visits / annual Wypecological 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 K Initial visit $10 Co--Davment AVM ED SPECIALISTS' ■ Office visits $ J per Visit SERVICES 0 Annu41gynecological exatnination when performed by a DartidiDating SDecialtv Health Care Pfivsician ■ Room and board - unlimited days (semi - private) ■ Physicians', specialists' and surgeons' services ■ Anesthesia, use of operating and recovery rooms,; oxygen, drugs and medication ■ Intensive me unit and other special units, general :arid special duty nursing • Laboratory and diagnostic imaging • Required special diets Radiation and iihalation,therames. and-angioploty ■ Outpatient therapeutic services, including.: Drug infusion therapy $250 per admissiow, 100% coverage thereafter $ 10.0 Cod paym =t Injectable Drugs (Co-payment for Injectable $75 Co-payment Drug waived if incidental to name day drug :infusion therapy).... OUTPATIENT DIAGNOSTIC CAT Scan, PET Scan, MRI $25 per test — """6P. --.— - .--- - , MERGENCY SERVICES An emergency is the sudden and -unexpected onset ofa condition requiring immediate medical or surgical care. (Co- payment waived if admitted) . Emergency services at Participating Hospitah. $75 Cb-payment 0 Eiiier$ency services gtiioii-partic* p giting-HospitAls. i facilities, and/or physicians. $100 co-payment AvMed must be notified within 24 hours of hiDationt admission following emergency services or as soon as reasonably Possible URGENT /IMMEDIATE CARE K Medical. Services at a participating Urgentl1m.mediate $40 Co payment. Care facility or services rendered after hours in your Primary Care Physicians office ■ Medical Services at a non participating $60 Co-payment Urgent/Immediate Care facility XV-STD-250A-66 UP-3411 (1,0106) A & # Venept Sumuzar, contmued YP MENTAL HEALTH ■ 20 outpatient visits $25 per visit FAMILY Voluntary -family planning services $10 per visit PLANNING Sterilization $100 Co-payment ALLERGY TREATMENTS 14jections $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 transnorted bvother means PHYSICAL, SPEECH, AND Short-term physical, speech or occupational therapy tor $10 per visit OCCUPATIONAL THERAPIES acute, conditions Coverage is limited to 30 visits per calendar year f6r all services conihitted SKILLEDRURSIND Up to 20 days post-hospitalizatidn care per Calendar $25 per day FACILI1TIE$ AND Year when prescribed b, Y physician and authorized by REHABILITATION CENTERS AvMed CARDIAC REHABILITATION `Qardftqc rehabilitation is cdvered for the following conditions: $20 per visit ■ Acute myooardi.a.l infarction to $500 per ■ Percutaneous translutnival coronary angioplasty (PICA) 13enefits limited Repair or replacement of heart valves: to $1,5.00 per PROSTHETIC DEVICES Coronary artery bypass graft (CABG), or Calendar Year ileart tansplant Coverage is limited to IS visits. per Calendar Year ,HOME HEALTH CARE ■ Limited to 60 skilled visits per calendar year NO C1MRCxE DURABLE MEDICAL Equipment includes: $so per episode of illness EQUIPMENT AND ■ Hospital beds ORTHOTIC APPLIANCES ® Walkers ■ Crutches Benefits limited A 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 o PLEASE CALL 1-800-88-AVMED (1-890-882-8633) THIS SCHEDULE OF BENEFITS 19 TROT ACONTRACT. FOR SPECIFIC. INFORMATION ON BENEFITS, EXCLUSIONS.,kNI) LWITATIONS, PLEASE, SEE YOUR AVX4ED GROUP INJEDICAL AND HOSPITAL SERVICE CONTRACT. "-STD= 250A-Q6 Me-3411 40106) AxiMED i i ' ' k-, -A � ' i " _T" _14' -, -P—L, - "A" P''S' 4 ' 'S' Benefit Summary SCHEDULE OF [Ifff "T-Am DEDUCTIBLE INDIMtJAL/FAMILY $5001$1,500 Annually T-OF- INDIVIDUAL/FAMMY $3,000/6,000 Annually PRIOR AUTHORIZATION Required for specific covered services. The penalty for not obtaining prior authorization is a 20% reduction in benefits. PHYSICIAN Services in physicians' offices include, but are not liiniW tot 30% of the UCR charge, ■ Routine office visits/annual gynecological exam wb ect to the Deductible ■ Maternity-outpatient visits ■ Pediatric care and well-child care ■ Diagnostic fin agin g, laboratory or other diagnostic c services ■ Minor surgical procedures ■ Vision and bearing examinations for children under 18 SPECIALIST'S SERVICES Office visits 30% of the UCR charge, subject to the Deductible HOSPITAL Inlyatient 1, at Hospitals includes: 30% of the UCR charge, ■ Room and board - unlimit6d days (somi-privrate) subject, to the Deductible ■ Phypipians', specialists' and surgeo& services ■ Anesthesia, use of operating and recovery rooms, oxygen, drugs and Ai 01cation ■ Intensive care unit and other special units, general and special duty nursing. ■ Laboratory and diagnostic imaging x Requircd.special diets, ■ Radiation and inhalation therapies OUTPATIENT SERVICES - Outpatient surgeries, including cardiac cathaerizations and 30% of the UICR 60fge,. angioplasty subjectto the Dedurtible ■ Outpatient therapeutic services,, including: 0 Drug infusion therapy * Injectable drugs �Co-payment for Injectable Drug waived if incidental to same-day gn1g.infusion therapy) UUTFATItNT U1AUNU$l It; ■ CAT :Scan, PET Scan, 1VW 30% of the UCR charge, TESTS Other diagnostic imaging testa subject to the Deductible ■ 20 outpatient` visits If mental health/substance abuse benefit riders are elected, benefits are subject to PUS' rider Deductible and Co-insurance arrangements when using Non-participating Providers. Specified: service I'M its are the total number of covered visits for both inland out-of-rietwork, combined. AV-POS-500-30-500M5 .W- 3440 (10005) 30ti"a of the WR charge, subject to the Deductible Benefit Sun?mary� continued ALLERGY TREATMENTS ■ Injections 30% of the UCR charge, ■ Skin testing subject to the Deductible 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 1-0 days per Contract Year when prescribedby physician 30% of the UCR charge, AND REHABILITATION and authorized by AvMed subject to the Deductible CENTERS CARDIAC REHABILITATION Cardiac Rehabilitation is covered for the following conditions: S20 per visit ■ Acute myocardial infarction ■ Percutaneous trans] . uminal. coronary .angioplasty (PTCA) Benefits limited to $1,500 per ■ Repair or replacement of heart valves Contract Year ■ Coronary artery bypass graft (CABG), or • Heart transplant. Coverage is limited to 18 visits per Contract Year HOME HEALTH CARE ■ Limited to 60 skilled visits per calendar year. 30% of the UCR charge, DURABLE MEDICAL Equipment includes: $50 per episode of illness. EQUIPMENT AND ■ Hospital beds ORTHOTIC APPLIANCES` ■ Walkers Benefits limited to $500 per ■ Crutches Contract Year. ■ Wheelchairs Orthatic appliances are limited to- * Leg, arm, back-, and neck custom -made braces. PROSTHETIC' DEVICES Prosthetic devices are limited to, 30% of the UCR charge,. ■ Artificial limbs. subject to the Deductible ■ Artificial joints ■ Ocular prostheses THIS SCHEDULE IS NOT A CONTRACT. FOR SPECIFIC INFORMATION ON BENEFITS, EXCLUSIONS AND LIMITATIONS PLEASE C-ONSULT'YOUR GROUP MEDICAL AND HOSPITAL SERVICE CONTRACT AND POINT-017• SERVICE AMENDMENT. ,kV-POS-500-30-3000-05 NIP- 3440 (0/05) AML H r . A 1, T ii P L A N -, Cla.9sic AvMed Health Plans Group Medical and Hospital Service Contract is hereby amended and supplemented by the terms and conditions of this Aniendinent. 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 specilFicaRy stated herein. Furthermore, when additional benefit. riders are selected, those benefits are subject to the POS Amendment Deductible, and Co-insurance, arrarigements, when using Non-participating Providers unless services are specifically excluded herein. Additionally, this Amendment in no mray 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. Pohit-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 wbileyou 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 XL mid XH. or any other provision, rider or amendment shade 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 iservices and supplies are accessed outside flia HMO system. You are free to choose arty 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 -oil how these options can work best for you. AWPOS amend-Classic-0 W-353�O (16t,05)' Classic, Po1*17II-qf-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. Payineitt 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 IB40 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 Croup Plan will pay depends on the Health Professional you select to provide covered stealth care services.: 1. If the Health Prof6s,sional 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 HMO Schedule of &o-payrnentg. 2. if the Health Professional used is not part of AvMed Health Plans' Particip4ting Provider network, benefits for sei-vices covered under this POS Amendment are payable at the Non-participatin I g Provider benefit level specified iii the POS Amet3& ient Schedule. 3: Services • rendered by a Participating Provider are, subject to the direction and approval of.AvMed or referral by an AvMed Primary Care Physician.. If you receive covered services through a Participating Provider which have not been Authorized b .y your PCP, benefits * . ay not be payable under the HMO in Participating Provider benefit. A service may be payable under the POS Amendment Non-participating Providet benefit if the service or supply received is a covered service as specified in this POS Amendment and Schedule.. AV-P03 mhend-Classic -05 MP-3530 (10105) 2 Classic Point-of-Service Amendment, continued Cost-Sliaring hdonnation 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. 'Ilse Deductible means the amount a Member must pay each calendar year for covered service,-, from his or her own pocket 'before AvIqed 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 i.neiribers of a family incur eligible expenses for which no benefits are payable because of the Deductible requirements and the amount of such eligible expe-aw 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 enstinig 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-Insumnee. Once the. calendar year Deductible has been met, you are responsible for paying a percentage of eligible, expenses. Ilie coverage percentage, hereinafter Called "co- insurance," is specified in the Schedule. You will be responsible for paying any charges nos considered an eligible expense: Usual, Customary, and Reasonable means the -usual, charge made by a physician or supplier of services, medicities, or supplies. The charge. will not exceed the general level of charges made by others rendering or ftirnishing such set-vices, medicines, or supplies within an area in which the charge is incurred for sickness or injuries compatible in severity and nature to the siclaios or injury being treated. The term "area!,' as it would apply to any particular service, medicine, or supp ly means: county or such greater are as 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- p Ayments you pay for benefit-, 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 wi I pa- g al l y 100% of the Usual, Customary, and Reasonable charge. for I covered services for the remainder of that calendar year. AV-POS aftend-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 atithorization, 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 Garoup Medical and Hospital Service Contract. :Lifetime Maximum. Benefit. While this Group Plan stays vs in force., the eligible expenses . incurred by a Member are limited to the applicable maximunt 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 on 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. A-%rMed Health Plaits 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 pvaviding AvMed Health Plan$ written, proof of what has been paid by prior coverage. Prior Authorization of Covered Set-vices In order to determine whether services and supplies are Medically Necessary, certain covered services require prior authorization fi-ont AvMed Health Plans. Prior authorization ensures a Member of receiving the most appropriate medical care available, in the most AV Pips amend-Clamic-05 AT-3530 (10105) 4 te 11111 I-qf-Service Amendment, continued appropriate setting. If your physician is a. Participating Provider, them lie 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, Slulled Nursing Facility, and /or acute rehabilitation). • Inpatient and outpatient surgery, in lading 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 anio-ur t 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 sim ilarly reduced.. Exclusions and Linait€ttions 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 �lhe Group ltedioal and Hospital Service Contract. • Secodd medical opinions are covered exclrlsively through the HMC� portion of the benefits and are not available as point -of- service benefits. • Transplantation services must be authorized by AvMed mid 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 rei nbursement.. • Any applicable prescription benefits are available only under the HMO portion of -coverage. They are not available. as out -of- network benefits. AV -PQS amend - Classic -05 MP -3530 (10105) 5 Classic Point-of-Service Amendment, contilzued • Hospice services. • Dialysis care, • Ambulance services. • Voluntary family planning nfe . I . g services, sterilization, i. iti ity 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 vtM be covered Wider the HMO Contract benefits. In order for the care to be covered under the M10, AvMed must be notified as described in Section 10.12 of the Ch-oup 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. • Dtitable medical equipment, orth9tic 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 Clahns 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 filing procedures when receiving covered services from Non-participatingr Providers. Notice of Claim. Notice of a claim for benefit's 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 niontlit 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 tinder this Plan, it shall be mail ed,to: AvMed Health Plans P. 0. Box 560844 Miami, Florida 33156 You should call 1-800-882-8633 if msigtancais needed regarding a claim or infoilijgtion about coverage. AV-POS affiend-Classic-05 IT-3530 (10105) 6 C 17 0 0 lassic 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 limitatiom fi-om the date written proof of claim, was required to be filed. Overview — Member Responsibilities WI-ten Receiving, Covered Services Responsibilities when using Participating PrDviders. All papetwork- is handled by Participating Providers, so there are no bills for you to a-ubmit 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 when using Non-participating Providers: 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- mstrance amount required. 4. Pay any amount of eligible expense which exceeds the Usual, Customary, and Reasonable charges. 5. Pay any increase in Co-insuranee if prior authorization requirements are not followed as stated in this Amendment. C. Pay any charges for services -mid suppfies not covered under this Amendment. 7. You must complete and submit claim forms and provider bills to AvMed Health Plans. AV-POS smcnd--Classic-05 NW-3530 (10105) 7 n . AvMED eW..."N"'. Hs�it.� ri Pr.a�s Prescr p"tion Drug $15130150175150% MPUMENT with "Brand" medication means a Prescription Drug that is usually manufactured and sold under a name or trademark by a phannaceut cal manufacturer or a medication that is identified as a .Brand medications by AvMed. AvMed delegates determination of Generic(Brand status to our Pharmacy Benefits Manager. "Brand Additional C "barge" 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: Tlus charge must, be paid in addition to the applicable Brand Co- payment (Preferred or Non Preferred). c n uo,; �t- sliaritig :hlc;dicaiions "err those medications, as designated by AvMed, which were designed to improve the quality of life by treating relatively minor non- life threatening conditions. Suchmedications are subject to Co- insurance and coverage is limited as ontlinecl below. "Dental--specific; Medicati(Jn" is medication used fur dental- specific purposes, including but not limited to fluoride medications and medications packaged and labeled for-dental-specific purposes. "Gonoric" 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 Medicatiorf' is a medication flat has been approved by the Food and. Ding Administration (:FDA) for ado irdsti'ation by one or more of the following routes: intramuscular inj ectim, intravenous irg ecteon, intravenous infusion, subcutaneous injection, intrathecal injection; intrarticular injection, intraeavernousinjectiGmorintraocularittjection. Pre- Autharizationisrequired for all lnjectableMedications. "Maintenance Medication"' is a medication that has been approved by the FDA,: for which the duration of:theropy can reasonably be expected to exceed one year. "Participating Pharmacy" means a pharniacy (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 arid. Therapeutics Committee based on clinical efficacy, relative safety and cost in comparison to similar. medications within a therapeutic class. This - multi= tiered list establirhes different levels of Co -priy iierit for medic atio s within therapeutic classes. As new medications become available they may be cottsi.dered excluded until they have been reviewed by AvMed's Pharmacy and Therapeutics Committee. "Pre eription Drug" means a, medication that has been approved by the FDA and that can only be dispensed putsuantto a prescription according to state and federal law. "Pre Authorization" means the process of cibtaining approval for certain Prescription Drags (prior to dispensing) according to AvMed's guidelines. The prescribing physician must obtain approval front AvMed, The list of Prescription Drugs requiring Pre - Authorization is subject to penodio 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 web5ite. "Self- Administered I *- tal-Ae 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 fair self injection'in the rnanufacturer's prescribing information (package insert). Pre- Authorization.is required for .611 Seelf Ad r 'roistered .injectable Medications. HOW DOES YOUR RETAIL PRESCRIPTION COVERAGE WORK? To obtain your :Prescription Drug, take your prescription to, or have your physician call, an AvMed Participating Pharmacy. Your physician should submit prescriptions. for Seif- Administered Injectable Medications to Av:Med's specialty pharmacy. htsent yiiur pre scription along with :your AvMed identification cad. Pay the following Co- payment (as well as the Brand Additional Chamge if you or your physioiau choose a Brand product when a G eneric equivalent is available). Tier 1 Preferred Generic Medications: $ 15.00 Co-payment Tier '2 Preferred Brand Medications: $ 30.00 Co- payiztetit Tier 3 Non- Preferred Brand or Generic Medications: $ 50.00 Co- payment Tier 4 Self- Administered.Injeetable Medications: $ 75.00 Co- payment Tier 5 Cost-sharing Medications 50% Ca= insurance ORDERING YOUR PRESCRIPTIONS THROUGH THE MAIL Mail service is a benefit option fm- maintenance- medications needed for chronic or long -tern health conditions. It is best to get an initial. prescription filled at your retail pharrnacy. Ask your physician for an additional prescription for up to a 90414y 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 equivalentis available). Tier 1 Preferred Generic Medications: $ 30.00 Co-payment Tier *2 Preferred Brand Medications: $ 60.00 Co- payment Tier 3 Non-Preferred Brand or Generic _Medications.: $160.00 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- LG- RX-2.x- 15130/501 75 /5U°c- L)C -b6 MP -3854 (10106) cr . rug en � continued HAT 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 protoeas 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 trail order after 75% of your previous fill has been used and subject to .a maximum of 13 refills per year. Y ou 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, lire- Authorization may be required for covered medications. • Your mail -order Prescription. Ding coverage includes up to a 90 -flay 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 mauy injectable medications approved by the FDA. These medications mugt be prescribed by a physician and dispensed by a retail or specialty pharmacy. The too- payment levels for Self - Administered Injectable Medications apply regardless of provider. This means that your are responsible for the- appropriate Co- pnymeni 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 Tier 5 coverage is limited to Terb rtafine (LSm sit ) and Itt`acottazcle (SporanoxO), in oral form, When prescribed by your physician for the freattneiit of doctimented fumgalinfectit)ns. Pre- authorization is not required. • 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 addiiional C�z)- payment raquired'far the office visit. • Quantity limits are set in accordance with FDA approved prescribing; limitations, generd practice guidelines supported by medical specialty. organizations, ,and/or evidence- based; statistically valid clinical studies without published conflicting .data. This rmean,§ that a, medycation- spechfic quantity :limit may apply for medications that have an (increased potential for over-utilization or an increased potential for Member to experience an, adverse effect at higher doses. QUESTIONS? Call yotrr AvMed Member Services Departiheitt at: 1= 800 =88- AvMed (1- 800 =882- 8633) EXCLUSIONS AND LIMITATIONS ■ Medications which do not require a prescription (j.e. river- the - counter medications) or when :a non - prescription alternative is available ■ Metrical supplies, including therapeutic devices, dressings; appliances, and support garments ■ Replacement h-esmiption 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 treatrdent of sexual dysfunction ■ Dental- specific Medications for dental purposes, including fluoride medications ■ Prescription and rime prescripti on vitamins and minerals except prenatal vitamins ■ Nutritional supplements ■ Irtun }uiiz7tions ■ 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 Servic�, Contract and inay be subject to Co- payments or Co-insurance as outlined: on Schedule of Benefits • Investigational and experimental drugs (except as required. by Florida. statute) ■ Cosmetic products, including, but not limited to, hail growth, skin bleaching, sun damage and. anti -wrinl 1e medications ■ Nicotine suppressants and smoking cessationproducts and,services. ■ Prescription and .rron prescription appetite suppressants "and products for the purpose of weight loss ■ Compounded prescriptions., except pediatric preparations ■ Medications and immunizations for iron - business related travel, including Transdennall Scopolamine Filling ;a. preseriptio a at a pharmacy is not a claim for bengfits and is not s7a8 jest to the Uaims.and j. ppea1s procedures under. ERIV. However, any medicines that requbv Pre - Authorization wilt be treated as a claitaa for benefus subject to the Minis and Appea& Prooedures, as outlined in the GroupAledical and Hospital Service Contract Av- LG- Rx- 2x- 15/3o,15.o;,515(l°, -oc -®6 W-1859 (1.0/46) AVMED H E A 1.T TI P L _.A ..N.,.5 Amendment Inpatient Mental Health and Partial Hospitalization Benefits As of the effective. elate, Inpatient Mental Health and Partial Hospitalization Benefits are being provided for an additional premium. • Inpatient treatment of mentalinervous.disorders for up to 30 days per patient, subject to a member copayinent 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 clay toward the inpatient Mental HealthBenefit subject to member eopayment as noted above. AV- GI00- MH;iPH4250 per adroit -04 NV-3522 (1 "0104) ME D ff T -A" T -T [W._ —P —L -A, -N- S Substance Abuse Benefits As of the effe.cfive date, the. following Sub-stance 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 progr6m(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 NIP-1527 (1/04) AvMED T -NS' Amendment Ditnable Medical Eqidpinent 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 Cove-rage or Schedule of Co-Payment5, *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 -DNE- 2000-R-06 Ndp-2 149 (4-06) AvMED if "L"_ A-T, _TI_I_P_L__A' _' IS' Amendment STUDENT EUGIBILITY As of the Effective Date, and in spite of anything in the Certificate to the contrary, the following benefit is revised for an additional premium. Coverage of dependents under the age of 19, or to the age of 25 if dependent is a full time student. AV-�TMENTWGIBILITY-R-02 NIP- 3.122 (1/04;) AvMED if—E AL_T11P Amendirnent 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 E figibility will be added for a Doweslic Partner and his or her children. Definition of Domestic Partner.- A DomcsticPartrier 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-, ■ B at least eighteen years of age. • Is mentally competent to consent to a contract, ■ Has filed it 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-44-02 W-3149 (1104) AWMED Amendment 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: Eloctive 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 $100.00 in addition to the -applicable facility copayment. AV- GIOO-ETP--R-97 MP -1321 {1104) ,ALYMED WIT __P' T -,A- _N I.; Addendum -Coverage for Mammograms — Waiver of Co -payment If selected, the following provision is hereby modified f6r an additional premium: Section 10.28 of-the AvMed Health Plans Group -Medical and.Hospital Service Contract is amended to state: Mammograms are covered in accordance with Flodda Statutes: oi)e baseline m anim ogram is covered for female . a Members between the ages of 35 and 39; a mammogram is available every two years for female Members between the ages of 40 and 49; and a mammogram is availaible every year for female Members aged 50 and older. fn addition, one or more mammograms year are available when based -upon a physician's recommendation for any woman who is at risk for breast cancer because of a personal or family history of breast cancer, because of having a history of biopsy-proven benign breast disease, because of having a mother, sister, or daughter who has had breast cancer, or because a woman has not given birth before the age of 30. This coverage will not be subject to diagnostic imaging Cd-payments. ANT-Mammogm-05 .MP-3229kI270$) AVIVIED, INC. d1b/a AVIVIED Health Plans Group Medical and Hospital Service Contract Group Master Application Contract Number(s): 106346 Subscribing Group Name: City Of South Miami Effective Date: 10101107 Group Contract This Group Contract provides the benefits listed below: Identifier 2gsLcdpjLo_n AV-BASIC-25OA-06 Summary of Benefits AV-LG,RX-2x-1 5130/50175/50%-OC-06 Prescription Drug AV-G'100 - , MH/PHI-$250 per -admit-04 I P Mental Health AV-SA-98 SubstanceAbuse AV4G 100- DME-2000-R-06 Durable Med. Equip, AwsTuDENT ELIGIBILITY -R -02 Student Eligibility AV-DP-6-R-02 Domestic Partner AV-G 100- ETP-R-97 ETOP AV-Mammograhl-05 Mammogram M E ElCgibilitlr Active Employees (Class 1) are required to Work 25 hours. per week to become eligible for coverage under this Cbhtfact. Employees will become eligible for coverage on the. first of the month followhg the first daysof erriployn-6nt. Active Employees-(Glass 2) are,required to work 25 hours per week to become eligible for coverage under this CohtracL EmployeesWill become eligible for coverage on the first of the month following the first day of employment. Termination For Active. Employees (Class 1), termination of coverage under this Contract shall become effective End of Month. For Active Employees (Class 2), termination of coverage under this Contract shall become effective End of Month. Monthly Membership Charges SubscriberOnly ......... ....... ........ .......................... -__ ............. $403.32 Subscriber plus Spoute —., ....................... ........ ............. ........ ........... _.__ . .......... _ .... $794.54 Subscriber plus One Dependent (No Spouse) ...... ........ ............ ...... ....... $713,87 Subscriber plus Two or More Dependents .................................... ..............7................ .. ..........., $713.87 Subscriber plus Spouse and One or More Dependents.. .............. ......................I........ $1,189.80 AV- Master Application -07 MP-2027(07) �r� AVMED, INC. dlbl /a AVMED Health Plans Group Medical and Hospital Service Contract Group Master Application, continued Agreement This Contract is issued in consideration of the Master Application of the Subscribing Group for group medical and hospital services and the monthly prepayment subscription charges and the mutual promises and benefits between AVMED; Inc. d /b /a AVMED Health Plans and the Subscribing Group. This Contract shall remain in effect for a period of twelve (12) months from the effective date of October 1, 2007 and may be renewed annually, not later than the anniversary date, upon .mutual agreement of the parties. This. Contract period begins at 12:01 a.m: Eastern Standard Time on the effective date or on the anniversary date, if a renewal. The Contract shall be governed by Chapter 641, Florida Statutes, and other applicable State and Federal laves. The first monthly payment is due on October 1, 2007. Subsequent payments are due on the 1st day of each month thereafter. 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 OF THETHIRD DEGREE. The provisions contained in the Schedule of Benefits applicable to this Contract and all Exhibits and Amendments executed . by the parties and attached hereto .are;, by reference, made a part of this Contract. AGREED TO AND ACCEPTED BY the parties the dayand year hereinafter written. The Effective Date of this Contract is October 1, 2007. Subscribing Group: City Of South Mlaml AVMED, Inc. d /b /a AVMED1 Health Plans By: By. _ P01" ')k Signature signature Evis Clavarez Name Name Director, Client Service Title Title Date: Date: AV MasterApplication -07 M124027 (1107) J;k,LVNhD Benefit Summa�y Ff"i A L L-;;7N BASIC OPTION SCHEDULE OF BENEFITS COST TO MEMBER 25040MIT OUT•OF-POCKET MAXIMUM $1,500 MIVIQUAL. Per Calendar Year $3,000 FAMLY AVM1EO 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= chflW care- • Periodic health evaluation immunizations ation and. imm uniz.at' ■ Diagnostic imaging„ laboratory or other diagnostic Services ■ Minor surgical procedures ■ Vision andhea±g examinations.,for children under IS. MATERNITY CARE ■ Initial visit $15 Co-payment a Subsequent visits NO CHARGE AVM ED SPECIALISTS' ■ Office visits $25 per visit it SERVICES ■ Amwal gynecological examination when perforit dd by a participating Specialty Health Care Physician HOSPITAL Inpatient care at, Participating Hospitals includes: $250 per admissiom ■ Room and board - unlimited days (semi- private) 100% covorqgc • Physicians', specialists' and surgeons' services thereafter ■ Anesthesia use of operating and re cov ery. rooms, ox Y ge ft drugs and in edication Intensive care unit and other special units, getieral and special. duty nurs' . I mg: ■ Laboratory and diagnostic imaging ■ Requited special diets Radiation and inhalation ihejapies OUTPATIENT SERVICES ■ Outpatient surgeries, including-cardiao,cathetenzations $2250 Co-payment arid:angioplasty ■ Outpatient therapeutic sery icesj including: ■ Drug infijsion therapy $100 Ca-payment • Injectable Drugs - (Cb-payinent for injinjectable. bl Drug waived if incidental to same• day drug $75 Co- payment OUTPATIENT DIAGNOSTIC ■ CAT Scan, PET Scan, MIZI $25 per test TESTS ■ Other diagnostic imaging tests $W per test EMERGENCY SERVICES An emergency is the sudden and unexpected onset of a condition requiring immediate medical orsurgical care. (Co-payment waived ifadmitW4)) ■ Emergency services at Pgrticipati�ng Hospitals $75 Co-payment Emergency services at non-participating Hospitals, 160 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 URSENT/IMMEOIATE CARE ■ Medical Services at a participating Urgent/Immediate Care $40 Co-paYm*6tit 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 AV-BASIC-25OA-06 NIP-3422 (10/06) '� z r c i. e MENTAL HEALTH * 20 outpatient visits $25 per visit FAMILY PLANNING ■ Voluntary family planning services $15 per visit Sterilization $250 Co- payment ALLERGY TREATMENTS Injections $10 per visit ■ Skin testin g $50 per course of testing AMBULANCE ■ Ambulance transport for emergency services $100 Co- payment w Non- emergent Ambulance services are covered when the skill of medically trained personnel is required and the Member cannotbe safer traMeorted by ether means PHYSICAL, SPEECH, AND Short -term physical, speech or occupational therapy for $15 per visit OCCUPATIONAL THERAPIES acute conditions Coverage is limited to 30 visits per calendar year for all services combined SKILLED NURSING Up to 20 days post - hospitalization care per Contract Year $50 per day FACILITIES AND when prescribed by physician and authorized by AvMed REHABILITATION CENTERS CARDIAC REHABILITATION Cardiac rehabilitation is - covered £or the following conditions. $20 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 Contract Year • Heart transplmit Coverage is limited to IS visits per Contract Year ROME HEALTH CARE Limited to 60 skilled visits per calendar year NO C14IRGE OURABLE MEDICAL Equipment includes: $50 per episode of . EQUIPMENT AND a �Iospital beds illness ORTHOTIC APPLIANCES ■ Walkers ■ Crutches Benefits liluited. ■ Wheelchairs to 5500 per Orthotic appliances are limited to Contract' ear ■ Leg, arm; :back, and neck custom -made braces PROSTHETIC DEVICES Prosthetic devices are limited to.: NO, CK4RGE • Artificial limbs • Artificial joints • Ocular prostheses FOR ADDITIONAL INFORMTIEIN, PLEASE CALL: 1.800.88 -AVMEO (1-800-882-8633) THIS SCHEDULE, OF BENEFITS IS NOT A CONTRACT. FOR SPECIFIC INFORMATION ON BENEFITS, .EXCLLISIONS AND LIMITATIONS, PLEASE ;SEE YOUR A'i?' 4ED GROUP NMICAL AND HOSPITAL SERVICE CON- TRACT. "- BMSIC- 250A -0.6 1%4P -3422 (10/06) AvMED W-IL T—A /611. Prescrip'tion Drug vellepts -8rand"medication means a Prescription Drug that is usually manufactured and sold under a name or trademark by a pharmaceutical manufacturer or 4 medication that is identified as 4 Brand medication by AvMed. AvMed delegates determination of Generi&Srand status to our Pharmacy Benefits Manager. "Bard Additionat 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 Brand Co- payment (Preferred or Non: Preferred). Cost - sharing cations" are those medications., as desigriated by AvMed, which were designed. to improve the quality of life by treating relatively minor non- life threatening conditions- Stlohinedications are subject, to Go- insurance and coverage is limited as outlined below. -Dental-specific Me(lcalioji," is medication used for -dental -;spocific purposes, including but not limited to fluoride medications and medications pack!4ged and labeled for -dental-specific purposes, "Gonetic" medication means a, medi6dtion that has the same active ingredient m a, Brand inedidation or is identified ass a Generic medication by AvMo&s Pharmacy Benefits Manager. `Tnjecultlle Medication" is a medication that has been approved by the Food and 'Drug Administration (FDA) for adn. striation by one or erne of 'the, following routes: intramuscular injection, .intravenous` injection, intravenous inthsion, subcutaneous injection, intraffiecal injection, intiarticular injection, int.racavemous injection or intraocular injection, Pre-Authorization is required for all Injectable Modicaltions. "tvlaimenanw. M edicatiorC is a medication that has been approved by the, FDA: for m1dch the duration of therapy can reasonably N expected to exceed one year "Participating Pharmacy, 'mean- 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 AvMod as a Participating Pharmacy. "Preferred Medication List." means the listing Pharmacy and Therapeutics Committee based on clinical efficacy., relative safety and cost imqomparison to similar medications within 4 therapeutic class. T1-d,s_mqJti-:tiered list establishes differentlevels of Co-pqyrnent for medications within therapeutic classes. As new modications become available; they may be considered exchided until they have been reviewed by AvMed's Pharrnacy -and Therapeutics Committee. "Prescgi tion Drug" mews 4 medication that has b approved by. the FDA and that can only be dispons-ted pursuant to. a ppesetiptiort according to state p beer and foderal law. Pre Authpiimfion" mean-% the process of obtaining approval for certain Presqript;ion Drugs (prior to dispensing) according to AvMe W s guidelines. The ,prescribing physician rimst obtain approval from AvMed. I'he list of Prescription Drugs requiring Pie-Authoti2ationis subject to periodic review And modification by AvMed. A copy of the list offfiedicatioris requiring Pi-e-Anthorization and the applicable criteria are available 'from Member Services; or from -the AvMed website. "Self-Administered. lq�ectable Medication" is a.medication that, has been approved by the FDA for self-injeation and is administered by subcutaneous ,injection br a medication for which there am instructions to the patient for self-inJection in the manufacturees prescribing information (package insert). Pre -AuthorizatLonis requiredfor all , $61f-Administered. Injectable Medications. NOW DOES YOUR RETAIL PRESCRIPTION COVERAGE WORK? To obtain your, Prescription Drug, take your prescription to, or have your physician call, an AvMed Participating Pharmacy. Your physician should subidt prescaiptionR for SW-Administered Injectable. Medications to AvMeWs specialty pharmacy, Present -your presotiption along with your AvMed identification card. Pay the -following co-payment (as well w the Brand Additional charge if you or your physician choose a Brand piodw when a Generic equivadentitavailable). Tier I Preferred Generic Medications. $ 15,00 Co- payment Tier 2 Preferred Brand Medications: 30.00 Co- payment Tier 3 Nort4"fetted Brand or Generic Wicdtion.,,r $ 50,00 Co-papneot Tier 4 Self-Administered injectable Medications: $ 75.00 Cr -payinent Tier 5 Cost-sharing Medications 50% Co- insurance ORDERING YOUR PRESCRIPTIONS THROUGH THE MAIL Mail service is a. benefit option for.mainfenance, 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 form additional prescription for T to a 90 -day supply of your medication to be ordered through maal service. Up to 3 refills are allowed per presedption. Pay the following Co-paymerit (as well as. the Brand Additional Charge if you or your physician YSA kin choose a Brand product whieri -a Generic equivalent is available). Tier 1 Preferred Generic Medications: S 36.00 Co-payment Tier 2 Preferred Brand Medications: $ 60.00 Co-payment Tier 3 Non-Preferred Brand or Generic - Medications; S 100.00 co-payment Tier 4 Self-Administered Injectable modications are not available through mail service, Tier 5 Cost-sharing Medications are not available through mail service AV-LG= R.K-2X-1 5f30/50117 5/500/0_0c_o 6 .MP -3859 (10106;) Prescri 0 ption