Loading...
08-16-05 Item 4Wei South Miami & City Commission FROM: Maria V. Davis/i��. City Manager RESOLUTION Re: Renewal � f Av Med Health Insurance 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. REQUEST The attached resolution seeks approval from the City Commission for the City Manager to renew a one - year contract with Av Med Health Care to provide health insurance coverage for the City of South Miami's full time employees. BACKGROUND We have received renewal rates from our current group health insurance carrier, AvMed, wherein there is a fifteen percent (15 %) increase in premiums. 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, AvMed, Humana and United Health Care. The Committee - which consisted of representatives from AFSCME, PBA, Human Resources Department and general employees - analyzed each plan, specifically reviewing the following areas: rates, benefit plan design (i.e. co- payments and deductibles) and network of providers and hospitals. Although Humana presented the lowest bid ($296.16 per employee per month), Av Med's ($332.40 per employee per month) benefits were much more advantageous to the City's employees in comparison. It was also noted that changing from one carrier to another would make it harder to find companies willing to bid on the City's health insurance in the future, as already indicated by only four of eight companies requested to bid actually submitting proposals. Below we have listed the major comparisons between Av Med and Humana: AVMED HUMANA 1. Specialist Office Visit $10 co -pay $20 co -pay 2. Inpatient Hospital no co -pay $100 co -pay /day up to $300 /admission 3. Outpatient Surgery no co -pay $100 co -pay 4. Mental Hlth. /Sub. Abuse no co -pay $100 co- pay /day up to $300 /admission 5. Rx Drugs $7/$20/$35 $10/$20/$40 6. Mail Order Rx 2 times co -pay 3 times co -pay 7. Provider Directory- In comparison to Av Med, Humana has a limited network of Primary Care Physicians and Specialists. Page Two Health Insurance Resolution 08/16/05 We also noted that Av Med received higher scores from the Florida Agency for Health Care Administration (AHCA) in comparison to Humana. The State of Florida measured each HMO in the following categories: a) Overall plan satisfaction b) Ease in getting to see a specialist c) Ease in getting needed care, tests, or treatment d) How well providers communicate with members e) Getting help from customer service Based on all the information reviewed, the Committee recommended renewing with AvMed Health Care. RECOMMENDATION Approval of the resolution is recommended. 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 fifteen percent (15 %) 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 solicited bids from eight (8) companies; only four (4) of those companies providing us with a proposal; and WHEREAS, a Review Committee consisting of representatives from AFSCME, PBA, Human Resources and general employees reviewed the proposals and compared the insurance companies' rates, benefit plan designs, network of providers and hospitals; and WHEREAS, after careful review, the Committee recommended renewing with Av Med Health Care; 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, which is attached to this resolution as exhibit 1, shall be effective October 1, 2005 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. Section 3. This resolution shall take effect immediately upon approval. PASSED AND ADOPTED this ATTEST: CITY CLERK day of , 2005. APPROVED: MAYOR Commission Vote: READ AND APPROVED AS TO FORM: Mayor Mary Scott Russell: Vice Mayor Velma Palmer: Commissioner Randy G. Wiscombe: Commissioner Marie Birts- Cooper: Commissioner Craig Z. Sherar: CITY ATTORNEY TABLE OF CONTENTS 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 Submitted a proposal. ' Neighborhood Health Partnership Declined to quote. i United HealthCare E Submitted a proposal. Vista Declined to quote. 1 3 Employee Benefits consulting Group Executive Samna 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 We were successful in reducing the AvMed premium increase to 15.2% for the upcoming plan year (assuming no changes with the current benefit structure). AvMed has the following municipalities as clients: City of Fort Lauderdale, Miami Dade County, Village of Bal Harbour, and the Village of Ivey Biscayne. The 15.2% increase from AvMed is favorable in comparison to the renewals that the City of South Miami has received over the last 3 years: 2002 40% increase - Blue Cross/Blue Shield 2003: 32% increase - Neighborhood Health Partnership 2004: ' 40% increase CIGNA Aetna, Humana, and United HealthCare submitted proposals. The proposal from Humana is competitive from a financial standpoint; `however the following` issues warrant consideration: . 1) The physician network with Humana would create a significant amount of disruption. Many employees would have to change their Primary Care Physician and Specialists if Humana was selected. 2) The benefits with Humana are not as "rich" in comparison to AvMed. 3) AvMed received higher scores from the Florida Agency for Health Care Administration (AHCA) in comparison to Humana. The State of Florida measured each HMO in the following categories: a) Overall plan satisfaction b) Ease in getting to see a specialist c) Ease in getting needed care, tests, or treatment d) How well providers communicate with members e) Getting help from customer service 1 The proposed rates with United HealthCare are 21.7 % above the current cost structure with AvMed. From a plan design standpoint the United Healthcare plans are "Open Access" (i.e. members can receive services from a specialist without a referral from a Primary Care Physician). United HealthCare has the largest network of providers in South Florida. We appreciate the opportunity the City of South Miami has given us in regards to this project. Employee Benefits Consulting Croup is prepared to assist the City of South Miami in managing, healthcare costs` while still maintaining the integrity of the benefits package: I I I 2 I D m �e CDC' mmmmlO mmmml�� mmmrnlO m m m m K E3' 3333Cn 333303 33330 333310 � R Ea72 - -a- -a � aa a 'a b -R a O t t t O _ t t t O y t t t O O _ t+ t O O 0 0 _ CL C CL = 0 _ _ 0 _ _. 0 y N CD CD CD CD CD O CD 7 CD CD CD CD CD y O. cn O co Cry N cn O CD CD (yp 0 C O W W W W W W N „r 0� o� �Ih NIotO ��V' wp�� io°c 000rn . - r* o w D o w w 3 X cn r- W E» 1-& -60 £9 -69 to -60 (D a CD m C1 O N V vI-�000 K) 00 -4 0) W �W 0) -4 CDrncnwg wcn cowl p 0 N c i�S W -' p P co N CO lD \mil N -CflU7 CO UtOV O< sll N '. (D (D 0 2 -' 0 0 A1. CP m X CD n rr-* Cp to N V W to -(A b9 " 5s. -69 to - ' <CD 0 00a) °� Vco� W ° °cns. IO C4 C-71 -I 6 0 w CD V O V V ,P O -• 0) N co CD V to CA w -4 iA to f» £fl C.oCACA W afl ff, £A tfi Cb0CnNO C) -4 —o-ice �� 1- 0a M, W!omi� Npww co 0 1,3: N V W N 0) 00 w - �. -Cfl 00 U1.. N da 0) CO m . C to C t9to{ 44{-�� Q- V V �I -°OOO W O WN ®N�A�AN Ch Wloo�� 0 4 0 -� . � N W V.AN -4 W.Np� IN 1!e fu � O M -+ (D a Al Q rt �. Q ¢� cc su = cD 3 0 0.' o u, Q CD tD CD N '0 r+ O Cl) O x n Fn ' O y N N 3Q S 0 CL (D D CD CL 3 J c n -1 �w CD n Z z 00 W- O 0 0 0 p Z N n n O� I w S CD o o m O 69 Co. < < 3 cd (D 0 o- . o _< .� °0 0 a : v w' - m O' 1 O PTI 69 ` \V O CP Z Z O o W cri (C2 0 ao o z mD m w m 00°0 � � CD CD Q �� vm ° a o NoA) �, _ CD 69 Efl ffl {� p - 'W O O W Gil O W OO O O O Z � v \ m o Q C m 3 o v n v ' < �O < v a m u m < < 3 a <Z 3 o 77 s v N ' O O C v -69 V7 Z Z Ch C.71 O 0 O 0 O .0 0 n. 0 0 3_. .� -Z .. z O_ X. o SU v v < < CD m' in' 65' 3 n X G) x O c CO 3 cQ a CL �, m z -n O N (D n N CD' 0 CD CD O r.� CD 3 c x'00 a.- 3 o D a 0 g C fu cn 0 -� C C. _ O - 0 t9 Gq .69 �fl�� cn p O Q .O. N N CD 04 ccn00 0) p D O NC W O zD 0 0 0 0 0-0 CD SU .0. 7 0 C� p 3 Sv Sv N v N N W O X `6 fn a SU O M O CD T SD -. a �7N .. .� a Z _ V N -60 W N 0 . O O z C z SU O O® O 0 0 0 Oy0C) Wn O-0 (,)0 d Nn O O W 0 zID O fll CD 0 0 0 -0 S1) 0 0 0 or O O 0 <. Sv o C' 0 < -0 O 0 0 0 � . , CD rt N ,0 °O p...'a -0 'O fn K fD -."0 •. SU O- 0 CD `G `G �G y. \ < cn C 7c CD �` .: dG N SOD N pOjSD O0 -+, A p a Efl -G9 � U � 0 CD 6-69 {H p to N 0 0 N {fl ffl W o P N -� <, G CD to N• -,-. Z C p) O CD CC W O O N -+ 0 - � � W O O O W W O CD x CD 00 = 'O -0 . -O\ o � 0 0 0 v G v 3 aQ n W 0 m v= m3\ 0 0. 0 00 v N p , v O v: tZ CTI 3.ao 3 3.oC) c -69 1W -69 N ffl {fl ffl � o O 0 -« Z -�a 0 U) (n N) ' 0 ® p w O W O N a) W O -h z W 0 C 0 � 0 6 0 O 0 0 <0- Cp O � < 00 Q CD , Q a)--a cn -0 SD N C ` _ < a c .O � n CD < — cn G CD CD < R !y N CD SU so \.zi C CD c a tD '� Q C fD Q1 O C C -� ' _ n O ,y _ n N CD 0 7 lD +n o_ cn G 'D fu CD a a k CL lD 3 Q _n' v c n Q � N CL • •d o a o O p W O a n n O O 0 0 p Z Z N . m 3. V/ rL p �\1 0 'p \ ne O n -4 -4 v 0 p CSl O OZ O (t7 CD CD 0 CD CD O. O� �� Z w CD c 3(1) 30 0 <, CD CD CD p U O Z z 0 0 - W- O 7 O n 0 0 -0 OCT1 0 O p ZO < ZfD v ° -a p -a O p << CD 3 rn o CD v _ cn m �69 Ills 3 0 W Z O O C-71 O O v O.... c O c O O o o 0: O\ \ \ O N Z. -na OZ CD Z 3� 3 0 0 .. cn Wpm x m,mm�� O a O ® o CD Q a m c ,, cQ _ CD CD (D 0 o o z -n (D CD -r, — a CD - lO Q - u C 3 C (D CL �G C� a' GA 0 4.9 -69 En 4 W N -69 O � OO P (nUtO v C0 Z p 00 OZ O O O p 00 n O o O 00 0 0 1;(ZD bOOOaG -� 'p �O ill ^ N ' O G G Q- CD n N O 0 CD CL o cn CD C a � v m sz j o \ o 0 z z z z z z z ` -• CD z o 0' � 0 0 0 0 0 0 0 v v o, v o 01 cp (Q @ oo -< oo <° -4 v °- o - o oV Z W o o \ \ m o 6® CD a @ @ an.an ° CD 0 CD 3 N• � a 000 S CD moo 0 o 0 a °a Oa 17Z °o -0 -o o -OO m -° o 0 0 o 0 0 0 < o ' - CD S. C - L _. _. SI) (n G zZz zzzz CD CD `` `` Z �. 0: 0 O O 0 0; 0 0 O p Z N ((DD CD . (D 0 (D fD �* m 3 O c -a O O a v y a ' a ^ CD r„ n N a CD to m fD O 3 fOD 0 A n (D �+ A @ S 30. `� pI C =,;! y � C C ¢7 � O `C fn 0 y. N � CD In fD O CD p 7 O Q Q < a k Q n_ - N CL w v a m N CL i N 6 O 0 {9 O O O O O n ill O O n O O 0 0 3 O Z z (D O \ O -0 O0 a O O (D � i'D Q 2) < 9) CD O CD y . Q . y (n - O o N rt O 3 0 O 0 0 v 0 V v y�C � CTt O0 Vo 0�0 '� 0O 0 Lrl 71l CD �o O 0 o 0 o 00 o 00o °� ZZ CD (D N CD o N 4t N, O t !� 0O O n O 0 n n 0 0 -� w -i 0 Z CD r~ o o m y o o � Z o g w 3 CD 0 <, c W W in rt -ea .W -69 - Z N 0 v O O V v O O p 0 0 y � O O z z �� O CD ' N C-o. N (D 3 in 0 :* co co C/) 03 WAX p 3t p p� CD ® CD CD ® y Q CL Q N0 7 C° CO'O. Cp FD' Z 'C7 'ny, Z ,.-� CD CD C CD 0) 0 a• � 3 W _ s 3� 3 v < CL Q 42 '` c a m N N -69 N ifl ffl Efl O O n 4fl O O . W O 0 ®OO \OOO Q - 0 0 'a N x "00 °00 -0 � •a 0 CD 'p ID w p -0 0 w _ O 3 O _. 3 o O p 0. �. p N W 0 Ort u, 3 o ® 7h < O_� CD -W co cn '3 ZZZ ZZZZ W �' � (D m Z o C 0 O O O CD < v ' 0 O Ln (D CCD o 0 0 0 0 0 0 3 -4 W CD N.N N O O <..< < O °' ° O CD O o Z CD lo a * * * * 9 c0i _. CD CD m aaa CL CL � 0 � v 0 CD 8 N� U) 3 '" �. i -69 Lrl C� 00 p 0 N O N � C W N Z �G Z p °0 O 15(ZD. -0. x 00 -0-0-0 '� 0 < m a c 3 a c 3 C �m ;q: cu ? CL _ o o (n X o� _ CD = < Q:. < Q CD su � cn � cn S zzz zzzz (D CD CD n CD O O O O O O O �. �... v. p < 0< V �' Z < O CD CD < < < O CD 0 0 N N \° °* 0 ° CD _CD (D C. CL Q 0 0 0 CD a. Q Q. Q 0 FLORIDA Plan 75 Option 001 Plan pays for services provided or arranged by your PARTICIPATING primary care physician HumanaHMO is a health plan that enables you to take advantage of care arranged by the primary care physician you select from the network of participating providers. Your personal physician provides your primary care, referring you to specialists when appropriate. FL- 10233 -HH 2/04 100% after $10 copayment per visit to primary care physician or Preventive Care •Routine physical exams $20 copayment per visit to specialist • Well -child care • Well -woman exam (may self -refer to OBIGYN) Physician Services • Primary care physician office visits (includes diagnostic lab and 100% after $10 copayment per visit (visits to specialists must be X -ray, office surgery, allergy testing, speech and hearing exams, screening exams, breast cancer screening treatment) authorized by your primary care physician). vision (Hearing exams and vision screening exams cover children through age 18.) • Specialist office visits (includes same items as primary care 100% after $20 copayment per visit physician office visit) • Allergy treatments and materials 100% • Immunizations • Emergency room visits • Outpatient surgical care (includes ambulatory surgical center and hospital outpatient) • Inpatient physician visits (while member is confined in a hospital) • Prenatal care (office visit copayment applies to first visit only) 100% after $10 copayment per visit to primary care physician or • Diabetes treatment, including self- management training $20 copayment per visit to specialist Hospital Services • Inpatient care (semiprivate room, ancillary services) 100% after $100 copayment per day for first three days • Outpatient nonsurgical care 100% after $50 copayment • Outpatient surgical care (includes ambulatory surgical center) 100% after $100 copayment • Preadmission testing 100% • Other inpatient supplies and services • Hospital emergency services 100% after $75 copayment per occurrence Prescription Drugs • See attached drug rider, if applicable • Diabetic supplies (30 -day supply per copayment) Subject to the applicable prescription drug copayment. If prescription drug coverage is not included, then a $5 Level One/$15 Level Two /$30 Level Three copayment applies per item (based upon an Rx3 Drug List). Other Medical Services • Skilled nursing facility (up to 100 days per calendar year) 100% • Home health care (up to 60 visits per calendar year) • Ambulance • Durable medical equipment • Diabetes equipment • Private duty nursing (inpatient or outpatient) • Hospice services (inpatient or outpatient) • Spine and back disorders (limited to 20 visits per calendar year) 100% after $10 copayment per visit • Short term physical, speech, hearing and occupational therapy 100% after $20 copayment per visit (limited to 60 visits combined per calendar year) Copayment Limits • Individual $1,500 • Family $3,000 Lifetime Maximum Unlimited Mental and Nervous • Physician services 100% Disorders (1) • Partial hospitalization • Inpatient services (maximum of 31 days per calendar year) 100% after a $100 copayment per day for the first three days HumanaHMO is a health plan that enables you to take advantage of care arranged by the primary care physician you select from the network of participating providers. Your personal physician provides your primary care, referring you to specialists when appropriate. FL- 10233 -HH 2/04 Mental and Nervous Disorders (1) (coned) Alcoholism and Drug Abuse Services (1) Plan 75 Option 001 • Outpatient services (maximum of 20 visits per calendar year) • Detoxification — Inpatient — Outpatient — Physician services for detoxification only • Outpatient visits (lifetime maximum 44 visits) Acist medical services must be provided or arranged :)y your participating primary care physician. Only emergency services, or urgent services received while gut of the service area, are covered when provided by -ionparticipating providers or facilities. Participating primary care and specialist physicians and other providers in Humana's networks are not the agents, employees or partners of Humana or any of its affiliates or subsidiaries. They are independent contractors. Humana is not a provider of medical services. Limitations and Exclusions This is a partial and summarized list of limitations and exclusions. Your group may have specific Imitations and exclusions not included on this list. Please check your Certificate for this complete fisting. The Certificate is the document upon which benefit payment will be determined. ,less stated otherwise, no coverage will be provided for .nn account of the following situations: °lastic, cosmetic or reconstructive surgery, except as specified in the Group Plan. 2. Any service, supply or treatment connected with custodial care. 3. Purchase or rental of supplies of common household use. 4. Investigational or experimental procedures or treatment methods. 5. Care for military service connected disabilities for which the member is legally entitled to services and for which facilities are reasonably available to the member. FL- 10233 -HH 2/04 Plan pays for services provided or arranged by your PARTICIPATING primary care physician 100% after $20 copayment per visit , 100% after $100 copayment per day for the first three days 100% 100% up to $35 per visit Humana does not endorse or control the clinical judgement or treatment recommendations made by the physicians or other providers listed in network directories or otherwise selected by you. To be covered, expenses must be medically necessary and specified as covered. Please see your Certificate for more information on medical necessity and other specific plan benefits. 6. Any service, supply, care or treatment provided to the member without the authorization of his or her primary care physician, unless the member is receiving emergency services as outlined in the Schedule of Emergency Coverage at nonparticipating providers. 7. Rehabilitative services, unless we determine that the member's condition can be significantly improved by our provision of such services. 8. Drugs or medicines, prescription or nonprescription, provided to the member while he or she is not hospital- confined, unless otherwise covered by an outpatient prescription drug rider attached to the Group Plan. 9. Infertility counseling, testing and treatment services, sex change services, or reversal of elective sterilization. 10. Care and treatment of teeth or periodontium, unless otherwise specified in the Group Plan. 11. Elective abortion. 12. Eye refraction, the purchase or fitting of hearing aids, eyeglasses, contact lenses or advice on their care, except as specified in the Group Plan or otherwise provided by a vision care rider attached to the Group Plan. 0 HUMANA. 1 "*� Guidance when you need it most Offered by Humana Medical Plan, Inc. 1) Any copayments for the treatment of mental and nervous disorders or alcoholism and drug abuse services do not apply toward copayment limit. 77ie amount of benefit provided depends upon the plan selected. Aemiurns udll vary according to the selection made. For general questions about the plan, contact your benefits administrator. 13. Any care, treatment, services or supplies received outside of the service area, unless otherwise specified in the Group Plan. 14. Any treatment to reduce obesity including, but not limited to, surgical procedures. 15. Sickness or injury for which the member refuses to accept the recommended care and treatment of his or her physician when: a. the physician believes that no professionally acceptable alternative exists; and b. we have given the member written notice that we will only provide the physician's recommended care and treatment. The member has the right to appeal a decision of this nature by using the Grievance Procedure outlined in the Group Plan. 16. Services and supplies for treatment of temporomandibular joint disorder or dysfunction (TMJ) and craniomandibular jaw disorders (CMJ) which are recognized as dental procedures. This includes, but is not limited to, the extraction of teeth and the application of orthodontic devices and splints. LG /SG How the Rx4 Covered prescription drugs are assigned to one of four different levels with corresponding copayment structure works amounts.The levels are organized as follows: • Level One: lowest copayment for low cost generic and brand -name drugs. • Level Two: higher copayment for higher cost generic and brand -name drugs. • Level Three: higher copayment than Level Two for higher cost, mostly brand -name drugs that may have generic or brand - name alternatives on Levels One or Two. • Level Four: highest copayment for high - technology drugs (certain brand -name drugs, biotechnology drugs and self - administered injectable medications). Prescription drug products, or classes of certain prescription drug products, are generally reviewed on an ongoing basis by a Humana Pharmacy and Therapeutics committee which is composed of physicians and pharmacists. Drugs are reviewed for safety, effectiveness and cost - effectiveness prior to assignment or a change in assignment to one of the levels. Coverage of a prescription drug or placement of the drug within a level are subject to change throughout the year. In the event drugs are moved to categories with higher member cost, advance notice is provided based on past usage. Always discuss prescription drugs with your physician to determine appropriateness or clinical effectiveness with respect to you or any specific illness. Check our Website or contact Customer Service for the most up -to -date information about the Drug List. Some drugs in all levels may be subject to dispensing limitations, based on age, gender, duration or quantity. Additionally, some drugs may need prior authorization in order to be covered. In these cases, your physician should contact Humana Clinical Pharmacy Review at 1- 800 - 555 -CLIN (2546). Members can visit Human's Website, wwwhumana.com, to obtain information about their prescription drug and corresponding benefits and for possible lower cost alternatives, or they can call Humana's Customer Service with questions or to request a partial Humana Rx4 Drug List by mail. For a complete listing of participating pharmacies, please refer to our Website or your participating provider directory. Coverage at When you present your membership card at a participating pharmacy, you are required to make a copayment participating for each prescription based on the current assigned level of the drug. pharmacies Drugs assigned to: Copayment per prescription or refill Level One: $10 Level Two: $20 Level Three: $40 Level Four: 25 %* of the total required payment to the dispensing pharmacy per prescription or refill. * The total maximum out -of- pocket copayment costs for drugs in Level Four is limited to $2,500 per calendar year, per member. • If the dispensing pharmacy's charge is less than the corresponding copayment, you will only be responsible for the lower amount. • Your copayments for covered prescription drugs are made on a per prescription or refill basis and will not change'if Humana receives any retrospective volume discounts or prescription drug rebates. • If you use a nonparticipating pharmacy, there is no coverage, except for prescriptions required during an emergency for treatment of an emergency medical condition. There are no claim forms to file if you use a participating pharmacy and present your membership card with each prescription. Coverage Your coverage includes the following: specifics • A 30 -day supply or the amount prescribed, whichever is less, for each prescription or refill. • Contraceptives. • Certain self - administered injectable drugs and related supplies approved by Humana. • Certain drugs, medicines or medications that, under federal or state law, may be dispensed only by prescription from a physician. Mail -order For your convenience, you may receive a maximum 90 -day supply per prescription or refill through the benefit mail (maximum 30 -day supply for self - administered injectable drugs). The same requirements apply when purchasing medications through a participating mail -order pharmacy as apply when purchasing in person at a pharmacy. Members can call Customer Service or visit our Website for more information, including mail -order forms. GN- 12278 -HH 5/05 Definition • Drug List: a list of prescription drugs, medicines, medications and supplies specified by Humana. This list of terms identifies drugs as Level One, Level Two, Level Three or Level Four and indicates applicable dispensing limits and /or any prior authorization requirements. (This list is subject to change.) • Copayment: the amount to be paid by the member toward the cost of each separate prescription or refill of a covered drug when dispensed by a pharmacy. • Participating pharmacy: a pharmacy that has signed a direct agreement with us as an independent contractor or has been designated by us as an independent contractor to provide services to all covered persons • Nonparticipating pharmacy: a pharmacy that has not been designated by us to provide services to covered persons. Limitations and Unless specifically stated otherwise, no coverage is provided for the following: exclusions • Any drug prescribed for a sickness or bodily injury not covered under the master group contract. • Any drug, medicine or medication labeled "Caution- Limited by Federal Law to Investigational Use" or any experimental drug, medicine or medication, even though a charge is made to you. • Anorectic or any drug used for the purpose of weight control. • Any drug used for cosmetic purposes, including but not limited to: - Tretinoin, e.g. Retin A, except if you are under the age of 45 or are diagnosed as having adult acne; - Derinatologicals or hair growth stimulants; or - Pigmenting or de- pigmenting agents, e.g. Solaquin. • Any drug or medicine that is: - Lawfully obtainable without a prescription (over the counter drugs), except insulin; or - Available in prescription strength without a prescription. • Abordfacients (drugs used to induce abortions). • Infertility services including medications. • Any drug prescribed for impotence and /or sexual dysfunction, e.g.Viagra. • Any drug for which prior authorization is required, as determined by us, and not obtained. • Any service, supply or therapy to eliminate or reduce a dependency on, or addiction to tobacco and tobacco products, including but not limited to nicotine withdrawal therapies, programs, services or medications. • Treatment for onychomycosis (nail fungus). • Any portion of a prescription or refill that exceeds a 30 -day supply (or a 90 -day supply for a prescription or refill that is received from a mail order pharmacy). • Legend drugs which are not recommended and not deemed necessary by a health care practitioner. • Prescriptions filled at a non - network pharmacy except for prescriptions required during an emergency (Unless specifically listed on this benefit summary.) This is only a partial list of limitations and exclusions. Please refer to the certificate of coverage for complete details regarding prescription drug coverage. H77UMANA. Guidance when you need it most Humana Plans are offered by the Family of Insurance and Health Plan Companies including Humana Employers Health Plan of Georgia, Inc., Humana Medical Plan, Inc., Humana Health Plan, Inc., Humana Health Benefit Plan of Louisiana, Inc,. Humana Health Plan of Ohio, Inc.,Humana Health Plans of Puerto Rico, Inc., Humana Wisconsin Health Organization Insurance Corporation, or Humana Health Plan of Texas, Inc. —A Health Maintenance Organization. Our Health Benefit Plans have limitations and exclusions. GN- 12278 -HH 5/05 HumanaHMO FLORIDA Plan 25, Option 40 Plan pays for services provided or arranged by your participating primary care physician Plan pays for services not provided or arranged by your participating primary care physician Preventive Care • Routine physical exams (limited to one exam per calendar year) 100% after a $10 primary care/ pediatrician copayment per visit (other specialists covered in full) Not covered • Well -child care • Well -woman care (1) 100% after a $10 primary care/ pediatrician copayment per visit (other specialists covered in full) 70% after nonparticipating deductible Physician Services • Office visits in conjunction with a sickness or injury • Outpatient physician care 100% after a $10 primary care/ pediatrician copayment per visit (other specialists covered in full) 70% after nonparticipating deductible • Diagnostic lab testing and X -rays • Emergency room visits • Surgery performed in a physician's office • Allergy tests/serum Hospital Services • Inpatient care (semiprivate room and ancillary services) 100% after $200 copayment per admission 70% after nonparticipating deductible • Ancillary services 100% 100% e Preadmission testing • Emergency room 100% after $50 copayment per visit (waived if admitted) 100% after $50 copayment per visit (waived if admitted) Outpatient Services • Outpatient surgical 100% 70% after nonparticipating deductible • Outpatient nonsurgical • See attached rider if applicable Prescription Drugs • Durable medical equipment (2) • Skilled nursing facility (limited to 100 days 100% 70% after nonparticipating deductible Other Medical Services per lifetime) (2) • Ambulance • Therapy (includes occupational, physical and speech therapy,- must be determined by primary care physician that the member's condition can improve significantly within 60 days of the date therapy begins.) (2) • Home health care (2) 100% after $10 copayment per visit 70% after nonparticipating deductible 100% up to $5,000 inpatient and outpatient combined maximum Hospice Services • Individual $0 $400 Deductible • Family (two times the individual amount) $0 $800 • Individual $1,500 $2,500 Out -Of- Pocket Maximum • Family (two times the individual amount) $3,000 $5,000 Unlimited $1,000,000 Lifetime Maximum Benefit • Inpatient facility (limited to 30 days per calendar year) (3) 100% after $200 copayment per admission 70% after deductible Mental Health Services • Inpatient professional services 100% 70% after deductible e Outpatient (maximum of 20 visits per 100% after $10 copayment per visit 70% after deductible calendar year) HumanaPOS allows you to seek care from any provider without a referral. Care received from or arranged by your participating primary care physician will be covered at a higher benefit level. FL- 10011 -HH 4/04 Alcohol and Drug Abuse Plan 25, Option_ 40 Inpatient facility (3) • Inpatient professional services • Outpatient (detox) Plan pays for services provided or Plan pays for services not provided or arranged by your participating arranged by your participating primary care physician primary care physician 100% after $200 copayment per admission 100% • Outpatient (excluding detox) (limited to a 100% not to exceed $35 per visit lifetime maximum of 44 visits) Payments - Plan benefits are paid based on maximum allowable fees, as defined in your Certificate. Participating providers agree to accept maximum allowable fees as paid in full. For services rendered by nonparticipating providers, the member is responsible for amounts exceeding maximum allowable fees, as defined in your Certificate. Emergency services, or urgent services received while out of the service area, are covered at the referred level. Participating primary care and specialist physicians and other providers in Humana`s networks are not the agents, employees or partners of Humana or any of its affiliates or Limitations and Exclusions This is a partial and summarized list of limitations and exclusions.Your group may have specific limitations and exclusions not included on this list. Please check your Certificate for this complete 'fisting. The Certificate is the document upon which enefit payment will be determined. Jmmless stated otherwise, no coverage will be provided for the following situations. 1. Plastic, cosmetic or reconstructive surgery, except as specified in the Group Plan. 2 Any service, supply or treatment connected with custodial care. 3. Purchase or rental of supplies of common household use. 4. Investigational or experimental procedures or treatment methods. 5. Care for military service connected disabilities for which the member is legally entitled to services and for which facilities are reasonably available to the member. 6. Any service, supply, care or treatment provided to the member without the authorization of his or CR 0304 FL- 10011 -HH 4/04 subsidiaries. They are independent contractors. Humana is not a provider of medical services. Humana does not endorse or control the clinical judgement or treatment recommendations made by the physicians or other providers listed in network directories or otherwise selected by you. To be covered, expenses must be medically necessary and specified as covered. Please see your Certificate for more information on medical necessity and other specific plan benefits. (1) Insureds may self -refer to a participating specialist for an annual OB /GYN exam and for any medically necessary follow -up care identified at the annual her participating primary care physician, unless the member is receiving emergency services or unless such services have been expressly authorized under the terms of this Group Plan. 7. Rehabilitative services, unless we determine that the member's condition can be significantly improved by our provision of such services. 8. Drugs or medicines, prescription or nonprescription, provided to the member while he or she is not hospital- confined; unless otherwise covered by an outpatient prescription drug rider attached to the Group Plan. 9. In -vitro fertilization, sex change services or reversal of elective sterilization. 10. Care and treatment of the teeth or periodontium, unless otherwise specified in the Group Plan. 11. Elective abortion, except as specified in the Group Plan. 12. Eye refraction, the purchase or fitting of hearing aids, eyeglasses, contact lenses or advice on their care, except as specified in the Group Plan or otherwise provided by a vision care rider attached to the Group Plan. 70% after deductible 70% after deductible 70% after deductible (not to exceed $35 per visit) visit. Limited to one exam per insured per benefit year. (2) Failure to preauthorize may result in financial penalty or denial of payment. (3) Services require prior approval of plan or designee. Expenses do not apply toward out -of- pocket maximum. The amount of benefit prot4ded depends upon the plan selected. Premiums u ill vary according to the selection made. For general questions about the plan, contact your bents administrator. 13. Any care, treatment, services or supplies received outside of the service area, unless otherwise specified in the Group Plan. 14. Any treatment to reduce obesity, including, but not r` limited to, surgical procedures. 