Drug, Bensr, continued WHAT 19 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 chmiges in coverage criteria for covered products and services. Coverage criteria are medical and pharmaceutical protocols used. to determine payment ofproducts and services and are based on independent clinical practice guidelines and standards of care established by government agencies and medical/phannacetifical 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 maxiniurti, of 13 refills peryear. You also have the opportunity to obtain a 90-day supply of medications used for chronic conditions including, but not limited to astfuna, 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 coven. go 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, 00-day supply, you will still be charged the listed mail order Co payment.. ■ Your Self-Administered Injectable Medication coverage extends to Tnony injectable, medications approved by the FDA. These medications roust be prescribed by a physician and dispensed by q retail or specialty pliarmacy. The Oir-pqment levels for Self-Admirdftdred Inido-table Medications apply regal dless of provider. Thi4 iftearis that you are reoporisible for the appropriate Co-poyment 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 Tier 5 coverage is limited to Terbinafme (Larr�isill)) and ItraconazoIe (Sporanoxft in oral form, when prescribed by your phykcian for the treatment of documented fungal infections. Pre-authorizatibri is not recItikod, ■ Your Prescription Drug coverage includes coverage for injectable confinceptives. There is a Co-pqyment of $110 for each injection. If there is an office Nfisitass,ociated with the injection, th6re will be an additional Co-payment required-for the officavisit. ■ Quantity limits we set in accordance with FDA approved prescribing, limitations, general practice giridelines supported by medical specialty organitations, •and/or evidence-based, statistically valid dirtical studies without published conflicting .data. This means that a medication- spedfio quantity limit may apply for medioations that have an increased potential for over-utilimfion or an increased potential for.a. Member to experience an :adverse effect at higher doses. QUESTIONS? Call Your AvMed Member Services Departifiefit at: 1-800-88-AvMed (1-800-882-8633) EXCLUSIONS AND LIMITATIONS ■ Mddications, 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 gaiments • Replacement Prescription Drug products resulting from a lost expired, ired, broken, or destroyed prescription order or refill ■ D. iaphrp gms and other contraceptive devices ■ Fertility drugs ■ Medications or devices for the diagnosis or treatment of sexual dysfunction ■ Dental-specific Me& cat ons for dental putpoaes; fitcludirg finori de me& cati ons ■ Prescription and rion-prescription vitarnins and minerals except prenatal vitamins ■ Nutritional supplements ■ 11runuffizations ■ 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 Hb§pital Service Contract and inay be subject to Co-payments or Co-h-nuraftce as outlined on the Schedule of Benafit% • Investigational and experimental drugs (except as required by Floridaotatute) ■ Cosmetic products, including, but not limitedto. hair gromth, Ain bleaching, sua,damage and anti-wrizild e medications ■ Nicotine suppressants and smolang cc s ' -ationproducts and services. ■ Prescription and non-prescription appetite suppressants and products for the purpose of weight loss ■ Compounded prescriptions, exceptpediatricpreparations ■ 1,dedications and imaninizations; for nonbusmiess related travel, including Thansdermal Scopolamine Filling a prescription at a pharmacy is not a claim for be-neft and, 11T not subject to the Claims and Appeals procedures under PRISM. However. any medicines, that require Pre-A uthorizzation will be tr,•eated as d,61aimfir banqfits subject to the Claims andAppeats Procedures, as outlined in the 16irwipAledical andHospital:Seevice Contract. AV-LG-RX-2x-I5130/5K 150%_OC_06 NT-3859 (10100) M iEALTI[-L- LA NS 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-GlOO-.'N -$250 per admit-04 hdP-35222 (10/04) AvMED ff " -F, ' -A, - "L-, -1 1 -� -1 " —P, T -A- .N...5 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 prograna(§) 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 weelocs per contract year, AV-SA-R-98 W-1527 (1104) .M-ED if-F-A -L--T-14- L-A--�-i Amendment Dunable Medical EqW.pnient If selected, the following coverage is hereby modified, for an additional premium. DURABLE MEDICAL EQUIPMENT 9 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 maxinitifti limitation and shall not be subject to the durable medical equipment 'benefit limitation. AV.-G I OO-DNE- 2000-R-06 I\dP-2149 (4-06) i _AvMED _-E A..,t-_ r li_.w. --P'-'-A-?4 ._".; STUDENT ELMGABILITV Amendment As of the Effective Date, and in spite of anything in the Certificate to the contrary, the following benefit is revised for an additional premium. Coverage of dependents under the age. of 19, or to the age of 25 if dependent is a full time student. AY- STMENT ELIGISIL.ITY =R -42 W -3.122 (1 /04) A.M.ED ff-i —A",-L---T—"H . ........ F _L_A_ _N_'__S 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 provv-,ion: Dependent Eligibility will be idded for a Domestic I'lartner 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, 1s mentally competent to consent to a contract-, Has filed s, DomestiaPartnership agreement or registration with the Employer, if available, M' the state (Eindfor 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. Ay R -6 -Pi ,NIP-3149 (VOO AvM--,ED `� H L A L T tµ � L 4 fit 5 ` i ELECTIVE TERMINATION OF PREGNANCY If selected, the following optional coverage is hereby added:. The Avl\Ied Health Plan Group Medical and Hospital Sei vice +' ontract is amended to state: Elective tomination 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 copayinent of $100.00 in addition to the applicable facility copayment. Av- 0100 -ETP R 97 A P -Ml (1/04) AvMed Health Plans Group Medical and Hospital Service Contract AV-6.10-2066 W-3905 (10-06. TABLE OF CO24TENTS SERVICE AREAS ..................... .......................................... ............................ i I. GENERAL......... .............................., ... .................... :..................................... I II. INTERPRETATION ......................................................... ............................... I III. DEFINITIONS :............................................................... ..............................2 IV. ELI+ CrIBILITIr ....................................,................................. ...,......,............ „......8 V. EtRC7LLl1! IENT ................................,,.......,.....,...,....,..................... .............. 10 VI. EFFECTIVE DATE OF MEMBERSHIP ,..: ........................ ............................... I I VII. MONTHLY PAYMENTS AND CO-PAYMENTS MENTS . .. ....................... ...........,......12. VIII. CONVERSION ...................4........... .... ,............... ..................................... 13 IX. T ERMINATION ........................ ...... ... ......... ......... .............................15 X. SCHEDULE OF BASIC BENEFITS........ ..................... . ... . ...................... .............. 21 M. LIMITATIONS OF BASIC BENEFITS ....... ............ ...... ..............................9 XII. EXCLUSIONS FROM BASIC BENEFITS ..........................,. XIII. COORDINATION OF BENEFITS ... ..I .,.... .... .................. ............................... 34 XIV. SUBROGATION AND RIGI=3T OF RECOVER'Y' .................... ................. 37 XV. DISCLAIMER OF LIABILITY. ......... :...... .... .. ........: .......::........ 38 XVI. GRIEVANCE 1'ROCEDiJItE .............. ...................... ...... ...,.................. I ....... 39 XVH. MISCELLANEO US ..................................:....... .............................45 AV-0106-2066 nv -�903 tio.96) 9400 South Dadejand Boulevard Post Office Box 569004 Miami, Florida 33156-9004 (305) 671-5437 (800) 432-6676 Miami-Dade FT. LAUDERDALE 13450 W. Suntisc Boulevard Suite 370 Sunrise, Florida 13323-2947 (954) 462-2520 (900) 368-91.89 Broward PA44 Beach JACKSONVILLE 1300 Riveq)lace Boulevard Suite 200 Jacksonville, Florida 32207 (904 ) $50-1300 (800) 227-4184 Bakdr Clay Duval Nassau St. Johns AV-G100-22006 NIP-3905 (16-106) AVMED CORPORATE OFFICE 9400 S. DADELAND BLVD. P.O. BOX 569004 MIAMI, Fl, 33156.9004 SERVICE AREAS GAINESVILLE 4300 N.W. 89`h Boulevard Post Office Box 749 Gainesville, Florida ,32606-0749 (352) 372-8400 (900) 346w0231 Alachua Bradford Citrus Columbia Dixie Gilchrist Hamilton Levy Marion Suwannee Vnioit ORLANDO 541 South -Orlando Avenue Suite 205 Maitland, Florida 32751 (407) 539-0007 (800) 227-4848 Orange Osceola -Semindle TAMPA BAY/ SOTTIHWE9T FLORIDA 1511 NorthWestshore Boulevard Suite 450 Tampa, Florida 33607 (813) 2816650 (800) 257-2273 Hernando Hillsboro Lee Pasco Pinellas Polk Sarasota AVI%49D MEMBER SERVICES _ ALL AREAS 1-800-88. AV.N,(.ED (1.•00-882-863-3) AVM'ED- ff'eF —A,-L- —T,-I—I PL--ANs Coverage for Mammogram — Waiver of Co-- paymeint 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 SfrxWvs: 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 -Mmm ogrmi -05 1\4P- 3228.(12/05) AvX11ed, INC. d /b /a AvMed HEALTH PLANS GROUP MEDICAL AND HOSPITAL SERVICE CONTRACT IN CONSIDERATION of the payment of monthly prepayment subscription charges as provided herein and of mutual promises and benofits hereinafter described, AvMed, Inc., a Florida corporation, d /bla. AvMed Health Plans, (hereinafter referred to .as "AvMed "), and the Subscribing .Group as named on the Master Application attached hereto ( herainafter referred to as "Subscribing Group ") agree as follows: I. GENERAL The Subscribing Group engages AvMed Health Plans, on behalf of the group health plan described herein (the "Plan "), to arrange for the provision of Medical Services or benefits which are Medically Necessary for the diagnosis and treatment of Members of the Subscribing Group through a network of contracted independent physicians and Hospitals and other independent health care providers who are not agents or employees of AvMed (see Section 15.04). AvMed, in so arranging for the delivery of Medical Services or benefits,, does not directly provide. these Medical S'eivices or benefits: A.vMdd arranges for the provision of said services in accordance with the covenants and conditions contained in this Contract. AvMed shall rely upon the statements of the Subscriber in his application in providing coverage and benefits hereunder. This Contract is not intended to and does not cover or provide any Medical Services or benefits that are not Medically Necessary far the diagnosis and treatment of'the Member. The determination: as to which services are Medically Necessary shall be made by AvMed subject to the term's and conditions of this Contract. 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 tare established by government agencies and medical/pharmaceutical societies. The Medical and Hospital Services covered by this 'Contract shall be provided without regard to the zace, color, religion, physical handicap,. or national origin of the Member in the .diagnosis. and treatment of patients; in the use of equipment and other facilities; or in the assignment of personnel to provide services, pursuant to the provisions of Title VI of the Civil Rights Act of 1964, as amended, and the Americans with Disabilities Act of 1990. II. INTERPRETATION In order to provide the advantages. of Hospital and medical facilities and of the Participating; Providers, AvMed operates on a direct service rather than indemnity basis:. The interpretation of this Contract ;shall be guided by the direct service nature of AvMe&s program and the definitions and other provisions contained herein. l Av- 0160_2016 NIP -3405 (10 -06) III. DEFINITIONS As used in. thL4 Contract, each of the following torim shall have the meaning indicated: 3.01 "Adverse.Benofit Determination"- means a denial, reduction, or terramation of, or a failure to provide or make payment, in whale or in part, for a benefit, including any such denial, reduction, terniination, 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, of 1 failure to provide or make payment (in whole or in pail) 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 I'AyMed," means a private not for profit Florida corporation, state licensed as a health maintenance organization under Chapter 641, Florida Statutes, for the purpose of artanging 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 Meluber. 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-Scrvic-, Claim, a Health Professional, with k-ftowledge of the Member"s . medical condition, shall bepermitted to act as the Member's authorized representative and will be notified of all approvals on the Claimant's behalf. In the event of att Adverse Benefit Deterrhination, AvMed will notify both the Member and the Heath Professional. 3.05 "Concurrent Care" means an ongoing course of treatinentto be provided over a period of time or number Of treatments that was previougly approved by AvMcd. 3.00 "Con1ract" means this Group Medical and Hospital Service Contract which may at timtg be referred to as ''Group Contract!' or "Subscrlbing Group Contract" and all applications, rate letters,, face sheets,, riders, amendments, addenda . hiibits,. supplemental agreements, and ., ex schedules which are or may be incorporated in this Contract from time to time,. 3-07 "Contract YeAel means the period of 12 consecutive mondw- comtnexlcing on the affective date of this Contract. 3.08 "Conversion Contract" means an individual Member or Subscriber contract which shall be available to continue coverage (as provided for thercin) ofthe 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 charg es, which the Subscriber is re. quired 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 responsible for the payment of any Co payment charges directly to the provider of the health services at the time of service. 2 AV-0100-2006 NIP-3905 (10,06) 3.10 "Custodial Cate" means services and supplies that are furnished mainly to train or assist in the activities of daily lining, such as bathing, feeding, dressing, walking, and 'taking oral medications. "Custodial Care" also means services and supplies that can be safely and adequately provided by persons other than licensed health care professionals, such as dressing changes and catheter care; or that ambulatory patients customarily provide for themselves, such as ostomy care, administering insulin; and measuring and recording urine and Mood sugar levels. 3.11 "Dental Care" means dental x -rays, examinations and treatmentt of the teeth or any services, supplies or charges directly related to (i) the care, filling, removal or replacement of teeth, or (ii) the treatment of injuries to or disease of the teeth, gums or structures directly supporting or attached to the teeth, that are customarily provided by dentists (including orthodontics reconstructive jaw surgery, casts, splints, and services for dental malocclusion). 3.12 "Dependent" means any member of a, Subscriber`s family who meets all applicable requirements of Part IV and is enrolled hereunder and for whom the prepayment required by Part NTH has actually been received by AvMed. 3.13 "Durable Medical Equipment @ME),. Orthotics, and/or Prostlieticel Coverage for 1)1V1E, orthotics and pzosthetics is limited as outlined in Sections 10.201 10.21 and 1022, subject to specific Limitations and Exclusions as listed in Part XII. The determination of whether a covered item will be paid under the I)NIE, orthotios or prosthetics benefits will be based upon. its classification as defined by the Centers for Medicare and Medicaid Services, 3.14 IT mergency Medical Condition" means: 3.14.01 A medical condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate: medical attention could reasonably be expected to result in any of the following: a) Serious jeopardy to the health of a patient, including; a pregnant woman or fetus. b) Serious impairment to bodily functions. c) Serious dysfunction of any bodily organ or part. 3.14.02 With respect to a pregnant w v an. a) That there is inadequate trine to effect safe transfer to another Hospital prior to delivery.; b) That a. transfer may loose a threat to the health and safety of the patient or fetus; or c) That there is evidence of the onset and persistence of utcrine contractions or rupture of the membranes.. 3.14.03 Examples of Emergency Medical Conditions. include, but are not limited to: heart attack, stroke, massive internal or exteml bleeding, fractured limbs, or severe trauma, 3 av- Boa -?tm� NO -3405 (10.06) 3.15 "Emergency Medical Services and Cure" means medical screening, exanlination, and evaluation by a physician, or, to the extent permitted by applicable law; by other appropriate personnel under the supervision of 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 cowl d 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 deieixnination as to whether or not an illness or .injury constitutes an emergency shall be made by AvM. ed and may be made retrospectively based upon all information mown 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" 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 student in accordance with the requir6ments of the school. (See Subsection 4.02.02(f)) 3.18 "Group Health Insurance" (for purposes of Paid XUI) means that ferin 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), F%prida Steitutes. 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 temps "policy," "insurance policy,," "health insurance policy," and "Group Health. Insurance policy" include plaits ofself4lisurance providing :health insurance benefits. 3.19 `Health ProfessionaW means physicians, osteopaths, podiatrists, chiropractors, physician. assistants, nurses, social 'workers; phaimuicists, +optometrists, clinical psychologists, - nutritionists; occupational therapists, physical therapists; and .other professionalst 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 taw and who are Participating Providers ofAvMed Health Plans. 3.20 "Horne Heath Care Services (Spilled .Home Health Care)" means services that are provided for a Member who dares not require confinement in a Hospital or Other health Care Facility. Such services include, but are not .limited to, the services of professional visiting nurses or other health care personnel for services cove. red under this Contract. See Section 10.08 regarding physical and occupational therapy Limitations. 4 �v- �ioo -acas XIM905 (M061 3.21 "Hospice" means a public agency or private organization that is duly licensed by the State to provide Hospice services and with whom AvMed has a current provider agreement. Such licensed entity must be principally engaged in providing pain relief, symptom management, and supportive services to terminally ill Members. 3.22 "Hospital," means any general acute care facility which is licensed by the State and with which AvMed has contracted or established arrangements for inpatient Hospital Services and/or Emergency Medical Services and Care, and shall at times be referred to as a "Participating Hospital.' 1 3.23 "'Hospital Services" (except as expressl=y limited or excluded by this Contract) means those services for registered bed patients that are: a) Generally and customatity provided by acute care general Hospitals within the Service Area. b) Pert-ormed, prescribed, or directed by Participating Providers; and 0) Medically Necessary for conditioms which cannot be -adequately treated in Other Health Care Facilities or with Home Health Care Services or on an ambulatory basis. 3.24 "HospitalistUdmitting Panelist',' means a physician who specializes in treating inpatients and who may coordinate a Member's health care whon the Member has been admitted for a Medically Necessary procedure or treatment at a Hospital. 3.25 "Injectable Medication" means a medication that has beet 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, i=arficular injection, intracaveinous injection or intraocular injection. Pro- authorization is required for Injectable Medications. 3.26 "Limitation" means, an)r provision other than an Exclusion which restricts coverage. under this Contract. 3.27 "Maste.r Application" ineans, the Subscribing Group application form entitled. "Master Application" which becomes a part of the Contract when the Master Application has boon completed and executed by the Subseribins Group and AvMod. 3,28 ",Medically Necessary" means the use Gf any appropriate medical treatmenti service, equipment, and/or supply as provided by a Hospital, skilled nursing facility, physicia r other provider id 0 0 ovi or which is necessary for the diagnosis, care, andlor treatment of a Memboes illness -or injwy, and which is: a) Consistent with the symptom, diagnosis,, and treatment ofthe Member's condition, b) The most apprdpfiate, level of supply and/or service for the diagnosis and treatment of the Member's condition; C) In accordance with standards of acceptable community practice; d) Not primarily intended for the personal comfort or convenience of the Member, the Member's family, the physician, or other health care providers; e) Approved by the appropriate medical body or health care specialty involved as effective,, appropriate, and essential for the care and treatment of the Members condition; NT-39055 (10-06) f) Not experimental or investigational. 3.29 "Aledica:l Office' means any outpatient f6icifity 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) Medicably Necessary (except for preventive seiv ces as stated herein) for the diagnosis and treatment of injuty or illness. 3.31 "Member" means any Subscriber or Dependent, as described in Part I11, 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 "+fuller Health Care Faeility(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 (tihysician), 459 (osteopath), 460 (chiropractor) or 461 (podiatrist), FlarFda 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 Pipe- Service Claim. 137 "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 fi om 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 deesignated by AvMed as a "'Primary Care Physician." in AvMed`s current list of physicians and Hospitals. 3.39 "Relevant Document" means any documentation that: 6 AV 4100-2006 NP-3905 Q0.06) a) Was relied Upon in making the benefit determination; b) Was submitted; considered or generated in the course of making the benefit determination, without regard to whether it was relied upon in making the determination; c) Demonstrates compliance with the administrative process; and d) Constitutes a statement of policy or guidance with respect to the Plats concerning the Adverse Benefit Determination for the Claimant's diagnosis, without regard to whether such advice or statement was relied upon in making the Adverse Benefit Detenni nation. 3.40 "Self - Administered Injectable Medication" means 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 patientt for self injection in the manufacturer's prescribing information (package insert). 3.41 "Sendee Area" means those counties in Clio Mate of Florida where AvMed has been approved to conduct business by the Flor da Dep ittnent of Financial Sol viceis.. 3.42 "Specialty Health Care Physician" means: any Participating Physician licensed under Chapter 458 ( physician), 459 (osteopath), 460 (chiropractor) or 461 (podiatrist),. Florida Statutes, other than the Member's chosen Primaxy Care Physician. 3.43 "Subscriber" means a person who meets all applicable requirements of Section 4.01, enrolls in the Plan, and for whom the premium prepayment required by Part VIT has actually been received by AvMed. 3.44 "Subscribing Group" means a coxperati. rn. partnership, limited liability company or:other legal entity (and its wholly. - owned subsidiaries) that negotiates and agrees to contract for the health services and benefits provided herein for its eligible employees. 3.45 "Total Disability" means a totally disabling condition. resulting froth an illness .air injury which prevents the Member from engaging in any employment or occupation for which he may otherwise become qualified by reason of education, training,, or experience, and for which the Member is under the regular care of a physician. 146 11trgent Care Claim" means any Claim for medical care or treatment that could seriously jeopardizo the Member's life or health or the Member's ability to regain maximum function or, in the .opinion of a physician with knowledge of the Member's medical condition; would subject the Member to severe pain that cannot be adequately managed without the care or treatment requested. Generally, the determination of whether a Claim is an Urgent Care Claim shall be made by an individual acting on behalf of AvMed applying the judgment of a prudent layperson who possesses an average knowledge of health and medicine. However, if a physician with knowledge of the Member's medical condition determines that the Claim is an Urgent Care Claim, it shall be deemed as such 3.47 "Urgent Care/Immediate Care" means medical screening, examination, and evaluation received in an Urgent Care Center or Immediate Care Center or rendered in your Primary Care 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. 7 AV-0160w2006 NIP-3905 (10.06) 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: ( l) 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 acuto 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 fide standing facility or maintained in a Hospital or skilled nursing, facility setting. Coverage is. limited to 100 days lifetime maximum. IV. ELJGIBILITY 44.01 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 as set 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 Ul.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 furnished 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); b) The child resides with the Subscriber (except for 'TI and "h" below); AV-0160-2006 W -:3905 (10' -06) c) The child is under the age of lit (except for T' and "g" below or Section 4.04 below); d) The child is principally dependent upon the Subscriber for maintenance and support and is not regularly employed by one or more employers for a total of 30 hours or more per week; e) The child is not married; f) The child is age 19 or over but under the age of 23, or other limiting age as specified by the parties vi a fully executed addendum to this Contract, and is enrolled as a Full -Time Student (see Section 3.17) at a college, university, vocational., or secondaiy .school. Subscriber is responsible for notifying AvMed when full-tune attendance commences or terminates, and coverage ;shall. commence or terminate upon such notification. Termination of coverage will be retroactively applied if AvMed is not notified. Subscriber agrees to provide documentation of Full -Time Student status upon request by AvMed; g) The child is age 19 or over and is wholly dependent on the Subscriber due to mental retardation or physical handicap. (See Section 4.04) h) In the event an eligible Dependent child does not reside with the Subscriber, coverage will be extended when. the Subscriber is obligated to provide medical care by a Qualified Medical Child Support Order. You (or your beneficiaries) may obtain, without charge, copies of the Plan's procedures governing qualified medical child .support orders and a: sample qualified medical child support order by contacting the Plan Administrator. i) In the case of a newborn child, AvMed should be notified in writing prior to the scheduled delivery date of the Subscribers intention. to enroll the newborn child, but such notice shall not be later than 31 days after the birth: If timely notice is provided, no additional premium. will be charged for the .additional coverage of the newborn during the 31 -day period following the birth of the child. If timely notice is not provided, the, additional premium for the additional coverage of the newborn. child will be charged from the child's date of birth. If notice is not provided within 60 .day, s of the birth, the child may not be enrolled until the next open enrollment period of'the Subscribing Oroup. All services applicable for covered Dependent children under this Contract shall be provided to an enrolled newborn child of the Subscriber or to the enrolled newborn child of a, covered Dependent of the Subscriber or to the newborn adopted child of the Subscriber pivvided that a written agreement to adCOt such clued has been entered into. (prior to the birth of the child) from the moment of birth (as provided in :Part X, Section 10.11). In the case of the newborn adoptod child, however, coverage shall not be effective .if the child is not ultimately placed in the Subscriber's residence in compliance with Florida law, Coverage for the newborn child of a covered Dependent of the Subscriber (other than the spouse of the Subscriber) shall terminate 18 months after the birth of the newborn child. 4.03 No person is eligible to enroll hereunder whto has had his coverage previously terminated under Part W, Subsection 9.0.1.05, except with the written approval of AvMed. 4.04 Attairunent of the limiting age by a Dependent child shall not operate to exclude from or terminate the eomrage of such .child nor shall coverage prevent die. enrollment of a child while such child is and continues to be both: 9 AV-0160- 20005 NV -3405 (10 =06) 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 finidshed to A-%,Med 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 pax ticipation shall be pertnittO 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., ex eluding and Hawaii. V. ENROLLMFINT 5.01 Prior to the effective date of this Contract and at a proper time prior to each anniversary thereof, AvMod 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 AVIVed; othervyiso, the eligible ligible Subscribers and Dependents may not enroll until the next open enrollment period of sub-scribing Group. 5.03 Special Enrollinent Periods. An eligible Subscilbek or .Dependent y may ,request to enroll in the Plan outside of the initial enrollment and annual open crtrollinent periods if that individual, within the immediately preceding 31 days, was covered under another employer health benefit plan as an employoc or the dependent of an employee at the time he was initially eligible to enroll for coverage under the Plan., and: 5:03.01 Demonstrates that he or his Dependent has experienced one of the following status Ohagge events, including-. a) Marriage; b) Birth, adoption or placement for adoption; G) Legal separation, divorce or annuhnent-, d) Change in legal custody or legal guardianship; b) Death, 1) Relocation into or out of the Service Area; g) Termination/commencel-ftent of employment; h) Reduction inthe number of hours of employment; 10 AV-0100-2006 NO-3905 (10-06) i) Commencement of or return from leave of absence; j) Change in employment status; k) Change in work-site; 1) Strike or lock-out; in) Termination of employer contributions toward such coverage: n) Exhaustion of COBRA coverage, o) Attainment of lifetime maximurn; and 5.03.02 Requests: enrollment within 31 (lays after the termination of coverage under another employer health benefit plan, and 3:03.03 Provides proof of continuous coverage under the other employer health benefit plan. 5.04 The eligibility requirements set forth in Part IV shall at all times control and no coverage contrary thereto shall be effective. Coverage shall riot be implied due to clerital or administrative errors if such coverage would be contrary to Part INT. (Also.see Section 17.10) 5.05 This Contract, at the sole option of AvMed, will not be accepted if at the time of initial offering to Subscribing Group or, following re-enrollment, the total enrollment does not result in a predetermined minimum enrollment as established by AvMed. Thee required mininmin group enrollment, is included in: the rate letter submitted to Subscribing Group. VI. EFFECTNEDALTE OF MEMBERSHIP Subject to the payment of applicable monthly premium charges set forth in Part V11 and to thoprovisiong of this Contract coverage under this Plan shall become effootive 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 TV) of acquiling the now Dependent, you completb and submit an enrollment form on behalf of such Dependent. If received by AvItAed within the 31 day time period (or 60 days as permitteid 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 tinder the Plan due to other health coverage, and that coverage is subsequently terminated as a result of either a loss of W-3905 (IM6) 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 3.1 days of the loss of such other coverage or the terinination of employer contributions. The effectiv e elate 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 newboal child of the Subscriber's covered Dependent is effective at birth if Subsection 4.02.02(i) and Section 6.1712 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 prerniuin 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 far which. such payment is applicable. Failure of the Subscribng 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 thol parties in a fully executed addendum, to this Contract. An additional charge will apply to all late premium payments. (See Section 17.14) 7.02 Grace Period. This Contract has a ten•day grace period. This provision means that. if any rewired premium is not paid on or before the date it is due, it mast be paid during the following grace period. During the ,grace period, the Contract will stay in force. However, if :payment is not received by the last day of the grace period; termination of this Contract for nonpayment of the premium will be retroactive to 1.2:00 a.m. (midnight) on the last day of the month for which, the premium was paid. Note: Certain provisions in Section 7:01 may apply if the parties Have executed an addendum affecting premium payments. 7.03 Alaximum Co- payments. Total annual Co-payments are .limited as described in your Schedule of Benefits. The Co payment limits apply to Co payments made for all core benefits contained in this Contract; and do not apply to services provided under the Prescription Drug; 'Mental Health, Substance Abuse; Vision and other stipple rental riders. 7.04 Member shall pay premiums,. applicable supplemental :charges, or Co-payments as provided in this Contract. if the Member fails to pay the applicable premiums, upon ten days written notice from AvMed to Member, the Member's tights ;hereunder shall be terminated. Consideration for reinstatement with AvMed shall re uire anew application, and any re- enrollment shall be at the sole discretion of AvMed and shall not be retroactive. 7.05 .refund of premiums paid to . AvMed by the Subscribing Group for any Member after the date on which that Member's eligibility ceased or the Member was terminated shall be limited to the total excess premium amounts paid up to a maximum of 60 days from the date of such ineligibility or termination, provided there are no Claims incurred subsequent to the effective date of termination. 1.2 O-Cri OM 066 MP-3905 (10-06) No retroactive terminations of Members will be made beyond 60 days from notification of the terminating event. 7.06 In the event of the retroactive termination of an individual Member (as described in Subsections 9.01.02 and 9.02.01 of this Contract),. AvMed shall not be responsible for medical expenses incurred by AvMed in providing benefits to the Member under the terms of this Contract after the effective elate of termination (due to the S.ubscriibing Group's nonpayment of premiums or failure to timely notify AvMed of Member ineligibility). At the discretion of AvMed, and based on the facts available at the time, AvMed may pursue either the Subscribing Group or the Member for payment. VIII. CONVERSION 8.01 A Subscriber or covered Dependent whose coverage under the Subscribing. Group Contract has been terminated for any reason, including -discontinuance of the Subscribing .Group Contract in its entirety or with respect to a covered class, and who has been continuously covered under the Subscribing Group Contract, and under any group health maintenance contract providing similar benefits which it replaces, for at least three months immediately prior to tertnination, shalt be entitled, subject to the exceptions contained herein, to have issued to him or her a Conversion Contract (See Section 3.08), unless there is a replacement of discontinued group coverage by similar giioup coverage. within 31 days. S.U1..Q] The converting Subscriber and each of the eligible Dependents of the Subscriber who are converting must be Members .of the Plan in good standing on the date when their coverage terminates under this Group Contract, and all such Subscribers and Dependents, after complying with Subsection .$..01.02 below, shall be covered under the Individual. Conversion Contract. 8:01.02 A completed status change fibrin 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 sane time, or a child with respect to hiinself by reason of ceasing to be a qualified family member, may convert and must eon ply with Subsection *9M.02 above. c) A former spouse whose coverage would otherwise terminate :because. of annulment or dissolution of marriage may convent if the former spouse is dependent for financial support. The former spouse must comply with Subsection 9,01.02 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 13 AV-G On-aa0s W -3905 ttn -osi application has been timely completed (within 63 days after termination of the Group Contract) and the first preittium, due has been paid, AvMed sliall 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 Giroup Contract) and continues through the end of the calendar year. The Contract Year, upon renewal, shall be the calendar year. 9.02 Individual Conversion Contracts may not include supplemental benefits, notwithstanding the supplemental benefits included under this Subscribing Ciroup Contract; and may in other respects, as determined by AvMed, differ from this Group Contract. 8.03 The conversion privilege will not apply to a Subscriber or covered Dependent if termination of his caverage'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 AvMeds identification card by the Subscriber; Willfully and knowingly furnishing, incorrect or incomplete information to AvMed for the purpose of fraudulently obtaining coverage or benefits from AvMed; or f) Termination from coverage, under this Contract in accordance with Subsection 9.01.05.. 