15. Sickness or injury for which the member refuses to —' accept the recommended care and treatment of his or her physician when: a. the physician believes that no professionally acceptable alternative exists; and . b. we have given the member written notice that we will only provide the physician's recommended care mid treatient.The member has the right to appeal a decision of this nature by using the Grievance Procedure outlined in the Group Plan. 16. Services and supplies for treatment of temporomandibular joint disorder or dysfunction (TMJ) and craniomnandibular jaw disorders (CMJ) which are recognized as dental procedures.This includes, but is not limited to, the extraction of teeth and the application of orthodontic devices and splints. r 04 HUN1ANAV 1 ` Guidance when you need it most Offered and insured by Humana Medical Plan, Inc. How the Rx4 Covered prescription drugs are assigned to one of four different levels with corresponding copayment structure works amounts. The levels are organized as follows: • Level One: lowest copayment for low cost generic and brand -name drugs. • Level Two: higher, copayment for higher cost generic and brand -naive drugs. • Level Three: higher copayment than Level Two for higher cost, mostly brand -name drugs that may have generic or brand -name alternatives on Levels One or Two. • Level Four: highest copayment for high - technology drugs (certain_ brand -name drugs, biotechnology drugs and self - administered injectable medications). Prescription drug products, or classes of certain prescription drug products, are generally reviewed on an ongoing basis by a Humana Pharmacy and Therapeutics committee which is composed of physicians and pharmacists. Dings are reviewed for safety, effectiveness and cost - effectiveness prior to assignment or a change in assignment to one of the levels. Coverage of a prescription drug or placement of the drug within a level are subject to change throughout the year. In the event drugs are moved to categories with higher member cost, advance notice is provided based on past usage. Always discuss prescription drugs with your physician to determine appropriateness or clinical effectiveness with respect to you or any specific illness. Check our Website or contact Customer Service for the most up -to -date information about the Drug List. Some drugs in all levels may be subject to dispensing limitations, based on age, gender, duration or quantity. Additionally, some drugs may need prior authorization in order to be covered. In these cases, your physician should contact Humana Clinical Pharmacy Review at 1- 800 - 555 -CLIN (2546). Members can visit Humana's Website, www.humana.com, to obtain information about their prescription drug and corresponding benefits and for possible lower cost alternatives, or they can call Human's Customer Service with questions or to request a partial, Humana Rx4 Drug List by mail. For a complete listing of participating pharmacies, please refer to our Website or your participating provider directory. Coverage at When you present your membership card at a participating pharmacy, you are required to make a copayment participating for each prescription based on the current assigned level of the drug. pharmacies Drugs assigned to: Copayment per prescription or refill Level One: $10 Level Two: $20 Level Three: $40 Level Four: 25 %* of the total required payment to the dispensing pharmacy per prescription or refill. * The total maximum out -of- pocket copayment costs for drugs in Level Four is limited to $2,500 per calendar year, per member. • If the dispensing pharmacy's charge is less than the corresponding copayment, you will only be responsible for the lower amount. • Your copayments for covered prescription drugs are made on a per prescription or refill basis and will not change if Humana receives any retrospective volume discounts or prescription drug rebates. There are no claim forms to file if you use a participating pharmacy and present your membership card with each prescription. Nonparticipating You may also purchase prescribed medications from a nonparticipating pharmacy.You will be required to pay pharmacy for your prescriptions according to the following rule. coverage • You pay 100 percent of the dispensing pharmacy's charges. — You file a claim form with Humana (address is on the back of ID card). — Claim is paid at 70 percent of the dispensing pharmacy's charges, after they. are first reduced by the applicable copayment. • Your copayments for covered prescription drugs are made on a per prescription or refill basis and will not change if Humana receives any retrospective volume discounts or prescription drug rebates. GN- 12195 -HH 5/05 Coverage Your coverage includes the following: specifics • A 30 -day supply or the amount prescribed, whichever is less, for each prescription or refill. • Contraceptives. • Certain self- administered injectable drugs and related supplies approved by Humana. • Certain drugs, medicines or medications that, under federal or state law, may be dispensed only by prescription from a physician. Mail -order For your convenience, you may receive a maximum 90 -day supply per prescription or refill through the benefit mail (maximum 30 -day supply for self - administered injectable drugs). The same requirements apply when purchasing medications through a participating mail -order pharmacy as apply when purchasing in person at a pharmacy. Members can call Customer Service or visit our Website for more information, including mail -order forms. Definition • Drug List: a list of prescription drugs, medicines, medications and supplies specified by us. This list identifies of terms drugs as Level One, Level Two, Level Three or Level Four and indicates applicable dispensing limits and /or any prior authorization requirements. (This list is subject to change.) • Copayment: the amount to be paid by the member toward the cost of each separate prescription or refill of a covered drug when dispensed by a pharmacy. • Nonparticipating pharmacy: a pharmacy that has not been designated by us to provide services to covered persons • Participating pharmacy: a pharmacy that has signed a direct agreement with us as an independent contractor or has been designated by us as an independent contractor to provide services to all covered persons. Limitations and Unless specifically stated otherwise, no coverage is provided for the following: ekciusions • Any drug prescribed for a sickness or bodily injury not covered under the master group contract. • Any drug, medicine or medication labeled "Caution- Limited by Federal Law to Investigational Use" or any experimental drug, medicine or medication, even though a charge is made to you. • Anorectic or any drug used for the purpose of weight control. • Any drug used for cosmetic purposes, including but not limited to: - Tretinoin, e.g. Retin A, except if you are under the age of 45 or are diagnosed as having adult acne; - Dermatologicals or hair growth stimulants; or - Pigmenting or de- pigmenting agents, e.g. Solaquin. • Any drug or medicine that is: Lawfully obtainable without a prescription (over the counter drugs), except insulin; or Available in prescription strength without a prescription. • Abortifacients (drugs used to induce abortions). • Infertility services including medications. • Any drug prescribed for impotence and /or sexual dysfunction, e.g.Viagra. • Any drug for which prior authorization is required, as determined by us, and not obtained. • Any service, supply or therapy to eliminate or reduce a dependency on, or addiction to tobacco and tobacco products, including but not limited to nicotine withdrawal therapies, programs, services or medications. • Treatment for onychomycosis (nail fungus). • Any portion of a prescription or refill that exceeds a 30 -day supply (or a 90 -day supply for a prescription or refill that is received from a snail order pharmacy). • Legend drugs which are not recommended and not deemed necessary by a health care practitioner. • Prescriptions filled at a non - network pharmacy except for prescriptions required during an emergency. (Unless specifically listed on this benefit summary.) This is only a partial list of limitations and exclusions. Please refer to the Certificate of Coverage for complete details regarding prescription drug coverage. HUMANA. Guidance when you need it most f' Humana Plans are offered by the Family of Insurance and Health Plan Companies including Humana Medical Plan, Inc., Humana Employers Health Plan of Georgia, Inc., Humana Health Plan, Inc., Humana Health Benefit Plan of Louisiana, Inc., Humana Health Plan of Ohio, Inc., Humana Health Plans of Puerto Rico, Inc., Humana Wisconsin Health Organization Insurance Corporation, or Humana Health Plan ofTexas, Inc. - A Health Maintenance Organization or insured by Humana Health Insurance Company of Florida, Inc., Humana Health Plan Inc., Humana Health Benefit Plan of Louisiana, Inc., Humana Insurance Company, Humana Insurance Company of Kentucky, or Humana Insurance of Puerto Rico, Inc. Our Health Benefit Plans have limitations and exclusions. GN- 12195 -HH 5/05 HumanaPOS YOUR BENEFITS UnitedHealthcare Choice Plan S56 Choice plan gives you the freedom to see any Physician or other health care professional from our Network, including specialists, without a referral. With this plan, you will receive the highest level of benefits when you seek care from a network physician, facility or other health care professional. In addition, you do not have to worry about any claim forms or bills. Some of the Important Benefits of Your Plan: You have access to aNetwork of physicians, facilities and other health care professionals, including specialists, without designating a Primary Physician or obtaining a referral. Benefits are available for office visits and hospital care, as well as inpatient and outpatient surgery. Care CoordinationSM services are available to help identify and prevent delays in care for those who might need specialized help. FLLFMS5602 Emergencies are covered anywhere in the world. Pap smears are covered. Prenatal care is covered. Routine check -ups are covered. Childhood immunizations are covered. Mammograms are covered. Vision and hearing screenings are covered. Choice Benefits Summary Types of Coverage Network Benefits / Copayment Amounts This Benefit Summary is intended only to highlight Annual Deductible: No Annual Deductible. your Benefits and should not be relied upon to fully determine coverage. This benefit plan may not cover Out -of- Pocket Maximum: $2,500 per Covered Person, per calendar year, not to exceed $5,000 for all Covered all of your health care expenses. More complete Persons in a family. descriptions of Benefits and the terms under which Maximum Policy Benefit: No Maximum Policy Benefit. they are provided are contained in the Certificate of Coverage that you will receive upon enrolling in the Plan. If this Benefit Summary conflicts in any way with the Policy issued to your employer, the Policy shall prevail. Terms that are capitalized in the Benefit Summary are defined in the Certificate of Coverage. Benefits are payable for Covered Health Services provided by or under the direction of your Network physician. *Prior Notification is required for certain services. 1. Ambulance Services - Emergency only 2. Dental Services - Accident only Ground Transportation: No Copayment Air Transportation: 0% of Eligible Expenses *Same as 8, 11, 12 and 13 *Prior notification is required before follow -up treatment begins. 3. Durable Medical Equipment No Copayment Benefits for Durable Medical Equipment are limited to $2,500 per calendar year. Limits do not $15 per visit apply to Durable Medical Equipment classified as Same as 8, 11, 12 and 13 No Copayment applies to Physician office visits for prenatal care after the first visit. diabetic equipment or supppies. 4. Emergency Health Services $150 per visit S. Eye Examinations $15 per visit Refractive eye examinations are limited to one For lab and radiology/Xray: No Copayment every other calendar year from a Network $250 per test Provider. 6. Home Health Care No Copayment Benefits are limited to 60 visits for skilled care $15 per visit except that the Copayment for a Specialist Physician office visit is $25. No Copayment applies services per calendar year. when a Physician charge is not assessed. 7. Hospice Care No Copayment Benefits are limited to 360 days during the entire lies $15 per visit except that the Copayment for a Specialist Physician office visit is $25. No Copayment applies period of time a Covered Person is covered under when a Physician charge is not assessed. the Policy. 8. Hospital - Inpatient Stay $500 per Inpatient Stay 9. Injections Received in a Physician's Office $15 per visit 10. Maternity Services Same as 8, 11, 12 and 13 No Copayment applies to Physician office visits for prenatal care after the first visit. 11. Outpatient Surgery, Diagnostic and Therapeutic Services Outpatient Surgery. $250 per surgical procedure Outpatient Diagnostic Services For lab and radiology/Xray: No Copayment Outpatient Diagnostic/Therapeutic Services - CT $250 per test Scans, Pet Scans, MRI and Nuclear Medicine Outpatient Therapeutic Treatments No Copayment 12. Physician's Office Services $15 per visit except that the Copayment for a Specialist Physician office visit is $25. No Copayment applies Covered Health Services for preventive medical when a Physician charge is not assessed. care. Covered Health Services for the diagnosis and treatment of a Sickness or Injury received in a lies $15 per visit except that the Copayment for a Specialist Physician office visit is $25. No Copayment applies Physician's office. when a Physician charge is not assessed. 13. Professional Fees for Surgical and Medical No Copayment Services 14. Prosthetic Devices No Copayment Benefits for prosthetic devices are limited to $2,500 per calendar year. 15. Reconstructive Procedures Same as 8, 11, 12, 13 and 14 YOUR BENEFITS Types of Coverage Network Benefits / Copayment Amounts 16. Rehabilitation Services - Outpatient Therapy $15 per visit Benefits are limited as follows: 20 visits of physical therapy, 20 visits ofoccupational therapy; 20 visits of speech therapy; 20 visits of pulmonary rehabilitation; and 36 visits of cardiac rehabilitation per calendar year. 1 i. in�uutea tvursmg racitity /inpatient No Copayment Rehabilitation Facility Services Benefits are limited to 60 days per calendar year. ia. transpiantation Services *Same as 8 and 13 19. Urgent Care Center Services $50 per visit Additional Benefits Bones or Joints of the Jaw and Facial Region Same as 8, 11, 12 and 13 Child Health Supervision Services Same as 11, 12 and 13 Cleft Lip /Cleft Palate Treatment Same as 8, 11, 12, 13, and 16 Dental Procedures - Anesthesia and Hospitalization Same as 8, 11, and 13 Diabetes Treatment Same as 3, 11, 12 and 13 Mammography No Copayment Mastectomy Same as 8, 11, 12 and 13 Mental Health and Substance Abuse Services - $15 per individual visit; $10 per group visit Outpatient Must receive prior authorization through the Mental Health/Substance Abuse Designee. Benefits are limited to 30 visits per calendar year. Mental Health and Substance Abuse Services - $500 per Inpatient Stay Inpatient and Intermediate Must receive prior authorization through the Mental Health/Substance Abuse Designee. Benefits are limited to 30 days per calendar year. Osteoporosis Treatment Same as 11, 12 and 13 — Prescription and Non - Prescription Enteral No Copayment Formulas Benefits for low protein food products for Covered Persons through age 24 are limited to $2,500 per calendar year. Spinal Treatment $15 per visit Benefits include diagnosis and related services and are limited to one visit and treatment per day. Benefits are limited to 24 visits per calendar year. United HealthCare Insurance Company Exclusions Appearance Except as maybe specifically provided in Section 1 of the Certificate of Coverage (COC) or through a Cosm ticiProc Procedures including, but not limited to, pharmacological regimens; nutritional procedures Rider to the Policy, the following are not covered: or treatments; salabrasion, chemosurgery and other such skin abrasion procedures associated with the l� A. Alternative Treatments Acupressure; hypnotism; rolling; massage therapy; aromatherapy; acupuncture; and other forms of ex removal existing breast implant is exuded if ther earlier breast implant was of Cosmetic Replacement of an alternative treatment. (Replacement of an existing breast implant is considered reconstructive if the initial breast implant C fort or Convenience followed mastectomy.) Physical conditioning programs such as athletic training, bodybuilding, for medical B. OUR Personal comfort or convenience items or services such as television; telephone; barber or beauty service; guest service; supplies; equipment and similar incidental services and supplies for personal comfort including air conditioners, air purifiers and filters, batteries and battery chargers, dehumidifiers and humidifiers; devices or computers to assist in communication and speech. C. Dental Except as specifically described as covered in Section I of the COC under the headings Dental Services - Accident only and Cleft Lip /ClefI Palate Treatment, dental services are excluded. There's no coverage for services provided for the prevention, diagnosis, and treatment of the teeth or gums (including extraction, restoration, and replacement of teeth and services to improve dental clinical outcomes). Dental implants and dental braces are excluded. Dental x -rays, supplies and appliances and all associated expenses arising out of such dental services (including hospitalizations and anesthesia) are excluded, except as might otherwise be required for transplant preparation, initiation of immunosuppressives, the direct treatment of acute traumatic Injury, cancer, or cleft palate, or as described in Section 1 of the COC under the heading of Dental Procedures Anesthesia and Hospitalization. Treatment for congenitally missing, malpositioned, or super numerary teeth is excluded, even if part of a Congenital Anomaly except in connection with cleft lip or cleft palate. D. Drugs Prescription drug products for outpatient use that are filled by a prescription order or refill. Self - injectable medications except as described in Section I of the COC under the heading of Diabetes Treatment. Non - injectable medications given in a Physician's office except as required in an Emergency. Over - the - counter drugs and treatments. E. Experimental, Investigational or Unproven Services Experimental, Investigational or Unproven Services are excluded, except (a) bone marrow transplants and (b) medically appropriate medications prescribed for the treatment of cancer, for a particular indication, if that drug is recognized for the treatment of that indication in a standard reference compendium or recommended in medical literature. The fact that an Experimental, Investigational or Unproven Service, treatment, device or pharmacological regimen is the only available treatment for a particular condition will not result in Benefits if the procedure is considered to be Experimental, Investigational or Unproven in the treatment of that particular condition. exercise, fitness, flexibility, and diversion or general motivation. Weight loss programs and non - medical reasons. Wigs, regardless of the reason for the hair loss. K. Providers Services performed by a provider with your same legal residence or who is a family member by birth or marriage, including spouse, brother, sister, parent or child. This includes any service the provider may perform on himself or herself. Services provided at a free - standing or Hospital -based diagnostic facility without an order written by a Physician or other provider as further described in Section 2 of the COC (this exclusion does not apply to mammography testing). L. Reproduction Health services and associated expenses for infertility treatments. Surrogate parenting. The reversal of voluntary sterilization. M Services Provided under Another Plan Health services for which other coverage is paid under arrangements required by federal, state or local law. This includes, but is not limited to, coverage paid by workers' compensation, no -fault automobile insurance, or similar legislation. Health services for treatment of military service- related disabilities, when you are legally entitled to other coverage and facilities are reasonably available to you. Health services while on active military duty. N. Transplants Health services for organ or tissue transplants are excluded, except those specified as covered in Section l of the COC. Any solid organ transplant that is performed as a treatment for cancer. Health services connected with the removal of an organ or tissue from you for purposes of a transplant to another person. Health services for transplants involving mechanical or animal organs. Transplant services that are not performed at a Designated Facility. Any multiple organ transplant not listed as a Covered Health Service in Section 1 of the COC. F. Foot Care Routine foot care (including the cutting or removal of toms and calluses); nail trimming, cutting, or debriding; hygienic and preventive maintenance foot care; treatment of flat feet or subluxation of the foot; shoe orthotics. C. Medical Supplies and Appliances Devices used specifically as safety items or to affect performance primarily in sports - related activities. Prescribed or non - prescribed medical supplies and disposable supplies including but not limited to elastic stockings, ace bandages, ostomy supplies, gauze and dressings. Orthotic appliances that straighten or re-shape a body part (including cranial banding and some types of braces). Tubings and masks are not covered except when used with Durable Medical Equipment as described in Section I of the COC. H. Mental Health /Substance Abuse Services performed in connection with conditions not classified in the current edition of the Diagnostic and Statistical Manual of the American Psychiatric Association. Services that extend beyond the period necessary for short-term evaluation, diagnosis, treatment, or crisis intervention. Mental Health treatment of insomnia and other sleep disorders, neurological disorders, and other disorders with a known physical basis. Treatment of conduct and impulse control disorders, personality disorders, paraphilias and other Mental Illnesses that will not substantially improve beyond the current level of functioning, or that are not subject to favorable modification or management according to prevailing national standards of clinical practice, as reasonably determined by the Mental Health/Substance Abuse Designee.: Services utilizing methadone treatment as maintenance, L.A.A.M. (1- Alpha- Acetyl - Methadol), Cyclazocine, or their equivalents. Treatment provided in connection with or to comply with :involuntary commitments, police detentions and other similar arrangements, unless authorized by the Mental Health/Substance Abuse Designee. Residential treatment services. Services or supplies that in the reasonable judgment of the Mental Health/Substance Abuse Designee are not; for example, consistent with certain national standards orprofessional research further described in Section of the COC. I. Nutrition Megavitamin and nutrition based therapy; nutritional counseling for either individuals or groups. Enteral feedings and other nutritional and electrolyte supplements, including infant formula and donor breast milk, except as described in Section 1 of the COC under the heading Prescription and Non- prescription Enteral Formulas. O. Travel Health services provided in a foreign country, unless required as Emergency Health Services. Travel or transportation expenses, even though prescribed by `a Physician. Some travel expenses related to covered transplantation services may be reimbursed at our discretion. P. Vision and Hearing Purchase cost of eye glasses, contact lenses, or hearing aids. Fitting charge for hearing aids, eye glasses or contact lenses. Eye exercise therapy. Surgery that is intended to allow you to see better without glasses or other vision correction including radial kemtotomy, laser, and other refractive eye surgery. Q. Other Exclusions Health services and supplies that do not meet the definition of a Covered Health Service - see definition in Section 10 of the COC. Physical, psychiatric or psychological examinations, testing, vaccinations, immunizations or treatments otherwise covered under the Policy, when such services are: (1) required solely for purposes of career, education, sports or camp, travel, employment, insurance, marriage or adoption; (2) relating to judicial or administrative proceedings or orders; (3) conducted for purposes of medical research; or (4) to obtain or maintain a license of any type. Health services received as a result of war or any act of war, whether declared or undeclared or caused during service in the armed forces of any country. Health services received after the date your coverage under the Policy ends, including health services for medical conditions arising prior to the date your coverage under the Policy ends. Health services for which you have no legal responsibility to pay, or for which a charge would not ordinarily be made in the absence of coverage under the Policy. Charges in excess of Eligible Expenses or in excess of any specified limitation. Services for the evaluation and treatment of temporomandibular joint syndrome (TMJ), whether the services are considered to be medical or dental in nature, except as described in Section I of the COC under the heading Bones or Joints of the Jaw and Facial Region. Surgical treatment and non - surgical treatment of obesity (including morbid obesity). Surgical treatment and non - surgical treatment of obesity (including morbid obesity). Growth hormone therapy; sex transformation operations; treatment ofbenign gynecomastia (abnormal breast enlargement in males); medical and surgical treatment of excessive sweating (hyperhidrosis); medical and surgical treatment for snoring, except when provided as part of treatment for documented obstructive sleep apnea. Oral appliances for snoring. Custodial care; domiciliary care; private duty nursing; respite care; rest cures. Psychosurgery. Speech therapy except as required for treatment of a speech impediment or speech dysfunction that results from Injury, stroke, cleft lip /cleft palate or Congenital Anomaly. This summary of Benefits is intended only to highlight your Benefits and should not be relied upon to fully determine coverage. This plan may not cover all your health care expenses. Please refer to the Certificate of Coverage for a complete listing of services, limitations, exclusions and a description of all the terms and conditions of coverage. If this description conflicts in anyway with the Certificate of Coverage, the Certificate of Coverage prevails. Terms that are capitalized in the Benefit Summary are defined in the Certificate of Coverage. 213 -1157 0604 02I BS Chc FLLEMS5602 OAH YOUR BENEFITS UnitedHealthcare Pharmacy Management Program Plan 023 UnitedHealthcare's pharmacy management program provides clinical pharmacy services that promote choice, accessibility and value. The program offers a broad network of pharmacies (more than 56,000 nationwide) to provide convenient access to medications. While most pharmacies participate in our network, you should check first. Call your pharmacist or visit our online pharmacy service at www.myuhc.com. The online service offers you home delivery of prescriptions, ability to view personal benefit coverage, access health and well being information, and even location of network retail neighborhood pharmacies by zip code. Copayment per Prescription Order or Refill Your Copayment is determined by the tier to which the Prescription Drug List Management Committee has assigned the Prescription Drug Product. All Prescription Drug Products on the Prescription Drug List are assigned to Tier 1, Tier 2 or Tier 3. Please access www.myuhc.com through the Internet, or call the Customer Service number on your ID card to determine tier status. For a single Copayment, you may receive a Prescription Drug Product up to the stated supply limit. Some products are subject to additional supply limits. You are responsible for paying the lower of the applicable Copayment or the retail Network Pharmacy's Usual and Customary Charge, or the lower of the applicable Copayment or the Home Delivery Pharmacy's Prescription Drug Cost. Also note that some Prescription Drug Products require that you notify us in advance to determine whether the Prescription Drug Product meets the definition of a Covered Health Service and is not Experimental, Investigational or Unproven. Retail Network Home Delivery Network Pharmacy Pharmacy For up to a 31 day supply For up to a 90 day supply Tier 1 $10 $25 Tier 2 $30 $75 Tier 3 $50 $125 FLNPP02304 Other Important Cost Sharing Information Annual Drug No Annual Drug Deductible Deductible Out -of- Pocket Drug No Out -of- Pocket Drug Maximum Maximum Exclusions Exclusions from coverage listed in the Certificate apply also to this Rider. In addition, the following exclusions apply: Outpatient Prescription Drug Products obtained from a non - Network Pharmacy. Coverage for Prescription Drug Products for the amount dispensed (days supply or quantity limit) which exceeds the supply limit. Prescription Drug Products dispensed outside the United States, except as required for Emergency treatment. Drugs which are prescribed, dispensed or intended for use while you are an inpatient in a Hospital, Skilled Nursing Facility, or Alternate Facility. Experimental, Investigational or Unproven Services and medications medications used for experimental indications and/or dosage regimens determined by us to be experimental, investigational or unproven. Prescription Drug Products furnished by the local, state or federal government. Any Prescription Drug Product to the extent payment or benefits are provided or available from the local, state or federal government (for example, Medicare) whether or not payment or benefits are received, except as otherwise provided by law. Prescription Drug Products for any condition, Injury, Sickness or mental illness arising out of, or in the course of, employment for which benefits are available under any workers' compensation law or other similar laws, whether or not a claim for such benefits is made or payment or benefits are received. Any product dispensed for the purpose of appetite suppression and other weight loss products. A specialty medication Prescription Drug Product (such as immunizations and allergy serum) which, due to its characteristics as determined by us, must typically be administered or supervised by a qualified provider or licensed/certified health professional in an outpatient setting. This exclusion does not apply to Depo Provera and other injectable drugs used for contraception. United HealthCare Insurance Company Durable Medical Equipment. Prescribed and non - prescribed outpatient supplies, other than the diabetic supplies and inhaler spacers specifically stated as covered. General vitamins, except the following which require a Prescription Order or Refill: prenatal vitamins, vitamins with fluoride, and single entity vitamins. Unit dose packaging of Prescription Drug Products. Medications used for cosmetic purposes. Prescription Drug Products, including New Prescription Drug Products or new dosage forms, that are determined to not be a Covered Health Service. Prescription Drug Products as a replacement for a previously dispensed Prescription Drug Product that was lost, stolen, broken or destroyed. Prescription Drug Products when prescribed to treat infertility. Drugs available over - the - counter that do not require a Prescription Order or Refill by federal or state law before being dispensed. Any Prescription Drug Product that is therapeutically equivalent to an over -the- counter drug. Prescription Drug Products that are comprised of components that are available in over - the - counter form or equivalent. Prescription Drug Products for smoking cessation. Compounded drugs that do not contain at least one ingredient that requires a Prescription Order or Refill. Compounded drugs that contain at least one ingredient that requires a Prescription Order or Refill are assigned to Tier 3. New Prescription Drug Products and/or new dosage forms until the date they are reviewed by our Prescription Drug List Management Committee. Growth hormone therapy for children with familial short stature (short stature based upon heredity and not caused by a diagnosed medical condition). This summary of Benefits is intended only to highlight your Benefits for outpatient Prescription Drug Products and should not be relied upon to determine coverage. Your plan may not cover all your outpatient prescription drug expenses. Please refer to your Outpatient Prescription Drug Rider and the Certificate of Coverage for a complete listing of services, limitations, exclusions and a description of all the terms and conditions of coverage. if this description conflicts in any way with the Outpatient Prescription Drug Rider or the Certificate of Coverage, the Outpatient Prescription Drug Rider and Certificate of Coverage prevail. Capitalized terms in the Benefit Summary are defined in the Outpatient Prescription Drug Rider and/or Certificate of Coverage. 04I BS RX NET FLNPP02304 H9 213-13770804 YOUR BENEFITS UnitedHealthcare Choice Plus Plan S59 Choice Plus plan gives you the freedom to see any Physician or other health care professional from our Network, including specialists, without a referral. With this plan, you will receive the highest level of benefits when you seek care from a network physician, facility or other health care professional. In addition, you do not have to worry about any claim forms or bills. You also may choose to seek care outside the Network, without a referral. However, you should know that care received from a non - network physician, facility or other health care professional means a higher deductible and Copayment. In addition, if you choose to seek care outside the Network, UnitedHealthcare only pays a portion of those charges and it is your responsibility to pay the remainder. This amount you are required to ppay, which could be significant, does not apply to the Out-of-Pocket maximum. We recommend that you ask the non - network physician or health care professional about their billed charges before you receive care. Some of the Important Benefits of Your Plan: You have access to a Network of physicians, facilities and other health care professionals, including specialists, without designating a Primary Physician or obtaining a referral. Benefits are available for office visits and hospital care, as well as inpatient and outpatient surgery. Care Coordinationsm services are available to help identify and prevent delays in care for those who might need specialized help. FLLGMS5902 Emergencies are covered anywhere in the world. Pap smears are covered. Prenatal care is covered. Routine check -ups are covered. Childhood immunizations are covered. Mammograms are covered. Vision and hearing screenings are covered. Choice Plus Benefits Summary Types of Coverage Network Benefits / Copayment Amounts Non- Network Benefits / Copayment Amounts This Benefit Summary is intended only to highlight your Annual Deductible: No Annual Deductible. calendar Annual Deductible: tib e exceed per Covered reed Person Coeted Benefits and should not be relied upon to fully determine coverage. This benefit plan may not cover all *Same as 8, 11, 12 and 13 persons in a family. of your health care expenses. More complete descriptions of Benefits and the terms under which Out -of- Pocket Maximum: $2,500 per Covered Person, calendar year, not to exceed $5,000 for all Covered Out -of- Pocket Maximum: $5,000 per Covered Person, per calendar year, not to exceed $10,000 for all Covered they are provided are contained in the Certificate of Coverage that you will receive upon enrolling in the per Persons in a family. Persons in a family. The Out -of- Pocket Maximum does not include the Annual Deductible. Plan. No Copayment *40 % of Eligible Expenses If this Benefit Summary conflicts in any way with the Maximum Policy Benefit: No Maximum Policy Maximum Policy Benefit: $1,000,000 per Covered Policy issued to your employer, the Policy shall prevail. Benefit. Person. Terms that are capitalized in the Benefit Summary are defined in the Certificate of Coverage. Where Benefits are subject to day, visit and/or dollar limits, such limits apply to the combined use of Benefits $150 per visit Same as Network Benefit whether in- Network or out -of- Network, except where *Notification is required if results in an Inpatient Stay. mandated by state law. $15 per visit 40% of Eligible Expenses Network Benefits are payable for Covered Health Eye Examinations for refractive errors are not covered. Services provided by or under the direction of your Network physician. No Copayment *40% of Eligible Expenses *Prior Notification is required for certain services. 1. Ambulance Services - Emergency only Ground Transportation: No Copayment Same as Network Benefit Air Transportation: 0% of Eligible Expenses 2. Dental Services - Accident only *Same as 8, 11, 12 and 13 *Same as Network Benefit *Prior notification is required before follow -up *Prior notification is required before follow -up treatment begins. treatment begins. 3. Durable Medical Equipment No Copayment *40 % of Eligible Expenses Network and Non - Network Benefits for Durable *Prior notification is required when the cost is more Medical Equipment are limited to $2,500 per than $1,000. calendar year. Limits do not apply to Durable Medical Equipment classified as diabetic equipment or supppies. 4. Emergency Health Services $150 per visit Same as Network Benefit *Notification is required if results in an Inpatient Stay. 5. Eye Examinations $15 per visit 40% of Eligible Expenses Refractive eye examinations are limited to one Eye Examinations for refractive errors are not covered. every other calendar year from a Network Provider. 6. Home Health Care No Copayment *40% of Eligible Expenses Network and Non - Network Benefits are limited to 60 visits for skilled care services per calendar year. 7. Hospice Care No Copayment *40% of Eligible Expenses Network and Non - Network Benefits are limited to 360 days during the entire period of time a Covered Person is covered under the Policy. 8. Hospital - Inpatient Stay $500 per Inpatient Stay *40% of Eligible Expenses 9. Injections Received in a Physician's Office $15 per visit 40% per injection 10. Maternity Services Same as 8, 11, 12 and 13 Same as 8, 11, 12 and 13 No Copayment applies to Physician office visits for *Notification is required if Inpatient Stay exceeds 48 prenatal care after the first visit. hours following a normal vaginal delivery or 96 hours following a cesarean section delivery. 11. Outpatient Surgery, Diagnostic and Therapeutic Services Outpatient Surgery $250 per surgical procedure 40% of Eligible Expenses Outpatient Diagnostic Services For lab and radiology/Xray: No Copayment 40% of Eligible Expenses Outpatient Diagnostic/Therapeutic Services - CT $250 per test 40% of Eligible Expenses Scans, Pet Scans, MRI and Nuclear Medicine Outpatient Therapeutic Treatments No Copayment 40 % of Eligible Expenses 12. Physician's Office Services $15 per visit except that the Copayment for a Specialist 40% of Eligible Expenses. No Benefits for preventive Covered Health Services for preventive medical Physician office visit is $25. No Copayment applies care, except for Child Health Supervision Services. when a Physician charge is not assessed care. 40% of Eligible Expenses Covered Health Services for the diagnosis and $15 per visit except that the Copayment for a Specialist treatment of a Sickness or Injury received in a Physician office visit is $25. No Copayment applies when a Physician charge is not assessed. Physician's office. 