8.04 Conversion After Continuation Coverage. When continuation coverage asprovided under the provisions of the Consolidated omnibus Budget Reconciliation Act '6f 1986 (COBRA) "pires, the Subscriber or covered Dependent may be eligible for conversion coverage and may apply by completing an application for an Individual Conversion Contract, subject to the -conditions described in,this, Part Vill. I'lie eligible Subscriber or Dependent must send a completed applicatioti and the applicable premium payment, postmarked not later than 63 days after the termination of COBRA coverage,, directly to: AvMed Health Plans Accounts Reveivable Department Suite 510 9400 South Dadeland Blvd. Miami, Florida 33156 The Subscriber or Dependent may obtain an application. folin and a statement of current, premium . ..t. .. PPI la 69 for the Individual Conversion Contract by calling AvMed Member Services. It is the responsibility of the Subscribing. Group to notify Sub.§cfiber of Subscriber's rights under COBRA. For any specific questions concerning COBRA, contact the Subscribing Group. 14 AV-01 66-2006 X2.3905 (10.06) IX. TERAMATION All rights and benefits under this Contract shall cease as of the effective date of termination, unless otherwise provided herein. This Contract shall continue in effect for one year from the effective date hereof and may be renewed from year to year 'thereafter, subject to the following termination provisions. All rights to benefits under this Contract shall cease at 12:00 a.m. (midnight) on the effective date. of termination. 9.01 Reasons for Termination: 9.01.0:1 Loss ofEli_ i� bility - Subject to the conversion frights under Section 8:04: a) Upon a loss of the Subscriber's or Dependent's eligibility as :defined in fart IV, including but not limited to the permanent relocation. outside the Service Area, coverage shall automatically terminate on. the last day of the month for which the monthly premium was paid and during which the Subscriber and/or Dependent was eligible for coverage. b) Coverage for all Dependents shall automatically terminate on the last day of the month for which the monthly premium was paid upon a loss of the- Subscriber's eligibility, as defined in Part IV. 9.01.02 Failure to AUke 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 am. (midnight) on the last day of the month for which the monthly premium was paid. Av142ed, regarding :cancellation or non - renewal of this coverage, may retroactively cancel the policy to the date for which the 5utiscribing 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 A-vmed 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. 0.01.03 Termination of Croup Contract by Subscribinr Grouu — 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 Termination of Crroup Contract by AvIylecl - 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 am. (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 Ai Med has not received timely premium payments (See Part VII., Monthly Payments and Co payments and Subsection 15 AV-0-160-2006 1� -3�os tr:p•b� 9.01.02). Termination of coverage will be effective on the last clay of the month for which payments were received by AvMed. b) Subscribing Group has perfortned an act or practice that constitutes faud 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. e) AvMed ceases to offer coverage in the applicable market. AvMed will provide written notice to Subscribing Group at least 190 days prior to such termination. 9.01.05 Termination of CoveM far Cause: - AvMed may termurate any Member immediately upon written notice for the following reasons which lead to a lass of eligibility of the Winber: a) fraud,, material misrepresentation, or omission in applying, for membership, benefits, or coverage under this Con. trsct. However, relative to a misstaterir►.ont in the :Application, after two years from the issue date; only .fraudulent misstatements in the ?application may be used to void the policy or deny any claim for a loss occurred or disability starting after the two year period; b' .misuse of AvM. c &s i.dentiJacation card futuished to the Member; c) furnishing to AvMed .incorrect or incomplete information for the purpose of obtaining membership, coverage, or benefits under this Contract,. d) behavior which is disruptive, unruly, abusive, or uncooperative to the extent that the Member's continuing coverage under this Contract seriously impairs Avi,+ted's ability to administer this Contract or to arrange for the delivery of health. care services to the Member or other, Members after AvMed has attempted to resolve the Member's problem. At the affective date of such termination, premium payments received by AvMed on account of such ternairtation :whIall be refunded on a pro rata basis, and. AvMed shall have no fitrther liability or responsibility for the Member under this Contract. 9.02 Notification Requirements: 9:02.01 Loss of eligibility of Subscriber - It is the responsibility of Subscribing. Croup to notify AvMed in writing within 31 days from the effective date of termination regarding any Subscriber andlor Dependent who becomes ineligible to participate in the Plan. Failure of the Subscribing Group to provide timely written notice as described above may lead to retroactive termination of the Subscriber and/or Dependent. The effective date for such retroactive termination will be the last day of 16 Av -G100 -2006 AP-3905 {10.06) the month for which the prerrium was paid and during which the Subscriber and/or Dependent was eligible for coverage,, (See Section 7.06) 9.02.02 Loss of eligibility of Dependent - When a Dependent becomes ineligible for Dopendent.coverage, the Subscriber is required to notify AVA4ed in writing within 31 days of the Dependent becoming ineligible. 9.02.03 Contract Termination In the event this Contract is terminated, the Subscribing Group agrees that it shall provide 45 days prior written notification of the date of such termination to its employee Subscribers who are covered under this Contract. In no event will any retroactive termination of a Member be made beyond 60 days from notification of the terminating event. 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 tho Plan. You will only need to do thi.4 if the other health care plan has a pro-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 ibllowing qualifying events result in the loss of Plan coverage: a) logs of benefits due to a ireduction in your hours of employment, b) termination of your ernploymmt, including retirement but excluding termination for gross misconduct; c) termination of employment following leave under the Family and Medical Leave Act of 1903 (AffiA), in which case the qualifying event will occur on the -earlier of the date yowindicated you were not r6tuiniing to work or the last day of the FULA leave-, or d) you or a Dependent first become -entitled to Medicare or -covered under another group health !plan prior to yout loss of coverage due to termination of employment or reduction in hours. 9.04-02 In addition, your Dependents will become eligible for C013RA 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 NP-3905 (IM6.) 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 ti'O"lits as a Dependent child described above. 9.04.03 Notifloation. If a qualifying: event other than divorce, legal separation, logs 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 forra. 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. If divorce, legal separation, ton of Dependent status or entitlement to Medicare under the Plan occurs, you or your covered Dependent must notify the Plan Administrator that a qualifying -event has occurred: This notification must be received by the Plan Administrator within 60 days after the later of the date of such event, or the date you or your eligible Dependent would lose coverage on account of such event. Failure to promptly notify the Plan Administrator of these events will result in loss of the right to continue coverage for you and your Dependents. After receiving this notice., the Platt Administrator will send you an election form within 14 days. If you or your Dependents wish to elect continuation coverage, the election form must be returned to the Platt Administrator witjurt'60,days from the later of the date you receive the form or the date your coverage ends due to the qual*ingievent. 0.04.04 Cost. If you elect to continue oorveragq, you must pay the entire cost of coverage (the em loyer's contribution and the active employee portion of the contributioti), plus a 2% administrative fee for the duration of COBRA continuation coverage. If you or your Dependent is Social Security disabled (Social Security disability status must occur as defined by Title. Il or Title XVI of the Social, Secutity, Act), you may elect to continue coverage for the disabled person only or for some or all of COBRA eligible family members for up to 29 months if your employment is terminated or your hours are reduced. You inu,5t pay 10 0/ 6 .2 o f the cost of coverage for the first 18 months of COBRA continuation coverage and 150% of the cost of coverage for the 190 through the '29L months of coverage. The Social Security disability date must occur within the first 60 days of loss of coverage due to your termination of employment or reduction in hours. For COBRA coverage to remain in effect, payment must be received by the Platt Administrator by the first day of the month for which the premium is due. (Your first payment is -duo no later than 45 days after your election to continue coverage, and it must cover the period of tirno back to the first day of your COBRA continuation coverage.) 9.04.05 Duration. -COBRA Continuation Coverage can be extended for: 4) 18 months if cove-rage ended clue to a reduction in your work hours or ,termination of your employment and you or one of your covered Dependents is not Social Security disabled within 60 days of the date you lose coverage due to 18 AV-0100-2006 ND-3905 (1.0,06) termination of employment or reduction in hours, the Medicare entitled person may elect up to 18 months of COBRA. If you are that Medicare entitled person, your Dependents may elect COBRA for the longer of 36 months from your pfiar Medicare entitlement date, or 18 months from the date of your termination or reduction in hours. b) 36 months for your Dependents, if your Dependents lose eligibility for medical coverage due to your death, your divorce or legal separation, your entitlement to Medicare after your termination or reduction in hours, or your Dependent child ceasing to qualify as a Dependent under the Plan. c) 29 months if you lose coverage due to a termination of employment or reduetion in hours and you or a Dependent is disabled, as defined by Title, II or Title XVI of the Social Security Act, within 60 days of the original qualifying event.. In this case, you may continue coverage for an additional 11 months. after the , original 18 -month period either for the disabled person only or for one or all of your covered family members. 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 19 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 disabilit y. 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 19 months of COBRA continuation, and must provide notice to -the Plan Administrator within the required time period. COBRA continuation overage 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 pjan after the loss of coverage due to your termination or reduction mi hours,. unless the new group coverage is limited dub. to pro-existing condition exclusion; this PlIn 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 *he remainder of the originzfl 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 Medi"cal Leaves of Absence (FW.A). U114prPSALA, you maybe entitled to up to a total of 12 weeks of unpaid, job-protected leave during each calendar year for the following: 1.9 AV-15106-2006 W-3905 (10.06) 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 FAALA leave begins. If your FMLA leave is unpaid, you will be required to pay your contributions directly to the emplo- yer until you return to active pay status. If you notify your employer that you are terminating employment during your FMLA leave, your coverage will end on the date of your notificatiom. If you do not return to work on your expected FMLA retain date, and you do not notify your employer of your intent either to terminate your employittent or to extend the period of leave, your coverage will end on the date you were expected to return. You may not change your Plan elections during your FMLA leave unless an open enrollment occurs or unless you are on a paid FWMA leave and you have a change in status event or a special enrollment event under The Health Insurance Portability and AcootiatabititY Act of 1996 (HIPAA). 9.05.02 Military Leaves of Absence. If you are absent from work due to military service, you may elect to continue coverage under the Man (including coverage for enrolled Dependents) for up to 18 ilaonflig front the -first day of absence (or, if earlier, until the day after the date you are required to apply for or return to active employment with your employer under the Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA)). Your contributions for continued coverage will be the same as for similarly situated active pat ficipants in the Plan. Whether or not you continue coverage during military service, you may reinstate coverage under the Plan option you elected on your return to employment under USERRA. The reinstatement Will be without any waiting, period otherwise required under the Plan, except to the extent that you had not folly completed any iequiivd waiting period prior to the start of the military service. 9.06 Conversion After 'Continuatio Continuation Coverage.. See Section 8.04. 9.07 Extension of Benefits. In the event this Contract is terminated for any reason, except nonpayment of premium or as set forth in 9.07.(13., such tevnination :shalt be without prejudice to any continuous losses to a Subscriber or Member which coMinenced while this Contract was in force, but any extension of benefits� beyond the date of termination shall be predicated upon the continuous Total Disability as defined in Section 3.45, of the Subscriber or Member and shall be limited to payment for the treatment of 4 specific, accident or illness incurred while the Subscriber was Member. 9.07.01 The extension of benefits covered under this Contract shalt be limited to the occurrence of the earliest of the Uldwing events: a) The expiration of 12 months; b) Such time as the. Member is no longer totally disabled; e) A succeeding carrier elects to provide replacement coverage without limitation at to the disability condition; or 20 AV-0460-2006 W-3905 (10-06) d) The maximum benefits payable under thus Contract have been paid. 9.07.02 In the case of inateinity coverage, when not covered by the succeeding. carrier, a reasonable extension of this Contract's benefits will be provided to cover maternity expenses for a covered pregnancy that commenced while the policy was in effect. The extension shall be for the period of that pregnancy only and shall not be based upon Total Disability. 9.07.03 Except as provided above, no Subscriber is entitled to an extension of benefits if the termination by AvMed of this Contract is based upon one or more of the following reasons: a) Fraud or intentional misrepresentation in applying for any benefits under this Contract; b) Disomollment 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 ogre 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 Chapiers 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 ofbitectors, 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 ill (Definitions), Part X (Schedule of Basic Benefits), Part M (Limitations of Basic Benefits), Part X11 (Exclusions from Basic Benffits) and the Schedule of Benefits, which by reference is incorporated herein, are covered by AvAled. It is the IvIernbcr's responsibility when seeking benefits under this Contract to identify hiingelf as a Member of AvMed and to assure that the services received by the Member are being tendered by Participating Providers. 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 authorizcd under the terms of this Contract or when required to treat an Emergency Medical Condition. Except for Emergency Medical Services and C i are� all services must be received from Participating Providers: If a Member does not and supplies racei follow the access rulers; he risks having the services. received ,not covered under this (7 ofttract. 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 Avlvled Health Plans: • Inpatient admissions • All Home Health Care Services • Complex diagnostic procedures performed in an outpatient Hospital, Hospital-affiliated diagnostic treatment facility, or free-standing diagnostic treatment facility 21 N2-3905:(10-06,) • Surgical procedures or services pedormed in an outpatient I-Iospital, Hospital- affiliated arnbulatory 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 Also, Members must understand that services will not be covered if they are not, in AvMed Health Plans, opinion, Medically Necessary. Any and all decisions made by AvMed :in administerhig the provisions of this Contract, including without limitation, the provisions of Part X (Schedule of Basic Benefits), Part M (limitations of Basic Benefits), and Part XII (Axelusions from Basic Benefits), are made only to determine whether payment for any benefits will be made by AvMed. Any and all decisions that pertain to the medical need for, or desirability of the provision or non-provision of Medical Services or benefits, including without limitation, the most appropriate level of such Medical Services or benefits, must be made solely by the Member and his physiciatij in accordance with the normal patient/phy.sician relationship for purposes of determining what is in the best interest of the, Member. AvMed does not Have the right of control over the medical decisions made by the Members physician or health, care providers. The ordering of a.servioc by a physician, whether participating or non-participating, does not in itself make such service Medically, Necessary. Subscribing Group and Member acknowledge that it is possible that a Member and his physician may determine that such services or supplies are -appropriate even though such services or supplies are not covered and will not be arranged or paid for by AvMed. MEMBERS ARE RESPONSIBLE AND WILL BE LIABLE FOR CO-PAYMENTS WHICH MUST BE PAID TO HEALTH CARE PROVEDE RS FOR CERTAIN SERVICES, AT THE TIME SERVICES ARE RENDERED, AS SET FORTH IN THE SCHEDULE OF BENEFITS. 10.01 The names and addresses of Participating Providem and Hospitals are set forth in a separate booklet, which, by reference, is made apart hereof. The list of Participating Providers,. which may change from time to time, will be provided to all Subscribing Groups. The list of Participating Providers may also be accessed ftom the.AvMed website at www.AvMed.org. Notwithstanding the printed, booklet, the names and addresses of Paoicipajing.Pioviiderp an We with AvMed at any given time shall constitute the official and controlling list of Participating Providers. Pursuant to Florida Statute, there is a link available on the AvMed website to view the perfdrmance outooide and financial data that is published by the Florida Agency for Health Care Administration. 10.02 Within the Service Area, Members are entitled to receive the covered services and benefits only as herein specified, appropriately prescribed or directed by Participating Physicians. The covered services and benefits listed in the section entitled Schedule of Basic Benefits arc available only from Participating Providers within the Service Area and, except for Emergency Medical Services and Care as provided in Section 10.12, AvMed shall have no liabilit y or obligation whatsoever on account of services or benefits sought or received by any Member from any Non- participating Provider, or other person, institution or organization, unless prior arrangements have been made for the Member and confirmed, by written referral or authorization from AvMed. 10.03 Each Member -shall select one Primary Cate Physician upon enrollment. If you do not select a Primary Care Physician upon enrollment, AvMed will assign one for you. You must notify and receive approval from AvMed prior to changing your Primary Cate Physician. Such change will become effective on the first day of the month after you notify AvMed. You cannot change your 22 AV-0160-201% NO-3905 (10-06.) Primary Care Physician selection more than once per month. The services of Specialty Health. Care Physicians are covered only when you are referred by your Primary Care Physician and as approved by A1rMed. Health Professionals may from time to time cease their affiliation with AvMed. In such cases, you will be. required to receive services from another participating Health. Professional. 10.04 Any Member requiring medical, Hospital, or ambulance services for emergencies (as described in .Sections 3.14 and =x,.15), either while temporarily outside the Service Area,; or within the Service Area but before they can reach a Participating Provider, ma: y receive the emergency benefits as specified in Section 10.12. 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 requited 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 provided while the )Member is admitted to a Participating Hospital as a registered bed patient. When available and requester) by the Member, AvMed coueers the services of a certified nurse anesthetist licensed under Chapter 464, Florida Statutes. 10.07 Physician Cars:; 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 .hexing examinations and vision etaminations 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 Caro Physicians. Also included are non - reusable materials and surgical supplies. These services and materials are subject to the Limitations outlined in Part XI (Limitations ofBasic Benefits). See Part XII for Exclusions. 10.07.02 Preventive and Health Maintenance Services. The services ofthe Membefs 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 Caro of the American Academy. of Pediatrics and/or the Advisory Committee on Immunization Practices; sterilization (See Schedule of Benefits), periodic health 23 AV-WOO-4006 XT -3905 (10.06) assessment, physical examinations, and voluntary family planning services are also covered. These services are subject: to Limitations as outlined ut Part XI (Limitations of Basic Benefits). See Pail X:II 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 Physioian, and each visit requires a Co-payment. (See Schedule of Benefits) 10.11$ Physical, Occupational or Speech Therapy. Short -term physical, occupational or speech therapy provided in an outpatient or home care setting is covered for acute conditions, including exacerbation of previously treated conditions, for which therapy applied for a consecutive two month period can be expected to result in significant improvement. Coverage of outpatient short- term and rehabilitative services is limited as outlined on the Schedule of Benefits. Long -terra physical therapy, occupational 'therapy, speech therapy, rehabilitation, or other treatment is :not covered. 10.09 Cardiac Rehabilitation. Cardiac rehabilitation is covered for the following conditions: acute myocardial infarction, percutaoeous translunvnal coronary ang olilasty (PTCA), coronary artex r bypass. graft (CABG); repair or, .replacement of heart valves or heart transplant. Coverage is limited to a maximum of 18 visits per calendar year. See Schedule of Benefits: for detailed information regarding Co payments and U[mitations. 10.10 Obstetrical and Gynecological Care. Obstetrical care benefits as specified herein orer covered and include Hospital care, anesthesia,, diagnostic .imaging, and laboratory services for conditions related to pregnancy unless ouch pregnancy is the result of ai preplanned adoption arrangement, more commonly known as surrogacy. The length of maternity stay in a Hospital: will be that detennined to be Metlically 'Necessary in compliance with Florida law and, in accordance with the Newborns' and Mothers' Health Protection Act, as follows: 1) hospital stays of tat least 48 hours following. a normal vaginal delivety, or at least 96 hours following a cesarean section; 2) the Attending Physician does not need to obtain authorization from AvMed to prescribe a Hospital stay of this length; and 3.) AvMed will cover an extended stay, if Medically Necessary; however, your physician or your Hospital must precertiljt the extended stay; and (4) shorter Hospital stays are permitted if the attending Health care provider, in consultation with the mother; detennines that this is the best course of action. Coverage for maternity care is subject to applicable Co- payments and all :other Plan limits and requirements. Newborn childcare is covered as provided in Subsection 4.02.0 (i) and Section 101.11. An annual gynecological examination and Medically Necessary follow -up came detected at that visit are available without the need for a. prior referral from the Primary Care Physician. 10.11 Newborn Care. All services applicable for children: under this Contract are covered for an enrolled newborn child of the Subscriber or the enrolled newborn child of a covered Dependent of the Subscriber or the newborn adopted child of the Subscriber (as described in Subsection 4.02.02 (i)), from the moment of birth, including the Medically Necessary care or treatment of medically diagnosed congenital defects,, birth abnormalities or prematurity, and transportation costs to the nearest facility appropriately staffed and equipped to treat the newborn's condition, when such transportation is Medically Necessary. Circumcisions are provided for up to one year from date of birth. 10.12 Etnergency Services. AvMed will cover all necessary physician and Hospital Services for Emergency Medical Services and Care. (See Part III, Sections 3.14 and 3.15) in the event that 24 AV -6166 -2006 NIP-3905 (10.M Hospital inpatient services are provided following Emergency Medical Services and Care, AvMed should be notified by the Hospital, Member or designee; within 24 hours of the inpatient admission if reasonably possible. AvMed may elect to transfer the Member to a P articipating provider as soon as it is medically appropriate to (to so. if the Member chooses to stay in the Non-participating facility after the date AvMed decides a transfer is medically appropriate, out- of-network benefits may be available if the continued stay is determined to be a covered health service. 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. 10.13 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 reitnbuT8ement (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 X11 for Exclusions. 1.0.15 Other Heap CIS) , h Care Facility( * i . All rou6rte 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 ainbulatoiy basis. 10.16 Diagnostic Imaging and Laboratory. All prescribed diagnostic ima&g 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.Phykxician as part of the diagnosis andlor 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 Membefs Attending Physician. Physical ' o 00131) ational 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 nursed licensed practical (vocational) nurse or other healthcare personnel are not covered. Homemaker or other C-u%todial Car-; 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. 25 AV-031 00-2006 NO-3905 (IMO 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- participatirmg physician, the service is subject to prior authorization requirements. You are also responsible for 40% of the amount of usual, customary and reasonable charges associated with the consultation. Any tests that may be required to render the second medical opinion must be arranged by AvMed and performed by- Participating Providers, Once a second medical opinion has been tendered, AvMed shall review and determine AvMed's obligations under the Contract and that judgment is controlling. Any -treatment the Member obtains that is not authorized by AvMed shall be at the Member's expense, AvMed may limit second medical opinions in connection with a,parficulat diagnosis or treatment to flixec, per calendar year, if AvMed deems additional opinions to be an unreasonable over- utilization by the Member. 10-20 Durable Medical Equipment. This Contract provides benefits, when Medically Necessary, for the .purchase or rental of such DNE that: a) Can withstand repeated use (Le. could normally be rented and used by successive patients); b) Is primalily and customarily used to serve a medical purpose; 0 Generally is not useful to a poroon in the absence of illness or injury; and d) Is appropriate for use in a.patient's home. Some examples of DME are. hospital beds, crutches, canes; walkers, wheelchairs, respiratory equipment apirea monitors And insulin purrips. It does not include hearing aids or corrective lenses, or the professional fee for fitting same. it also does i not include medical supplies and devices, such as -a corset,, which . do not require presoiriptiong. AvMed will pay .far rental of equipment up to the purchase price. Repair and/or replacements are not covered. See Schedule ofBonefits for any Co- payments Or Limitations. :See Part >M for Exclusions. 10.21 Orthotic Appliances. Coverage for orthotic appliances islimited t 0 custom -made orn - t made log, arm, back and neck braces when related to a surgical procedure or when used in an attempt to avoid sul' cry and when necessary to carry out normal activities of daily living, excluding sports activities. Coverage includes the initial purchase, fitting or adjustment. Replacements are covered only when Medically Necessary duo to a change in bodily configuration. All other orthotio appliances are not covered. See Schedule of Benefits for any Co-payments or Limitations. See Part XII for Exclusions. 1.0.22 Prosthetic Devices. This Contract provides benefits, when Medically. Necessary, for prosthetic devices. Coverage for prosthetic devices is limited to artificial limbs, artificial joints, and ocular prostheses. Coverage includes the initial purchase,, fitting, or adjustment. Replacement is covered only when Medically Necessari, due to a change in bodily configuration. The initial dily mfiguration prosthetic device following a covered mastectoiny is also covered. Replacement of intraocular lenses is covered only if there is a change in prescription that cannot be accommodated by 26 AV-000-2006 NIP -3905 (10-06) eyeglasses. All other prosthetic devices are not covered. See Schedule of Benefits for any Co- payments or Limitations. See Pant .X1 for Exclusions. 10.23 Payment to Non- participating Providers. When, in the professional judgment of AvMed's Medical Director, a Member needs covered Medical Services or Hospital Services which require shills or facilities not available from Participating Providers and it is in the best interest of the Member to obtain the needed care from a Non - participating Provider, upon authorization by the Medical Director; payment not to exceed usual, customary and reasonable charges for such covered services rendered by a Nan. - participating Provider will be made. by Avlvled. 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 C. 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 argon transplants at a .facility deemed appropriate and authorized by AvMad, as well as associated immunosuppressant 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- mnanagemient 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 DAM maximum lituitation. Insulin, insulin syringes, lancets, and test strips are covered under the Subscribing Qroup'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 ships are covered subject to a $25 Go- payment per item for a. 30 -day supply. 10.28 Maminagranvi 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. 27 AV-6106-:2006 XT 3905 (10.06) 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 glucocarti,co d (steroid) therapy, individuals with primary hyperparathyroidism, and individuals with a family history of osteoporosis. 1030 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, 10.31 Mastectomy surgery when performed for breast cancer. Coverage for post-mastectomy reconstructive surgery shall include: 1) reconstruction of the breast on which the mastectomy has been performed; 2) surgery and reconstruction on the other Breast to produce a symmetrical appearance; and 3) prostheses and physical complications during all stages of imastectoiny including lyrnphedemas. The length of stay will not be less titan that determined by the Attending Physician to be Medically Necessaq in accordance with prevailing medical standards and after consultation with the covered patient. Coverage is subject to. any applicable Co- payments and will require pre - authorization of`services as applicable to other surgical procedures or hospitalizations under the Plan. 10,32 General anesthesia and hospitalization services to a Member who is under S years of age and is determined by a licensed dentist and the Member's physician to require necessary dental treatment in a Hospital or ambulatory surgical center due to a significantly complex dental condition or a developmental disability, in which patient management in the dental office has proved to be ineffective; or if the Member has one or more rrredical conditions that would create significant or undue medical risk for the Member in the course of delivery of any necessary dental treatment or surgery if not rendered in a Hospital or ambulatory surgical center. Pre - authorization by AvMed is required. 'Mere, is no coverage for diagnosis or treat went of dental disease. 10.33 Coverage for cleft lip and cleft palate. for ,Members under 1$ years of age. The coverage provided by this Section is subject to the terns and conditions applicable ;to other benefits, 10.34 tutpatient therapeutic services. Covered health services for therapeutic treatments received on an outpatient basis in your home, physician's office,, other Health Care Va.cility or Hospital, including intravenous chemotherapy or other intravenous :infusion therapy and Injectable Medications. Injectable Medications that are approved for sel f-injection are only a covered benefit when included in the supplemental Prescription Drug Benefits. (.See Section 12,10) 10.3:5 Ostomy supplies -and urinary catheter bags are covered when Medically Necessary. Provisions of ostomy and urostorny supplies are liniitedl to a one -month supply every 30 days; Items which are not medical supplies or which could be used by the Member or a family member for purposes father than ostoray care are not covered. 10,36 Wontrd care supplies; as ;part of an approved treatment plan, when one of the following criteria is met: (i) treatment of a wound caused by, or treated by, a surgical procedure; or (ii) treatment of a. wound that required debridement. Provision of wound care supplies is limited to a one -month supply every 30 clay's, 28 AV -0160 -2066 DO-3905 {10.00 10.37 Diagnostic testing and treatment related to Attention Deficit Hyperactivity Disorder (ADFID). XT. LIMITATIONS OF BASIC BENEFITS 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 Xledical 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. 1.1.02 In the event of circumstances not reasonably within. , the control of AvMed; such as complete or ,partial destruction of facilities,. an act of God, rear, 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 t of such delay or failure to provide services; however, AvMed shall make a good faith effort to arrange for the timely.piovision 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 Me bob good health. 11.04 A Member shall select one Rimy. Cam Physician upon eprollrnertt. If you do not select a Primary Care Physician upon enrollments 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 Corpayment. (See Schedule ofBenefrts and also Section 12.21) 11.07 Spinal manipulations will be covered on* 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 14on- 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 ifreasonably possible. (See Section 10.12 with regard to Emeigenoy Services). 11.10 Other Health Care Facility(ies). All roulne inpatient services of Other Health Care Facilities (See Section 3.33), including phy sician visits, phy siothera py, dia gnostic imaging and laboratory work, are covered for a maxim-tun of 20 clays per calendar year when a Member is admitted to 29 av- Gi�n_hoi�s N2 -3903 (to -06) 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. 11.12 Surgical or non - surgical procedures which are undertaken to improve or otherwise modify the Member's external appearance shaill be limited to reconstructive surgery to correct and repair a functional disorder as a result of a disease, .injury, or congenital defect or initial implanted prosthesis and reconstructive surgery incident to a mastectomy for cancer of the breast. 11.13 Hyperbaric oxygen treatments are limited to 44: treatments per condition as appropriate pursuant to the Centers for Medicare and Medicaid Services (CMS) guidelines, .subject to applicable Co- payments as listed for physical; speech and occupational therapies. XIL EXCLUSIONS FROM, BENEFITS Medical Services and benefits for the following. classifi , ons and conditions are not covered and are excluded from the Schedule of Basic Benefits provided under this Contract: 12;01 Treatment of a condition resulting from: a) Participation in a riot or rebellion; b) Engagement in. an illegal occupations c) Commission, or attempted corntnission, of an assault; conurdssion or attempted commission. of a crime punishable as a felony. 12.02 Cosmetic, surgical or non - surgical procedures which are undertaken primatly to improve or otherwise modify the Member's external appearance. Also excluded are ..surgical excision or reformation of any sagging skin of any part of the bodily, including, but not limited to: the eyelids, face, neck, abdomen, arms, legs, or buttocks;. any services performed in connection with the enlargement, reduction, implantation or change in appearance of a portion of the body, including, but not limited to: the face, lips, jaw, chin, nose, ears, breasts, or genitals (including circumcision, except newborns for up to one year fiom date of birth;, see also Section 10;..111 fair transplantation, chemical face peels or abrasion of the skin, electrolysis depilation,: removal of tattooing; or any other surgical, or non - surgical procedures which are primarily for cosmetic purposes or to create body symmetry. Additionally, all medical complications as a result of cosmetic, surgical or non = surgical procedures are excluded. 