13. Professional Fees for Surgical and Medical No Copayment 40% of Eligible Expenses Services YOUR BENEFITS Types of Coverage Network Benefits / Copayment Amounts Non - Network Benefits / Copayment Amounts 14. Prosthetic Devices No Copayment 40% of Eligible Expenses Network and Non - Network Benefits for prosthetic devices are limited to $2,500 per calendar year. - - wnstrucuve rroceaures Same as 8, 11, 12, 13 and 14 *Same as 8, 11, 12,13 and 14 16. Rehabilitation Services - Outpatient Therapy $15 per visit 40% of Eligible Expenses Network and Non - Network Benefits are limited as follows: 20 visits of physical therapy; 20 visits of occupational therapy; 20 visits of speech therapy; 20 visits of pulmonary rehabilitation; and 36 visits of cardiac rehabilitation per calendar year. .11. sKmea tvursmg r acuity/inpatient Rehabilitation No Copayment *40% of Eligible Expenses Facility Services Network and Non - Network Benefits are limited to 60 days per calendar year. 18. Transplantation Services *Same as 8 and 13 No Benefits iy. urgent tare center services $50 per visit 40% of Eligible Expenses Additional Benefits Bones or Joints of the Jaw and Facial Region Same as 8, 11, 12 and 13 *Same as 8, Ii, 12 and 13 Child Health Supervision Services Same as 11, 12 and 13 Same as 11, 12 and 13 Cleft Lip /Cleft Palate Treatment Same as 8, 11, 12, 13, and 16 *Same as 8, 11, 12, 13 and 16 Dental Procedures - Anesthesia and Hospitalization Same as 8, 11, and 13 *Same as 8, 11, and 13 Diabetes Treatment Same as 3, 11, 12 and 13 Same as 3, 11, 12 and 13 Mammography No Copayment Same as Network Benefit Mastectomy Same as 8, 11, 12 and 13 *Same as 8, 11, 12 and 13 Mental Health and Substance Abuse Services - $15 per individual visit; $10 per group visit 40% of Eligible Expenses Outpatient Must receive prior authorization through the Mental Health/Substance Abuse Designee. Network and Non - Network Benefits are limited to 30 visits per calendar year. Mental Health and Substance Abuse Services - $500 per Inpatient Stay 40% of Eligible Expenses Inpatient and Intermediate Must receive prior authorization through the Mental Health/Substance Abuse Designee. Network and Non - Network Benefits are limited to 30 days per calendar year. Osteoporosis Treatment Same as 111 12 and 13 Same as 11, 12 and 13 Prescription and Non - Prescription Enteral Formulas No Copayment 40% of Eligible Expenses Benefits for low protein food products for Covered Persons through age 24 are limited to $2,500 per calendar year. Spinal Treatment $15 per visit 40% of Eligible Expenses Benefits include diagnosis and related services and are limited to one visit and treatment per day. Network and Non - Network Benefits are limited to 24 visits per _ calendar year. Exclusions Except as maybe specifically provided in Section 1 of the Certificate of Coverage (COC) or through a Rider to the Policy, the following are not covered: A. Alternative Treatments Acupressure; hypnotism; rolling; massage therapy; aromatherapy; acupuncture; and other forms of alternative treatmeht B. Comfort or Convenience Personal comfort or convenience items or services such as television; telephone; barber or beauty service; guest service; supplies, equipment and similar incidental services and supplies for personal comfort including air conditioners, air purifiers and filters, batteries and battery chargers, dehumidifiers and humidifiers; devices or computers to assist in communication and speech. C. Dental Except as specifically described as covered in Section i of the COC under the headings Dental Services - Accident only and Cleft Lip /Cleft Palate Treatment, dental services are excluded. There is no coverage for services provided for the prevention, diagnosis, and treatment of the teeth or gums (including extraction, restoration, and replacement of teeth and services to improve dental clinical outcomes). Dental implants and dental braces are excluded. Dental x -rays, supplies and appliances and all associated expenses arising out of such dental services (including hospitalizations and anesthesia) are excluded, except as might otherwise be required for transplant preparation, initiation of immunosuppressives, the direct treatment of acute traumatic Injury, cancer, or cleft palate, or as described in Section 1 of the COC under the heading of Dental Procedures - Anesthesia and Hospitalization. Treatment for congenitally missing, malpositioned, or super numerary teeth is excluded, even if part of a Congenital Anomaly except in connection with cleft lip or cleft palate. D. Drugs Prescription drug products for outpatient use that are filled by a prescription order or refill. Self. injectable medications except as described in Section 1 of the COC under the heading cf Diabetes Treatment. Non - injectable medications given in a Physician's office except as required in an Emergency. Over - the - counter drugs and treatments. E. Experimental, Investigational or Unproven Services Experimental, Investigational or Unproven Services are excluded, except (a) bone marrow transplants and (b) medically appropriate medications prescribed for the treatment of cancer, for a particular indication, if that drug is recognized for the treatment of that indication in a standard reference compendium or recommended in medical literature. The fact that an Experimental, Investigational or Unproven Service, treatmenk device or pharmacological regimen is the only available treatment for a particular condition will not result in Benefits if the procedure is considered to be Experimental, Investigational or Unproven in the treatment of that particular condition F. Foot Care Routine foot care (including the cutting or removal of corns and calluses); nail trimming, cutting, or debriding; hygienic and preventive maintenance foot care; treatment of flat feet or subluxation of the foot; shoe orthotics. C. Medical Supplies and Appliances Devices used specifically as safety items or to affect performance primarily in sports-related activities. Prescribed or non - prescribed medical supplies and disposable supplies including but not limited to elastic stockings, ace bandages, ostomy supplies, gauze and dressings. Orthotic appliances that straighten or re -shape a body part (including cranial banding and some types of braces). Tubings and masks are not covered except when used with Durable Medical Equipment as described in Section l of the COC. H. Mental Health /Substance Abuse Services performed in connection with conditions not classified in the current edition of the Diagnostic and Statistical Manual of the American Psychiatric Association. Services that extend beyond the period necessary for short-tern evaluation, diagnosis, treatment, or crisis intervention. Mental Health treatment of insomnia and other sleep disorders, neurological' disorders, and other disorders with a known physical basis. Treatment of conduct and impulse control disorders, personality disorders, paraphilias and other Mental Illnesses that will not substantially improve beyond the current level of functioning, or that are not subject to favorable modification or management according to prevailing national standards of clinical practice, as reasonably determined by the Mental Health/Substance Abuse Designee. Services utilizing methadone treatment as maintenance, L.A.A.M. (1- Alpha - Acetyl - Methadol), Cyclazocine, or their equivalents. Treatment provided in connection with or to comply with involuntary commitments, police detentions and other similar arrangements, unless authorized by the Mental Health/Substance Abuse Designee. Residential treatment services. Services or supplies that in the reasonable judgment of the Mental Health/Substance Abuse Designee are not, for example, consistent with certain national standards or professional research fitrtlter described in Section 2 of the COC. I. Nutrition Megavitamin and nutrition based therapy; nutritional counseling for either individuals or groups. Enteral feedings and other nutritional and electrolyte supplements, including infant formula and donor breast milk, except as described in Section 1 of the COC under the heading Prescription and Non- prescription Enteral Formulas. United HealthCare Insurance Company J. Physical Appearance Cosmetic Procedures including, but not limited to, pharmacological regimens; nutritional procedures or treatments; salabrasion, chemosurgery and other such skin abrasion procedures associated with the removal of scars, tattoos, and/or which are perforated as a treatment for acne. Replacement of an existing breast implant is excluded if the earlier breast implant was a Cosmetic Procedure. (Replacement of an existing breast implant is considered reconstructive if the initial breast implant followed mastectomy.) Physical conditioning programs such as athletic training, bodybuilding, exercise, fitness, flexibility, and diversion or general motivation. Weight loss programs for medical and non - medical reasons. Wigs, regardless of the reason for the hair loss. K. Providers Services . performed by a provider with your same legal residence or who is a family member by birth or marriage, including spouse, brother, sister, parent or child. This includes any service the provider may perform on himself or herself. Services provided at a free - standing or Hospital -based diagnostic facility without an order written by a Physician or other provider as further described in Section 2 of the COC (this exclusion does not apply to mammography testing). L. Reproduction Health services and associated expenses for infertility treatments. Surrogate parenting. The reversal of voluntary sterilization. M. Services Provided under Another Plan Health services forwhich other coverage is paid under arrangements required by federal, state or local law. This includes, but is not limited.to, coverage paid by workers' compensation, no -fault automobile insurance, or similar legislation. Health services for treatment of military service - related disabilities, when you are legally entitled to other coverage and facilities are reasonably available to you. Health services while on active military duty. N. Transplants Health services for organ or tissue transplants are excluded, except those specified as covered in Section I of the COC. Any solid organ transplant that is performed as a treatment for cancer. Health services connected with the removal of an organ or tissue from you for purposes of a transplant to another person. Health services for transplants involving mechanical or animal organs. Any multiple organ transplant not listed as a Covered Health Service in Section I of the COC. O. Travel Health services provided in a foreign country, unless required as Emergency Health Services. Travel or transportation expenses, even though prescribed by a Physician. Some travel expenses related to covered transplantation services may be reimbursed at our discretion. P. Vision and Hearing Purchase cost of eye glasses, contact lenses, or hearing aids. Fitting charge for hearing aids, eye glasses or contact lenses. Eye exercise therapy. Surgery that is intended to allow you to see better without glasses or other vision correction including radial keratotomy, laser, and other refractive eye surgery. Q. Other Exclusions Health services and supplies that do not meet the definition of a Covered Health Service - see definition in Section 10 of the COC. Physical, psychiatric or psychological examinations, testing, vaccinations, immunizations or treatments otherwise covered under the Policy, when such services are: (1) required solely for purposes of eareer education, sports or camp, travel, employment, insurance, marriage or adoption; (2) relating to judicial or administrative proceedings or orders; (3) conducted for purposes of medical research; or (4) to obtain or maintain a license of any type. Health services received as a result of war or any act of war, whether declared or undeclared or caused during service in the armed forces of any country. Health services received after the date your coverage under the Policy ends, including health services for medical conditions arising prior to the date your coverage under the Policy ends. Health services for which you have no legal responsibility to pay, or for which a charge would not ordinarily be made in the absence of coverage under the Policy. In the event that a Non - Network provider waives Copayments and/or the Annual Deductible for a particular health service, no Benefits are provided for the health service for which Copayments and/or the Annual Deductible are waived. Charges in excess of Eligible Expenses or in excess of any specified limitation. Services for the evaluation and treatment of temporomandibular joint syndrome (TMJ), whether the services are considered to he medical or dental in nature, except as described in Section I of the COC under the heading Bones or Joints of the Jaw and Facial Region. Surgical treatment and non - surgical treatment of obesity (including morbid obesity). Surgical treatment and non - surgical treatment" of obesity (including morbid obesity). - Growth hormone therapy; sex transformation operations; treatment of benign gynecomastia (abnormal breast enlargement in males); medical and surgical treatment of excessive sweating (hyperhidrosis); medical and surgical treatment for snoring, except when provided as part of treatment for documented obstructive sleep apnea. Oral appliances for snoring. Custodial care; domiciliary care; private duty nursing; respite care; rest cures. Psychosurgery. Speech therapy except as required for treatment of a speech impediment or speech dysfunction that results from Injury, stroke, cleft lip /cleft palate or Congenital Anomaly. This summary of Benefits is intended only to highlight your Benefits and should not be relied upon to fully determine coverage. This plan may not cover all your health care expenses. Please refer to the Certificate of Coverage for a complete listing of services, limitations, exclusions and a description of all the terms and conditions of coverage. If this description conflicts in any way with the Certificate of Coverage, the Certificate of Coverage prevails. Terms that are capitalized in the Benefit Summary are defined in the Certificate of Coverage. 02I BS ChcPls FLLGMS5902 OBE 213- 1151_0604_Rev01 YOUR BENEFITS UnitedHealthcare Pharmacy Management Program Plan 023 UnitedHealthcare's pharmacy management program provides clinical pharmacy services that promote choice, accessibility and value. The program offers a broad network of pharmacies (more than 5600 nationwide) to provide convenient access to medications. While most pharmacies participate in our network, you should check first. Call your pharmacist or visit our online pharmacy service at www.myuhc.com. The online service offers you home delivery of prescriptions, ability to view personal benefit coverage, access health and well being information, and even location of network retail neighborhood pharmacies by zip code. Copayment per Prescription Order or Refill Your Copayment is determined by the tier to which the Prescription Drug List Management Committee has assigned the Prescription Drug Product. All Prescription Drug Products on the Prescription Drug List are assigned to Tier 1, Tier 2 or Tier 3. Please access www.myuhc.com through the Internet, or call the Customer Service number on your ID card to determine tier status. For a single Copayment, you may receive a Prescription Drug Product up to the stated supply limit. Some products are subject to additional supply limits. You are responsible for paying the lower of the applicable Copayment or the retail Network Pharmacy's Usual and Customary Charge, or the lower of the applicable Copayment or the Home Delivery Pharmacy's Prescription Drug Cost. Also note that some Prescription Drug Products require that you notify us in advance to determine whether the Prescription Drug Product meets the definition of a Covered Health Service and is not Experimental, Investigational or Unproven. Retail Network Home Delivery Network Pharmacy Pharmacy For up to a 31 day supply For up to a 90 day supply Tier 1 $10 $25 Tier 2 $30 $75 Tier 3 $50 $125 FLNPP02304 r^ Other Important Cost Sharing Information Annual Drug No Annual Drug Deductible Deductible Out -of- Pocket Drug No Out -of- Pocket Drug Maximum Maximum Exclusions Exclusions from coverage listed in the Certificate apply also to this Rider. In addition, the following exclusions apply: Outpatient Prescription Drug Products obtained from a non - Network Pharmacy. Coverage for Prescription Drug Products for the amount dispensed (days supply or quantity limit) which exceeds the supply limit. Prescription Drug Products dispensed outside the United States, except as required for Emergency treatment. Drugs which are prescribed, dispensed or intended for use while you are an inpatient in a Hospital, Skilled Nursing Facility, or Alternate Facility. Experimental, Investigational or Unproven Services and medications; medications used for experimental indications and/or dosage regimens determined by us to be experimental, investigational or unproven. Prescription Drug Products furnished by the local, state or federal government. Any Prescription Drug Product to the extent payment or benefits are provided or available from the local, state or federal government (for example, Medicare) whether or not payment or benefits are received, except as otherwise provided by law. Prescription Drug Products for any condition, Injury, Sickness or mental illness arising out of, or in the course of, employment for which benefits are available under any workers' compensation law or other similar laws, whether or not a claim for such benefits is made or payment or benefits are received. Any product dispensed for the purpose of appetite suppression and other weight loss products. A specialty ' medication Prescription Drug Product (such as immunizations and allergy serum) which, due to its characteristics as determined by us, must typically be administered or supervised by a qualified provider or licensed/certified health professional in an outpatient setting. This exclusion does not apply to Depo Provera and other injectable drugs used for contraception. United HealthCare Insurance Company Durable Medical Equipment. Prescribed and non - prescribed outpatient supplies, other than the diabetic supplies and inhaler spacers specifically stated as covered. General vitamins, except the following which require a Prescription Order or Refill: prenatal vitamins, vitamins with fluoride, and single entity vitamins. Unit dose packaging of Prescription Drug Products. Medications used for cosmetic purposes. Prescription Drug Products, including New Prescription Drug Products or new dosage forms, that are determined to not be a Covered Health Service. Prescription Drug Products as a replacement for a previously dispensed Prescription Drug Product that was lost, stolen, broken or destroyed. Prescription Drug Products when prescribed to treat infertility. Drugs available over - the - counter that do not require a Prescription Order or Refill by federal or state law before being dispensed. Any Prescription Drug Product that is therapeutically equivalent to an over -the- counter drug. Prescription Drug Products that are comprised of components that are available in over - the - counter form or equivalent. Prescription Drug Products for smoking cessation. Compounded drugs that do not contain at least one ingredient that requires a Prescription Order or Refill. Compounded drugs that contain at least one ingredient that requires a Prescription Order or Refill are assigned to Tier 3. New Prescription Drug Products and/or new dosage forms until the date they are reviewed by our Prescription Drug List Management Committee. Growth hormone therapy for children with familial short stature (short stature based upon heredity and not caused by a diagnosed medical condition). this summary of Benefits is intended only to highlight your Benefits for outpatient Prescription Drug Products and should not be relied upon to determine coverage. Your plan may not cover all your terms and prescription drug of expenses. Please refer to your Outpatient Prescription Drug Rider and the Certificate of Coverage for a complete listing of services, limitations, exclusions and a description of all the terms and conditions of coverage. If this description conflicts in any way with the outpatient Prescription Drug Rider or the Certificate of Coverage, the Outpatient Prescription Drug Rider and Certificate of Coverage prevail. Capitalized terms in the Benefit Summary are defined in the Outpatient Prescription FLNPP02304 der and/or Certificate of Coverage. 213- 1377_0804 04I_BS_RX_NET . L:. kAetn- Health Maintenance Organization Program Final Proposal for CITY OF SOUTH MIAMI Effective Date: 10/1/05 Referred Care Primary Office Visit Copay: $10 Specialist Copay: $10 Outpatient (SPU) Surgery Copay: $0 Hospitalization Copay /A: $0 Bariatric Surgery- Not Covered Emergency Room Copay: $75 Urgent Care Copay: $35 MH O/P Copay: $25 20v /cal Routine Eye Exam Copay: $10 Routine GYN Exam Copay: $10, Iv/cal Rehab I/P Copay/D: ($0) 30d/cal Rehab O/P Copay: $10 30v /cal Prescription Copay: $10/$20/$35, 30 Day Oral Contraceptives: $10/$20/$35, 30 Day 31 -90 Day Supply: 2 Copays (Retail and MOD) Chiropractic Copay: $10 20v /cal DME Item Copay: $0 Out of Pocket Limit: $1500/$3000 In Net Lifetime Maximum Benefit: Unlimited The foregoing rates apply in the Service Area specified above. Rates will vary for other service areas. Service Area is determined by location of the subscriber's primary care doctor. Quote Conditions Lssmned Dependent FAgibility Dependent children to the end of the billable year in which he/she turns 25 r full-time students to the end of the billable year in which he/she turns 25. Coverage will continue for dependents ,ho become mentally /physically handicapped prior to the end of the billable year they reach age 25. Rates are pending approval by state regulators and are subject to adjustment based on regulatory determinations. These monthly quoted rates are valid as of the Effective Date and apply only to the benefit level and conditions stated above and are subject to the terms and conditions as are set forth in the HMO's Group Master Contract and/or the Corporate Health Insurance Policy. Any changes in benefit level or conditions stated above may require a change in rates. This proposal is subject to change at any time prior to the acceptance by AETNA of employer's offer. Final Rates Please see Rating Conditions, Assumptions and Information Requests document for quote details. FL Single ,$351.68 Parent/Child(ren) $654.12 Couple $735.01 Family $1,040.97 Referred Care Primary Office Visit Copay: $10 Specialist Copay: $10 Outpatient (SPU) Surgery Copay: $0 Hospitalization Copay /A: $0 Bariatric Surgery- Not Covered Emergency Room Copay: $75 Urgent Care Copay: $35 MH O/P Copay: $25 20v /cal Routine Eye Exam Copay: $10 Routine GYN Exam Copay: $10, Iv/cal Rehab I/P Copay/D: ($0) 30d/cal Rehab O/P Copay: $10 30v /cal Prescription Copay: $10/$20/$35, 30 Day Oral Contraceptives: $10/$20/$35, 30 Day 31 -90 Day Supply: 2 Copays (Retail and MOD) Chiropractic Copay: $10 20v /cal DME Item Copay: $0 Out of Pocket Limit: $1500/$3000 In Net Lifetime Maximum Benefit: Unlimited The foregoing rates apply in the Service Area specified above. Rates will vary for other service areas. Service Area is determined by location of the subscriber's primary care doctor. Quote Conditions Lssmned Dependent FAgibility Dependent children to the end of the billable year in which he/she turns 25 r full-time students to the end of the billable year in which he/she turns 25. Coverage will continue for dependents ,ho become mentally /physically handicapped prior to the end of the billable year they reach age 25. Rates are pending approval by state regulators and are subject to adjustment based on regulatory determinations. These monthly quoted rates are valid as of the Effective Date and apply only to the benefit level and conditions stated above and are subject to the terms and conditions as are set forth in the HMO's Group Master Contract and/or the Corporate Health Insurance Policy. Any changes in benefit level or conditions stated above may require a change in rates. This proposal is subject to change at any time prior to the acceptance by AETNA of employer's offer. Final Rates Please see Rating Conditions, Assumptions and Information Requests document for quote details. AVNEU PRIMARY CARE Services at participating doctors' offices include, but are not pHySIcIM limited to: ■ ROUTINE OFFICE VISITS / ANNUAL GYN VISIT WHEN PERFORMED BY PRIMARY CARE PHYSICIAN ■ MATERNITY- OUTPATIENT VISITS $10 PER VISIT ■ PEDIATRIC CARE & WELL -BABY CARE ■ PERIODIC HEALTH EVALUATION & IMMUNIZATIONS ■ DIAGNOSTIC IMAGING, LABORATORY OR OTHER DIAGNOSTIC SERVICES ■ MINOR SURGICAL PROCEDURES ■ VISION & HEARING EXAMINATIONS FOR CHILDREN UNDER 18 ■ OFFICE VISITS $10 PER VISIT AI9LIE® SPECIALIST'S SERVICES ■ ANNUAL GYN EXAMINATION WHEN PERFORMED BY PARTICIPATING SPECIALIST Inpatient care at participating hospitals includes: NO CHARGE HOSPITAL ■ ROOM & BOARD - UNLIMITED DAYS (SEMI - PRIVATE) ■ PHYSICIANS, SPECIALIST'S & SURGEON'S SERVICES ■ ANESTHESIA, USE OF OPERATING & RECOVERY ROOMS, OXYGEN, DRUGS & MEDICATION ■ INTENSIVE CARE UNIT & OTHER SPECIAL UNITS, GENERAL & SPECIAL DUTY NURSING ■ LABORATORY & DIAGNOSTIC IMAGING ■ REQUIRED SPECIAL DIETS ■ RADIATION & INHALATION THERAPIES ■ OUTPATIENT SURGERIES, INCLUDING CARDIAC NO CHARGE OUTPATIENT SURGERY CATHETERIZATIONS AND ANGIOPLASTY ■ CAT Scan, PET Scan, MRI IMAGING TESTS $25 PER TEST $10 PER TEST OUTPATIENT DIAGNOSTIC TESTS M OTHER DIAGNOSTIC An emergency is the sudden & unexpected onset of a condition requiring immediate medical or surgical care. ■ EMERGENCY ROOM AT PARTICIPATING $75 COPAYMENT HOSPITALS ■ EMERGENCY SERVICES -NON- PARTICIPATING $100 COPAYMENT HOSPITALS, FACILITIES, & /OR PHYSICIANS PLAN MUST BE NOTIFIED WITHIN 24 HOURS OF INPATIENT ADMISSION FOLLOWING EMERGENCY SERVICES OR AS SOON AS REASONABLY POSSIBLE. URCENTBONNE®IATE CAPE ■ MEDICAL SERVICES AT A PARTICIPATING $40 COPAYMENT URGENT/IMMEDIATE CARE FACILITY OR SERVICES RENDERED AFTER HOURS IN YOUR PRIMARY CARE PHYSICIAN'S OFFICE ■ MEDICAL SERVICES AT A NON - PARTICIPATING $60 COPAYMENT URGENT/IMMEDIATE CARE FACILITY -AvMED Beni Summary HEALTH PLANS fit STANDARD OPTION SCHEDULE OF COMMENTS COST TO MEMBER - O -ADMIT OUT-OF-POCKET MAXIMUM $1,500 INDIVIDUAL $3,000 FAMILY AVINED PRIMARY CARE Services at participating doctors' offices include, but are not PHYSICIM limited to: CATHETERIZATIONS AND ANGIOPLASTY • ROUTINE OFFICE VISITS / ANNUAL GYN VISIT OUTPATIENT DIAGNOSTIC WHEN PERFORMED BY PRIMARY CARE $25 PER TEST PHYSICIAN 0 OTHER DIAGNOSTIC IMAGING TESTS • MATERNITY - OUTPATIENT VISITS $10 PER VISIT EMERGENCY SERVICES • PEDIATRIC CARE & WELL -BABY CARE • PERIODIC HEALTH EVALUATION & requiring immediate medical or surgical care. IMMUNIZATIONS • DIAGNOSTIC IMAGING, LABORATORY OR OTHER $75 COPAYMENT DIAGNOSTIC SERVICES HOSPITALS ■ MINOR SURGICAL PROCEDURES ■ VISION & HEARING EXAMINATIONS FOR $100 COPAYMENT CHILDREN UNDER 18 AVMED SPECIALIST'S ■ OFFICE VISITS $10 PER VISIT SERVICES ■ ANNUAL GYN EXAMINATION WHEN PERFORMED BY PARTICIPATING SPECIALIST HOSPITAL Inpatient care at participating hospitals includes: NO CHARGE • ROOM & BOARD - UNLIMITED DAYS (SEMI - PRIVATE) • PHYSICIANS, SPECIALIST'S & SURGEON'S SERVICES • ANESTHESIA, USE OF OPERATING & RECOVERY ROOMS, OXYGEN, DRUGS & MEDICATION • INTENSIVE CARE UNIT & OTHER SPECIAL UNITS, GENERAL & SPECIAL DUTY NURSING ■ LABORATORY & DIAGNOSTIC IMAGING ■ REQUIRED SPECIAL DIETS ■ RADIATION & INHALATION THERAPIES OUTPATIENT SURGERY 0 OUTPATIENT SURGERIES, INCLUDING CARDIAC NO CHARGE CATHETERIZATIONS AND ANGIOPLASTY OUTPATIENT DIAGNOSTIC ■ CAT Scan, PET Scan, MRI $25 PER TEST TESTS 0 OTHER DIAGNOSTIC IMAGING TESTS $10 PER TEST EMERGENCY SERVICES An emergency is the sudden & unexpected onset of a condition requiring immediate medical or surgical care. • EMERGENCY ROOM AT PARTICIPATING $75 COPAYMENT HOSPITALS • EMERGENCY SERVICES - NON - PARTICIPATING $100 COPAYMENT HOSPITALS, FACILITIES, &/OR PHYSICIANS PLAN 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 $40 COPAYMENT URGENTMI WEDIATE CARE FACILITY OR SERVICES RENDERED AFTER HOURS IN YOUR PRIMARY CARE PHYSICIAN'S OFFICE ■ MEDICAL SERVICES AT A NON - PARTICIPATING $60 COPAYMENT URGENTAMMEDIATE CARE FACILITY AvMED I[ A L T H P L A n' S Benefit Summa P PURBIT- OF- SERVICE RIDER SCHEDULE FOUR COST BENEFITS OUT- OF- MEMORK BENEFITS CASH DEDUCTIBLE INDIVIDUAL/FAMILY $500 1$1,500 ANNUALLY COINSURANCE OUT-OF. INDIVIDUAL/FAMILY $3,000/6,000 ANNUALLY POCKET MAXIMUM LIFETIME MA11U 6UFA $2,000,000 PER MEMBER PRIOR AUTHORIZATION REQUIRED FOR SPECIFIC COVERED SERVICES. THE ELIGIBLE EXPENSE, SUBJECT TO THE CASH DEDUCTIBLE AND 30% COINSURANCE PENALTY FOR NOT OBTAINING PRIOR AUTHORIZATION IS ELIGIBLE EXPENSE, A 20% REDUCTION IN BENEFITS. SUBJECT TO THE CASH PHYSICIAM Services at doctors' offices include, but are not limited to: ELIGIBLE EXPENSE, • ROUTINE OFFICE VISITS /ANNUAL GYN VISIT SUBJECT TO THE CASH • MATERNITY- OUTPATIENT VISITS DEDUCTIBLE AND 30% • PEDIATRIC CARE & WELL -CHILD CARE COINSURANCE • DIAGNOSTIC IMAGING, LABORATORY OR OTHER DIAGNOSTIC SERVICES • MINOR SURGICAL PROCEDURES • VISION & HEARING EXAMINATIONS FOR CHILDREN UNDER 18 SPECIALIST'S SERVICES ■ OFFICE VISITS ELIGIBLE EXPENSE, SUBJECT TO THE CASH DEDUCTIBLE AND 30% COINSURANCE HOSPITAL Inpatient care at hospitals includes: ELIGIBLE EXPENSE, ■ ROOM & BOARD — UNLIMITED DAYS (SEMI - PRIVATE) SUBJECT TO THE CASH ■ PHYSICIAN'S, SPECIALIST'S & SURGEON'S SERVICES DEDUCTIBLE AND 30% ■ ANESTHESIA, USE OF OPERATING & RECOVERY ROOMS, COINSURANCE OXYGEN, DRUGS & MEDICATION ■ INTENSIVE CARE UNIT & OTHER SPECIAL UNITS, GENERAL & SPECIAL DUTY NURSING ■ LABORATORY & DIAGNOSTIC IMAGING ■ REQUIRED SPECIAL DIETS ■ RADIATION & INHALATION THERAPIES OUTPATIENT SURGERY ■ OUTPATIENT SURGERIES, INCLUDING CARDIAC EL1U1JiL1 hXYrdV fir, CATHETERIZATIONS AND ANGIOPLASTY SUBJECT TO THE CASH DEDUCTIBLE AND 30% COINSURANCE OUTPATIENT +DBAGNOSTIC ■ CAT SCAN, PET SCAN, MRI ELIGIBLE EXPENSE, TESTS • OTHER DIAGNOSTIC IMAGING TESTS SUBJECT TO THE CASH DEDUCTIBLE AND 30% COINSURANCE MENTAL HEALTH . 20 OUTPATIENT VISITS ELIGIBLE EXPENSE, SUBJECT TO THE CASH (20 VISITS IS THE TOTAL NUMBER OF COVERED VISITS DEDUCTIBLE AND 30% FOR BOTH IN AND OUT OF NETWORK, COMBINED) COINSURANCE IF MENTAL HEALTH/SUBSTANCE ABUSE BENEFIT RIDER IS ELECTED, BENEFITS ARE SUBJECT TO POS RIDER DEDUCTIBLE AND COINSURANCE ARRANGEMENTS WHEN USING NON - PARTICIPATING PROVIDERS. SPECIFIED SERVICE LIMITS ARE THE TOTAL NUMBER OF COVERED VISITS FOR BOTH IN AND OUT OF NETWORK, COMBINED. ALLERGY TREATMENTS benefit Summary, continued • INJECTIONS • SKIN TESTING PHYSICAL, SPEECH, & ■ SHORT -TERM PHYSICAL, SPEECH OR OCCUPATIONAL OCCUPATIONAL TIaEP,APIES THERAPY FOR ACUTE CONDITIONS COVERAGE IS LIMITED TO 24 VISITS PER CALENDAR YEAR FOR ALL SERVICES COMBINED. SKILLED NURSING FACILITIES ■ UP TO 20 DAYS PER C ELIGIBLE EXPENSE, SUBJECT TO THE CASH DEDUCTIBLE AND 30% COINSURANCE ELIGIBLE EXPENSE, SUBJECT TO THE CASH DEDUCTIBLE AND 30% COINSURANCE REHABILITATION CENTERS ONTRACT YEAR POST - HOSPITALIZATION CARE WHEN PRESCRIBED BY ELIGIBLE EXPENSE, PHYSICIAN & AUTHORIZED BY AVMED SUBJECT TO THE CASH DEDUCTIBLE AND 30% COINSURANCE CARDIAC REHABILITATION Cardiac Rehabilitation is covered for the following conditions: $20 PER VISIT • ACUTE MYOCARDIAL INFARCTION • PERCUTANEOUS TRANSLUMINAL CORONARY BENEFITS LIMITED TO ANGIOPLASTY (PTCA) $1,500 PER CONTRACT • REPAIR OR REPLACEMENT OF HEART VALVE(S) YEAR. • CORONARY ARTERY BYPASS GRAFT (CABG), or • HEART TRANSPLANT COVERAGE IS LIMITED TO 18 VISITS PER YEAR. HOME HEALTH CARE ■ PER OCCURRENCE ELIGIBLE EXPENSE, SUBJECT TO THE CASH DEDUCTIBLE AND 30% COINSURANCE DUP�ABLE MEDICAL Equipment includes: EQUIPMENT & ■ HOSPITAL BEDS $50 PER EPISODE OF ORTHOTIC APPLIANCES • WALKERS ILLNESS. BENEFITS ■ CRUTCHES LIMITED TO $500 PER ■ WHEELCHAIRS CONTRACT YEAR. Orthotic appliances are limited to: ■ LEG, ARM, BACK, AND NECK CUSTOM -MADE BRACES PROSTHETIC DEVICES Prosthetic devices are limited to: ELIGIBLE EXPENSE, • ARTIFICIAL LIMBS SUBJECT TO THE CASH • ARTIFICIAL JOINTS DEDUCTIBLE AND 30% • OCULAR PROSTHESES COINSURANCE THIS SCHEDULE IS NOT A CONTRACT. FOR SPECIFIC INFORMATION ON BENEFITS, EXCLUSIONS AND LIMITATIONS PLEASE CONSULT YOUR AVMED HMO MEDICAL AND HOSPITAL SERVICE CONTRACT AND POINT -OF- SERVICE RIDER. V -POS- 500 -30- 3000 -03 4P- 3440 (9/03) KAetna, i Health Maintenance Organization Program Final Proposal for CITY OF SOUTH MIAMI Effective Date: 10/1/05 FL Single t$351.68 Parent/Child(ren) $654.12 Couple $735.01 Family $1,040.97 Referred Care Primary Office Visit Copay: $10 Specialist Copay: $10 Outpatient (SPU) Surgery Copay: $0 Hospitalization Copay/A- $0 Bariatric Surgery: Not Covered Emergency Room Copay: $75 Urgent Care Copay: $35 MH O/P Copay: $25 20v /cal Routine Eye Exam Copay: $10 Routine GYN Exam Copay: $10, Iv/cal Rehab I/P Copay/D: ($0) 30d/cal Rehab O/P Copay: $10 30v /cal Prescription Copay: $10/$20/$35, 30 Day Oral Contraceptives: $10/$201$35, 30 Day 31 -90 Day Supply: 2 Copays (Retail and MOD) Chiropractic Copay: $10 20v /cal DME Item Copay: $0 Out of Pocket Limit: $1500/$3000 In-Net Lifetime Maximum Benefit: Unlimited The foregoing rates apply in the Service Area specified above. Rates will vary for other service areas. Service Area is determined by location of the subscriber's primary care doctor. Quote Conditions Assumed Dependent Eligibility Dependent children to the end of the billable year in which he /she tums 25 or full-time students to the end of the billable year in which he/she turns 25. Coverage will continue for dependents who become mentally /physically handicapped prior to the end of the billable year they reach age 25. Rates are pending approval by `state regulators and are subject to adjustment based on regulatory determinations. These monthly quoted rates are valid as of the Effective Date and apply only to the benefit level and conditions stated above and are subject to the terms and conditions as are set forth m the HMO's Group Master Contract and/or the Corporate Health Insurance Policy. Any changes in benefit level or conditions stated above may require a change in rates. This proposal is subject to change at any time prior to the acceptance by AETNA of employer's offer. Final Rates Please see Rating Conditions, Assumptions and Information Requests document for quote details. o, I, 1 9 Z 7 0 RA City of South Miami Human Resources Department Health Insurance Selection July 12, 2005 Please select one vendor: AvMed Blue Cross / Blue Shield Cigna Health Care Humana Neighborhood Health Partnership United Health Care Vista * e�rn Qk COY-0 I !,")Vnljm Employee Name - 43lease Print Of V1 /14 1 0 Declined to quote Declined to quote /VO Declined to quote -Vic ff) V/, Declined to quote E ployee Sign - 4 Date # South Miami A&AmeftCfIY 201 City of Miami 6130 Sunset Drive, South Miami, Florida 33143 -T ATET Ex J.Z1 City of South Miami Human Resources Department Health Insurance Selection July 12, 2005 Please select one vendor: AvMed Blue Cross / Blue Shield Cigna Health Care Humana Neighborhood Health Partnership United Health Care Vista f\ t in Employee Name - Please Print Declined to quote Declined to quote —Ala Declined to quote A-d . uote , ature - D South Miami kyftld AMlme mCAY `'i1► 2001 City of South Miami 6130 Sunset Drive, South Miami, Florida 33143 r eo & 1 D2 0 RIV City of South Miami Human Resources Department Health Insurance Selection July 12., 2005 Please select one vendor: AvMed Blue Cross / Blue Shield Cigna Health Care Humana Neighborhood Health Partnership United Health Care Vista OEW P loyvle.e Name - Please A/G Declined to quote Declined to quote A) 0— Declined to quote B�e-Nined to Signature '- Date South Miami as am 1111 jr 2001 City of Miami 6130 Sunset Drive, South Miami, Florida 33143 City of South Miami Human Resources Department Health Insurance Selection July 12, 2005 Please select one vendor: AvMed Blue Cross / Blue Shield Cigna Health Care Humana Neighborhood Health Partnership United Health Care Vista k1#1v,1O / C-2�,e4 Employee Name - Please Print Declined to quote Declined to quote Declined to quote Declined to quote {-- mployee Sig tore - Date /L South Miami n�amafcaCib zoos City of South Miami 6130 Sunset Drive, South Miami, Florida 33143 4 o U. pA ffi R City of South Miami Human Resources Department Health Insurance Selection July I2, 2005 Please select one vendor: AvMed Blue Cross / Blue Shield Cigna Health Care Humana Neighborhood Health Partnership United Health Care Vista 6--jAme", (nt � c Employee Name - Please Print 1'1� Declined to quote Declined to quote Declined to quote Declined to quote mployee Signature - Date South Miami `111[f 2001 City of South Miami 6130 Sunset Drive, South Miami, Florida 33143 % rYb 1ti 7` City of South Miami Human Resources Department Health Insurance Selection July 12, 2005 Please select one vendor: AvMed Blue Cross / Blue Shield Cigna Health Care Humana Neighborhood Health Partnership United Health Care V*{ ista F Employee Name - Please Print Declined to quote Declined to quote Declined to quote r),�J, Declined to quote Employee Signature -Date south Miami kylftml an- am�ir�cdFr 2001 City of South Miami 6130 Sunset Drive, South Miami, Florida 33143 13c. C City of South Miami Human Resources Department Health Insurance Selection July 12, 2005 Please select one vendor: AvMed Blue Cross / Blue Shield Cigna Health Care Humana Neighborhood Health Partnership United Health Care Vista Employee Name - Please Print Declined to quote Declined to quote A/0 Declined to quote —-4/0 _ Declined to quote Employee Signature -Date South Miami A®- 6mMicaCRf 2001 City of South Miami 6130 Sunset Drive, South Miami, Florida 33143 City of South Miami Human Resources Department Health Insurance Selection July I2, 2005 Please select one vendor: AvMed Blue Cross / Blue Shield Cigna Health Care Humana Neighborhood Health Partnership United Health Care Vista Employee Name - Please Print Declined to quote Declined to quote ko Declined to quote tV Declined to quote /24�4 . 1I 1 Z1oE� Employee Signature -Date South Miami AgArnMIOCRY 1111 "f 2001 City of South Miami 6130 Sunset Drive, South Miami, Florida 33143 b C;c 71 R City of South Miami Human Resources Department Health Insurance Selection July 12., 2005 Please select one vendor: AvMed Blue Cross / Blue Shield Cigna Health Care Humana Neighborhood Health Partnership United Health Care Vista .6,eo E'Mployee'Name - Please Print Declined to quote Declined to quote JOG Declined to quote I ju 0 Declined to quote /A Employee Sign9ture -Date South Miami tom City of South Miami 6130 Sunset Drive, South Miami, Florida 33143 ti m AV- Gloo -2oo4 hg-3533 (10/04) AvMed Health plans Group Medical and Hospital Service Contract 8 I a TABLE OF CONTENTS SERVICEAREAS ....................................................... ............................... i I. GENERAL ...................................................................... .............................1. H. INTERPRETATION ..................................................... ............................... l III. DEFINITIONS ............................................................... ..............................2 IV. ELIGIBILITY ................................................................ ..............................9 V. ENROLLMENT ........................................................... .............................11 VI. EFFECTIVE DATE OF MEMBERSHIP ..................... .............................12 VII. MONTHLY PAYMENTS AND CO- PAYMENTS ..... .............................13 VIII. CONVERSION ............................................................. .............................14 IX. TERMINATION ........................................................... .............................16 X. SCHEDULE OF BASIC BENEFITS ........................... .............................24 XI. LMTATIONS OF BASIC BENEFITS ...................... .............................31 XH. EXCLUSIONS FROM BASIC BENEFITS ................. .............................33 X M- COORDINATION OF BENEFITS .............................. .............................37 XIV. REIMBURSEMENT .................................................... .............................40 XV. DISCLAIMER OF LIABILITY ................................... .............................40 XVI. GRIEVANCE PROCEDURE ....................................... .............................41 XVII. MISCELLANEOUS ............................ ............................... 48 i AV -GI00 -2004 MP -3533 (10104) AvMed CORPORATE OFFICE 9400 S. DADELAND BLVD. P.O. BOX 569004 MIAMI, FL 33156 -9004 SERVICE AREAS MIAMI GAINESVILLE 9400 South Dadeland Boulevard 4300 N.W. 89* Boulevard Post Office Box 569004 Post Office Box 749 Miami, Florida 33156 -9004 Gainesville, Florida 32606 -0749 (305) 671 -5437 (352) 372 -8400 (800) 432 -6676 (800) 346 -0231 FT. LAUDERDALE ORLANDO 13450 W. Sunrise Boulevard 541 South Orlando Avenue Suite 370 Suite 205 Sunrise, Florida 33323 -2947 Maitland, Florida 32751 (954) 462 -2520 (407) 539 -0007 (800) 368 -9189 (800) 227 -4848 JACKSONVILLE TAMPA BAY/ SOUTHWEST FLORIDA 1300 Riverplace Boulevard 1511 North Westshore Boulevard Suite 200 Suite 700 Jacksonville, Florida 32207 Tampa, Florida 33607 (904) 858 -1300 (813) 281 -5650 (800) 227 -4184 (800) 257 -2273 AV -0100 -2004 W-3533 (10/04) AVMED MEMBER SERVICES - ALL AREAS 1- 800 -88 AVMED (1 -800- 882 -8633) F, AvMed, INC. D/D /A AvMed HEALTH PLAN GROUP MEDICAL AND HOSPITAL SERVICE CONTRACT IN CONSIDERATION of the payment of monthly prepayment subscription charges as provided herein and of mutual promises and benefits hereinafter described, AvMed, Inc., a Florida corporation, d/b /a AvMed Health Plans, (hereinafter referred to as "Health Plan"), and (hereinafter referred to as "Subscribing Group ") agree as follows: I. GENERAL The Subscribing Group engages Health 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 the Health Plan (see Section 15.04). The Health Plan, in so arranging for the delivery of Medical Services or benefits, does not directly provide these Medical Services or benefits. Health Plan arranges for the provision of said services in accordance with the covenants and conditions contained in this Contract. Health Plan 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 which are not Medically Necessary for the diagnosis and treatment of the Member. The determination as to which services are Medically Necessary shall be made by Health Plan subject to the terms and conditions of this Contract. Health Plan reserves the right to make changes in coverage criteria for covered products and services. Coverage criteria are medical and pharmaceutical protocols used to determine payment of products and services and are based on independent clinical practice guidelines and standards of care established by government agencies and medical /pharmaceutical societies. The Medical and Hospital Services covered by this Contract shall be provided without regard to the race, 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 medical and Hospital facilities and of the Participating Providers, Health Plan operates on a direct service rather than indemnity basis. The interpretation of this Contract shall be guided by the direct service nature of the Health Plan's program and the definitions and other provisions contained herein. AV -GI00 -2004 III. DEFINITIONS As used in this Contract, each of the following terms shall have the meaning indicated: 3.01 "Adverse Benefit Determination" means a denial, reduction, or termination of, or a failure to provide or make payment, in whole or in part, for a benefit, including any such denial, reduction, termination, or failure to provide or make payment that is based on a determination of a Member's eligibility to participate in the Health Plan, a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) of, a benefit resulting from the application of any Utilization Management Program, as well as a failure to cover an item or service for which benefits are otherwise provided because it is determined to be Experimental and/or Investigational or not Medically Necessary. 3.02 "AvMed, Inc." . otherwise known as "Health Plan" means a private, not for profit Florida corporation, state licensed as a health maintenance organization under Chapter 641, Florida Statutes for the purpose of arranging for prepaid health care services to its Members under the terms and conditions set forth in this Contract. 3.03 "Claim" means a request for benefits under the Health Plan made by a Member in accordance with the Health Plan's procedures for filing benefit claims, including Pre - Service Claims and Post - Service Claims. 3.04 "Claimant" means a Member or a Member's authorized representative acting on behalf of the Member. The Health Plan may establish procedures for determining whether an individual is authorized to act on behalf of the Member. If the Claim is an Urgent Care or Pre - Service Claim, a Health Professional, with knowledge of the Member's medical condition, shall be permitted to act as the Member's authorized representative and will be notified of all approvals on the Claimant's behalf. In the event of an adverse benefit determination, AvMed will notify both the Member and the Heath Professional. 3.05 "Concurrent Care" means an ongoing course of treatment to be provided over a period of time or number of treatments that AvMed previously approved. 3.06 "Contract" means this Group Medical and Hospital Service Contract which may at times be referred to as "Group Contract" and all applications, rate letters, face sheets, riders, amendments, addenda, exhibits, supplemental agreements, and schedules which are or may be incorporated in this Contract from time to time. 3.07 "Contract Year" means the period of twelve (12) consecutive months commencing on the effective 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 therein) of the Subscriber or the Dependent of the Subscriber upon termination of the Subscribing Group Contract as provided in Part VIII of this Contract, and shall at times be referred to as the "Individual" or "Conversion Contract." 2 AV -G100 -2004 3.09 "Co- payment" means the charge, in addition to the prepaid premium charges, which the covered Subscriber is required to pay at the time certain health services are provided under this Contract. The Co- payment may be a specific dollar amount or a percentage of the cost. The covered Subscriber/Member is responsible for the payment of any Co- payment charges directly to the provider of the health services at the time of service. 3.10 "Custodial Care" means services and supplies that are furnished mainly to train or assist in the activities of daily living, such as bathing, feeding, dressing, walking, and taking oral medicines. "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, measuring and recording urine and blood sugar levels, and administering insulin. 3.11 "Dental Care" means dental x -rays, examinations and treatment of the teeth or structures directly supporting 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 VII has actually been received by Health Plan. 3.13 "Durable Medical Equipment (DME), Orthotics, and/or Prosthetics" Coverage for DME, Orthotics and Prosthetics is limited as outlined in Section(s) 10.20 and 10.21 subject to specific Limitations and Exclusions as listed in Part XII. The determination of whether a covered item will be paid under the DME, Orthotics or Prosthetics benefit will be based upon its classification as defined by the Centers for Medicare and Medicaid Services. 3.14 "Emergency 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 woman: a) That there is inadequate time to effect safe transfer to another Hospital prior to delivery; b) That a transfer may pose a threat to the health and safety of the patient or fetus; or AV -GI00 -2004 c) That there is evidence of the onset and persistence of uterine 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 external bleeding, 'fractured limbs, or severe trauma. 3.15 "Emergency Medical Services and Care" means medical screening, examination, and evaluation by a Physician, or, to the extent permitted by applicable law, by other appropriate personnel under the supervision of a Physician, to determine if an Emergency Medical Condition exists and, if it does, the care, treatment, or surgery for a covered service by a Physician necessary to relieve or eliminate the Emergency Medical Condition within the service capability of the Hospital. 3.15.01 In -Area Emergency does not include elective or routine care, care of minor illness, or care that can reasonably be sought and obtained from the Member's Primary Care Physician. The determination as to whether or not an illness or injury constitutes an emergency shall be made by Health Plan and may be made retrospectively based upon all information known at the time patient was present for treatment. 3.15.02 Out -of -Area Emergency does not include care for conditions for which a Member could reasonably have foreseen the need of such care before leaving the Service Area or care that could safely be delayed until prompt return to the Service Area. The determination as to whether or not an illness or injury constitutes an emergency shall be made by Health Plan and may be made retrospectively based upon all information known at the time 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 requirements of the school. (See Subsection 4.02.02(f)). 3.18 "Group Health Insurance" (for purposes of Part XIIn means that form of health insurance covering groups of persons under a master Group Health Insurance policy issued to any one of the groups listed in Sections 627.552 (employee groups), 627.553 (debtor groups), 627.554 (labor union and association groups), and 627.5565 (additional groups), Florida Statutes. 3.18.01 The terms "amount of insurance" and "insurance" include the benefits provided under a plan of self - insurance. 3.18.02 The term "insurer" includes any person, entity, or governmental unit providing a plan of self - insurance. 3.18.03 The terms "policy," "insurance policy," "health insurance policy," and "Group Health Insurance policy" include plans of self - insurance providing health insurance benefits. 4 AV -G100 -2004 3.19 "Health Plan" means AvMed, Inc., a not for profit Florida corporation, d/b /a AvMed Health Plan, which has been certified as a health maintenance organization by the Department of Insurance of the State of Florida to arrange for provision by the plan of prepaid health benefits and services covered by this Contract_ 3.20 "Health Professionals" means Physicians, osteopaths, podiatrists, chiropractors, Physician assistants, nurses, social workers, pharmacists, optometrists, clinical psychologists, nutritionists, occupational therapists, physical therapists, and other professionals engaged in 'the delivery of health care services who are licensed and practice under an institutional license, individual practice association, or other authority consistent with state law and who are Participating Providers of Health Plan. 3.21 "Home Health Care Services" means services that are provided for a Member who is homebound and who does 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 covered under this Contract. See Section 11.11 regarding Physical and Occupational Therapy Limitations. 3.22 "Hospice" means a public agency or private organization which is duly licensed by the State to provide Hospice services and with whom Health Plan 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. 3.23 "Hospital" means any general acute care facility which is licensed by the state and with which Health Plan has contracted or established arrangements for inpatient Hospital Services and/or Emergency Services, and shall at times be referred to as "Participating Hospital." 3.24 "Hospital Services" (except as expressly limited or excluded by this Contract) means those services for registered bed patients which are: 3.24.01 Generally and customarily provided by acute care general Hospitals within the Service Area; 3.24.02 Performed, prescribed, or directed by Participating Providers; and 3.24.03 Medically Necessary for conditions which cannot be adequately treated in Other Health Care Facilities or with Home Health Care Services or on an ambulatory basis. 3.25 "Hospitalist/Admitting Panelist" means a Physician who specializes in treating inpatients and who may coordinate a Member's health care when the Member has been admitted for a Medically Necessary procedure or treatment at a Hospital. 3.26 "Limitation" means any provision other than an Exclusion which restricts coverage under this Contract. 5 AV-G100-2004 B 3.27 "Master Application" means the Subscribing Group application form entitled "Master Application" which becomes a part of the Contract when the Master Application has been completed and executed by the Subscribing Group and Health Plan. 3.28 "Medically Necessary" means the use of any appropriate medical treatment, service, equipment, and/or supply as provided by a Hospital, skilled nursing facility, Physician, or other provider which is necessary for the diagnosis, care, and/or treatment of a Member's illness or injury, and which is: 3.28.01 Consistent with the symptom, diagnosis, and treatment of the Member's condition; 3.28.02 The most appropriate level of supply and/or service for the diagnosis and treatment of the Member's condition.; 3.28.03 In accordance with standards of acceptable community practice; 3.28.04 Not primarily intended for the personal comfort or convenience of the Member, the Member's family, the Physician, or other health care provider; 3.28.05 Approved by the appropriate medical body or health care specialty involved as effective, appropriate, and essential for the care and treatment of the Member's condition; 3.28.06 Prescribed, directed, authorized, and/or rendered by a participating or authorized provider, except in the case of an emergency; and 3.28.07 Not experimental or investigational. 3.29 "Medical Office" means any outpatient facility or Physician's office in the Service Area utilized by a Participating Provider. 3.30 "Medical Services" (except as limited or excluded by this Contract) means those professional services of Physicians and other Health Professionals including medical, surgical, diagnostic, therapeutic, and preventive services which are: 3.30.01 Generally and customarily provided in the Service Area; 3.30.02 Performed, prescribed, or directed by Participating Providers; and 3.30.03 Medically Necessary (except for preventive services as stated herein) for the diagnosis and treatment of injury or illness. 3.31 "Member" means any Subscriber or Dependent, as described in Part III, Sections 3.12 and 3.42 of this Contract. 6 AV -G100 -2004 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 Health Plan has neither made arrangements nor contracted to render the professional health services set forth herein. 3.33 "Other Health Care Facility(ies)" means any licensed facility, other than acute care Hospitals and those facilities providing services to ventilator dependent patients, providing inpatient services such as skilled nursing care or rehabilitative services for which Health Plan 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 Health Plan has made arrangements or contracted to render the professional health services set forth herein. 3.35 "Participating Physician" means any participating Physician licensed under Chapter 458 (physician), 459 (osteopath), 460 (chiropractor) or 461 (podiatrist), Florida Statutes. "Attending Physician" means ` the Participating Provider 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 Health Plan that is not a Pre - Service Claim. 3.37 "Pre - Service Claim" means any Claim for benefits under the Health Plan with respect to which, in whole or in part, a Member must obtain authorization from AvMed in advance of such services being provided to or received by the Member. 3.38 "Primary Care Physician" means a Participating Provider Physician engaged in family practice, pediatrics, internal medicine, obstetrics /gynecology, or any specialty Physician from time to time designated by Health Plan as "Primary Care Physician" in Health Plan's current list of Physicians and Hospitals. 3.39 "Relevant Document" means any documentation that: 3.39.01 Was relied upon in making the benefit determination; 3.39.02 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; 3.39.03 Demonstrates compliance with the administrative process; and 3.39.04 Constitutes a statement of policy or guidance with respect to the Health Plan 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 Determination. 7 AV -G100 -2004 3.40 "Service Area" means those counties in the State of Florida where AvMed has been approved to conduct business by the Florida Department of Financial Services. 3.41 "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 Primary Care Physician. 3.42 "Subscriber" means a person who meets all applicable requirements of Part IV, enrolls in Health Plan, and for whom the premium prepayment required by Part VII has actually been received by Health Plan. 3.43 "Subscribing Group" means an employer who negotiates and agrees to contract for the health services and benefits provided herein for its eligible employees, and shall at times be referred to herein as "Employer" or "Contract Holder." 3.44 "Total Disability" means a totally disabling condition resulting from an illness or injury which prevents the Member or Subscriber 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 or Subscriber is under the regular care of a Physician. 3.45 "Urgent Care Claim" means any Claim for medical care or treatment that could seriously jeopardize 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 the Health Plan 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. 3.46 "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. 3.47 "Utilization Management Program" means those procedures adopted by Health Plan to assure that the supplies and services provided to Members are Medically Necessary. These include, but are not limited to: (1) pre- authorization for specialty referrals, Hospital admissions (except emergencies), outpatient surgery, and certain outpatient diagnostic tests and procedures; (2) concurrent review of all patients hospitalized in acute care, psychiatric, rehabilitation, and skilled nursing facilities, including on -site review when appropriate; (3) case management and discharge planning for all inpatients and those requiring continued care in an alternative setting (such as homecare or a skilled nursing facility) and for outpatients when deemed appropriate. E:3 AV -G100 -2004 3.48 "Ventilator Dependent Care Unit" means care received in any facility which provides services to ventilator dependent patients other than acute Hospital care, including all types of facilities known as sub -acute care units, ventilator dependent units, alternative care units, sub -acute care centers, and all other like facilities whether maintained in a free standing facility or maintained in a Hospital or skilled nursing facility setting. Coverage is limited to 100 days lifetime maximum. IV. ELIGIBILITY 4.01 To be eligible to enroll as a Subscriber, a person must be: 4.01.01 An employee of the Subscribing Group who works the required number of hours per week 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 Services, the covered services and benefits are available only from Participating Providers. 4.01.02 Employed for the period of time required for eligibility as set forth in the Master Application; and 4.01.03 Entitled on his own behalf to participate in the medical and Hospital care benefits arranged by the Subscribing Group under this Contract. 4.02 To be eligible to enroll as a Dependent, a person must be: 4.02.01 the spouse of the Subscriber; a new spouse must be enrolled within thirty-one (3 1) 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 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 Health Plan upon request); a child for whom the Subscriber is permanent legal guardian; 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 "f' and "h" below); c) The child is under the age of 19 (except for "f' 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 thirty (30) hours or more per week; e) The child is not married; 9 AV -G100 -2004 f) The child is age 19 or over but under the age of 23, or other limiting age as specified by the parties in 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 secondary school. Subscriber is responsible for notifying Health Plan when full-time attendance commences or terminates, and coverage shall commence or terminate upon such notification. Ceasing of coverage will be retroactively applied if Health Plan is not notified. Subscriber agrees to provide documentation of Full -Time Student status upon request of Health Plan; 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 where the Subscriber is obligated to provide medical care by Qualified Medical Support Order provided the eligible Dependent resides within the Service Area. You (or your beneficiaries) may obtain, without charge, copies of the Plan's procedures governing qualified medical support orders and a sample qualified medical support order by contacting the Plan Administrator. i) In the case of a newborn child, Health Plan should be notified in writing prior to the scheduled delivery date of the Subscriber's intention to enroll the newborn child, but such notice shall not be later than thirty-one (3 1) days after the birth. If timely notice is provided, no additional premium will be charged for the additional coverage of the newborn during the thirty-one (3 1) 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 days of the birth, the child may not be enrolled until the next open enrollment period of the Subscribing Group. 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 provided that a written agreement to adopt such child 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 adopted 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 eighteen (18) months after the birth of the newborn child. 4.03 No person is eligible to enroll hereunder who has had his coverage previously terminated under Part IX, Subsection 9.01.05, except with the written approval of Health Plan. 10 AV -G100 -2004 4.04 Attainment of the limiting age by a Dependent child shall not operate to exclude from or terminate the coverage of such child nor shall coverage prevent the enrollment of a child while such child is and continues to be both: 4.04.01 Incapable of self - sustaining employment by reason of mental retardation or physical handicap; and 4.04.02 Chiefly dependent upon the Subscriber for support and maintenance, provided proof of such incapacity and dependency is furnished to Health Plan by Subscriber within thirty-one (3 1) days of the child's attainment of the limiting age and subsequently as may be required by Health Plan, but not more frequently than annually after the two - year period following the child's attainment of the limiting age. 4.05 During the term of this Contract, no changes in the Subscribing Group eligibility or requirements of participation ,shall be permitted to affect eligibility or enrollment under this Contract unless such change is agreed to by Health Plan. V. ENROLLMENT 5.01 Prior to the effective date of this Contract and at a proper time prior to each anniversary thereof, Health Plan may allow an open enrollment period of thirty-one (3 1) days, in which any eligible Subscriber on behalf of himself and his Dependents may elect to enroll in Health 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 thirty-one (31) days after becoming eligible by submitting application forms acceptable to or provided by Health Plan; otherwise, the eligible Subscribers and Dependents may not enroll until the next open enrollment period of Subscribing Group. 5.03 Special Enrollment Periods. An eligible Subscriber or Dependent may request to enroll under Health Plan outside of the initial enrollment and Annual Open Enrollment Periods if that Individual, within the immediately preceding thirty-one (31) days, was covered under another employer health benefit plan as an employee or Dependent at the time he was initially eligible to enroll for coverage under Health Plan, and: 5.03.01 Demonstrates that he or his Dependent has experienced one of the following status change events, including: a) marriage; b) birth, adoption or placement for adoption; c) legal separation, divorce or annulment; d) change in legal custody or legal. guardianship; 11 AV -G100 -2004 e) death; f) relocation into or out of a Service Area; g) termination/commencement of employment; h) reduction in the number of hours of employment; i) commencement of or return from leave of absence; j) change in employment status; k) change in worksite; 1) strike or lockout; m) termination of coverage due to the termination of employer contributions toward such coverage; and 5.03.02 Requests enrollment within thirty-one (3 1) days after the termination of coverage under another employer health benefit plan; and 5.03.03 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 not be implied due to clerical or administrative errors if such coverage would be contrary to Part IV. (Also see Section 17.10) 5.05 This Contract, at the sole option of Health Plan, will not be accepted if at 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 Health Plan. The required minimum group enrollment is included in the rate letter submitted to Subscribing Group. VI. EFFECTIVE DATE OF MEMBERSHIP Subject to the payment of applicable monthly membership charges set forth in Part VII and to the provisions of this Contract, coverage under this Contract shall become effective on the following dates: 6.01 Eligible Subscribers and .Dependents who enroll during the open enrollment period will be covered Members as of the effective date of this Contract or subsequent anniversary thereof. 6.02 If a Subscriber acquires an eligible Dependent through birth, adoption, placement for adoption or marriage, such Dependent shall be treated as immediately covered under the Plan if, within 31 days (or as otherwise provided for newborns in Part IV) of acquiring the new Dependent, you complete and submit an enrollment form on behalf of such Dependent. If received by the Plan within the 31 -day time period (or 60 -days as permitted for newborns), the enrollment for such 12 AV -G100 -2004 D b Dependent shall become effective on the date of the birth, adoption or placement for adoption, or for marriage, the first day of the month following the date you enroll your new spouse. 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 is not received by the Plan within the required timeframe, you and your eligible Dependents will be required to wait until the next open enrollment period to apply for coverage. 6.03 If you or your Dependents originally declined medical coverage under the Plan due to other health coverage, and that coverage is subsequently terminated as a result of either a loss of eligibility,for such coverage or the termination of any employer contributions for such coverage, you and your Dependents will be eligible to enroll in the Plan. To enroll, you must properly complete an enrollment form within 31 days of the loss of such other coverage or termination of employer contributions. The effective date of any coverage provided under the Plan will be the first day of the month following the date you enroll. If you fail to enroll within 31 days after the loss of other coverage, you must wait until the next open enrollment period to apply for coverage. 6.04 Coverage for the newborn child of the Subscriber or the newborn child of the Subscriber's covered Dependent is effective at birth if Subsection 4.02.02(i) and Section 6.02 are complied with. VII. MONTHLY PAYMENTS AND CO- PAYMENTS 7.01 On or before the first day of each month for which coverage is sought, Subscribing Group or its designated agent shall remit to Health Plan, on behalf of each Subscriber and his Dependents, the monthly premium based on the rate letter and Master Application. Only Members for whom the stipulated payment is actually received by Health Plan shall be entitled to the health services covered under this Contract and then only for the period for which such payment is applicable. Failure of the Subscribing Group to pay premiums for the group 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 group, effective at 12:00 a.m. (midnight) on the last day of the month for which premium was paid, unless the payment of premiums has otherwise been contractually adjusted and specified by the parties in a fully executed addendum to this Contract. An additional charge will apply to all late premium payments. (See Section 17.14) 7.02 Grace Period. This Contract has a ten (10) day grace period. This provision means that if any required premium is not paid on or before the date it is due, it must 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 premium will be retroactive to 12:00 a.m. (midnight) on the last day of the month for which premium was paid. Note: Certain provisions in Section 7.01 may apply if the parties have executed an addendum affecting premium payments. 7.03 Maximum Co- payments. Total annual Co- payments are limited as described in your Schedule of Co- payments. 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 supplemental riders. It is the responsibility of the 13 AV -G100 -2004 Subscriber/Member to retain receipts and to notify and document to the satisfaction of Health Plan when either of the Co- payment limits has been reached. 7.04 ' Member shall pay premiums, applicable supplemental charges, or Co- payments as provided in this Contract. If he fails to do so, upon ten (10) days written notice from Plan to Member, the Member's rights- hereunder shall be terminated. Consideration for reinstatement with the Plan shall require a new application, and any re- enrollment shall be at the sole discretion of Health Plan and shall not be retroactive. 7.05 Refund of premiums paid to Health Plan 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 premiums paid up to a maximum of sixty (60) days from the date of such ineligibility or termination, provided there are no claims incurred subsequent to the effective date of termination. 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), Health Plan shall not be responsible for medical expenses incurred by Health Plan in providing benefits to the Member under the terms of this Contract after the effective date of termination (due to the Subscribing Group's nonpayment of premiums or failure to timely notify the Plan of Member ineligibility). At the discretion of Health Plan based on the facts available to Health Plan at the time, Health Plan 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 (3) months immediately prior to termination, shall 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 group coverage within thirty-one (3 1) days. 8.01.01 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 8.01.02 below, shall be covered under the Individual Conversion Contract. 8.01.02 A completed status change form requesting conversion shall be sent to Health Plan or its designated administrator with the first applicable premium and shall be received 14 AV -G100 -2004 W by Health Plan or its designated administrator not later than sixty -three (63) days after the date of termination of this Group Contract. 8.01 A3 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 of the same time or a child with respect to himself, by reason of ceasing to be a qualified family member, may convert and must comply with Subsection 8.01.02 above. c) A former spouse whose coverage would otherwise terminate because of annulment or dissolution of marriage may convert if the former spouse is dependent for financial support. The former spouse must comply with Subsection 8.01.02 above and must provide written evidence of financial dependence upon request of Health Plan. 8.01.04 Payment for health care services rendered to a Member after termination and prior to conversion shall be the responsibility of the Member. When the conversion application has been timely completed (within sixty -three (63) days after termination of the Group Contract) and the first premium due has been paid, Health Plan shall reimburse the Subscriber for any payment made by the Subscriber for covered Medical Services under the converted Contract. 8.01.05 A new Conversion Contract is established upon application and payment of premium on the day following the Member's termination from group coverage (due to ineligibility under the Group Contract) and continues through the end of the calendar year. The Contract Year, upon renewal, shall be the calendar year. 8.02 Individual Conversion Contracts may not include supplemental benefits, notwithstanding the supplemental benefits included under this Subscribing Group Contract, and may in other respects, as determined by Health Plan, differ from this Group Contract. 8.03 The conversion privilege will not apply to a Subscriber or covered Dependent if termination of his coverage under this Contract occurred for any of the following reasons: 8.03.01 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; 8.03.02 Replacement of any discontinued group coverage by similar group coverage within thirty-one (3 1) days; 8.03.03 Fraud or material misrepresentation in applying for any benefits under this Contract; (See Subsection 9.01.05) 15 AV -G100 -2004 t d 8.03.04 Willful and knowing misuse of Health Plan's membership identification card by the Subscriber; 8.03.05 Willfully and knowingly furnishing incorrect or incomplete information to Health Plan for the purpose of fraudulently obtaining coverage or benefits from Health Plan; or 8.03.06 Termination from coverage under this Contract in accordance with Subsection 9.01.05. 8.04 Conversion After Continuation Coverage. When continuation coverage as provided under the provisions of the Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA) expires, 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 Part VIII, above. The eligible Subscriber or Dependent must send a completed application and the applicable premium payment, postmarked not later than sixty -three (63) days after the termination of COBRA coverage, directly to: AvMed Health Plans Accounts Receivable Department Suite 510 9400 South Dadeland Blvd. Miami, Florida 33156 . The Subscriber or Dependent may obtain an application form and a statement of current premium rates for the individual Conversion Contract by calling AvMed Member Services. It is the responsibility of the Subscribing Group to notify Subscriber of Subscriber's rights under COBRA. For any specific questions concerning COBRA, contact the Subscribing Group. IX. TERMINATION 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: 9.01.01 Loss of Eli ibg ility - Subject to the conversion rights under Section 8.04: a) Upon a loss of the Subscriber's or Dependent's eligibility as defined in Part IV, including but not limited to the permanent relocation outside Health Plan Service 16 AV -G100 -2004 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 Make Premium Payment - Upon failure of the Subscribing Group to make payment of the monthly premiums provided in Part ; VII within ten (10) days following the due date specified herein, benefits hereunder shall terminate, for all Subscribers and any Dependents for whom such payment has not been received, at 12:00 a.m. (midnight), on the last day of the month for which the monthly premium was paid. Upon failure of the Subscriber to make payment of any premium contributions or applicable supplemental charges required by Section 7.04 of this Contract, coverage . shall automatically terminate for the Subscriber and all Dependents on the tenth day after written notice from Health Plan. AvMed Health Plan, regarding cancellation or non - renewal of this coverage, may retroactively cancel the policy to the date for which the employer'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 premium was due. AvMed will include a reason for the Contract termination in its written notification to the Subscribing Group. The Subscribing Group will forward such notification to all Subscribers when AvMed has notified the Subscribing Group of the cancellation or non - renewal, and AvMed is deemed to have complied with its notification requirements by providing said notice to the Subscribing Group. 9.01.03 Termination of Group Contract by Subscribing Group - Group may terminate this Group Contract on the anniversary date by giving written notice to Health Plan fifteen (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 Group Contract by Health Plan - Health Plan may non -renew or discontinue this Group Contract based on one or more of the following conditions. In such event, benefits hereunder shall terminate for all Members at 12:00 a.m. (midnight) on 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 Health Plan has not received timely premium payments (See Part VII, Monthly Payments and Co- payments and Subsection 9.01.02). Termination of coverage will be effective on the last day of the month for which payments were received by Health Plan. 17 AV -G100 -2004 b) Subscribing Group has performed an act or practice that constitutes fraud or made an intentional misrepresentation of material fact under the terms of this Contract. This will result in immediate termination of Subscribing Group. c) Subscribing Group has failed to comply with a material provision of the plan which relates to rules for employer contributions or group participation. Termination will be effective upon forty-five (45) days written notice from Health Plan to Subscribing Group. d) There is no longer any enrollee in connection with the plan who lives, resides, or works in Health Plan's Service Area. Termination of coverage will be effective on the last day of the month for which payments were received by Health Plan. e) Health Plan ceases to offer coverage in the applicable market. Termination will be effective upon one - hundred and eighty (180) days written notice from Health Plan to Subscribing Group. 