12.03 Medical care or surgery not authorized by a Participating Provider; except for Emergency Medical Services and Care, or not within the benefits covered by AvMed. 12.014 Dental Care; as defined in 3.11, for any, condition except: 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 30. NIP-3905 (10.06) C) Full mouth extraction when required before radiation therapy. 12.05 Services related to the diagnosis /treatment of ternporomandibular joint (TNIJ) dysfunction except when Medically Necessary; all dental treatment for TMJ. 12.06 Mandibular and inaxillary osteotornies except when Medically Necessary to treat conditions caused by congenital or developmental deformity, disease, or injury. 12.07 Except as provided in Sections 10.55 anel 1030;. metrical supplies including, but not limited to: pre-fabricated splints; Thromboemboletic/ Support Bose 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; intiaocular lenses, artificial joints and orthopedic hardware, and vascular grafts. Dental appliances, other corrective lenses and hearing aids; including the professional fee for fitting their, are. not covered. 12.10 Qvemhe- counter medications,, all contraceptives (including medications and devices), hypodermic needles and syringes. and Self Administered Injectable Medications except insulin and insulin syringes for the treatirient of diabetes as outlined in Section 10.27: 12..7.1 Travel expenses including expenses for ambulance services to and from a physician .ar 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). 12.133 Treatment far armed forces seivice- connected medical care (for both sickness and injury). 12.14 Custodial Care (as deftned in Part III, Section 3.1:01): 12.15 Experimental and/dr investigational procedures, except for bo'tie marrow transplants,, as appiwed per Florida Administrative Code, ;'Section 59B,- 12.0011. 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 fallowing. applies: a) The FDA has not granted the approval for general use; b) There are iosufficcient outcomes data available front controlled clinical trials published in peer - reviewed literature to substantiate its safety and effectiveness for the .disease or injury involved; c,) There is no consensus among practicing physicians that the medication, treatment, therapy, procedure or device is safe or eMetive for the treatment in question or such medication, treatment, therapy, procedure or device is not the standard treatment; therapy, procedure or device utilized by practicing physicians in treating other patients with the same or a similar condition; of 31 :�.V' -GI L�41 -2Qt16 W -3405 (10 -06) d) Such medication, treatment, procedure or device is the subject of an ongoing Phase T or Phase II clinical investigation, or experimental or research arms of a Phase Ili clinical investigation, or under study to determine: maximum tolerated dosages, toxicity, safety,, efficacy, or efficacy as compared with the standard means for treatment or diagnosis of the condition in question. 12.16 Personal comfort items not medically Necessary for proper medical care as part of the therapeutic plan to treat or arrest the progression of an illness or injury. This Exclusion includes, but is not limited to: wigs (including partial hair pieces, weaves, and toupees), personal care kits, guest meals and accommodations, . maid services, telavisions/radios, telephone charges, photographs, complimentaty meals, birth. announcements, take home supplies; travel expenses (other than, Medically Necessary ambulance services that are, provided for in Section 10.14), air conditioners; humidifiers, dehumidifiers, and air purifiers or filters, 12.17 Physical exanunations or tests,, such as premarital blood Costs or tests for continuing. employment, education, licensing, or insurance or.. that are otherwise required by a third party. 12.18 Eye care including: a) Eye examinations for Mefmbers 18 years of age or older for the purpose of determining the need for sight correction (such as eye glasses or contact lenses), b) Training or orthoptics, including eye exercises; or c) Radial keratotomy, refractory keiatoplasty, Lasik surgery or any other corneal surgical procedure to correct refiactive error. 12.19 Hearing examinations for Members 18 years of age or older for the purpose of determining the need for hearing correction... 12.20 Cosmetics, dietary supplements,, nutritional formulae, health or beauty aids. 1121 Gastric stapling, gastric bypass, gastric banding, gastric Bubbles, and :other procedures for the treatment of obesity or morbid obesity, as well as any related evaluations or diagnostic tests. Ongoing visits other than establishing a program of obesity control. 12.22 Gender reassignment surgery as well as any service, supply, or medical care associated with gender reassignment or gender identity disorders. 12.23 ,till medications, devices, and other forms of treatment related to a diagnosis4 of sexual dysfunction. 12.244 Infertility diagnosis, treatment, and supplies, including infertility testing, treatment of infertility, diagnostic .procedures and artificial insemination, to deteimine or correct the cause or reason for infertility or inability to achieve conception. This includes artificial insemination, in vitro fertilization, ovum or embryo placement or transfer,: gamete. intra- fallopian tube transfer, or cryogenic or other, preservation techniques used in such or similar procedures. Also excluded are obstetrical benefits when such .pregnancy :is the subject of a preplanned adoption arrangement, or surrogacy, as defined under Chapter 63, Florida Statutes. Medications for the treatment of infertility ai e not covered, 12.25 Reversal of sterilization procedures. 32 Av- 616(M006 NT3905 (r0-06) 12.25 Immunizations and medications for the purpose of foreign travel or employment. 12..27 Acupuncture, biofeedback, Hypnotherapy, maissage tlteralxy, sleep therapy, sex therapy, behavioral training; cognitive therapy, and vocational rehabilitation. 12.28 Toot supports are not covered. These include orthopedic or specialty shoes, shoe build -ups, shoe orthotics, shoe braces, and shoe supports. Also excladed 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 sank extent as the insured recipient. Tlie reasonable costs of searclvng for the bone marrow donor is limited to family members and the National Bone Marrow Donor P'rog'ram. 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 iSoectrurn 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 as'sociatedwith excluded.surgery or Dental Cart: 12.33 Any treatment or service from ,Nan- partcipating Provider, except in the case of an emergency or when specifically pre - authorized by AvMed. ($ee Sections. 3.14 and 3.15) 12.34 Speech therapy for .delayed or abnormal speech pathology. 123.5 Alcohol or substance .,abuso rehabilitationn, vocational rehabilitation, pulmonary rehabilitation, long term rehabilitation, or any other rehabilitation program. 12.35. 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 clue to an emergency or with the prior written authorization of AvMed. 12.39 'ventilator Dependent Care, except as provided in. Part X ('Schedule of Basic Benefits) for 100 days lifetime maximum benefit. 12.40 Private duty nursing services. Itt l AV -6100-2006 W-3905 (r0-06) 12.41 Any Sickness or injury for which the covered person is paid benefits, or may be paid benefits if claimed, if the covered person is covered or required to be covered by Workers' Compensation. In addition, if the covered person enters into a settlement giving up rights to recover past or future medical benefits under a Workers' Compensation law, AvMed shall not cover past or future .Medical Services that are the subject of or related to that settlement. Furthermore, if the covered person is covered by a Worker's Compensation program that limits benefits if other than specified health care providers are used and the covered person receives care or services from a health care provider not specified by the program, AvMed shall not cover the balance of any costs .remaining after the program has paid. 12.42 Complications of any non- covered service, including the evaluation or treatment of any condition that arises as a complication of a non - covered service. 12.43 Any service or supply to eliminate or reduce dependency on or addiction to tobacco, including but not limited to: nicotine withdrawal programs,. facilities, and supplies (e.g. transdermal patches, Nicorette gun). 12.44 Services associated with autopsy or postmortem examinations, including the autopsy. 12.45 Exercise programs, gym memberships, or exercise equipment of any kind, including, but not limited to: exercise bicycles; treadmills; star masters, rowing miacitines, free weights or resistance equipment. Also excluded are massage devices, portable whirlpool pumps, hot tubs; jacuzzis, sauna baths, swimming pools and similar equipment. 12.44E Removal of warts, moles, skin tags, .lipomas, keloids, scars, and other benign skin lesions is not covered, even with a recommendation or prescription by .a physician, unless AvMed determines that there is sufficient justification for removal. XM. COORDINATION OF BE' NE FITS 13.01 The services and benefits provided under this Contract are not intended to and do not duplicate any benefit to which Members are entitled under any, other Group Health Insurance, HMt3, personal injury protection and medical payments under the automobile insurance laws of this or any other jurisdiction, governmental organization, agency, or any other entity providing health or accident benefits, to a Member, including but not limited to: Medicare, Worker's Compensation, Public Health: Service; Chainpus, Maritime Health Benefits, or similar state programs as permitted by contract, policy, or law. AvMed coverage will be primary to Medicaid benefits.. 13.02 If any covered person is eligible for services or benefits under two or more plans as set forth in Section 13.01, the coverage under those plans will be coordinated so that up to but not more than ltlfi°fo of env eligible expense will be paid for or provided by all such plans combined. The Member skull execute and deliver such instruments and papers as may be required and do whatever else is necessary to secure such rights to AvMed. Failure to do so will result in nonpayment of Claims. Requested information should be provided to AvMed within 30 days of request or Member will be responsible for payment of the Claim. Information received after one year fiom date of service will not be considered. 13.03 The standards governing the coordination ofbenefits are the following, pursuant to the provisions of Section 627.4235, Florida S"tatute&: 34 AV -0140 -2405 I�IP -3405 (1 © =06} 13.03.01 The benefit.; 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 staged above coordinates with an out- oPstate policy or plan which contains provisions under which the benefits of a policy or plain which covers a person as a dependent of a finale are determined before those of a policy or plan which covers the person as a dependent of 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 plain 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 G) 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 chi] ld 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 tbAt person as a laid off or retired employee or as that employee's dependent. If the ether 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. 13.03.05 If none of the rules in Subsections 13.03.01, 13.03.02, 13.03.03, or 13.03.04 determine the order of benefits, the 'benefits of the policy or plan which covered an 35 Av -4100 -2005 W-3905 (10.06) employee, member, or subscriber for a longer period of time are determined before those of the policy or plan which covered that person for the shorter period of time. 13.03.06 Coordination of benefits shall not be peruti.tted against an indemnity -type policy, an excess .insurance policy as defined in Section 627.635, Florida Statutes, a policy with coverage limited to specified illnesses or accidents, or a Medicare supplement policy. However, if the person is also a Medicare beneficiary, and if the rule established under the Social Security Act of 1965, as amended, makes Medicare secondary to the plan covering the person as a dependent of an active employee, the order of benefit detetinination is: a) First, benefits of a plan covering a person as an employee, member, or subscriber. b) Second, benefits of a plan of an active worker covering a person as a dependent. c) Third, Medicare benefits. 13.0347 If an individual is covered under a C013RA continuation plan as a result of the purchase of coverage as provided under the Consolidation E7rnnibug Budget Reconciliation Act of 1997 (Pub.L. No. 99 -272), and also tender another Group Health Insurance plan, the following order of benefits applies: a) First, the plan coveting the person as an employee; or as the employee's dependent. b) Second, the coverage purchased under the plan covering the person as a, former employee, or as the former employee's dependent provided according to the provisions of COBRA. 13.04 For the purpose of determining the applicability and implemeinting, the terms of the Coordination n of Benefits provision of this Contract, AvMed may; without the consent of or notice to any person, release to or obtain from any other insurance company, organizations or person, any information, with respect to any Subscriber or applicant for subscription, which AvMed deems to be necessary .for such purposes. 13.05 Whenever payments which should have been made under this flan in accordance with this provision have been made under any other plans, AvMed shall have the right, exercisable alone and in its sole discretion; to pay over to any organizations making such other payments any amounts AvMed shall determine to be warranted in order to satisfy -the intent of this provision, and amounts so paid shall be doomed to be benefits paid under this Plan. 13.06 All treatments rnts't. be Medicallyy Necessary and comply with all teens,, conditions,, Limitations, and Vxclusions of this Plan evert if AvMed is secondary to other coverage and the treatment is covered under the other coverage, 13.07 If the amount of the payments made by Av:1vled is more than it should have paid under the provisions of this Section iii,, it may recover the excess fiom one or more of the persons it has paid or for whom it. has paid; or any other person or organization that may be responsible for the 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. 36 AV -044 -2006 AV-3905 (10 -06) 13.08 In the event the Subscribing Group offers Health Reimbursement Arrangements (HRA) in connection with this Plan, the I-IRA is intended to pay solely for otherwise tut- reimbursed medical cxp6nses. 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 AvM[dd retains the right to repayment of the -fall 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 be-half of the Member from the following third-party sources, as allowed by law, including but not limited to: payments made by a third-party torMagor or any insurance company an behalf of the third-p4i-ty 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 uses or homeowners; medic-at 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 Cofttract, a torffeasor is any party who has comorittod injury, or wrongful act done wittingly, 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 gubrogatiom When AVAIed provides health care benefits for injuries or illnesset for which athird party is or may be responsible, AvMed shall be subrogated to the Abmber's rights of recovery against any �pamr to the extent of the fun cost of an benefits provided by AvAled, to -the fullest extent permitted by law. AvMed may proceed against any party with or without the Member consent, Member also specifically acknowledges AvMed's light of itimbutsement. Ibis right of reinAtnenient attaches, to the fullest 'extent permitted by law, when AvMed has provided health Care benefits for injuries or illness far which another party is or may be responsible and the Member and/or the Member's representative has recovered any amounts fi-orn 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 a settlement judgment or other payment received by the Member to the extent of the full any J cost of all benefits provided by AvMed AvMed's right of reimbursement is cumulative with and not exclusive of AWeds subrogation fight and AvMed may choose to exercise either or both rights of recovery. Aleinber and the Member's representatives further agree to: ,a) Notify AvMed promptly e is given o any y and in writing when notice i . " t , 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 party; and b) Cooperate with AYA)Iod and do whatever is necessary to secure AvMed!s tights of subrogation and/or reimbursement under this Contract, and 0) Give AvMed a first priority lien an 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 associated with injuries or illness provided by AvMed for which a third party is or. may be responsible (regardless of whether s . pacifically set forth in the recovery, settlement, judgment or compensation agreement),, And 37 AV-0160-2066 W-3905 (10706) d) Pay, as the first priority, from any recoveq, settlement or judgment or other 'source of compensation, any and all amounts due AvMed as reimbursement for the full cost of all benefits associated with injuries or illness provided by AvMed for which a third party is or may be responsible, (regardless of whether specifically set forth in the recovely, settlement, judgment, or compensation agreement),, unless otherwise agreed to by AvMed in writing; and e) Do nothing to prejudice AvMed's rights its set forth above. This includes, but is not limited to, refraining from making any settlement or recovery, which specifically attempts to reduce or exclude the full cost of all benefits, provided by.AvMQd. AvMed may recover the full cost of all benefits- provided by AvMed under this Contract without regard to an claim y cla of fault on the part of the Member, whether by comparative negligence or otherwise. No court costs or attorney fees may be, deducted from AvMed's recovery without the prior express written consent of AvMed. In the event the Member or the Member's roprescatativc Ws to cooperate with AvMed, the Member shall be responsible for all benefits paid by AvNiod in addition to costs and attorney's fees incurred by AvMed in obtaining repayment. XV. DISCLAWER OF LIABIL= 15.01, Neither Subscribing Group nor its: agents-, servants or employees, nor any Member is the agent or representative Of AvMed,, and none of them shall be liable for any acts or omissions of AvMed., its agents, or employees or of a Participating Hospital, or a Participating Physician, or any other person or organization with which AvMed has made -or hereafter shall make arrangements for file pe-iformance of services under this contract. 15.02 Neither Subscribers of Subscribing Group nor their Dependents shall be liable to AvMed or Participating Providers except as specifically set forth herein, provided all procedures set forth herein are -followed. 15.03 Neither AvMed nor its agents; servants or employees, not any -Member is the agent or representative of the Subscribing Group, and none- of them aluall be liable for any acts or omissions of Subscribing Group,, its agents or employees or any other person representing or acting on behalf of Subscribing Group. 