9.01.05 Termination of Membership for Cause - Health Plan may terminate any Member immediately upon written notice for the following reasons which lead to a loss of eligibility of the Member: a) fraud, material misrepresentation, or omission in applying for membership, benefits, or coverage under this Contract. However, relative to a misstatement in the Application, after two (2) 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 (2) year period; b) misuse of Health Plan's Membership Card furnished to the Member; c) furnishing to Health Plan 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 the Health Plan's ability to administer this Contract or to arrange for the delivery of health care services to the Member or other Members after Health Plan has attempted to resolve the Member's problem. At the effective date of such termination, premium payments received by Health Plan on account of such termination shall be refunded on a pro rata basis, and Health Plan shall have no further liability or responsibility for the Member(s) under this Contract. 9.02 Notification Requirements: 9.02.01 Loss of eli ig bility of Subscriber It is the responsibility of Subscribing Group to notify Health Plan in writing within thirty-one (31) days from the effective date of 18 AV -GI00 -2004 termination regarding any Subscriber and/or Dependent who becomes ineligible to participate in Health 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 the month for which premium was paid and during which the Subscriber and/or Dependent was eligible for coverage. (See Section 7.06) 9.02.02 Loss of eligibili1y of Dependent - When a Dependent becomes ineligible for Dependent coverage, the Subscriber is required to notify Health Plan in writing within thirty-one (3 1) 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 forty-five (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 the Plan. You will only need to do this if the other health care plan has a pre - existing condition limit. You can request a Certificate of Group Health Plan Coverage anytime during the 24 -month period after the date your coverage under the Plan has ended. 9.04 Continuation Coverage under COBRA. Under certain provisions of the Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA), the Subscriber or his Dependent(s) 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 the Consolidated Omnibus Reconciliation Act of 1986, as amended (COBRA) after any of the following qualifying events result in the loss of plan coverage: a) loss of benefits due to a reduction in your hours of employment; b) termination of your employment, including retirement but excluding termination for gross misconduct; c) termination of employment following FMLA leave, in which case the qualifying event will occur on the earlier of the date you indicated you were not returning to work or the last day of the FMLA leave; or d) you or a Dependent first become entitled to Medicare or covered under another group health plan prior to your loss of coverage due to termination of employment or reduction in hours. 19 AV -G100 -2004 9.04.02 In addition, your enrolled Dependents will become eligible for COBRA continuation coverage after any of the following qualifying events occur to cause a loss of plan coverage: a) your death; b) your divorce or legal separation; c) you first become entitled to Medicare after your loss of coverage due to termination of employment or reduction in hours; or d) your Dependent child no longer qualifies as a Dependent under the plan. A child who is born to or placed for adoption with a covered former employee during the continuation coverage period has the same continuation coverage rights as a Dependent child described above. 9.04.03 Notification. If a qualifying event other than divorce, legal separation, loss of Dependent status or entitlement to Medicare occurs, the plan administrator will be notified of the qualifying event by your employer and will send you an election form. To continue plan coverage, you must return the election form within 60 days from the later of the date you receive the form, or the date your coverage ends due to a qualifying event. If divorce, legal separation, loss 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 plan 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 plan administrator within 60 days from the later of the date you receive the form, or the date your coverage ends due to the qualifying event. 9.04.04 Cost. If you elect to continue coverage, you must pay the entire cost of coverage (the employer's contribution and the active employee portion of the contribution), 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 II or Title XVI of the Social Security 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 20 AV -G100 -2004 your hours are reduced. You must pay 102% of the cost of coverage for the first 18 months of COBRA continuation coverage and 150% of the cost of coverage for the 19ah through the 29th 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 plan administrator by the first day of the month for which the premium is due. (Your first payment is due no later than 45 days after your election to continue coverage, and it must cover the period of time back to the first day of your COBRA continuation coverage.) 9.04.05 Duration. COBRA Continuation Coverage can be extended for: a) 18 months if coverage ended due to a reduction in your work hours or termination of your employment and you or one of your covered Dependent(s) is not Social Security disabled within 60 days of the date you lose coverage due to 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 prior 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 reduction 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 18 months of COBRA continuation coverage and within 60 days following the date you or a covered Dependent is determined to be disabled by the Social Security Administration. If the disabled individual should no longer be considered to be disabled by the Social Security Administration, you must notify the plan administrator within 30 days following the end of the disability. Coverage that has exceeded the original 18 -month continuation period will end when the individual is no longer Social Security disabled. If more than one qualifying event occurs, no more than 36 months total of COBRA continuation coverage will be available. The COBRA beneficiary must experience the second qualifying event during the first 18 months of COBRA continuation, and must provide notice to the plan 21 AV -G100 -2004 administrator within the required time period. COBRA continuation coverage will end sooner if the plan terminates and the employer does not provide replacement medical coverage, or if a person covered under COBRA: a) first becomes covered under another group health plan after the loss of coverage due to your termination or reduction in hours, unless the new group coverage is limited due to a pre - existing condition exclusion; this plan will be primary for the pre- existing condition and secondary for all other eligible health care expenses, provided contributions for COBRA coverage continue to be paid. Coverage may only continue for the remainder of the original COBRA period; b) fails to make required contributions when due; C) first becomes entitled to Medicare benefits after the initial COBRA qualifying event; or d) is extending the 18 -month coverage period because of disability and is no longer disabled as defined by the Social Security Act. 9.05 Continuation Coverage During Leaves of Absence. 9.05.01 Family and Medical Leaves of Absence (FMLA). Under the Family and Medical Leave Act of 1993, you may be entitled to up to a total of 12 weeks of unpaid, job - protected leave during each calendar year for the following: a) the birth of your child, to care for your newborn child, or for placement of a child in your home for adoption or foster care; b) to care for your spouse, child or parent with a serious health condition; or c) for your own serious health condition. If your FMLA leave is a paid leave, your pay will be reduced by your before -tax contributions as usual for the coverage level in effect on the date your FMLA leave begins. If your FMLA leave is unpaid, you will be required to pay your contributions directly to the employer until you return to active pay status. If you notify your employer that you are terminating employment during your FMLA leave, your coverage will end on the date of your notification. If you do not return to work on your expected FMLA return date, and you do not notify your employer of your intent either to terminate your employment or to extend the period of leave, your Plan 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 FMLA leave and you have a change in status event or a special enrollment event under 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 Plan (including coverage for enrolled 22 AV -G100 -2004 Dependents) for up to 18 months from 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 participants 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 fully completed any required waiting period prior to the start of the military service. 9.06 Conversion After 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 9.07.03, such termination shall be without prejudice to any continuous losses to a Subscriber or Member which commenced 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 3.44, of the Subscriber or Member and shall be limited to payment for the treatment of a specific accident or illness incurred while the Subscriber was a Member. 9.07.01 The extension of benefits covered under this Contract shall be limited to the occurrence of the earliest of the following events: a) The expiration of 12 months; b) Such time as the Member is no longer totally disabled; c) A succeeding carrier ,elects to provide replacement coverage without Limitation as to the disability condition; or d) The maximum benefits payable under this Contract have been paid. 9.07.02 In the case of maternity 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 Health Plan 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) Disenrollment for cause. 23 AV -G100 -2004 c) The Subscriber has left the geographic Service Area of Health Plan with the intent to relocate or establish a new residence outside Health Plan's Service Area. X. SCHEDULE OF BASIC BENEFITS Health Plan is committed to arranging for comprehensive prepaid health care services rendered to its Subscribers through Health Plan's network of contracted independent Physicians and Hospitals and other independent health care providers, under reasonable standards of quality health care. The professional judgment of a Physician licensed under Chapters 458 (physician), 459 (osteopath), 460 (chiropractor) or 461 (podiatrist), Florida Statutes, concerning the proper course of treatment of a Subscriber shall not be subject to modification by Health Plan or its Board of Directors, Officers, or Administrators. However, this subsection is not intended to and shall not restrict any Utilization Management Program established by Health Plan. Only services and benefits in conformity with Part'III (Definitions), Part X (Schedule of Basic Benefits), Part XI (Limitations of Basic Benefits), Part XII (Exclusions From Basic Benefits) and Schedule of Co- payments, which by reference, is incorporated herein, are covered by Health Plana It is the Member's responsibility when seeking benefits under this Contract to identify himself as a Health Plan Member and to assure that the services received by the Member are being rendered by Participating Providers. Members should remember that services that are provided or received without having been authorized in advance by AvMed Health Plan's Medical Department, or if the service is beyond the scope of practice authorized for that Provider under state law, except in instances of Emergency Services and Care, are not covered unless such services otherwise have been expressly authorized under the terms of this Contract. Except for Emergency Services and Care, all services must be received from Participating Providers on referral from AvMed. If a Member does not follow the access rules, he risks having services and supplies received not covered under this Contract. In such a circumstance, the Member will be responsible for reimbursing AvMed for the reasonable cost of the services and supplies received. Also, Members must understand that services will not be covered if they are not, in AvMed Health Plan's opinion, Medically Necessary. Any and all decisions made by Health Plan in administering the provisions of this Contract, including without limitation, the provisions of Part X (Schedule of Basic Benefits), Part XI (Limitations of Basic Benefits), and Part XII (Exclusions from Basic Benefits), are made only to determine whether payment for any benefits will be made by Health Plan. 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 Physician, in accordance with the normal patient/physician relationship for purposes of determining what is in the best interest of the Member. The Health Plan does not have the right of control over the medical decisions made by the Member's Physician or health care providers. The ordering of a service 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 paid for or arranged by AvMed Health Plan. 24 AV -G100 -2004 MEMBERS ARE RESPONSIBLE AND WILL BE LIABLE FOR CO- PAYMENTS WHICH MUST BE PAID TO HEALTH CARE PROVIDERS FOR CERTAIN SERVICES, AT THE TIME SERVICES ARE RENDERED, AS SET FORTH IN THE SCHEDULE OF CO- PAYMENTS. 10.01 The names and addresses of Participating Providers and Hospitals are set forth in a separate booklet which, by reference, is made a part 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 from the AvMed website at www.AvMed.org. Notwithstanding the printed booklet, the names and addresses of Participating Providers on file with Health Plan at any given time shall constitute the official and controlling list of Participating Providers. 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 Schedule of Basic Benefits are available only from Participating Providers within the Service Area and, except for Emergency Services as provided in Section 10.12, Health Plan shall have no liability or obligation whatsoever on account of services or benefits sought or received by any Member from any nonparticipating Physician, health professional, Hospital or Other Health Care Facility, or other person, institution or organization, unless prior arrangements have been made for the Member and confirmed by written referral or authorization from Health Plan. 10.03 Each Member shall select one Primary Care Physician upon enrollment. If you do not select a Primary Care Physician upon enrollment, Health Plan will assign one for you. You must notify and receive approval by Health Plan prior to changing your Primary Care Physician. Such change will become effective on the first day of the month after you notify Health Plan. You cannot change your PCP 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 the Health Plan. Health Professionals may from time to time cease their affiliation with Health Plan. 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 3;15), either while temporarily outside the Service Area or within the Service Area but before they can reach a Participating Provider, may 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 Health Plan. 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 room and related facilities, intensive care unit and services, diagnostic imaging, laboratory and other diagnostic tests, drugs and 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 Services. 25 AV -G100 -2004 Health Plan pre - authorization is required for inpatient Hospital Services for substance abuse, and these services are subject to the conditions set forth in the optional coverage selected. (Also see Section 11.05) 10.06 Physician Care`. Inpatient. All Medical Services rendered by Participating Physicians and other Health Professionals when requested or directed by the Attending Physician, including surgical procedures, anesthesia, consultation and treatment by Specialists, 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 requested by the Member, Health Plan covers the services of a certified nurse anesthetist licensed under Chapter 464, Florida Statutes. 10.07 Physician Care: Outpatient 10.07.01 Diagnosis and Treatment. All Medical Services rendered by Participating Physicians and other Health Professionals, as requested or directed by the PCP, are covered when provided at Medical Offices, including surgical procedures, routine hearing examinations and vision examinations for glasses for children under age 18 (such examinations may be provided by optometrists licensed pursuant to Chapter 463, FS or by ophthalmologists licensed pursuant to Chapter 458 or 459, FS) and consultation and treatment by Specialty Health Care Physicians. Also included are non - reusable materials and surgical supplies. These services and materials are subject to the Limitations outlined in Part XI (Limitations of Basic Benefits). See Part XII for Exclusions. 10.07.02 Preventive and Health Maintenance Services. The services of the Member's Primary Care Physician for illness prevention and health maintenance, including Child Health supervision services, and immunizations provided in accordance with prevailing medical standards consistent with the Recommendations for Preventive Pediatric Health Care of the American Academy of Pediatrics and/or the Advisory Committee on Immunization Practices; sterilization (See Schedule of Co- payments), periodic health assessment, physical examinations, and voluntary family planning services are also covered. These services are subject to Limitations as outlined in Part XI (Limitations of Basic Benefits). See Part XII for Exclusions. 10.07.03 Outpatient Mental Health Services are covered only for diagnostic evaluation and crisis intervention. These services are limited to a total of twenty (20) outpatient visits per Contract Year. Referral for outpatient mental health services must be arranged by the Member's Participating Physician, and each visit requires a Co- payment. (See Schedule of Co- payments) 10.08 Physical, Occupational or Speech Therapy. Short-term Physical, Occupational or Speech Therapy provided in the Outpatient or Home Care setting is covered for acute conditions, including exacerbation of previously treated conditions, for which therapy applied for a consecutive two (2) month period can be expected to result in significant improvement. Coverage of outpatient short-term and rehabilitative services is limited to twenty -four (24) visits per calendar year for all 26 AV -G100 -2004 services combined. Long -term 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, percutaneous transluminal coronary angioplasty (PTCA), coronary artery bypass graft (CABG), repair or replacement of heart valve(s) or heart transplant. Coverage is limited to a maximum of eighteen (18) visits per calendar year. See Schedule of Co- payments for detailed information regarding Co- payments and Limitations. 10.10 Obstetrical and Gynecological Care. Obstetrical care benefits as specified herein are covered and include Hospital care, anesthesia, diagnostic imaging, and laboratory services for conditions related to pregnancy unless such pregnancy is the result of a preplanned adoption arrangement, more commonly known as surrogacy. The length of maternity stay in a Hospital will be that determined to be Medically Necessary in compliance with Florida law and in accordance with the Newborns' and Mothers' Health Protection Act, as follows: 1) hospital stays of at least 48 hours following a normal vaginal delivery, or at least 96 hours following a cesarean section; 2) the attending physician does not need to obtain authorization from the Plan to prescribe a Hospital stay of this length or longer; and 3) shorter Hospital stays are permitted if the attending health care provider, in consultation with the mother, determines 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 child care is covered as provided in Subsection 4.02.02 (i) and Section 10.1 L An annual gynecological examination and Medically Necessary follow -up care 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 provided that newborn was continuously covered by Health Plan from date of birth. 10.12 Emergency Services. All necessary Physician and Hospital Services will be covered by Health Plan for Emergency Care. (See Part III, Sections 3.14 and 3.15) In the event that Hospital inpatient services are provided following Emergency Services, Health Plan should be notified within 24 hours or as soon as the Member is lucid and able to notify Health Plan of the inpatient admission. Health Plan will pay the usual, reasonable, and customary charges to a non - Participating Physician or facility only for those services rendered before a Member's condition permits him to be reasonably able to travel to a Participating facility. In addition, any Member requests for reimbursement (of payment made by the Member for services rendered) must be filed within ninety (90) days after the Emergency or as soon as reasonably possible but not later than one (1) 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 27 AV -GI00 -2004 described in Section 3.46 will be covered by Health Plan. See Schedule of Co- payments for details. In addition, any Member requests for reimbursement (of payment made by the Member for services rendered) must be filed within ninety (90) days after the Emergency or as soon as reasonably possible but not later than one (1) year unless the claimant was legally incapacitated. 10.14 Ambulance Service. For an Emergency or when pre - authorized by Health Plan, ambulance service to the nearest Hospital appropriately staffed and equipped to treat the condition will be covered. 10.15 Other Health Care Facility(ies). All routine services of Other Health Care Facilities (see Section 3.33), including Physician visits, physiotherapy, diagnostic imaging and laboratory work, are covered for a maximum of twenty (20) days per Calendar Year when a :Member is admitted to such a facility, following discharge from a Hospital, for a condition that cannot be adequately treated with Home Health Care Services or on an ambulatory basis. 10.16 Diagnostic Imaging and Laboratory. All prescribed diagnostic imaging and laboratory tests and services including diagnostic imaging, fluoroscopy, electrocardiograms, blood and urine and other laboratory tests, and diagnostic clinical isotope services are covered when Medically Necessary and ordered by a Participating Physician as part of the diagnosis and/or treatment of a covered illness or injury or as preventive health care services. 10.17 Home Health Care Services. With prior authorization by Health Plan, Home Health Care Services (as defined in Section 3.21) are covered when ordered by and under the direction of the Member's Attending Physician. Physical,. Occupational or Speech Therapy services provided in the home are limited as noted in 10.08. Homemaker or other Custodial Care services are not covered. 10.18 Hospice Services. With prior authorization by Health Plan, services are available from a Health Plan affiliated Hospice organization for a Member whose Participating Physician has determined the Member's illness will result in a remaining life span of six (6) months or less. 10.19 Second Medical Opinions. The Member is entitled to a second medical opinion when he: 1) disputes the appropriateness or necessity of a surgical procedure; or 2) is subject to a serious injury or illness. With prior notice to Health Plan, the Member may obtain the second medical opinion from any Participating or non - Participating Physician, chosen by the Member, who is within Health Plan's Service Area. If a Participating Physician is chosen, there is no cost to the Member other than any applicable Co- payment. If the Member chooses a non - Participating Physician, the Member will be responsible for 40% of the amount of reasonable and customary charges for the second medical opinion. Any tests that may be required to render the second medical opinion must be arranged by Health Plan and performed by Participating Providers. Once a second medical opinion has been rendered, Health Plan shall review and determine Health Plan's obligations under the contract and that judgment is controlling. Any treatment the Member obtains that is not authorized by Health Plan shall be at the Member's expense. 28 AV -G100 -2004 Health Plan may limit second medical opinions in connection with a particular diagnosis or treatment to three (3) per Contract Year, if Health Plan deems additional opinions to be an unreasonable over- utilization by the Member. 10.20 Durable Medical Equipment and Orthotic Appliances. 10.20.01 Durable Medical Equipment. This Contract provides benefits, when Medically Necessary, for the purchase or rental of such DME that: a) Can withstand repeated use (i.e. could normally be rented and used by successive patients); b) Is primarily and customarily used to serve a medical purpose; c) Generally is not useful to a person 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, apnea monitors and insulin pumps. In accordance with Florida Statutes, coverage of insulin pumps for the treatment of diabetes will not apply toward or be subject to the annual DME maximum Limitation. It does not include hearing aids or corrective lenses, including the professional fee for fitting same. It also does not include medical supplies and devices, such as a corset, which do not require prescriptions. AvMed will pay for rental of equipment up to the purchase price. Repair and/or replacement is not covered. See Schedule of Co- payments for any Co- payments or Limitations. See Part XII for Exclusions. 10.20.02 Orthotic Appliances. Coverage for orthotic appliances is limited to custom -made leg, arm, back and neck braces when related to a surgical procedure or when used in an attempt to avoid surgery and when necessary to carry out normal activities of daily living, excluding sports activities. Coverage is limited to the first such item; repair and/or replacement is not covered. All other orthotic appliances are not covered. See Schedule of Co- payments for any Co- payments or Limitations. See Part XII for Exclusions. 10.21 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 Necessary due to a change in bodily configuration. The initial prosthetic device following a covered mastectomy is also covered. Replacement of intraocular lenses is covered only if there is `a change in prescription which cannot be accommodated by eyeglasses. All other prosthetic devices are not covered. See Schedule of Co- payments for any Co- payments or Limitations. See Part XII for Exclusions. 29 AV -G100 -2004 10.22 Payment to Non - Participating Providers. When, in the professional judgment of Health Plan's Medical Director, a Member needs covered medical or Hospital Services which require skills 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 Non - Participating Provider will be made by Health Plan. 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. 10.23 Prescription Drug Benefits. Allergy serums and chemotherapy for cancer patients are covered. Coverage for insulin and other diabetic supplies is described in Section 10.26, below. Other prescription drugs are a covered benefit only when the Subscribing Group Contract includes a supplemental Prescription Drug Rider. 10.24 Ventilator Dependent Care. With prior authorization by Health Plan, Ventilator Dependent Care (See Section 3.48) is covered up to a total of 100 days lifetime maximum benefit. 10.25 Major Organ Transplants at a facility deemed appropriate and authorized by Health Plan, as well as associated immunosuppressant drugs are covered except those deemed experimental. (See Section 12.15) 10.26 Diabetes Treatment for all Medically Necessary equipment, supplies, and services to treat diabetes. This includes outpatient self - management training and educational services, if the Member's Primary Care Physician, or the Physician to whom the Member has been referred who specializes in diabetes treatment, certifies the equipment, supplies, or services are Medically Necessary. Insulin pumps are covered under Section 10.20. Diabetes outpatient self - management training and educational services must be provided under the direct supervision of a certified diabetes educator or a board certified endocrinologist under contract with Health Plan. Insulin, insulin syringes, lancets, and test strips are covered under the Subscribing Group's supplemental Prescription Drug Rider. In the event that a Subscribing Group does not purchase a supplemental Prescription Drug Rider, insulin, insulin syringes, lancets, and test strips are covered subject to a $25 Member Co- payment per item for 30 -day supply. 10.27 Mammograms are covered in accordance with Florida Statutes: one baseline mammogram is covered for female Members between the ages of 35 and 39; a mammogram is available every two years for female Members between the ages of 40 and 49; and a mammogram is available every year for female Members aged 50 and older. In addition, one or more mammograms a year are available when based upon a Physician's recommendation for any woman who is at risk for breast cancer because of a personal or family history of breast cancer, because of having a history of biopsy - proven benign breast disease, because of having a mother, sister, or daughter who has had breast cancer, or because a woman has not given birth before the age of 30. 30 AV -G100 -2004 10.28 Osteoporosis Diagnosis and Treatment when Medically Necessary for high -risk individuals, e.g. estrogen- deficient individuals, individuals with vertebral abnormalities, individuals on long -term glucocorticoid (steroid) therapy, individuals with primary hyperparathyroidism , and individuals with a family history of osteoporosis. 10.29 Dermatological Services. Health Plan will cover up to five (5) office visits per calendar year to a Plan Dermatologist for Medically Necessary covered services subject to Sections 3.28 and 3.47. No prior referral is required for these services. 10.30 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 mastectomy including lymphedemas. The length of stay will not be less than that determined by the treating Physician to be Medically "Necessary 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. 10.31 General anesthesia and hospitalization services to a Member who is under 8 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 medical 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 Health Plan is required. There is no coverage for diagnosis or treatment of dental disease. 10.32 Coverage for cleft lip and cleft palate for Members under 18 years of age. The coverage provided by this section is subject to the terms and conditions applicable to other benefits. XI. 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 Medical Services provided under this Contract insofar as practical, according to their best judgment, within the Limitations of such facilities and personnel as are then available, but Health Plan 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. 31 AV -G100 -2004 11.02 In the event of circumstances not reasonably within the control of Health Plan, such as complete or partial destruction of facilities, act of God, war, riot, civil insurrection, disability of a significant part of Hospital or participating medical personnel or similar causes, if the rendition of medical and Hospital Services provided under this Contract is delayed or rendered impractical, neither Health Plan, Participating Providers nor any Physician shall have any liability or obligation on account of such delay or failure to provide services; however, Health Plan shall make a good faith effort to arrange for the timely provision of covered services during such event. 11.03 Periodic physical examinations are limited to those which in the judgment of the Member's Primary Care Physician are essential to the maintenance of the Member's good health. 11.04 A Member shall select one Primary Care Physician upon enrollment. If the Member does not select a Primary Care Physician upon enrollment, a Primary Care Physician will be assigned by Health Plan for the Member. The Member may obtain assistance in making a selection by contacting Health Plan. , 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 (3) outpatient visits per calendar year, and each visit requires a Co- payment. (See Schedule of Co- payments and also Section 12.21) 11.07 Spinal manipulations will be covered only when Medically Necessary and prescribed by a Participating Physician or by self - referral to a Participating Physician. 11.08 The total benefit for Ventilator Dependent Care is limited to 100 calendar days lifetime maximum. 11.09 Inpatient Hospital care for a medical "Emergency," in -area or out -of -area, will only be covered when authorized by Health Plan, after the Member or the Hospital notifies Health Plan within 24 hours of admission or as soon as the Member is lucid and able to notify Health Plan of the admission following Emergency Care and services. 11.10 Other Health Care Facility (ies). All routine inpatient. services of Other Health Care Facilities (See Section 3.33), including Physician visits, physiotherapy, diagnostic imaging and laboratory work, are covered for a maximum of twenty (20) days per Calendar Year when a Member is admitted to such a facility, following discharge from a Hospital, for a condition that cannot be adequately treated with Home Health Care Services or on an ambulatory basis. 11.11 Physical, Occupational or Speech Therapy. Physical, Occupational or Speech therapies shall be limited as explained in Section(s) 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 shall be limited to reconstructive surgery to correct and repair a 32 AV -G100 -2004 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 forty (40) 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. XII. EXCLUSIONS FROM BASIC BENEFITS Medical Services and benefits for the following classifications 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 occupation; c) Commission of or attempted commission of an assault; commission or attempted commission of a crime punishable as a felony; 12.02 Cosmetic, surgical or non - surgical procedures which are undertaken primarily 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 body, 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 from date of birth; see also Section 10.11); hair 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 Services, or not within the benefits covered by Health Plan. 12.04 Dental Care, as defined in 3.11, for any condition except: 12.04.01 When such services are for the treatment of trauma related fractures of the jaw or facial bones or for the treatment of tumors; 12.04.02 Reconstructive jaw surgery for the treatment of deformities that are present and apparent at birth, provided the Member was continuously covered by Health Plan from date of birth to date of surgery; or 33 AV -G100 -2004 12.04.03 Full mouth extraction when required before radiation therapy. 12.05 Services related to the diagnosis/treatment of temporomandibular joint (TMJ) dysfunction except when Medically Necessary; all dental treatment for TMJ. 12.06 Mandibular and maxillary osteotomies except when Medically Necessary to treat conditions caused by congenital or developmental deformity, disease, or injury. 12.07 Medical supplies including, but not limited to: ostomy supplies, urinary catheter bags, pre- fabricated splints, Thromboemboletic /Support hose and all bandages. 12.08 Home monitoring devices and measuring devices (other than apnea monitors), and any other equipment or devices for use outside the Hospital. 12.09 Surgically implanted devices and any associated external devices, except for cardiac pacemakers, intraocular lenses, artificial joints and orthopedic hardware, and vascular grafts. Dental appliances, other corrective lenses and hearing aids, including the professional fee for fitting them are not covered. 12.10 Over - the - counter medications, all contraceptives (including drugs and devices), hypodermic needles and syringes and self - administered injectable drugs except chemotherapy for cancer patients, insulin and insulin syringes, and allergy serums. 12.11 Travel expenses including expenses for ambulance services to and from a Physician or Hospital except in accordance with Section 1.0.12. 12.12 Treatment for chronic alcoholism and chronic drug addiction, except those services offered as a basic health service (See Section 11.05). 12.13 Treatment for armed forces service - connected medical care (for both sickness and injury). 