15.04 AvMed does not directly employ any practicing physicians nor any Hospital personnel or physicians. These health care providers are independent contractors and are not the agents or employees of AvMed. AvMed shall be deemed not to be a health care provider with respect ,to any services performed or rendered by any such independent contractors. Participating Providers . maintain the physician/patient relationship with Members and are solely responsible for all Medical Services which Participating Providers tender to Members. Therefore, A-med shall not be liable for any negligent act or omission committed by any independent t pra Oticin g physicians, nurses, or medical personnel, not any Hospital or health care facility, its personnel, other health care professionals or any of their employees or agents who may, from. time to time, ptovide Medical Services to a Member of AvMed. Furthermore, AvMed shall not be vicariously liable for any negligent act or omission. of any of these independent health rare professionals who treat a Member of AvMed. 15.05 Certain Members may, for personal reasons, refuse to accept procedures or treatment recommended .by Participating g Pli- ysiciams, Participating Physicians may regard such refusal to accept their recommendations as incompatible with the continuance. of the physician/patient 38 AV400-2006 NIP3905P.0.00 relationship and as obstructing the provision of proper medical care. If a Member refuses to accept the medical treatment or procedure recommended by the Paiticipating 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. ORM VANCE 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 notiN the Claimant of AvMcd'.g benofit,detemiination (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 ffilg 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, Avlk4ed shall notify the Claimant as soon as possible, but not later than 24 hours after Awed 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 but not less than 48 hours, to provide the specified information. AvIvIod 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"sltceiptoftliesp&cifiediffQraiation,,or 2) The end of the period afforded. the Claimant to provide the specified additional information. If the Claimant failg to supply the requested infoilliation within 'the 48-hour period, the claim shall be -denied. AvMed may notify the Claimant of the benefit deteimination orally ox iii writing. If tile 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 s 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 AVIVIed'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 P.O. Box 923 Gainesville, Florida 32602 -0823 Telephone: 1-'800-982-9633 Fax, (352) 337-8612 39 XV-01004006 1D-3905 Q.0.063 AvMed Member Services — South P.O. Box 569008 Miami, Florida 33156-9906 Telephone: 1-800-882-8633 Fax* (305) 6714736 If you are not satisfied with AvMed's final decision, you may contact the Florida Agency for Health Care Administration (AHCA) or the Department of Financial Services (DFS) in writing within 365 clays of roceipt 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 the AFICA 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 ifyou have instituted an action pending in State or Federal court. If you need fin -ther assistance, you may contact. Subscriber Assistance Panel (SAP) Agency for Health Care Administration HK40 Section 2727 Mahan. Drive, Mail Stop 26 Tallahassee.; Florida 32308 Telephone 1- 885 - 419 -3456 or 850- 921 -5458 Florida Department of Financial Services 200 East Gaines. Street Tallahassee, Florida 32399 Telephone 1- 800 -342 -2762 16.42 Pre- Service Claims. 16.112.01 Initial Claire — A Pre- Service Claim Oholl be deemed to be fined on the date roceivod by AvMed. AvMed shall notify the Claimant of the benefit determination (whether adverse or not) within a reasonable period of time appropriate to the medical circumstances, but not later than 15 days after AvMed receives the Pre - 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 AvMod's control and notifies the Claimant; before the expiration of the initial 15 -day period; of the circumstances requiring the extension of time and the elate by which ,AvMed expeets to render a decision. If such an extension is necessary because the Claimant failed: to submit the information necessary to decide the 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. In the case of :a failure by a Claimant to follow AvMod's procedures for filing a Pre-Service Claim, the Claimant shall be notified of the failure and the proper procedures to be followed in filing a Claire for benefits not later than five days following such failure. AvX1e(Vs. period for making the benefit determination .shall be tolled fi`om the date on which the notification of the extension is sent to the Claimant until the date on which the Claimant responds to the request for additional: information. If the Claimant fails to supply the requested information within the 45 -day period, the Claim shall be denied. 16.02.02 Appeal. A. Claimant may appeal an Adverse Benefit Determination with respect to a Pre - Service Claim within 180 days of receiving the Adverse Benefit Determination. AvMed shall notify the Claimant, in accordance with Section 16.07, of its determination on review within a reasonable period of thee. Such notification shall be 40 .kV- Gi6 -a0n6 AD -3905 (10.06) 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 P.O. Box 823 Gainesville, Florida 32602-0823 Telephone: 1-800-982-8633 Fax: (352) 337-9612 AvMed Member Services - South. P.O. Box 569008 Miami; Florida 33156-9906 Telephone.- 1-900-882-9633 Fax: (305) 671-4736 If you -ire not satisfied with AvMed's final decision, you may contact ATICA 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 DITS at any time to inform. them of an unresolved. gti evance. The Subscriber Assistance Program wily not hear a grievance if you have not completed the entire AvMed grievance process nor ifyou have instituted an action pending in State or Federal court. If you need further assistance, you may contact: Subscriber Assistano Panel (SAP) Agency for Health Care Administration I-A40 Section 2727 Mahan Drive, Mail Stop 26 Tallahassee, Florida 32309 Telephone 1-889-419-3456 or 950-921 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 notifyr the Claimant, in accordance with Soctioti 16.05 of AVMe(rs 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 0 1-5 days, pr6Nided that AVMed determixteg that such an extension is necessary due to matters beyond AVIVIed's control and notifies the Claimant, before the expiration of the initial 30-day period, of the circumstances requiring die extension of time and the date by which AvMed expect.$ 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 deterrninati on shall be tolled from the date on which the notification of the extension is sent to the Claimant until the date on which the Claimant responds to the request for additional information. If the 41 0-GOO-2046 XIP-3905 (M06.) Claimant fails to supply the requested information within the 45 -day period, the Clain shall be denied. 16.03;02 Appeal. A Claimant may appeal an Adverse Benefit Determination with respect to a Post- Service Claim within 180 days of receiving the Adverse Benefit Determination. AvMed shall notify the Claimant, in accordance with Section 16.07, of AvMed's determination on review within a reasonable period of time. Such notification shall be provided not later than 60 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 PA Box 823 Gainesville, Florida 32602 -0$23 Telephone. 1 -800- 882 -8633 Fax: (352) 337.8612 AvMed Member ,"services — South P.O. Box 569008 1V4iami, Florida 33156 -9906 Telephone: 1 -800-8 82 -8633 Fax: (305.) 671 -4736 If you are not satisfied with AvMed's final decision,, you may convict AHCA or DFS in writing, within 30 days of receipt of the final decision letter. If you appeal AvMed's decision, your grievance will be reviewed by the Subscriber Assistance Program. -irou ,also have the right to contact the AHCA, or DVS at ally time to inform them of an unresolved grievance. Ilia Subscriber Assistance Program will not hear a grievance if you have not completed the entire Av1ltled grievance process not if you have instituted an a.chon pending in State or Federal court. If you need further assistance, you may contact: Subscriber Assistance Panel (SAP) Agency for Health Care Administration HXIO Section 2727 Mahan Drive, Mail Stop 26 Tallahassee, Florida 32308 Telephone 1-588- 419 -3456 or 850. 921 -5458 Florida Department of Insurance 200 East Gaines Street Tallahassee, Florida 32399 Telephone 1 -800- 342 -2762 16.04 Concurrent Care. Claims 16.04.01, Any reduction or termination by AvMed of Concurrent Care (other than by Plan amendment or termination) before the end of an approved period of time or number of treatments, shall constitute an Adverse Benefit Determination. AvX4ed shall notify the Claimant, in accordance with Section 16.05, of die Adverse Benefit Determination at a time sufficiently in advance of the reduction or termination to allow the Claimant to -appeal and obtain a determination on review of the Adverse Benefit Determination before the benefit is reduced or terminated. 42 Av- 6160-20e6 XT 3903 (M06) 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 Claum or not, shall be made in accordance with the remainder of Part XVI. 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 Detemnation. b) Reference to the specific Plan provisions on which the determination is based. c) A description of any additional material or infortriation necessary for the Claimant to perfect the Claire and an explanation of why such material or information is necessary. d) AA 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 cinder Section 502(x) of the Employee Retirement Income Security: Act of 1974, as amended (ERISA), followimg an .Adverse Benefit Determination on final review: V) If an internal rule; guideline, protocol, or other similar criterion was relied upon in retaking 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. f) If the Adverse Benefit Detertnirtation 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 shalll be provided free of charge upon request; g) In the case of an Adverse Benefit Determination involving an Urgent Care Claim, a description o.fthe expedited review process applicable to such Claire. 16.06 Review Procedure Upon Appeal. AvAldd's appeal procedures shall include the following substantive procedures and safeguards: ,t) Claimant -ray submit written comments, documents, records, and other information relating . to the Claim. b) Uponrequest 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, docureenis, 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. d) The appeal shall be conducted by an appropriate named fiduciary of AvMed who is neither the individual who made the initial Adverse Benefit Determination nor the subordinate of such individual. Such person shall not defer to the initial Adverse Benefit Determination. 43 AV- 0160 -2006 M2-3905 (10-06) e) In deciding an appeal of any Adverse Benefit Determination that is based in whole or in part on a medical judgment, including, determinations with regard to whether a particular treatment, medication, or other item is experimental and/or investigational or not Medically Necessary, the appropriate named fiduciary siliall consult with a Health Professional, who has appropriate training and experience in the. field of medicine involved in the medical judgment. f) The appeal shall provide for the identification of medical or vocational experts whose advice was obtained on behalf of AvMed, in connection with a Claimant's Adverse Benefit Determination, without regard to whether the advice was relied upon in making the Adverse Benefit Determination. g) The appeal shall provide that the Health Professional engaged for purposes of a comultation in Subsection 16.0.6.(15 shall be an individual who is neither all individual who was consulted in connection with the initial .Adverse Benefit Determination that is the subject of the appeal, nor the subordinate of any such individual. h) in the case of an Urgent Care Claim, there 4,iall be an expedited review process pursuant to which: (i) request for on expedited appeal of an Adverse Benefit Determination may be submitted orally or irt writing by the Claimant; and (ii) all necessary information, including AvMddls benefit determination on review, shall be trammitted between AvMed and the Claimant by telephone, facsimile, or other available similarly expeditious. methods, 16.07 Manner and Content of Appeal Notification. AvMedshall provide a Claimant with written or electronic notification of.AvMed's benefit ,deterniination upon review. 16.07,01 In the case of an Adverse Benefit Determination, the notification shall set forth; in a mamer calculated to be under9tood by the Claimant, all of the following, as appropriate: a) The specific reasons for the Adverse Beriefit Doterinination. b) Reference to the specific, Plan provisions on which the Adverse, Benefit Determination is based. t) A statement that the Claimant -is entitled to receive, upon request, and free of charge, reasonable access to, and copies ofany Relevant Documents, d) A statement describing any voluntary appeal procedures offered by AvMed and the Claimant's right to obtain the inibnnation about such procedures and a statement of the Claimant'.§ right to bring an action under 1ER18A 8ection. 502(a) when applicable. c) If an internal rule, guideline, protocol; or other similar criterion was relied upon in makiftgo, the Adverse Benefit Determination, either the specific, Me,, 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 five of charge to the Claimant upon request. f) If the Adverse Benefit Determination is bated on whether tare treatment or service is experimental and/o• investigational or not Medically Necessary, either an explanation of the scientific or clinical judgment for the deteffnination, 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. 44 AV-6160-2006 NV=3905 (10-06) XVIL MISCELLANEOUS 17.01 Contracting Parties. By executing. this Contract, Subscribing Group and AvMed agree to M,*-e 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 te-jans, 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 Certifficate of COOrage. 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 applic4tiong or other farms 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/o r , . mernboriship to such individual. Any person who knowiney and with intent to injure, defiraud, or deceive any insurer files a statement of Claim or an application containing rxtiy false, incomplete, or misleading information is guilty of a felony, punishable as provided by thr.Flodela-Statutes-. 17.04 Identificatiox) Cards, Cards issued by AvMed to Members pursuant to this Contract are for ,purposes of identification only. Possession of an AVMed identification card conbn% no tight to Health -services or other benerfits under thts 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. Ilie. 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:iight of AvMed to thereafter enforce each and every such provision. 17.07 'Plan Administration. AvMed inay from time to time adopt reasonable policies, procedures, rules, and interpretations to promote the orderly and efficient administration of this Contract. 17.08 Notice. Any notice intended for and directed to a party to this Contract unless otherwise expressly pro-tit!4 should be sent by United States mail, postage prepaid, addressed as follows: If to AvMed, to: AvMed Health Plans 45 AV-01604006 NO-3903 (M06) P. O. Box 749 Gainesville, Florida 32602-0749 (OR if from a Member to AvTx/fed, see the Member's Service Area address listed on Page i.) If to a Member: To the last address provided by the Member and actually received by AvMed on the enrollment application or change of address notification. If to Subscribing Group: To the address provided in the Group Master Application. 17.09 Gender. Whenever used, the singular shall include the plural and the plural the singular and the use of any gender shall include allgenders, 17.10 Clerical Errors. Clerical errors shall neither deprive any individual Member of any benefits or coverage provided under this Gioup, Contract nor shall such errors act as authorization of benefits or coverage for the Member that is not otherwise validly in force. Retroactive adjustments in coverage, for clerical errors or otherwise will only be done for up to a 60 day period from the date of notification. Refunds of premiums are done for up to a 60 day period from the date of notification. Refunds of premiums are limited to a total of 60 days from the date of notification of the event, provided there are no Claim incurred subsequent to the effective date of such event. 17.11 Contract RevieW, Subscribing Group may= if this Contract is not satisfactory for any reason, return this Contract within three days after receipt and receive a fiall refund of the deposit paid, if Any, unless the services of AvMed were utilized during. the three, days. If this Contract is not returned within three days after receipt, then this Contract shall be deemed to have been accepted. .17.12 Premium Tax/Surcharge, if any government entity shall impose a premium tax or surcharge, then the gums due from the Subscribing Group under the terms of this Contract shall he increased by the amount of such premium tax or surchargp. 17.13 En c1le .. tiret . yofCont.ract Thi.gA.greemontmd4ll,applicibleS duleg, Exl-dbits Riders and Any other attachments and endorsements, constitute the entire Contract between the Subscribing, Group and AvMcd. No modification (or oral representation) of this Group Contract shall be of any force or effect unless it is in wrilini and signed by both parties. 17.14 Rate Letter. The "rate letter" is:AvMcft formal notice :to the Subscribing Group of the premium rates applicable W the Subscribing Group, the conditions under which the rates -am valid, the Premium Payment terms and due dates, the. additional charge will a a late remi ni e Whir, apply to 11 ]at 1) u payments, AvNIeft,reservation of the rigtit to adjust (re-rate) the premium quote to account for changes in the group size or in the data supplied by the Subscribing, Group to AvMed, the applicable employer-cinployee contribution to the premium payment and the charge for other optional, supplemental benefits selected by the Subscribing Group, if any. 17.15 TIflrd Par4r Beneficiary. This Contract is entered into exclusively between the Subscribing Group and AvMod. This Contract is intended only to benefit the Subscribing Group and the Members and does not confer any rights on any other third parties. 17.16 Assignment. ling. Contract, and all rights and benefits related thereto, may not be assigned by the Subscribing Group or the Members without written consent of AvMcd. 46 AV-0160-1006 NW-3905 (MOO 17.1.7 Applicability of Law. The provisions of this Contract shall be deemed to have been modified by the Parties, and shall be interpreted, so as to comply with the laws and regulations of the State of Flolida 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. 47 Av- 60M006 ND-3905 (10 -06)