12.14 Custodial Care (as defined in Part III, Section 3.10) 12.15 Experimental and/or investigational procedures unless approved per Florida Administrative Code, Section 59B- 12.001. For the purposes of this Contract, a drug, treatment, device, surgery or procedure may be determined to be experimental and/or investigational if any of the following applies: a) the Food and Drug Administration (FDA) has not granted the approval for general use; or b) there are insufficient outcomes data available from controlled clinical trials published in peer - reviewed literature to substantiate its safety and effectiveness for the disease or injury involved; or c) there is no consensus among practicing physicians that the drug, treatment, therapy, procedure or device is safe or effective for the treatment in question or such drug, treatment, therapy, procedure or device is not the standard treatment, therapy, procedure or device 34 AV -G100 -2004 utilized by practicing physicians in treating other patients with the same or similar condition; or d) such drug, treatment, procedure or device is the subject of an ongoing Phase I or Phase II clinical investigation, or experimental or research arm of a Phase III clinical investigation, or under study to determine: maximum tolerated dosage(s), 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 service; television/radio; telephone charges; photographs; complimentary meals; birth announcements; take home supplies; travel expenses other than Medically Necessary ambulance services that are provided for in the covered benefits section; air conditioners; humidifiers; dehumidifiers; and air purifiers or filters. 12.17 Physical examinations or tests, such as premarital blood tests 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 Plan Members 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 keratoplasty, Lasik surgery or any other corneal surgical procedure to correct refractive error. 12.19 Hearing examinations for Plan 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. 12.21 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 All drugs, devices, and other forms of treatment related to a diagnosis of sexual dysfunction. 12.24 Infertility diagnosis, treatment, and supplies, including infertility testing, treatment of infertility, diagnostic procedures and artificial insemination, to determine 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 35 AV -G100 -2004 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. Drugs for the treatment of infertility are not covered. 12.25 Reversal of sterilization procedures. 12.26 Immunizations and medications for the purpose of foreign travel or employment. 12.27 Acupuncture, biofeedback, hypnotherapy, massage therapy, sleep therapy, sex therapy, behavioral training, cognitive therapy, and vocational rehabilitation. 12.28 Foot supports are not covered. These include orthopedic or specialty shoes, shoe build -ups, shoe orthotics, shoe braces, and shoe supports. Also excluded is routine foot care, including trimming of corns, calluses, and nails. 12.29 The Medical and Hospital Services for a donor or prospective donor who is a Health Plan Member when the recipient of an organ transplant is not a Health Plan Member. Coverage is provided for costs associated with the bone marrow donor - patients to the same extent as the insured recipient. The reasonable costs of searching for the bone marrow donor is limited to immediate family members and the National Bone Marrow Donor Program. 12.30 Diagnostic testing and treatment related to mental retardation or deficiency, learning disabilities, behavioral problems, developmental delays, Autism Spectrum Disorder or Attention Deficit Disorder. Expenses for remedial or special education, counseling, or therapy including evaluation and treatment of the above -listed conditions or behavioral training whether or not associated with manifest mental disorders or other disturbances. 12.31 Emergency room services for non - emergency purposes. (See Sections 3.14 and 3.15) 12.32 Hospital Services that are associated with excluded surgery or Dental Care. 12.33 Any non -Plan treatment received by a Member, except in the case of an Emergency or when specifically pre - authorized by Health Plan. (See Sections 3.14 and 3.15) 12.34 Speech therapy for delayed or abnormal speech pathology is not covered. 12.35 Alcohol or substance abuse rehabilitation, vocational rehabilitation, pulmonary rehabilitation, long term rehabilitation, or any other rehabilitation program. 12.36 Surgery for the reduction or augmentation of the size of the breasts except as required for the comprehensive treatment of breast cancer. 12.37 Termination of pregnancy unless deemed Medically Necessary by the Medical Director, subject to applicable state and federal laws or as specified in the Elective Termination of Pregnancy supplement to the Subscribing Group Contract. 36 AV -G100 -2004 12.38 Hospital Exclusion. If a Member elects to receive Hospital care from a non - Participating attending Physician or a non - Participating Hospital, then coverage is excluded for the entire episode of care, except when the admission was due to an Emergency or with prior written authorization of Health Plan. 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. 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, Health Plan 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, this Health Plan 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 which 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 gum). 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; stairmasters, rowing machines; free weights or resistance equipment. Also excluded are massage devices; portable whirlpool pumps, hot tubs, jacuzzis, sauna baths, swimming pools and similar equipment. 12.46 Removal of warts, moles, skin tags, lipomas, keloids, scars, and other benign lesions is not covered. XIII. COORDINATION OF BENEFITS 13.01 The services and benefits provided under this Contract are not intended and do not duplicate any benefit to which Members are entitled under any other Group Health Insurance, HMO, 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, Champus, Maritime Health Benefits, or similar state programs as permitted by contract, policy, or law. Health Plan coverage will be primary to Medicaid benefits. 37 AV -G100 -2004 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 100% of any eligible expense will be paid for or provided by all such plans combined. The Member shall execute and deliver such instruments and papers as may be required and do whatever else is necessary to secure such rights to Health Plan. Failure to do so will result in nonpayment of claims. Requested information should be provided to Health Plan within thirty (30) days of request or Member will be responsible for payment of claim. Information received after one (1) year from date of service will not be considered. 13.03 The standards governing the coordination of benefits are the following; pursuant to the provisions of Section 627.4235, Florida Statutes: 13.03.01 The benefits of a policy or plan which 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 those of the policy or plan of the parent whose birthday, excluding year of birth, falls later in that year; but b) If both parents have the same birthday, the benefits of the policy or plan which covered the parent for a longer period of time are determined before those of the policy or plan which covered the parent for a shorter period of time. However, if a policy or plan subject to the rule based on the birthday of the parents as stated above coordinates with an out -of -state policy or plan which contains provisions under which the benefits of a policy or plan which covers a person as a Dependent of a male are determined before those of a policy or plan which covers the person as a Dependent of a female and if, as a result, the policies or plans do not agree on the order of benefits, the provisions of the other policy or plan shall determine the order of benefits. 13.03.03 If two or more policies or plans cover a Dependent child of divorced or separated parents, benefits for the child are determined in this order: a) First, the policy or plan of the parent with custody of the child; b) Second, the policy or plan of the spouse of the parent with custody of the child; and c) Third, the policy or plan of the parent not having custody of the child. 38 AV -G100 -2004 However, if the specific terms of a court order state that one of the parents is responsible for the health care expenses of the child and if the entity obliged to pay or provide the benefits of the policy or plan of that parent has actual knowledge of those terms, the benefits of that policy or plan are determined first. This does not apply with respect to any claim determination period or plan or policy year during which any benefits are actually paid or provided before that entity has that actual knowledge. 13.03.04 The benefits of a policy or plan which covers a person as an employee who is neither laid off nor retired, or as that employee's Dependent, are determined before those of a policy or plan which covers that person as a laid off or retired employee or as that employee's Dependent. If the other policy or plan is not subject to this rule, and if, as a result, the policies or plans do not agree on the order of benefits, this Subsection shall not apply. 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 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 permitted 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 determination 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. d) Third, Medicare benefits. 13.03.07 If an individual is covered under a COBRA continuation plan as a result of the purchase of coverage as provided under the Consolidation Omnibus Budget Reconciliation Act of 1987 (Pub.L. No. 99 -272), and also under another group plan, the following order of benefits applies: a) First, the plan covering the person as an employee, or as the employee's Dependent. 39 AV -G100 -2004 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 implementing the terms of the Coordination of Benefits provision of this agreement, Health Plan 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 Health Plan deems to be necessary for such purposes. 13.05 Whenever payments which should have been made under this plan in accordance with this provision have been made under any other plans, Health Plan shall have the right, exercisable alone and in its sole discretion, to pay over to any organizations making such other payments any amounts Health Plan shall determine to be warranted in order to satisfy the intent of this provision, and amounts so paid shall be deemed to be Benefits paid under this Plan. 13.06 All treatments must be Medically Necessary and comply with all terms, conditions, Limitations, and Exclusions of this Plan even if Health Plan is secondary to other coverage and the treatment is covered under the other coverage. XIV. REIMBURSEMENT In the event that Health Plan provides medical benefits or payments to a Member who suffers injury, disease, or illness by virtue of a negligent act or omission by a third party, Health Plan is entitled to reimbursement from the Subscriber in accordance with 768.76 (4), Florida Statutes. Member may be asked to provide a written assignment to Health Plan of Member's rights to all claims, demands, and rights to recovery that Member may have against the third party. Health Plan may take any action it deems necessary to protect its rights to recover the amount of any payments made by Health Plan, including the right to bring suit in Member's name. Member shall execute and deliver any and all instruments and papers as may be required by Health Plan and do whatever else is necessary to secure such recovery rights of Health Plan. Member shall hold such proceeds in trust for the benefit of Health Plan and pay them to Health Plan upon demand if the proceeds have been paid directly to the Member. XV. DISCLAIMER OF LIABILITY 15.01 Neither Subscribing Group nor its agents, servants or employees, nor any Member is the agent or representative of Health Plan, and none of them shall be liable for any acts or omissions of Health Plan, its agents or employees or of a Plan Hospital, or a Participating Physician, or any other person or organization with which Health Plan has made or hereafter shall make arrangements for the performance of services under this Contract. 40 AV -GI00 -2004 15.02 Neither Subscribers of Subscribing Group nor their Dependents shall be liable to Health Plan or Participating Providers except as specifically set forth herein, provided all procedures set forth herein are followed. 15.03 Neither Health Plan nor its agents, servants or employees, nor any Member is the agent or representative of the Subscriber Group, and none of them shall be liable for any acts or omissions of Subscriber Group, its agents or employees or any other person representing or acting on behalf of Subscriber Group. 15.04 Health Plan 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 Health Plan. Health Plan 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 render to Members. Therefore, Health Plan shall not be liable for any negligent act or omission committed by any independent practicing Physicians, nurses, or medical personnel, nor 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, provide Medical Services to a Member of the Health Plan. Furthermore, Health Plan shall not be vicariously liable for any negligent act or omission of any of these independent health care professionals who treat a Member(s) of Health Plan. 15.05 Certain Members may, for personal reasons, refuse to accept procedures or treatment recommended by Participating Physicians. Participating Physicians may regard such refusal to accept their recommendations as incompatible with the continuance of the Physician/patient relationship and as obstructing the provision of proper medical care. If a Member refuses to accept the medical treatment or procedure recommended by the Participating Physician and if, in the judgment of the Participating Physician, no professionally acceptable alternative exists or if an alternative treatment does exist but is not recommended by the Participating Physician, the Member shall be so advised. If the Member continues to refuse the recommended treatment or procedure, Health Plan may terminate the Member's coverage under this Contract as set forth in Part IX, Subsection 9.01.05. XVI. GRIEVANCE PROCEDURE 16.01 Urgent Care Claims. 16.01.01 Initial Claim. An Urgent Care Claim shall be deemed to be filed on the date received by Health Plan. AvMed shall notify the Claimant of the Health Plan's benefit determination (whether adverse or not) as soon as possible, taking into account the medical exigencies, but not later than 72 hours after the Health Plan receives, either orally or in writing, the Urgent Care Claim, unless the Claimant fails to provide sufficient information to determine whether, or to what extent, benefits are covered or payable under the Health Plan. If such information is not provided, AvMed shall notify the Claimant as soon as possible, but not later than 24 hours after the Health 41 AV -G100 -2004 Plan receives the Claim, of the specific information necessary to complete the Claim. The Claimant shall be afforded a reasonable amount of time, taking into account the circumstances, but not less than 48 hours, to provide the specified information. AvMed shall notify the Claimant of the Health Plan's benefit determination as soon as possible, but in no case later than 48 hours after the earlier of: 1) The Health Plan's receipt of the specified information; or 2) The end of the period afforded the Claimant to provide the specified additional information. If the Claimant fails to supply the requested information within the 48 -hour period, the Claim shall be denied. AvMed may notify the Claimant of its benefit determination orally or in writing. If the notification is provided orally, a written or electronic notification, meeting the requirements of Section 16.05 shall be provided to the Claimant no later than 3.days after the oral notification. 16.01.02 Appeal. A Claimant may appeal an Adverse Benefit Determination with respect to an Urgent Care Claim within 180 days of receiving the Adverse Benefit Determination. AvMed shall notify the Claimant, in accordance with Section 16.07, of the Health Plan's benefit determination on review as soon as possible, taking into account the medical exigencies, but not later than 72 hours after the Health Plan 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 823 Gainesville, Florida 32602 -0823 Telephone: 1- 800 - 882 -8633 Fax: (352) 337-8612 AvMed Member Services — South P.O. Box 569008 Miami, Florida 33256 -9906 Telephone: 1-800-882-8633 Fax: (305) 671 -4736 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 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 the AHCA or DFS at any time to inform them of an unresolved grievance. The Subscriber Assistance Program will not hear a grievance if the Member has not completed the entire AvMed Grievance process nor if the Member has instituted an action pending in the state or federal court. If you need further assistance, you may contact: Subscriber Assistance Panel (SAP) Agency for Health Care Administration HMO Section 42 AV -G100 -2004 2727 Mahan Drive, Mail Stop 26 Tallahassee, Florida 32308 Telephone 1- 888 -419 -3456 or 850- 921 -5458 The Florida Department of Financial Services 200 East Gaines Street Tallahassee, Florida 32399 Telephone 1- 800 - 342 -2762 16.02 Pre - Service Claims. 16.02.01 Initial Claim— A Pre - Service Claim shall be deemed to be filed on the date received by Health Plan. AvMed shall notify the Claimant of the Health Plan's benefit determination (whether adverse or not) within a reasonable period of time appropriate to the medical circumstances, but not later than 15 days after the Health Plan receives the Pre - Service Claim. The Health Plan 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 the Health Plan'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 date by which the Health Plan expects 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 the Plan'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 Claim for benefits not later than five (5) days following such failure. The Plan's period for making the benefit determination shall be tolled from the date on which the notification of the extension is sent to the Claimant until the date 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 the Health Plan's determination on review within a reasonable period of time. Such notification shall be provided not later than 30 days after the Health Plan receives the Claimant's request for review of the Adverse Benefit Determination. You may submit an appeal to: AvMed Member Services - North AvMed Member Services — South P.O. Box 823 P.O. Box 569008 Gainesville, Florida 32602 -0823 Miami, Florida 33256 -9906 Telephoner 1- 800 - 882 -8633 Telephone: 1- 800 - 882 -8633 Fax: (352) 337 - 8612 Fax: (305) 671 -4736 43 AV-GIOO -2004 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 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 the AHCA or DFS at any time to inform them of an unresolved grievance. The Subscriber Assistance Program will not hear a grievance if the Member has not completed the entire AvMed Grievance process nor if the Member has instituted an action pending in the state or federal court. If you need further assistance, you may contact: Subscriber Assistance Panel (SAP) Agency for Health Care Administration HMO Section 2727 Mahan Drive, Mail Stop 26 Tallahassee, Florida 32308 Telephone 1- 888 -419 -3456 or 850- 921 -5458 The 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 Health Plan. AvMed shall notify the Claimant, in accordance with Section 16.05 of the Health Plan's Adverse Benefit Determination within a reasonable period of time, but not later than 30 days after the Health Plan receives the Post - Service Claim. The Health Plan 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 the Health Plan's control and notifies the Claimant, before the expiration of the initial 30 -day period, of the circumstances requiring the extension of time and the date by which the Health Plan expects to render a decision. If such an extension is necessary because the Claimant failed to submit the information necessary to decide the Post- Service Claim, the notice of extension shall specifically describe the required information, and the Claimant shall be afforded at least 45 days from receipt of the notice within which to provide the specified information. The Plan's period for making the benefit determination shall be tolled from the date on which the notification of the extension is sent to the Claimant until the date 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. 16.03.02 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. 44 AV -G100 -2004 AvMed shall notify the Claimant, in accordance with Section 16.07, of the Health Plan's determination on review within a reasonable period of time. Such notification shall be provided not later than 60 days after the Health Plan receives the Claimant's request for review of the Adverse Benefit Determination. You may submit an appeal to: AvMed Member Services — North AvMed Member Services — South P.O. Box 823 P.O. Box 569008 Gainesville, Florida 32602 -0823 Miami, Florida 33256 -9906 Telephone: 1- 800 - 882 -8633 Telephone: 1- 800 - 882 -8633 Fax: (352) 337 -8612 Fax: (305) 671 -4736 If you are not satisfied with AvMed's final decision, you may contact the Florida Agency for Health Care Administration (AHCA) or the Department of Financial Services (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 the AHCA or DFS at any time to inform them of an unresolved grievance. The Statewide Provider and Subscriber Assistance Program will not hear a grievance if the Member has not completed the entire AvMed Grievance process nor if the Member has instituted an action pending in the state or federal court. If you need further assistance, you may contact: Subscriber Assistance Panel (SAP) Agency for Health Care Administration HMO Section 2727 Mahan Drive, Mail Stop 26 Tallahassee, Florida 32308 Telephone 1- 888- 419 -3456 or 850- 921 -5458 The 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 the Health Plan 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. AvMed shall notify the Claimant, in accordance with Section 16.05, of the Adverse Benefit Determination at a time sufficiently in advance of the reduction or termination to allow 45 AV -G100 -2004 the Claimant to appeal and obtain a determination on review of the Adverse Benefit Determination before the benefit is reduced or terminated. 16.04.02 Any request by a Claimant to extend the course of treatment beyond the period of time or number of treatments that relates to an Urgent Care Claim shall be decided as soon as possible, taking into account the medical exigencies, and AvMed shall notify the Claimant of the benefit determination, whether adverse or not, within 24 hours after the Health Plan receives the Claim, provided that any such Claim is made to the Plan at least 24 hours before the expiration of the prescribed period of time or number of treatments. Notification and appeal of any Adverse Benefit Determination concerning a request to extend the course of treatment, whether involving an Urgent Care Claim or not, shall be made in accordance with the remainder of Section 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: 16.05.01 The specific reason(s) for the Adverse Benefit Determination. 16.05.02 Reference to the specific Health Plan provisions on which the determination is based. 16.05.03 A description of any additional material or information necessary for the Claimant to perfect the Claim and an explanation of why such material or information is necessary. 16.05.04 A description of the Health Plan's review procedures and the time limits applicable to such procedures, including, when applicable a statement of the Claimant's right to bring a civil action under section 502(a) of the Employee Retirement Income Security Act of 1974, as amended (ERISA), following an Adverse Benefit Determination on final review. 16.05.05 If an internal rule, guideline, protocol, or other similar criterion was relied upon in making the Adverse Benefit Determination, either the specific rule, guideline, protocol, or other similar criterion or a statement that such rule, guideline, protocol or other similar criterion was relied upon in making the Adverse Benefit Determination and that a copy shall be provided free of charge to the Claimant upon request. 16.05.06 If the Adverse Benefit Determination is based on whether the treatment or service is Experimental and/or Investigational or not Medically Necessary, either an explanation of the scientific or clinical judgment for the determination, applying the terms of the Health Plan to the Claimant's medical circumstances, or a statement that such explanation shall be provided free of charge upon request. 16.05.07 In the case of an Adverse Benefit Determination involving an Urgent Care Claim, a description of the expedited review process applicable to such Claim. 46 AV-G100-2004 16.06 Review Procedure Upon Appeal. The Health Plan's appeal procedures shall include the following substantive procedures and safeguards: 16.06.01 Claimant may submit written comments, documents, records, and other information relating to the Claim. 16.06.02 Upon request and free of charge, the Claimant shall have reasonable access to and copies of any Relevant Document. 16.06.03 The appeal shall take into account all comments, documents, records, and other information the Claimant submitted relating to the Claim, without regard to whether such information was submitted or considered in the initial Adverse Benefit Determination. 16.06.04 The appeal shall be conducted by an appropriate named fiduciary of the Health Plan 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. 16.06.05 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, drug, or other item is Experimental and/or Investigational or not Medically Necessary, the appropriate named fiduciary shall consult with a Health Care Professional who has appropriate training and experience in the field of medicine involved in the medical judgment. 16.06.06 The appeal shall provide for the identification of medical or vocational experts whose advice was obtained on behalf of the Health Plan in connection with a Claimant's Adverse Benefit Determination, without regard to whether the advice was relied upon in making the Adverse Benefit Determination. 16.06.07 The appeal shall provide that the Health Care Professional engaged for purposes of a consultation in Subsection 16.06.05 shall be an individual who is neither an 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. 16.06.08 In the case of an Urgent Care Claim, there shall be an expedited review process pursuant to which: a) a request for an expedited appeal of an Adverse Benefit Determination may be submitted orally or in writing by the Claimant; and b) all necessary information, including the Health Plan's benefit determination on review, shall be transmitted between the Health Plan and the Claimant by telephone, facsimile, or other available similarly expeditious methods. 16.07 Manner and _Content of Appeal Notification. AvMed shall provide a Claimant with written or electronic notification of the Health Plan's benefit determination upon review. 47 AV -G100 -2004 16.07.01 In the case of an Adverse Benefit Determination, the notification shall set forth, in a manner calculated to be understood by the Claimant, all of the following, as appropriate: a) The specific reason(s) for the Adverse Benefit Determination. b) Reference* to the specific Health Plan provisions on which the Adverse Benefit Determination is based. c) A statement that the Claimant is entitled to receive, upon request, and free of charge, reasonable access to, and copies of any Relevant Document. d) A statement describing any voluntary appeal procedures offered by the Health Plan and the Claimant's right to obtain the information about such procedures and a statement of the Claimant's right to bring an action under ERISA Section 502(a) when applicable. e) If an internal rule, guideline, protocol, or other similar criterion was relied upon in making the Adverse Benefit Determination, either the specific rule, guideline, protocol, or other similar criterion or a statement that such rule, guideline, protocol, or other similar criterion was relied upon in making the Adverse Benefit Determination and that a copy shall be provided free of charge to the Claimant upon request. f) If the Adverse Benefit Determination is based on whether the treatment or service is Experimental and/or Investigational or not Medically Necessary, either an explanation of the scientific or clinical judgment for the determination, applying the terms of the Health Plan to the Claimant's medical circumstances, or a statement that such explanation shall be provided free of charge upon request. XVIL MISCELLANEOUS 17.01 Contracting Parties. By executing this Contract, Subscribing Group and Health Plan agree to make the medical 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 Health Plan and Subscribing Group, without the consent or concurrence of the Members. By electing or accepting medical and Hospital or other benefits hereunder, all Members legally capable of contracting and the legal representatives of all Members incapable of contracting, agree to all terms, conditions, and provisions hereof. No changes or amendments to this Contract shall be valid unless approved by an executive officer of Health Plan and endorsed herein or attached hereto. No agent has authority to change this Contract or to waive any of its provisions. 48 AV -G100 -2004 17.02 Certificate of Coverage. Health Plan 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 Health Plan such applications or other forms or statements as Health Plan may reasonably request. If Member or applicant fails to provide accurate information which Health Plan deems material then, upon ten (10) days written notice, Health Plan may deny coverage and/or membership to such individual. Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of Claim or an application containing any false, incomplete, or misleading information is guilty of a felony, punishable as provided by Florida Statutes. 17.04 Membership Cards. Cards issued by Health Plan to Members pursuant to this Contract are for purposes of identification only. Possession of a Health Plan identification card confers no right to health services or other benefits under this Contract. To be entitled to such services or benefits the holder of the card must, in fact, be a Member on whose behalf all applicable charges under this Contract have actually been paid and accepted by Health Plan. 17.05 Waiver. A Claim which has not been timely filed with Health Plan within one (1) year of date of service, shall be considered waived. 17.06 Non - Waiver. The failure of Health Plan 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 Subscriber Group of any of the provisions herein, shall not be construed to be a waiver of such provisions nor shall it affect the validity of this Contract or any part thereof or the right of Health Plan to thereafter enforce each and every such provision. 17.07 Plan Administration. Health Plan may 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 provided, should be sent by United States mail, postage prepaid, addressed as follows: If to Health Plan, to: AvMed Health Plans P. O. Box 749 Gainesville, Florida 32602 -0749 (OR if from a Member to Health Plan 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 Health Plan on the enrollment or change of address notification. If to Subscribing Group: To the address provided in the Group Master Application. 49 AV -G100 -2004 17.09 Gender. Whenever used, the singular shall include the plural and the plural the singular and the use of any gender shall include all genders. 17.10 Clerical Errors. Clerical error(s) shall neither deprive any individual Member of any benefits or coverage provided under this Group Contract nor shall such error(s) 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 Claims 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 (3) days after receipt and receive a full refund of the deposit paid, if any, unless the services of Health Plan were utilized during the three (3) days. If this Contract is not returned within three (3) 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 sums due from the Subscribing Group under the terms of this Contract shall be increased by the amount of such premium tax or surcharge. 17.13 Entirety of Contract. This Agreement and all applicable Schedules, Exhibits, Riders and any other attachments and endorsements, constitute the entire Contract between the Subscribing Group and Health Plan. No modification (or oral representation) of this Group Contract shall be of any force or effect unless it is in writing and signed by both parties. 17.14 Rate Letter. The "rate letter" is Health Plan's formal notice to the Subscribing Group of the premium rates applicable to the group, the conditions under - which the rates are valid, the premium payment terms and due dates, the additional charge which will apply to all late premium payments, Health Plan's reservation of the right 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 Health Plan, the applicable employer- employee contribution to the premium payment and the charge for other optional, supplemental benefits selected by the group, if any. 17.15 Third Party Beneficiary. This Contract is entered into exclusively between the Subscribing Group and Health Plan. This Contract is intended only to benefit the Subscribing Group and the Member(s) and does not confer any rights on any other third parties. 17.16 Assignment. This Contract, and all rights and benefits related thereto, may not be assigned by the Subscribing Group or the Member(s) without written consent of Health Plan. 17.17 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 Florida and the United States. 50 AV -G100 -2004 17.18 ERISA. When this Contract is purchased by the Subscribing Group to provide benefits under a welfare plan governed by the Employee Retirement Income Security Act (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. 51 AV -G100 -2004 AvMED H E A L T H P L A N S Contract Number (s): Subscribing Group Name: Effective Date: AVMED, INC. d /b /a AVMED Health Plans Group Medical and Hospital Service Contract Group Master Application 105345 CITY OF SOUTH MIAMI October 1, 2005 Group Contract This Group Contract provides the benefits checked below: BASIC OPTION ($15 Specialist) ❑ $0 per Admission ❑ $100 per Admission ❑ $250 per Admission ❑ $250 per Day, Days 1 -5 Benefit Desians BASIC OPTION ($35 Specialist) ❑ $250 per Day, Days 1 -5 ❑ $250 per Admission ❑ $300 per Day, Days 1 -5 BASIC OPTION ($25 Specialist) STANDARD OPTION ($10 Specialist) ❑ $0 per Admission ® $0 per Admission ❑ $100 per Admission ❑ $100 per Admission ❑ $250 per Admission ❑ $100 per Day, Days 1 -5 ❑ $250 per Day, Days 1 -5 ❑ $250 per Admission BASIC OPTION ($30 Specialist) STANDARD OPTION ($20 Specialist) ❑ $250 per Day, Days 1 -5 ❑ $100 per Day, Days 1 -5 ❑ $250 per Admission ❑ $250 per Admission Form: AV- STD -OA -05 OTHER LARGE GROUP BENEFITS ❑ $15/$250 PER Day, Days 1 -5 ❑ $25/$500 PER Day, Days 1 -5 ❑ $20/$250/10% ❑ $20/$250/20% ❑ $25/$500/20% ❑ $25/$750/20% ❑ $30/$750/20% CORE ❑ $15/$250/25 -40% ❑ $15/$500/15 -30% ❑ $25/$250/25 -40% ❑ $15/$1000/10 -25% ❑ $15/$100/30 -40% ❑ $25/$100/30 -40% CDHP ❑ Consumer - 1 A ❑ Consumer- 1 B ❑ Consumer - 1 C If selected, the following optional and supplemental coverage is also provided, as described in the amendments to this contract. ❑ Open Access Form: AV- 1Z Prescription Coverage Form: AV- G100 -RX- 7/20/35/75 -OC -05 ❑ Vision Coverage Form: AV- ❑ Dental Coverage (ADP) Form: AV- ►1 ►1 ►4, g—n ■ ►4 (All Dental Plans are administered by American Dental Plan) Elective Termination of Pregnancy Form: AV- G100- ETP -R -97 Mental Health /Partial Hospitalization Form: AV- G100- MH /PH -$0 per admit -04 ❑ Group declines mental health benefits (Section 627.668, Florida Statutes) Substance Abuse Form: AV- SA -R -98 ❑ Group declines substance abuse benefits (Section 627.669, Florida Statutes) Durable Medical Equipment Form: AV- G100 -DME- 2000 -R -01 Waiver of Co- payment — Coverage for Mammograms Form: AV- Other ® Student Eligibility ® Domestic Partner Form: AV- STUDENT ELIGIBILITY -13-02 Form: AV- DP- 12 -R -02 AVMED, INC. d /b /a AVMED Health Plans Group Medical and Hospital Service Contract Group Master Application, continued ELIGIBILITY An employee of the Subscribing Group must be employed a minimum of 30 hours per week to become eligible for coverage under this Contract. An employee becomes eligible for coverage under this Contract (Check and /or fill in, as appropriate) ❑ on the date of hire ❑ consecutive days after the date of hire. ® on the first day of the month following 0 consecutive days after the date of hire. ® other: Retirees covered. TERMINATION Termination of coverage under this Contract shall become effective: ❑ on the date the employee's employment is terminated. ® on the last date of the month in which the employee's employment is terminated. ❑ on the date the Group Contract is terminated. ❑ other: 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, 2005 and may be renewed annually, not later than the anniversary date, upon mutual agreement of the parties. The Contract period begins at 12:01 a.m. Eastern Standard Time on the effective date or on the anniversary date, if a renewal. This 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, 2005. Subsequent payments are due on the first 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. AVMED, INC. d /b /a AVMED Health Plans Group Medical and Hospital Service Contract Group Master Application, continued MONTHLY CHARGES Monthly Membership Charges SubscriberOnly .................................................................................................... ............................... $ 332.40 Subscriberplus Spouse ........................................................................................ ............................... Z� 004.00 Subscriber plus One Dependent (No Spouse) ..................................................... ............................... $ 589.07 Subscriber plus Two or More Dependents ........................................................... ............................... $ 589.07 Subscriber plus Spouse and One or More Dependents ........................................ ............................... $ 981.83 ❑ Other ............................................................................................................ ............................... $ The provisions contained in the Schedule of Co- payments 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, 2005. Subscribing Group: By: Signature Name Title Date: AV -G 100 - APP -04 MP -2027 (12/04) AVMED, Inc. d /b /a AVMED Health P ns By: Signat El is 6'10 V6kr z'R-- Name D,Y-e-�9- of TitIcU Date: -11 zq l m - AvNIED HEALTtt PLANS STANDARD OPTION O -ADMIT Benefit Summary SCHEDULE OF BENEFITS COST TO MEMBER OUT -OF- POCKET MAXIMUM $1,500 1ND1VWUAL 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 gynecological examination when performed by Primary Care Physician ■ Maternity- outpatient visits ■ 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 AVMED SPECIALISTS' ■ Office visits $10 per visit SERVICES N Annual gynecological examination when performed by a participatin� Specialty Health Care Physician HOSPITAL Inpatient care at Participating Hospitals includes: NO CHARGE • Room and board - unlimited days (semi - private) • Physicians', specialists' and surgeons' services • Anesthesia, use of operating and recovery rooms, oxygen, drugs and medication • Intensive care unit and other special units, general and special duty nursing • Laboratory and diagnostic imaging • Required special diets • Radiation and inhalation therapies OUTPATIENT SERVICES ■ Outpatient surgeries, including cardiac catheterizations NO CHARGE and angioplasty • Outpatient therapeutic services, including: • Drug infusion therapy $100 Co- payment plus applicable facility charge • Injectable Drugs (Co- payment for Injectable Drug $75 Co- payment waived if incidental to same -day chemotherapy infusion/treatment) OUTPATIENT DIAGNOSTIC ■ CAT Scan, PET Scan, NM $25 per test TESTS M Other diagnostic imaging tests $10 per test EMERGENCY SERVICES An emergency is the sudden and unexpected onset of a condition requiring immediate medical or surgical care. (Co- payment waived if admitted) $75 Co- payment • Emergency services at Participating Hospitals $100 Co- payment • 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 $60 Co- payment Care facility AV- STD -OA -05 MP- 3410 (10105) Benefit ,Summary, continued MENTAL HEALTH ■ 20 outpatient visits $25 per visit FAMILY PLANNING 0 Voluntary family planning services $10 per visit FACILITIES AND ■ Sterilization $100 Co- payment ALLERGY TREATMENTS ■ Injections $10 per visit CARDIAC REHABILITATION ■ Skin testing $50 per course of testing AMBULANCE _ N Ambulance transport for emergency services $100 Co- payment ■ Non - emergent ambulance services are covered when the Benefits limited skill of medically trained personnel is required and the Benefits limited Member cannot be safely transported by other means to $1,500 per PHYSICAL, SPEECH, AND M Short-term physical, speech or occupational therapy for $10 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 $25 per day FACILITIES AND Year when prescribed by physician and authorized by NO CHARGE REHABILITATION CENTERS AvMed $50 per episode of illness CARDIAC REHABILITATION Cardiac rehabilitation is covered for the following conditions: $20 per visit ORTHOTIC APPLIANCES • Acute myocardial infarction • Percutaneous transluminal coronary angioplasty (PTCA) Benefits limited • Repair or replacement of heart valves Benefits limited • Coronary artery bypass graft (CABG), or to $1,500 per • Heart transplant Contract Year PROSTHETIC DEVICES Prosthetic devices are limited to: NO CHARGE • Artificial limbs • Artificial joints • Ocular prostheses FOR ADDITIONAL INFORMATION, PLEASE CALL: 1- 800- 88 -AVMED (1. 800 - 882 -8633) THIS SCHEDULE OF BENEFITS IS NOT A CONTRACT. FOR SPECIFIC INFORMATION ON BENEFITS, EXCLUSIONS AND LIMITATIONS, PLEASE SEE YOUR AVMED GROUP MEDICAL AND HOSPITAL SERVICE CONTRACT. AV- STD -OA -05 MP- 3410 (10105) Coverage is limited to 18 visits per Contract Year HOME HEALTH CARE Limited to 60 skilled visits per calendar year NO CHARGE DURABLE MEDICAL Equipment includes: $50 per episode of illness EQUIPMENT AND ■ Hospital beds ORTHOTIC APPLIANCES ■ Walkers ■ Crutches Benefits limited ■ Wheelchairs to $500 per Orthotic appliances are limited to: Contract Year ■ Leg, arm, back, and neck custom -made braces PROSTHETIC DEVICES Prosthetic devices are limited to: NO CHARGE • Artificial limbs • Artificial joints • Ocular prostheses FOR ADDITIONAL INFORMATION, PLEASE CALL: 1- 800- 88 -AVMED (1. 800 - 882 -8633) THIS SCHEDULE OF BENEFITS IS NOT A CONTRACT. FOR SPECIFIC INFORMATION ON BENEFITS, EXCLUSIONS AND LIMITATIONS, PLEASE SEE YOUR AVMED GROUP MEDICAL AND HOSPITAL SERVICE CONTRACT. AV- STD -OA -05 MP- 3410 (10105) AvMED 14 E A 1 T It P L A N 5 Prescription Drug Benefits its $7/20/35/75 CO- PAYMENT with Contraceptives DEFINITIONS "Brand" drug means a Prescription Drug that is usually manufactured and sold under a name or trademark by a drug manufacturer or a drug that is identified as a Brand drug by AvMed. AvMed delegates determination of Generic/Brand status to our Pharmacy Benefits Manger. "Brand Additional Charge" means the additional charge that must be paid if you or your physician choose a Brand drug when a Generic equivalent is available. The charge is the difference between the cost of the Brand drug and the Generic drug. This charge must be paid in addition to the applicable Brand Co- payment (Preferred or Non - Preferred). "Generic" drug means a drug that has the same active ingredient as a Brand drug or is identified as a Generic drug by AvMed's Pharmacy Benefits Manager. "Injectable Drug" is a medication that has been approved by the Food and Drug Administration (FDA) for administration by one or more of the following routes: intramuscular injection, intravenous injection, intravenous infusion, subcutaneous injection, intrathecal injection, intrarticular injection, intracavernous injection or intraocular injection. Pre - Authorization is required for all Injectable Drugs. "Participating Pharmacy" means a pharmacy (either retail, mail order or specialty pharmacy) that has entered into an agreement with AvMed to provide Prescription Drugs to AvMed Members and has been designated by AvMed as a Participating Pharmacy. "Preferred Drug List" means the listing of preferred medications as determined by AvMed's Pharmacy and Therapeutics Committee based on clinical efficacy, relative safety and cost in comparison to similar medications within a therapeutic class. This multi- tiered list establishes different levels of Co- payment for medications within therapeutic classes. As new medications become available, they may be considered excluded until they have been reviewed by AvMed's Pharmacy and Therapeutics Committee. "Prescription Drug" means a medication that has been approved by the FDA and that can only be dispensed pursuant to a prescription according to state and federal law. "Pre - Authorization" means the process of obtaining approval for certain Prescription Drugs (prior to dispensing) according to AvMed's guidelines. The prescribing physician must obtain approval from AvMed. The list of Prescription Drugs requiring Pre - Authorization is subject to periodic review and modification by AvMed. A copy of the list of medications requiring Pre - Authorization and the applicable criteria are available from Member Services or from the AvMed website. "Self-Administered Injectable Drug" is a medication that has been approved by the FDA for self - injection and is administered by subcutaneous injection or a medication for which there are instructions to the patient for self - injection in the manufacturer's prescribing information (package insert). Pre- Authorization is required for all Self- Administered Injectable Drugs. 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 Self- Administered Injectable Drugs to AvMed's specialty pharmacy. Present your prescription along with your AvMed identification card. Pay the following Co- payment (as well as the Brand Additional Charge if you or your physician choose a Brand product when a Generic equivalent is available). Tier 1 Preferred Generic Drugs: $ 7.00 Co- payment Tier 2 Preferred Brand Drugs: $ 20.00 Co- payment Tier 3 Non - Preferred Brand or Generic Drugs: $ 35.00 Co- payment Tier 4 Self- Administered Injectable Drugs: $ 75.00 Co- payment ORDERING YOUR PRESCRIPTIONS THROUGH THE MAIL Mail service is a benefit option for maintenance medications needed for chronic or long -term health conditions. It is best to get an initial prescription filled at your retail pharmacy. Ask your physician for an additional prescription for up to a 90 -day supply of your medication to be ordered through mail service. Up to 3 refills are allowed per prescription. Pay the following Co- payment (as well as the Brand Additional Charge if you or your physician choose a Brand product when a Generic equivalent is available). Tier 1 Preferred Generic Drugs: $ 21.00 Co- payment Tier 2 Preferred Brand Drugs: $ 60.00 Co- payment Tier 3 Non - Preferred Brand or Generic Drugs: $105.00 Co- payment Tier 4 Self- Administered Injectable Drugs are not available through mail service A V -G 100 -RX- 7/20/35/75 -OC -05 MP -3460 (10105) Prescription .Drug Benefits, continued WHAT IS COVERED? ■ Your Prescription Drug coverage includes outpatient medications (including contraceptives) that require a prescription and are prescribed by your AvMed physician in accordance with AvMed's coverage criteria. AvMed reserves the right to make changes in coverage criteria for covered products and services. Coverage criteria are medical and pharmaceutical protocols used to determine payment of products and services and are based on independent clinical practice guidelines and standards of care established by government agencies and medical/pharmaceutical societies. • Your retail Prescription Drug coverage includes up to a 30 -day supply of a medication for the listed Co- payment. Your prescription may be refilled via retail or mail order after 75% of your previous fill has been used. You also have the opportunity to obtain a 90- day supply of medications used for chronic conditions including, but not limited to, asthma, cardiovascular disease and diabetes, from the retail pharmacy for the applicable Co- payment per 30 -day supply. However, Pre - Authorization may be required for covered medications. • Your mail -order Prescription Drug coverage includes up to a 90 -day supply of a routine maintenance medication for the listed Co- payment. If the amount of medication is less than a 90 -day supply, you will still be charged the listed mail order Co- payment. • Your Self - Administered Injectable Drug coverage extends to many injectable drugs approved by. the FDA. These drugs must be prescribed by a physician and dispensed by a retail or specialty pharmacy. The Co- payment levels for Self - Administered Injectable Drugs apply regardless of provider. This means that you are responsible for the appropriate Co- payment whether you receive your Self- Administered Injectable Drug from the pharmacy, at the doctor's office or during home health visits. Self - Administered Injectable Drugs are limited to a 30 -day supply • Your Prescription Drug coverage includes coverage for injectable contraceptives. There is a Co- payment of $30 for each injection. If there is an office visit associated with the injection, there will be an additional Co- payment required for the office visit. • Quantity limits are set in accordance with FDA approved prescribing limitations, general practice guidelines supported by medical specialty organizations, and/or evidence - based, statistically valid clinical studies without published conflicting data. This means that a medication- specific quantity limit may apply for medications that have an increased potential for over- utilization or an increased potential for a Member to experience an adverse effect at higher doses. QUESTIONS? Call your AvMed Member Services Department at: 1- 800 -88 -AvMed (1- 800 - 882 -8633) EXCLUSIONS AND LIMITATIONS ■ Drugs or medications which do not require a prescription (i.e. over- the - counter medications) or when a non - prescription alternative is available ■ Medical supplies, including therapeutic devices, dressings, appliances, and support garments ■ Replacement Prescription Drug products resulting from a lost, stolen, expired, broken, or destroyed prescription order or refill ■ Diaphragms and other contraceptive devices ■ Fertility drugs ■ Medications or devices for the diagnosis or treatment of sexual dysfunction ■ Medications for dental purposes, including fluoride medications ■ Prescription and non - prescription vitamins and minerals except prenatal vitamins ■ Nutritional supplements ■ Immunizations ■ Allergy serums, medications administered by the Attending Physician to treat the acute phase of an illness and chemotherapy for cancer patients are covered in accordance with the Group Medical and Hospital Service Contract and may be subject to Co- payments or Co- insurance as outlined on the Schedule of Benefits Investigational and experimental drugs (except as required by Florida statute) ■ Cosmetic products, including, but not limited to, hair growth, skin bleaching, sun damage and anti - wrinkle medications ■ Nicotine suppressants and smoking cessation products and services ■ Prescription and non - prescription appetite suppressants and products for the purpose of weight loss ■ Compounded prescriptions, except pediatric preparations ■ Medications and immunizations for non - business related travel, including Transdermal Scopolamine Filling a prescription at a pharmacy is not a claim for benefits and is not subject to the Claims and Appeals procedures under ERISA. However, any medicines that require Pre - Authorization will be treated as a claim for benefits subject to the Claims and Appeals Procedures, as outlined in the Group Medical and Hospital Service Contract. A V -G 100 -RX- 7/20/35/75 -OC -05 MP -3460 (10105) AvMED HEALTH PLANS 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, paid at 100 %, shall be provided by the Plan when a member is admitted to a Participating Hospital or Participating Health Care Facility as ,a registered bed patient. • Partial Hospitalization for mental health services is a Covered Service when it is provided in lieu of inpatient hospitalization and is combined with the inpatient hospital benefit. Two days of Partial Hospitalization will count as one day toward the inpatient Mental Health Benefit subject to member copayment as noted above. AV- G100- Nf"H -$0 per admit -04 MP -3519 (10/04) AvNIED HEALTH PLANS Substance Abuse Benefits Amendment As of the effective date, the following Substance Abuse Benefits have been added for an additional premium. ■ INPATIENT Inpatient treatment of alcohol and drug abuse is not provided except for acute detoxification. ■ OUTPATIENT An intensive treatment program(s) of one or more weeks by Plan Physicians, subject to a member copayment of $50 per week. Coverage is limited to a maximum of six weeks per contract year. AV- SA -R -98 MP -1527 (1/04) AvNIED HEALTH PLkX5 Durable Medical Equipment Amendment 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 copayment, limitations and exclusions remain as stated in the Certificate of Coverage or Schedule of Co- Payments. *In the treatment of diabetes, coverage for an infusion pump will apply toward the annual maximum limitation but shall not be subject to the durable medical equipment benefit limitation. A V -G 100 -DM&- 2000 -R -01 MP -2149 (1/04) AvMED HE ALT H P 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 provision: Dependent Eligibility will be added for a Domestic Partner and his or her children. Definition of Domestic Partner: A Domestic Partner means an unmarried adult who: • Cohabits with you in an emotionally committed and affectional relationship that is meant to be of lasting duration; • Is not related by blood or marriage; • Is at least eighteen years of age; • Is mentally competent to consent to a contract; • Has filed a Domestic Partnership agreement or registration with the Employer, if available, in the state (and/or city) of residence; • Has shared financial obligations including basic living expenses for the twelve 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- 12 -R -02 MP -3147 (1/04) AvMED HtALTH PLtANs STUDENT ELIGIBILITY 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. AV- STUDENT ELIGIBILITY -R -02 MP -3122 (1/04) AvM.IED HEALTH P LA.NS. ELECTIVE TERMINATION OF PREGNANCY Amendment If selected, the following optional coverage is hereby added: The AvMed Health Plan Group Medical and Hospital Service Contract is amended to state: ■ Elective termination of pregnancy will be a covered benefit if the services and treatment are provided by an AvMed participating provider in an AvMed participating facility. There shall be a physician copayment of $100.00 in addition to the applicable facility copayment. AV- G100- ETP -R -97 MP -1321 (1/04) Av H E A L T H P L A N S CITY OF SOUTH MIAMI — Group Selection Amendment As of the Effective Date, the above -named Subscribing Group has selected the following Amendments: Identifier: Amendment Name: AV- G100 -RX- 7/20/35/75 -OC -05 Prescription Drug Benefits AV- G100- ETP -R -97 Elective Termination of Pregnancy AV- GI00- MH /PH -$0 -per admit -04 Mental Health Benefits AV- SA -R -98 Substance Abuse Benefits AV- G100 -DME- 2000 -R -01 Durable Medical Equipment AV- STUDENT ELIGIBILITY -R -02 Student Eligibility AV- DP- 12 -R -02 Domestic Partner The provisions contained in the Schedule of Co- payments applicable to this Contract and all Exhibits and Riders 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, 2005. Subscribing Group: CITY OF SOUTH MIAMI By: Signature Name AVMED, Inc. d/b /a AVMED Health Plan By: fa X�" Sig ature Evis Clavareza Name Director of Client Service Title Title Date: Date: '7 AV- - SELECTION AMENDMENT -03 AvMED HE A L T H P L AN S Contract Number (s) AvMed Health Plans Group Medical and Hospital Service Contract Group Master Application - HMO with POS Rider Subscribing Group Name Effective Date: 105344 CITY OF SOUTH MIAMI October 1, 2005 This Group Contract provides the benefits checked below: Benefit Designs BASIC OPTION ($15 Specialist) ❑ $0 per Admission ❑ $100 per Admission ❑ $250 per Admission ❑ $250 per Day, Days 1 -5 BASIC OPTION ($25 Specialist) ❑ $0 per Admission ❑ $100 per Admission ❑ $250 per Admission ❑ $250 per Day, Days 1 -5 BASIC OPTION ($30 Specialist) ❑ $250 per Day, Days 1 -5 ❑ $250 per Admission POS Rider Benefit Designs BASIC OPTION ($35 Specialist) ❑ $250 per Day, Days 1 -5 ❑ $250 per Admission ❑ $300 per Day, Days 1 -5 STANDARD OPTION ($10 Specialist) ® $0 per Admission ❑ $100 per Admission ❑ $100 per Day, Days 1 -5 ❑ $250 per Admission STANDARD OPTION ($20 Specialist) ❑ $100 per Day, Days 1 -5 ❑ $250 per Admission Form: AV- STD -OA -05 $3,000/$6,000 OUT OF POCKET MAXIMUM ❑ $250 Individual Deductible, 30% Co- insurance ❑ $250 Individual Deductible, 40% Co- insurance ❑ $500 Individual Deductible, 20% Co- insurance ® $500 Individual Deductible, 30% Co- insurance ❑ $500 Individual Deductible, 40% Co- insurance OTHER LARGE GROUP BENEFITS ❑ $15/$250 per Day, Days 1 -5 ❑ $25/$500 per Day, Days 1 -5 ❑ $20/$250/10% ❑ $20/$250/20% ❑ $25/$500/20% ❑ $25/$750/20% ❑ $30/$750/20% $6,000/$12,000 OUT OF POCKET MAXIMUM ❑ $250 Individual Deductible, 30% Co- insurance ❑ $250 Individual Deductible, 40% Co- insurance ❑ $500 Individual Deductible, 20% Co- insurance ❑ $500 Individual Deductible, 30% Co- insurance ❑ $500 Individual Deductible, 40% Co- insurance Form: AV -POS- 500 -30- 3000 -03 AvMed Health Plans Group Medical and Hospital Service Contract Group Master Application - HMO with POS Rider, continued If selected, the following optional and supplemental coverage is also provided, as described in the amendments to this contract. ❑ Open Access Form: AV- ® Prescription Coverage Form: AV -G 100 -RX- 7/20/35/75 -OC -05 ❑ Vision Coverage Form: AV- E] Dental Coverage Form: AV- ® Elective Termination of Pregnancy Form: AV- G100- ETP -R -97 ® Mental Health /Partial Hospitalization Form: AV- G100- MH /PH -$0 per admit -04 ❑ Group declines additional mental health benefits (Section 627.668, Florida Statutes) ® Substance Abuse Form: AV- SA -R -98 ❑ Group declines additional substance abuse benefits (Section 627.669, Florida Statutes) ® Durable Medical Equipment Form: AV- G100 -DME- 2000 -R -01 ❑ Waiver of Co- payment — Coverage for Mammograms Form: AV- Other ® Student Eligibility Form: AV- STUDENT ELIGIBILITY -R -02 ® Domestic Partner Form: AV- DP- 12 -R -02 ❑ Form: AV- ELIGIBILITY FOR HMO COVERAGE WITH POS RIDER An employee of the Subscribing Group must be employed a minimum of 30 hours per week to become eligible for coverage under this Contract. In addition, the employee must work or reside in AvMed's service area to be eligible for coverage under this Contract, unless otherwise agreed to by the parties. The Subscribing Group may set criteria for eligibility for coverage under this Contract. Those criteria may include: ❑ Management employees only ❑ Salaried employees only ® All employees are eligible ❑ other criteria: An employee meeting any Subscribing Group criteria becomes eligible for coverage under this Contract (Check and /or fill in, as appropriate) ❑ on the date of hire ❑ consecutive days after the date of hire. ® on the first day of the month following 0 consecutive days after the date of hire. ® other: Retirees covered. TERMINATION Termination of coverage under this Contract shall become effective: ❑ on the date the employee's employment is terminated. ® on the last date of the month in which the employee's employment is terminated. ❑ on the date the Group Contract is terminated. ❑ other: AvMed Health Plans Group Medical and Hospital Service Contract Group Master Application - HMO with POS Rider, 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, 2005 and may be renewed annually, not later than the anniversary date, upon mutual agreement of the parties. The Contract period begins at 12:01 a.m. Eastern Standard Time on the effective date or on the anniversary date, if a renewal. This 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, 2005. Subsequent payments are due on the first 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. MONTHLY CHARGES Monthly Membership Charges SubscriberOnly ................................ ............................... Subscriber plus Spouse ................... ............................... Subscriber plus One Dependent (No Spouse) ................ Subscriber plus Two or More Dependents ....................... Subscriber plus Spouse and One or More Dependents ., ❑ Other .................................. ............................... .......... $ 372.65 .......... $ 733.81 .......... $ 660.39 .......... $ 660.39 ........ $ 1100.72 I.......... $ The provisions contained in the Schedule of Co- payments applicable to this Contract and all Exhibits and Riders 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, 2005. Subscribing Group: By: Signature Name Title Date: AV- G100- HM0/P0S- APP -04 MP -2080 (12/04) AVMED, Inc_ d /b /a AVMED Health Plans By:_ �rig�nature Name �,YeGfU�2- �� C�ie� .�.( ✓rz�5 Title Date: % /2J AvM-ED FIsALTH PLANS "APS M1 = STANDARD OPTION SCHEDULE OF BENEFITS COST TO MEMBER 0 -ADMIT OUT -OF- POCKET MAXIMUM $1,500 INDIVIDUAL 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 gynecological examination when performed by Primary Care Physician ■ Maternity - outpatient visits ■ Pediatric care and well -baby care ■ Periodic health evaluation and immunizations ■ Diagnostic imaging, laboratory or other diagnostic services ■ Minor surgical procedures N Vision and hearing examinations for children under 18 _ AVMED SPECIALISTS' ■ Office visits $10 per visit SERVICES ■ Annual gynecological examination when performed by a participating Specialty Health Care Physician HOSPITAL Inpatient care at Participating Hospitals includes: NO CHARGE • Room and board - unlimited days (semi - private) • Physicians', specialists' and surgeons' services • Anesthesia, use of operating and recovery rooms, oxygen, drugs and medication • Intensive care unit and other special units, general and special duty nursing • Laboratory and diagnostic imaging • Required special diets • Radiation and inhalation therapies OUTPATIENT SERVICES E Outpatient surgeries, including cardiac catheterizations NO CHARGE and angioplasty • Outpatient therapeutic services, including: • Drug infusion therapy $100 Co- payment plus applicable facility charge • Injectable Drugs (Co- payment for Injectable Drug $75 Co- payment waived if incidental to same -day chemotherapy infusion /treatment) OUTPATIENT DIAGNOSTIC ■ CAT Scan, PET Scan, MRI $25 per test TESTS 5 Other diagnostic imaging tests $10 per test EMERGENCY SERVICES An emergency is the sudden and unexpected onset of a condition requiring immediate medical or surgical care. (Co- payment waived if admitted) $75 Co- payment • Emergency services at Participating Hospitals $100 Co- payment • 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 $60 Co- payment Care facility AV- STD -OA -05 MP- 3410 (10105) Benefit Summary, continued MENTAL HEALTH ■ 20 outpatient visits $25 per visit FAMILY PLANNING 0 Voluntary family planning services , $10 per visit ■ Sterilization $100 Co- payment ALLERGY TREATMENTS ■ Injections $10 per visit ■ Skin testing $50 per course of testing AMBULANCE E Ambulance transport for emergency services $100 Co- payment to $1,500 per ■ Non - emergent ambulance services are covered when the Contract Year skill of medically trained personnel is required and the Member cannot be safely transported by other means PHYSICAL, SPEECH, AND ■ Short-term physical, speech or occupational therapy for $10 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 $25 per day FACILITIES AND Year when prescribed by physician and authorized by REHABILITATION CENTERS AvMed CARDIAC REHABILITATION Cardiac rehabilitation is covered for the following conditions: $20 per visit ■ Acute myocardial infarction ■ Percutaneous transluminal coronary angioplasty (PICA) ■ Repair or replacement of heart valves Benefits limited ■ Coronary artery bypass graft (CABG), or to $1,500 per ■ Heart transplant Contract Year Coverage is limited to 18 visits per Contract Year HOME HEALTH CARE ■ Limited to 60 skilled visits per calendar year NO CHARGE DURABLE MEDICAL Equipment includes: $50 per episode of illness EQUIPMENT AND ■ Hospital beds ORTHOTIC APPLIANCES ■ Walkers ■ Crutches Benefits limited ■ Wheelchairs to $500 per Orthotic appliances are limited to: Contract Year ■ Leg, arm, back, and neck custom -made braces PROSTHETIC DEVICES Prosthetic devices are limited to: NO CHARGE • Artificial limbs • Artificial joints • Ocular prostheses FOR ADDITIONAL: INFORMATION, PLEASE CALL: 1- 800 -88 -AVMED (1- 800 - 882 -8633) THIS SCHEDULE OF BENEFITS IS NOT A CONTRACT. FOR SPECIFIC INFORMATION ON BENEFITS, EXCLUSIONS AND LIMITATIONS, PLEASE SEE YOUR AVMED GROUP MEDICAL AND HOSPITAL SERVICE CONTRACT. AV- STD -OA -05 MP- 3410 (10105) AvMED ' H :E t T k P c A 14 S Be! Li �i`��� Summa .A POINT -OF- SERVICE RIDER SCHEDULE YOUR COST BENEFITS OUT -OF- NETWORK BENEFITS CASH DEDUCTIBLE INDIVIDUAL/FAMILY $500 /$1,500 ANNUALLY COINSURANCE OUT -OF- INDIVIDUAL/FAMILY $3,000/6,000 ANNUALLY POCKET MAXIMUM LIFETIME MAXIMUM $2,000,000 PER MEMBER PRIOR AUTHORIZATION REQUIRED FOR SPECIFIC COVERED SERVICES. THE PENALTY FOR NOT OBTAINING PRIOR AUTHORIZATION IS A 20% REDUCTION IN BENEFITS. PHYSICIAN Services at doctors' offices include, but are not limited to: ELIGIBLE EXPENSE, • ROUTINE OFFICE VISITS /ANNUAL GYN VISIT SUBJECT TO THE CASH • MATERNITY- OUTPATIENT VISITS DEDUCTIBLE AND 30% • PEDIATRIC CARE & WELL -CHILD CARE COINSURANCE • DIAGNOSTIC IMAGING, LABORATORY OR OTHER DIAGNOSTIC SERVICES • MINOR SURGICAL PROCEDURES • VISION & HEARING EXAMINATIONS FOR CHILDREN UNDER 18 SPECIALIST'S SERVICES ■ OFFICE VISITS ELIGIBLE EXPENSE, SUBJECT TO THE CASH DEDUCTIBLE AND 30% COINSURANCE HOSPITAL Inpatient care at hospitals includes: ELIGIBLE EXPENSE, • ROOM & BOARD — UNLIMITED DAYS (SEMI - PRIVATE) SUBJECT TO THE CASH • PHYSICIAN'S, SPECIALIST'S & SURGEON'S SERVICES DEDUCTIBLE AND 30% • ANESTHESIA, USE OF OPERATING & RECOVERY ROOMS, COINSURANCE OXYGEN, DRUGS & MEDICATION • INTENSIVE CARE UNIT & OTHER SPECIAL UNITS, GENERAL & SPECIAL DUTY NURSING • LABORATORY & DIAGNOSTIC IMAGING • REQUIRED SPECIAL DIETS • RADIATION & INHALATION THERAPIES OUTPATIENT SURGERY OUTPATIENT SURGERIES, INCLUDING CARDIAC ELIGIBLE EXPENSE, CATHETERIZATIONS AND ANGIOPLASTY SUBJECT TO THE CASH DEDUCTIBLE AND 30% COINSURANCE OUTPATIENT DIAGNOSTIC ■ CAT SCAN, PET SCAN, MRI ELIGIBLE EXPENSE, TESTS • OTHER DIAGNOSTIC IMAGING TESTS SUBJECT TO THE CASH DEDUCTIBLE AND 30% COINSURANCE MENTAL HEALTH ■ 20 OUTPATIENT VISITS (20 VISITS IS THE TOTAL NUMBER OF COVERED VISITS FOR BOTH IN AND OUT OF NETWORK, COMBINED) IF MENTAL HEALTH/SUBSTANCE ABUSE BENEFIT RIDER IS ELECTED, BENEFITS ARE SUBJECT TO POS RIDER DEDUCTIBLE AND COINSURANCE ARRANGEMENTS WHEN USING NON - PARTICIPATING PROVIDERS. SPECIFIED SERVICE LIMITS ARE THE TOTAL NUMBER OF COVERED VISITS FOR BOTH IN AND OUT OF NETWORK, COMBINED. ELIGIBLE EXPENSE, SUBJECT TO THE CASH DEDUCTIBLE AND 30% COINSURANCE Benefit Summary, continued ALLERGY TREATMENTS ■ INJECTIONS ELIGIBLE EXPENSE, ■ SKIN TESTING SUBJECT TO THE CASH DEDUCTIBLE AND 30% COINSURANCE PHYSICAL, SPEECH, & ■ SHORT -TERM PHYSICAL, SPEECH OR OCCUPATIONAL ELIGIBLE EXPENSE, OCCUPATIONAL THERAPIES THERAPY FOR ACUTE CONDITIONS SUBJECT TO THE CASH DEDUCTIBLE AND 30% COVERAGE IS LIMITED TO 24 VISITS PER CALENDAR COINSURANCE YEAR FOR ALL SERVICES COMBINED. SKILLED NURSING FACILITIES ■ UP TO 20 DAYS PER CONTRACT YEAR POST- ELIGIBLE EXPENSE, & REHABILITATION CENTERS HOSPITALIZATION CARE WHEN PRESCRIBED BY SUBJECT TO THE CASH PHYSICIAN & AUTHORIZED BY AVMED DEDUCTIBLE AND 30% COINSURANCE CARDIAC REHABILITATION Cardiac Rehabilitation is covered for the following conditions: $20 PER VISIT • ACUTE MYOCARDIAL INFARCTION • PERCUTANEOUS TRANSLUMINAL CORONARY BENEFITS LIMITED TO ANGIOPLASTY (PTCA) $1,500 PER CONTRACT • REPAIR OR REPLACEMENT OF HEART VALVE(S) YEAR. • CORONARY ARTERY BYPASS GRAFT (CABG), or • HEART TRANSPLANT COVERAGE IS LIMITED TO 18 VISITS PER YEAR. HOME HEALTH CARE ■ PER OCCURRENCE ELIGIBLE EXPENSE, SUBJECT TO THE CASH DEDUCTIBLE AND 30% COINSURANCE DURABLE MEDICAL Equipment includes: $50 PER EPISODE OF EQUIPMENT & • HOSPITAL BEDS ILLNESS. BENEFITS ORTHOTIC APPLIANCES ' WALKERS LIMITED TO $500 PER ■ CRUTCHES CONTRACT YEAR. ■ WHEELCHAIRS Orthotic appliances are limited to: ■ LEG, ARM, BACK, AND NECK CUSTOM -MADE BRACES PROSTHETIC DEVICES Prosthetic devices are limited to: ELIGIBLE EXPENSE, • ARTIFICIAL LIMBS SUBJECT TO THE CASH • ARTIFICIAL JOINTS DEDUCTIBLE AND 30% • OCULAR PROSTHESES COINSURANCE THIS SCHEDULE IS NOT A CONTRACT. FOR SPECIFIC INFORMATION ON BENEFITS, EXCLUSIONS AND LIMITATIONS PLEASE CONSULT YOUR AVMED HMO MEDICAL AND HOSPITAL SERVICE CONTRACT AND POINT -OF- SERVICE RIDER. AV- POS- 500 -30- 3000 -03 MP- 3440 (9/03) AvNIED L-TH PLANS Classic Point-of-Service Amendment AvMed Health Plans Group Medical and Hospital Service Contract is hereby amended and supplemented by the terms and conditions of this Amendment. Nothing contained in this Amendment will be held to vary, alter, waive, or extend any of the terms, conditions, provisions, exclusions or limitations of the HMO Contract to which this Amendment is attached, other than as specifically stated herein. Furthermore, when additional benefit riders are selected, those benefits are subject to the POS Amendment Deductible and Coinsurance arrangements when using Non - Participating Providers unless services are specifically excluded herein. Additionally, this Amendment in no way extends benefits beyond what has been stated in this Amendment and Schedule 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 the Subscriber may elect. Point -of- Service Benefits A Member is eligible to receive medical care and services including medical, surgical, diagnostic, therapeutic and preventive services. Coverage is provided for health services that are: • Received while you are covered under this Group Plan; • Performed, prescribed or directed by a Physician; • Medically Necessary (except for preventive services as stated herein) for the diagnosis and treatment of injury or illness, as determined by AvMed Health Plan; and • Not excluded under Parts XI. and XII. or any other provision, rider or amendment made a part of this Group Plan. This Point -of- Service (POS) Amendment allows you to receive benefits for covered services and supplies outside the AvMed HMO network. When medical services are needed, you are free to obtain care from your HMO Primary Care Physician or you may also consult with a Health Professional of your choice. However, your responsibilities for payment and claim filing will be greater when covered services and supplies are accessed outside the HMO system. You are free to choose any Health Professional when health care services are needed. By using a Health Professional who has contracted with the AvMed Provider Network (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 (Non- Participating Provider). See the HMO and POS Schedules for more details on how these options can work best for you. Classic Point -of- Service Amendment, continued This Point -of- Service Amendment does not eliminate the requirement that each Member choose a Primary Care Physician (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 your PCP in order to obtain maximum benefits under the HMO Coverage. Under the POS Amendment, some services will require your Non - Participating Provider to request Prior Authorization as described herein. Benefit Payment Levels This Point -of- Service Amendment has several special features that can influence how much you pay out of pocket for medical care. Your choice of a Health Professional may result in lower or higher costs and you will be required to follow certain procedures to avoid additional costs. Your choice of a Health Professional and wise use of these benefits can save you money. This POS Amendment to the HMO Group Medical and Hospital Service Contract creates two benefit payment levels; one for services provided by AvMed HMO Participating Providers and a second for services provided by Non - Participating Providers. The benefit level this Group Plan will pay depends on the Health Professional you select to provide covered health care services: 1. If the Health Professional used is part of the AvMed Health Plan Participating Provider Network, benefits for covered services are payable at the Participating Provider benefit level shown in the HMO Schedule of Copayments. 2. If the Health Professional used is not part of AvMed Health Plan's Participating Provider network, benefits for services covered under this POS Rider are payable at the Non - Participating benefit level specified in the POS Rider Schedule. 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 by your Primary Care Physician, benefits may not be payable under the HMO Participating Provider benefit. A service may be payable under the POS Amendment Non - Participating Provider benefit if the service or supply received is a covered service as specified in this POS Amendment and Schedule. AV -POS CLASSIC -04 MP- 3530 (10/04) 2 Classic Point-of-Service Amendment, continued Cost - Sharing Information Cash Deductible. Before AvMed Health Plan will begin paying expenses for services covered under this POS Rider, you must satisfy the annual Cash Deductible specified in the Rider Schedule. The Cash Deductible means the amount a Member must pay each Calendar Year for covered services from his or her own pocket before AvMed Health Plan 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 Plan for any claim. If two or more covered members of a family incur injury due to the same accident, the Cash Deductible applies only once for all such expenses. If during a Calendar Year, the covered members of a family incur Eligible Expenses for which no benefits are payable because of the Cash Deductible requirements and the amount of such Eligible Expense equals the Family Cash Deductible Limit, then no further Cash Deductible will apply to the covered members of the family during the remainder of such Calendar Year. Any Eligible Expenses credited by AvMed Health Plan towards your Cash Deductible requirement during the last three months of this Group Plan's prior Calendar Year, will be reduced to the extent of such application for the next ensuing Calendar Year. Only those Eligible Expenses submitted on claims to AvMed Health Plan will be credited toward the Deductible. Expenses that are not Eligible Expenses will not be counted toward the satisfaction of the Deductible. Coinsurance. Once the Calendar Year Cash Deductible has been met, you are responsible for paying a percentage of Eligible Expenses. The coverage percentage, hereinafter called "coinsurance" is specified in the Schedule. You will be responsible for paying any charges not considered an Eligible Expense. Annual Coinsurance Maximum Out -of- Pocket Limits. Coinsurance and Copayments you pay for benefits received during any Calendar Year under this Amendment are accumulated toward your Annual Coinsurance Maximum Out -of- Pocket. Once you meet your Individual or Family Coinsurance Maximum Out -of- Pocket in any Calendar Year, the Plan will pay 100% of the Usual, Reasonable and Customary charges for all covered services for the remainder of that Calendar Year. Expenses that do not count toward the Annual Coinsurance Maximum Out -of- Pocket are expenses related to charges for services not covered by this POS Amendment, additional charges incurred for failure to pre - authorize a service requiring prior authorization, expenses that relate to services that exceed any specific treatment limitations noted in the Benefit Summaries, expenses used to satisfy the Individual or Family Cash Deductible, and Copayments paid by you for services provided exclusively under the Group Medical and Hospital Service Contract. AV -POS CLASSIC -04 NIP- 3530 (10/04) Classic Point-of-Service - Service Amendment, continued Lifetime Maximum Benefit. While this Group Plan stays in force, the Eligible Expenses incurred by a Member are limited to the applicable maximum shown in the POS Schedule. When benefits in such amount have been paid or are payable under this Amendment, all coverage under this Amendment will terminate for the Member. Effect of Prior Coverage. The following provision applies to Members who, on the day before this Group Plan Effective Date, were covered under Prior Coverage. Prior Coverage means the Policyholder's group medical plan that this Group Plan replaced. AvMed Health Plan 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. Cash 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 ninety (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 ninety (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 Cash Deductible under the Prior Coverage by providing AvMed Health Plan written proof of what has been paid by Prior Coverage. Prior Authorization of Covered Services In order to determine whether services and supplies are Medically Necessary, certain covered services require Prior Authorization from AvMed Health Plan. Prior Authorization ensures a Member of receiving the most appropriate medical care available, in the most appropriate setting. If your physician is a Participating Provider, then he or she will handle all authorizations, notifications and utilization reviews with AvMed Health Plan. AV -POS CLASSIC -04 MP- 3530 (10/04) 4 Classic Point -of- Service Amendment, continued If your doctor is not a Participating Provider, you are responsible for making sure your Physician or Health Professional calls AvMed Health Plan 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 Plan. Please remember that failure to receive Prior Authorization of a service will result in a reduction in coverage. The amount of the reduction can be found in the POS Schedule. The following services require Prior Authorization: • Inpatient Admissions (Hospital, Skilled Nursing Facility, and/or Acute Rehabilitation). • Inpatient and Outpatient Surgery, including Cardiac Catheterization and Percutaneous Transluminal Coronary Angioplasty (PICA). • PET Scans. It is important to remember that benefits for Hospital Admissions not authorized in advance will be reduced by the amount shown in the POS Schedule. This reduction will occur regardless of whether such confinements are deemed Medically Necessary. If hospitalization is extended without authorization beyond the number of days approved, benefits for the extra days will be similarly reduced. Exclusions and Limitations The benefit exclusions and limitations specified in the HMO Group Medical and Hospital Service Contract are also applicable to the benefits specified in this POS Amendment. Additionally, services not covered under this Point -of- Service Amendment include: • Services provided exclusively under the HMO Group Medical and Hospital Service Contract. • Second medical opinions are covered exclusively through the HMO portion of the benefits and are not available as point -of- service benefits. • Transplantation services must be authorized by AvMed and provided exclusively through the HMO network. However, any follow -up care managed by a Participating Provider outside of the AvMed Service Area will be subject to the out -of- network benefit and reimbursement. • Any applicable prescription benefits are available only under the HMO portion of coverage. They are not available as out -of- network benefits. • Hospice services. • Dialysis care. AV -POS CLASSIC -04 MP- 3530 (10/04) 5 Classic Point -of- :service Amendment, continued • Ambulance services. • Voluntary family planning services, sterilization, infertility evaluation and medical treatment, surgery for the enhancement of fertility and genetic counseling. • Emergency Services and care for an Emergency Medical Condition. Emergency services administered by any provider will be covered under the HMO Contract benefits. In order for the care to be covered under the HMO, AvMed must be notified as described in Section 10.12 of the HMO Group Medical and Hospital Service Contract. If notification is not provided as specified under the HMO contract, services may be payable under the POS Amendment if the service or supply received is a covered service as specified in this POS Amendment and Schedule. • Durable medical equipment, orthotic appliances and prosthetic devices are limited to those items specified in the POS Schedule. In addition, custom wheelchairs, electric wheelchairs and scooters must be authorized by AvMed and provided by the HMO network. Payment of Claims When you receive services from a Non - Participating Provider, the provider must bill AvMed Health Plan 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 coinsurance. You must also comply with the following claim filing procedures when receiving covered services from Non - Participating Providers: Notice of Claim. Notice of a claim for benefits must be given to AvMed Health Plan. 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 (6) months after the start of the loss on which the claim is based. If notice is not given in time, the claim may be reduced or invalidated. If it can be shown that it was not reasonably possible to submit the notice within the six (6) month period and that notice was given as soon as possible, the claim will not be reduced or invalidated. When written notice is required under this Plan, it shall be mailed to: AvMed Health Plans P. O. Box 560844 Miami, Florida 33256 You should call 1- 800 - 882 -8633 if assistance is needed regarding a claim or information about coverage. AV -POS CLASSIC -04 MP- 3530 (10/04) 6 Classic Point -of- .service Amendment, continued Proof of Loss. Written proof of loss must be given to AvMed Health Plan within six (6) 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. Timely Payment of Claims. After receiving written proof of loss, AvMed Health Plan will reimburse all claims or any portion of any claim from a Member or a Member's assignees, within forty (40) days from our receipt of the claim. If a claim or portion of a claim is contested by AvMed Health Plan, you or your assignees will be notified in writing that the claim is contested within forty (40) days from our receipt of the claim. The notice that a claim is contested will identify the contested portion of the claim and the reasons for contesting the claim. Upon AvMed Health Plan's receipt of the additional information requested from a Member or his or her assignees, AvMed will pay or deny the contested claim or portion of the contested claim within sixty (60) days. AvMed Health Plan will pay or deny any claim no later than one - hundred -forty (140) days after receiving the claim. Payment will be treated as being made on the date a draft or valid instrument which is equivalent to payment was placed in the United States mail in a properly addressed post -paid envelope or, if not so posted, on the date of delivery. All overdue payments will bear simple interest at the rate of ten (10) percent per year. Upon written notification by a Member, AvMed Health Plan will investigate any claim of improper billing by a physician, hospital, or other Healthcare Provider. We will determine if you were properly billed for only those procedures and services you actually received. If AvMed Health Plan determines that you have been improperly billed, we will notify you and the provider of our findings and will reduce the amount of the payment to the provider by the amount determined to be improperly billed. If a reduction is made due to such notification, we will pay you twenty (20) percent of the amount of the reduction, up to $500. Legal Actions. No legal action may be brought to recover under this Amendment until at least sixty (60) days after written proof of claim has been filed with AvMed Health Plan. If such action is taken after the sixty (60) day period, it must be taken prior to the expiration of the statute of limitations from the date written proof of claim was required to be filed. AV -POS CLASSIC -04 MP- 3530 (10/04) 7 Classic Point -of- ;service Amendment, continued Overview — Member Responsibilities When Receiving Covered Services Responsibilities when using Participating Providers. All paperwork is handled by Participating Providers, so there are no bills for you to submit to AvMed Health Plan. 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 Copayment or Coinsurance 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 Coinsurance amount required. 4. Pay any amount of Eligible Expense which exceeds the Usual, Reasonable and Customary charges. 5. Pay any increase in Coinsurance if Prior Authorization requirements are not followed as stated in this Amendment. 6. Pay any charges for services and supplies not covered under this Amendment. 7. You must complete and submit claim forms and provider bills to AvMed Health Plan. Definitions "Eligible Expenses" means the Usual, Reasonable and Customary Charges for covered health services received while coverage under this Plan is in effect. "Usual, Reasonable, and Customary" means the usual charge made by a Physician or supplier of services, medicines, or supplies. The charge will not exceed the general level of charges made by others rendering or furnishing such services, medicines, or supplies within an area in which the charge is incurred for sickness or injuries comparable in severity and nature to the sickness or injury being treated. The term "area" as it would apply to any particular service, medicine, or supply means: a county or such greater areas as is needed to obtain a representative cross section of level of charges. AV -POS CLASSIC -04 MP- 3530 (10/04) 8 AvMED 14 F A L T H P L A N s Prescription .Drug Benefits $7/20/35/75 CO- PAYMENT with Contraceptives DEFINITIONS "Brand" drug means a Prescription Drug that is usually manufactured and sold under a name or trademark by a drug manufacturer or a drug that is identified as a Brand drug by AvMed. AvMed delegates determination of Generic/Brand status to our Pharmacy Benefits Manger. ".Brand Additional Charge" means the additional charge that must be paid if you or your physician choose a Brand drug when a Generic equivalent is available. The charge is the difference between the cost of the Brand drug and the Generic drug. This charge must be paid in addition to the applicable Brand Co- payment (Preferred or Non - Preferred). "Generic" drug means a drug that has the same active ingredient as a Brand drug or is identified as a Generic drug by AvMed's Pharmacy Benefits Manager. "Injectable Drug" is a medication that has been approved by the Food and Drug Administration (FDA) for administration by one or more of the following routes: intramuscular injection, intravenous injection, intravenous infusion, subcutaneous injection, intrathecal injection, intrarticular injection, intracavemous injection or intraocular injection. Pre - Authorization is required for all Injectable Drugs. "Participating Pharmacy" means a pharmacy (either retail, mail order or specialty pharmacy) that has entered into an agreement with AvMed to provide Prescription Drugs to AvMed Members and has been designated by AvMed as a Participating Pharmacy. "Preferred Drug List" means the listing of preferred medications as determined by AvMed's Pharmacy and Therapeutics Committee based on clinical efficacy, relative safety and cost in comparison to similar medications within a therapeutic class. This multi- tiered list establishes different levels of Co- payment for medications within therapeutic classes. As new medications become available, they may be considered excluded until they have been reviewed by AvMed's Pharmacy and Therapeutics Committee. "=Prescription Drug" means a medication that has been approved by the FDA and that can only be dispensed pursuant to a prescription according to state and federal law. "Pre - Authorization" means the process of obtaining approval for certain Prescription Drugs (prior to dispensing) according to AvMed's guidelines. The prescribing physician must obtain approval from AvMed. The list of Prescription Drugs requiring Pre - Authorization is subject to periodic review and modification by AvMed. A copy of the list of medications requiring Pre - Authorization and the applicable criteria are available from Member Services or from the AvMed website. "Self- Administered Injectable Drug" is a medication that has been approved by the FDA for self - injection and is administered by subcutaneous injection or a medication for which there are instructions to the patient for self - injection in the manufacturer's prescribing information (package insert). Pre- Authorization is required for all Self - Administered Injectable Drugs. 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 Self- Administered Injectable Drugs to AvMed's specialty pharmacy. Present your prescription along with your AvMed identification card. Pay the following Co- payment (as well as the Brand Additional Charge if you or your physician choose a Brand product when a Generic equivalent is available). Tier 1 Preferred Generic Drugs: $ 7.00 Co- payment Tier 2 Preferred Brand Drugs: $ 20.00 Co- payment Tier 3 Non - Preferred Brand or Generic Drugs: $ 35.00 Co- payment Tier 4 Self- Administered Injectable Drugs: $ 75.00 Co- payment ORDERING YOUR PRESCRIPTIONS THROUGH THE MAIL Mail service is a benefit option for maintenance medications needed for chronic or long -term health conditions. It is best to get an initial prescription filled at your retail pharmacy. Ask your physician for an additional prescription for up to a 90 -day supply of your medication to be ordered through mail service. Up to 3 refills are allowed per prescription. Pay the following Co- payment (as well as the Brand Additional Charge if you or your physician choose a Brand product when a Generic equivalent is available). Tier 1 Preferred Generic Drugs: $ 21.00 Co- payment Tier 2 Preferred Brand Drugs: $ 60.00 Co- payment Tier 3 Non- Preferred Brand or Generic Drugs: $105.00 Co- payment Tier 4 Self- Administered Injectable Drugs are not available through mail service AV- G100 -RX- 7/20/35/75 -OC -05 MP -3460 (10105) Prescription Drug Benefits, continued WHAT IS COVERED? • Your Prescription Drug coverage includes outpatient medications (including contraceptives) that require a prescription and are prescribed by your AvMed physician in accordance with AvMed's coverage criteria. AvMed reserves the right to make changes in coverage criteria for covered products and services. Coverage criteria are medical and pharmaceutical protocols used to determine payment of products and services and are based on independent clinical practice guidelines and standards of care established by government agencies and medical/pharmaceutical societies. • Your retail Prescription Drug coverage includes up to a 30 -day supply of a medication for the listed Co- payment. Your prescription may be refilled via retail or mail order after 75% of your previous fill has been used. You also have the opportunity to obtain a 90- day supply of medications used for chronic conditions including, but not limited to, asthma, cardiovascular disease and diabetes, from the retail pharmacy for the applicable Co- payment per 30 -day supply. However, Pre - Authorization may be required for covered medications. • Your mail -order Prescription Drug coverage includes up to a 90 -day supply of a routine maintenance medication for the fisted 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 Drug coverage extends to many injectable drugs approved by the FDA. These drugs must be prescribed by a physician and dispensed by a retail or specialty pharmacy. The Co- payment levels for Self- Administered Injectable Drugs apply regardless of provider. This means that you are responsible for the appropriate Co- payment whether you receive your Self - Administered Injectable Drug from the pharmacy, at the doctor's office or during home health visits. Self - Administered Injectable Drugs are limited to a 30 -day supply • Your Prescription Drug coverage includes coverage for injectable contraceptives. There is a Co- payment of $30 for each injection. If there is an office visit associated with the injection, there will be an additional Co- payment required for the office visit. • Quantity limits are set in accordance with FDA approved prescribing limitations, general practice guidelines supported by medical specialty organizations, and/or evidence - based, statistically valid clinical studies without published conflicting data. This means that a medication - specific quantity limit may apply for medications that have an increased potential for over - utilization or an increased potential for a Member to experience an adverse effect at higher doses. QUESTIONS? Call your AvMed Member Services Department at: 1- 800 -88 -AvMed (1- 800 - 882 -8633) EXCLUSIONS AND LIMITATIONS ■ Drugs or medications which do not require a prescription (i.e. over - the - counter medications) or when a non - prescription alternative is available ■ Medical supplies, including therapeutic devices, dressings, appliances, and support garments ■ Replacement Prescription Drug products resulting from a lost, stolen, expired, broken, or destroyed prescription order or refill ■ Diaphragms and other contraceptive devices ■ Fertility drugs ■ Medications or devices for the diagnosis or treatment of sexual dysfunction ■ Medications for dental purposes, including fluoride medications ■ Prescription and non- prescription vitamins and minerals except prenatal vitamins ■ Nutritional supplements ■ Immunizations ■ Allergy serums, medications administered by the Attending-Physician to treat the acute phase of an illness and chemotherapy for cancer patients are covered in accordance with the Group Medical and Hospital Service Contract and may be subject to Co- payments or Co- insurance' as outlined on the Schedule of Benefits ■ Investigational and experimental drugs (except as required by Florida statute) ■ Cosmetic products, including, but not limited to, hair growth, skin bleaching, sun damage and anti - wrinkle medications ■ Nicotine suppressants and smoking cessation products and services ■ Prescription and non - prescription appetite suppressants and products for the purpose of weight loss ■ Compounded prescriptions, except pediatric preparations ■ Medications and immunizations for non - business related travel, including Transdermal Scopolamine Filling a prescription at a pharmacy is not a claim for benefits and is not subject to the Claims and Appeals procedures under ERISA. However, any medicines that require Pre - Authorization will be treated as a claim for benefits subject to the Claims and Appeals Procedures, as outlined in the Group Medical and Hospital Service Contract. A V -G 100 -RX- 7/20/35/75 -0C -05 MP -3460 (10/05) AvMED HEALTH PLANS 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, paid at 100 %, shall be provided by the Plan when a member is admitted to a Participating Hospital or Participating Health Care Facility as a registered bed patient. • Partial Hospitalization for mental health services is a Covered Service when it is provided in lieu of inpatient hospitalization and is combined with the inpatient hospital benefit. Two days of Partial Hospitalization will count as one day toward the inpatient Mental Health Benefit subject to member copayment as noted above. AV- G100- MH/PH -$0 per admit -04 MP -3519 (10/04) AvMED HEALTH P L A N t, Substance Abuse Benefits Amendment As of the effective date, the following Substance Abuse Benefits have been added for an additional premium. ■ INPATIENT Inpatient treatment of alcohol and drug abuse is not provided except for acute detoxification. ■ OUTPATIENT An intensive treatment program(s) of one or more weeks by Plan Physicians, subject to a member copayment of $50 per week. Coverage is limited to a maximum of six weeks per contract year. AV- SA -R -98 MP -1527 (1/04) AvMED H E A L T.H P L A N 5, Durable Medical Equipment Amendment 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 copayment, limitations and exclusions remain as stated in the Certificate of Coverage or Schedule of Co- Payments. *In the treatment of diabetes, coverage for an infusion pump will apply toward the annual maximum limitation but shall not be subject to the durable medical equipment benefit limitation. A V -G 100 -D ME-2 000 -R -01 MP -2149 (1/04) AvMED HE At! H P LAN 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 provision: Dependent Eligibility will be added for a Domestic Partner and his or her children. Definition of Domestic Partner. A Domestic Partner means an unmarried adult who: • Cohabits with you in an emotionally committed and affectional relationship that is meant to be of lasting duration; • Is not related by blood or marriage; • Is at least eighteen years of age; • Is mentally competent to consent to a contract; • Has filed a Domestic Partnership agreement or registration with the Employer, if available, in the state (and/or city) of residence; • Has shared financial obligations including basic living expenses for the twelve 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- 12 -R -02 MP -3147 (1104) AvNIED HE.A.Lr1i PLANS STUDENT ELIGIBILITY 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. AV- STUDENT ELIGIBILITY -R -02 MP -3122 (1/04) AvM-ED HEALTH PLANS ELECTIVE TERMINATION OF PREGNANCY Amendment If selected, the following optional coverage is hereby added: The AvMed Health Plan Group Medical and Hospital Service Contract is amended to state: Elective termination of pregnancy will be a covered benefit if the services and treatment are provided by an AvMed participating provider in an AvMed participating facility. There shall be a physician copayment of $100.00 in addition to the applicable facility copayment. AV- G100- ETP -R -97 MP- 1321 (1/04) AvNIED H E A L T H P L A N S CITY Off' SOUTH MIAMMI — Group Selection Amendment As of the Effective Date, the above -named Subscribing Group has selected the following Amendments: Identifier: AV -G 100 -RX- 7/20/3 5/75 -OC -05 AV -G 100- ETP -R -97 AV- G100- MH /PH -$0 -per admit -04 AV- SA -R -98 AV -G 100 -DME- 2000 -R -01 AV- STUDENT ELIGIBILITY -R -02 AV- DP- 12 -R -02 AV- POS- 500 -30- 3000 -03 AV -POS- CLASSIC -04 Amendment Name: Prescription Drug Benefits Elective Termination of Pregnancy Mental Health Benefits Substance Abuse Benefits Durable Medical Equipment Student Eligibility Domestic Partner Point -of- Service Rider Benefits Classic Point -of- Service Amendment The provisions contained in the Schedule of Co- payments applicable to this Contract and all Exhibits and Riders 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, 2005. Subscribing Group: CITY OF SOUTH MIAMI By: Signature Name AVMED, Inc. d/b /a AVMED Health Plan ' By: SignatuYe Evis Clavareza Name Director of Client Service Title Title Date: Date: AV— — SELECTION AMENDMENT -03 we TABLE OF CONTENTS I. Executive Summary II. Proposed Medical Rates III. HMO Benefit Comparison IV. POS Benefit Comparison V. Appendix 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 Submitted a proposal. Neighborhood Health Partnership United HealthCare Vista Declined to quote. Submitted a proposal. Declined to quote. 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 We were successful in reducing the AvMed premium increase to 15.2% for the upcoming plan year (assuming no changes with the current benefit structure). AvMed has the following municipalities as clients: City of Fort Lauderdale, Miami Dade County, Village of Bal Harbour, and the Village of Key Biscayne. The 15.2% increase from AvMed is favorable in comparison to the renewals that the City of South Miami has received over the last 3 years: 2002: 40% increase - Blue Cross/Blue Shield 2003: 32% increase - Neighborhood Health Partnership 2004: 40% increase - CIGNA Aetna, Humana, and United HealthCare submitted proposals. The proposal from Humana is competitive from a financial standpoint; however the following issues warrant consideration: 1) The physician network with Humana would create a significant amount of disruption. Many employees would have to change their Primary Care Physician and Specialists if Humana was selected. 2) The benefits with Humana are not as "rich" in comparison to AvMed. 3) AvMed received higher scores from the Florida Agency for Health Care Administration (AHCA) in comparison to Humana. The State of Florida measured each HMO in the following categories: a) Overall plan satisfaction b) Ease in getting to see a specialist c) Ease in getting needed care, tests, or treatment d) How well providers communicate with members e) Getting help from customer service 1 The proposed rates with United HealthCare are 21.7% above the current cost structure with AvMed. From a plan design standpoint the United HealthCare plans are "Open Access (i.e. members can receive services from a specialist without a referral from a Primary Care Physician). United HealthCare has the largest network of providers in South Florida. 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. 2 ��� .�. t D z V NV m N OR V W NCJO0 W ;P 000 90 W CT tV 3 �4 N V n CD 3 333° 33330° W S aaaa aaaa ? a 3"< Q a Q fl C Q (D (D fD CD CD (D v u t mmmm mmmm D � a O O CD S � 2. to CD "o `< 7' -a =r 0 -CA EflfflH9 a c u a c a a N 'yam CD CD CD CD (p O W O W :3 v (D m OOCWOUNI N N N + + � O m CL a a n O O m c c cn CD cn CD N �w O � co OD VI -'000 N10) (D 0o W al v � v � z V NV VI- 000 NIOCo �-4 N OR V W NCJO0 W ;P 000 (D W CT tV 3 �4 N V n N 0 VI -000 N10C0N) co c W O � bo V I-• 0 0 0 N lrn co - °-4 o CA W V N V V1 —O0 W _ ICAO V V W V OR N EAwiflW z 3333° 333 30 aaaa a a a a NCJO0 W ;P 000 W IV O 0o W CT tV 3 mmmm n C) W WO m m m m + t + O t + + O S 7 a S `< ? a 3"< Q a Q fl C Q (D (D fD CD CD (D v u t t co O a a O O c c cn to CD CD EAwiflW n N CA CO cn N r- .OA N c NCJO0 W ;P 000 W IV O 0o W CT tV 3 W -'CO n C) W WO 00ccn(PN� OcoNLn M0C1o'* cn 0)4 W(O O.AcoD -�vOO OD W V O W W .p fD S TI C `G (D 7 C O 7 O 0 -CA EflfflH9 {n -60w19 Q. a W 0) V 0 OD cn W W p N W O W - �ACflN— co m OOCWOUNI N Q N W U�ioO< 3 >Z O m CL n O Cn m m n N 69 w 69 �rn69 CD avo ?�� WONO�1p V 4h, �CW31 - _0 O V 0) -4 N 00o� EAwiflW w4Aw<Am N CA CO cn N r- .OA N V NCJO0 W ;P 000 W IV O 0o W CT tV 3 W -'CO n c 7 �N rt 0 W N W W Omoom otom4 �OOoN NN 0WV.PN -4 N Cr) 4� n O V c OC c E 0 CL 1w r.9 GR 0 0 0 v . S \ m O J =@ o C ■ 4 f 0 C) CD < 2 « a 2\ G k / 0 0 m m m \ k & ■ m R o ¢ I = R E � I \/ƒ \ o ■ ° B n Q ■ S @ 2 ° g ° . X a ■ $ \ § § k k l k � E � / k � . \ $ z \ f7 Ul 2\» � \ \ 0 0 / _ k k \ \m° » f o » m n m m 2 k \ < < $ § » S ® &£ «2 E � 0 f & 2 \ � O / ƒ »f a a q 4 32 2 r / 0 \ k k / \ \ / \ n \ \ 0 2 J g m $ &© / p J 2 \ E 2 » 7 3 ■ 0 � c E 0 CL 1w r.9 GR ] * ® $ ® 0 4.9 S \ e n / w \ \ k� CD 4 f 0 C) CD < \2 0 8 �p / } / = m m m \ \ ° & ■ c \ < c cn �2 & \ \J ;:v \ c E 0 CL 1w r.9 GR ] * ® $ cn z z / / S \ n / \ \ \ 4 f < < ¥& in && c E 0 CL §. k so rx ] * ® $ ] U a � CD z � _ _ CD \ \ \k Z -n \) CL 32 / 0k/ 000 f %f 000 / -0 7J7 C"kk \\\ M�� \\\ ;a «¥=ox 2to 0 Z -n m o , o 3 a 3 0 \ 2 3 _ � k0 \/\ 8 &7fk @ / J} C \j a > / � ^ ƒ0 \- \a ol 0 CD \ 0 0- (D. 2 m S 0 $ , x � \ o CD .§S 0 ƒ /\ E2 _. 0 � \ 3 0 \k EJ «/ # \ ■ \� _0) 2 \ 0 2 00 ƒf E2 �f %0 +5 CD U 3 3 \a 3 \z (D. se @# kG \E» a% 7722 $E 00 .§S 0 ƒ \\ E2 /\ 0-0-0-0 CD #& %f // \7 , Ln. I I - 0) k k ƒ k »■ ■ \� _0) 2 \ 0 2 00 ƒf E2 �f %0 +5 CD U & 77c = 3 (D. 0 0 \e \E» (D »___ i£&z E��0 \k e/ @ 0 ƒ zI \ Ewen / 0.0 / \ n \7 7342 0C LW 2 0) CD �- =m22 ƒ _ «¥ / »■ ® « _] F. \0 l< % CD � �� F CD �$\ 0 � & 77c = �% tkCD 0 0 \e \E» »___ i£&z E��0 \k e/ &\ J#S zI $000 Ewen eW 7000 N0 °p Won Q° nc /§ gGSg 7342 0C LW fJ 0) ___ 2777 �- =m22 x < _ «¥ < �$e »■ ® « _] F. \0 l< CD �� CD �$\ a 4A 4.9 C \/ \ \70 c 0 a°� - 00 0 22 0 -000 0 \k owe C)0 on CD< ,s 00 �m /m S. c a 0. \\\ 0 = �� 0 SO �k <0ww \§k \/ _ c I m I m CD « - M�c $ § \ < - % ; �\ � ��S � CD . D 7 \ � k E E 0 ƒ CD 2 k 0]m ƒ \ o .. \ \ W § ( k fu & m @ o U) . / . c a G E CD \ m k D E \ � (D D E ? �§ ± / k E . . 4 « 2 z oo ga S / z ƒ \ /\ D� \\ < \ 2 < 2 e ±@ a m » 'D & ® < && & && �/ . � � < . ■ . CL 0 ) 0 7 \ /7 ƒ m \ / 2 / / \ k / � z (=D:' 2 \ \ \ \ } 2. ° } a ° 2 a �_ & 0k C k [ o ] . � ■ 3 ■ . o . � » »± ee « z \ c = 0 _ 2 2 -a n \ / / \ $ 7 <& m R2 y e 2 « &3 �3 . to 0 . 77 »n z o e\ ao q \ \\ aJ /\ D zC z CD a em °° < &§ 23 \ % + q m m @ . X ƒ 77/0 2 / /ia 2 �/ 2 �k —__�� _ &g = k■ \ \" M. ff� ƒ §R \ \C \ &§ CD —E . z- a2m —m a # § 2 Q U. a a > g / 0 f /\ cn0 § $ $ C � ® / R 7 9 # # @# # z \ 2 /A# /%a \ S o E o z CD § S S S G S G S S / � _ o & ƒƒ 3 o m \E @a \� \ \ «\ $ 0 0 D R < o_— cn \ k / \ - n o D ch ` ¢ /// /i // C ƒ k z ca ( k \ ( ( ( \ \ \ ƒ \ m ? < © a a % a e 0 e , , , » / m EEE Ekkk ° . /n o ] ■ 3 . ■ . o 2 5 � \� k ƒ � ƒ ��� Cil n n ƒ k \ / E \// \ k \ o �k �< _\ 777 CD \\ 3\ 3 3� a a a \ / § CD . § / S = & _ — @ f @ f 2 / « / cn /// 0 /ii/ / / / / / \ } \ } \ } / \ \ \ \ / kkk kkkk o & 2 2 k O 0 CD . ® ƒ « k E 7 §.3 ° x® - $ _ ° n — \ \ a \ / ƒ \ 0 a $_ 2 o ( E m @ e w \$ C g / o c 2 \ m CL r+ (D % \x CD E] � & �3 \ k E � -69 0 4.9 e #_ \ 0 z S 20 2a z \ \ 0- _ f // m 0 \ m \ = 2 \ / q ® ° < 4 3 7< \ o k ± E - & �2 cn K 2 cn @ / k I en � %� 0 CD S / 2 // / U / ° / J z 7 z m m. . ° \ \ \\ a 2 m o n (D' m u /2 7§ / / § & 77 �2 » E E o ] . � � F . o � 4 »» z . a z z 0 a o n ¥ o o n n ] S z ƒ & G _ G ¥¥ = f w x e » q m ƒ/ o ƒ �i F5, 2 i I E k ® 33 9 2m / 76 bo �a a o o / \ \ \ \ \ \ ƒ & � \ \C / \ / �\ * � CD a q_ m m �kk 03 OJiv v \ \\\ ® � d % _ \99/ � / « ° \JCo \ �\ \3I k a o (j) n a ■ \ E f/ 2 a 0 0 = o o w \ / _- Cl \ .__- o / 0 ƒ / 0 ƒ . ƒ ]/ ]/ \ a 2 2 _0 E 3 E � � cc CL & k / R \ k ° m m 7 '< CD I a � \ k k EEE \0c0 a �kk # -0 \ \\\ mm/ 3 CD $47 7744 �© 0000 2� \§< CDM f t/ $ $ $ A \ $ s � \ k k EEE @ / \(D � U $ � / k k ] / \ \ 9 w / k 7� \ § � g 7\ a # / 7 W 2222 �© 0000 2� 0000 CDM f \ $ $ $ A \ a a a a \ _CL CL CL o§ @ / \(D � U $ � / k k ] / \ \ 9 w / k 7� \ § � g a # / »G 4 f og \ z o§ 0 �\ 0 \ 0 \ a & _0 \_\ 3 o 0 E\ \» / cc CL k / J \ k ° m m 7 '< \0 I a \ Cl) �i $�< k &$E C) \$c &� S a 2 U) \ \ 2 § ■ ��/ \ \// / k w 0 cn m �/ �\ C) / m ca @ \ ° \ a ƒ a § ; / E f 2 f - 7 / » / iiE / /// 0) / o w 0) ■ o; ] � ■ $ / / 3 / / \ } \ \ \ / m ■ \ \ 0 ƒ 2 a # »G 4 og o§ �\ 0 k\ 0 z ��� cn 0kkk 0 E\ \» / cc CL k �- J \ ° m m 7 '< . o / a Cl) �i $�< ® ® &$E 7� \$c &� ��/ \ \// / k C) % C) @ I & a & _� ; E f 2 f - 7 / » / iiE / /// 0) 0) w 0) ■ o; $ / / / / \ } \ \ \ / m \ \ \ \ ƒ kkk ° 0- Cl z FLORIDA Plan 75 Option 001 I Preventive Care • Routine physical exams o Well -child care • Well -woman exam (may self -refer to OB /GYN) Physician Services • (visits to specialists must be authorized by your primary care physician). diagnostic lab and Primary care physician office visits (includes and hearing exams, X-ray office surgery, allergy testing, speech vision screening exams, breast cancer screening treatment) (Hearing exams and vision screening exams cover children through age 18.) Specialist. office visits (includes same items as primary care physician office visit) Plan pays for services providedorac anged by your PARTICIpAT /NG primary care p l y s 11111111111111110 100% after $10 copayment per visit to Pr' care physician or $20 copayment per visit to specialist 100% after $10 copayment per visit 100% after $20 copayment per visit 100% • Allergy treatments and materials • Immunizations • Emergency room visits center and surgical • Outpatient surgical care (includes ambulatory hospital outpatient) visits (while member is confined in • Inpatient physician a hospital) 100% after $10 copayment per visit to primary care physician or • Prenatal care (office visit copayment applies to first visit only) treatment, including self- management training $20 copayment per visit to specialist day for first three days • Diabetes 100% after $100 copayment per Hospital Services • Inpatient care (semiprivate room, ancillary services) 100% after $50 copayment • Outpatient nonsurgical care 100% after $100 copayment • Outpatient surgical care (includes ambulatory surgical center) 100% • Preadmission testing and services • Other inpatient supplies ° copayment per occurrence 100 /o after $75 oa • Hospital emergency services Prescription Drugs • See attached drug rider, if applicable copayment. If Subject to the applicable prescription drug copay then a $5 Level • Diabetic supplies (30 -day supply per copayment) prescription drug coverage is not included, One /$15 Level Two /$30 Level Three copayment applies per item (based upon an Rx3 Drug ). • Skilled nursing facility (up to 100 days per calendar year) Other Medical Services care (up to 60 visits per calendar year 100% • Home health • Ambulance • Durable medical equipment • Diabetes equipment • Private duty nursing (inpatient or outpatient) • Hospice services (inpatient or outpatient) 100% after $10 copayment per visit • Spine and back disorders (limited to 20 visits per calendar year) 100% after $20 copayment per visit • Short term physical, speech, hearing and occupational therapy to 60 visits combined per calendar year) (limited $1,500 Copayment Limits • Individual $3,000 • Family Unlimited Lifetime Maximum 100% Mental and Nervous •Physician services Disorders (1) • Partial hospitalization 100% after a $100 copayment per day for the first three days • Inpatient services (maximum of 31 days per calendar year) ed by the Ian that enables you to take advantage of care arranged HumanaHMO is a health p You to specialists when appropriate. primary care physician you select from tcareereferring yartici atin providers. Your personal physician provides your primary FL- 10233 -HH 2/04 Plan 75 Option 001 Plan pays for services provided or arranged by your PARTICIPATING primary care physician Mental and Nervous • Outpatient services (maximum of 20 visits per calendar year) 100% after $20 copayment per visit Disorders (1) (cont'd) Alcoholism and Drug • Detoxification Abuse services (1) 1 — Inpatient — Outpatient — Physician services for detoxification only • Outpatient visits (lifetime maximum 44 visits) Most medical services must be provided or arranged by your participating primary care physician. Only emergency services, or urgent services received while out of the service area, are covered when provided by nonparticipating providers or facilities. Participating primary care and specialist physicians and other providers in Humana's networks are not the agents, employees or partners of Humana or any of its affiliates or subsidiaries. They are independent contractors. Humana is not a provider of medical services. Limitations and Exclusions This is a partial and summarized list of limitations and exclusions. Your group may have specific limitations and exclusions not included on this list. Please check your Certificate for this complete listing. The Certificate is the document upon which benefit payment will be determined. less stated otherwise, no coverage will be provided for m account of the following situations: �Olastic, cosmetic or reconstructive surgery, except as specified in the Group Plan. I Any service, supply or treatment connected with custodial care. 3. Purchase or rental of supplies of common household use. 4. Investigational or experimental procedures or treatment methods. 5. Care for military service connected disabilities for which the member is legally entitled to services and for which facilities are reasonably available to the member. 100% after $100 copayment per day for the first three days 100% 100% up to $35 per visit Humana does not endorse or control the clinical judgement or treatment recommendations made by the physicians or other providers listed in network directories or otherwise selected by you. To be covered, expenses must be medically necessary and specified as covered. Please see your Certificate for more information on medical necessity and other specific plan benefits. 6. Any service, supply, care or treatment provided to the member without the authorization of his or her primary care physician, unless the member is receiving emergency services as outlined in the Schedule of Emergency Coverage at nonparticipating providers. 7. Rehabilitative services, unless we determine that the member's condition can be significantly improved by our provision of such services. 8. Drugs or medicines, prescription or nonprescription, provided to the member while he or she is not hospital - confined, unless otherwise covered by an outpatient prescription drug rider attached to the Group Plan. 9. Infertility counseling, testing and treatment services, sex change services, or reversal of elective sterilization. 10. Care and treatment of the teeth or periodondum, unless otherwise specified in the Group Plan. 11. Elective abortion. 12. Eye refraction, the purchase or fitting of hearing aids, eyeglasses, contact lenses or advice on their care, except as specified in the Group Plan or otherwise provided by a vision care rider attached to the Group Plan. t Guidance when you need it most FL- 10233 -HH 2/04 f Offered by Humana Medical Plan, Inc. 1) Any copayments for the treatment of mental and nervous disorders or alcoholism and drug abuse services do not apply toward copayment limit. The amount of benefit provided depends upon the plan selected. Premiums trill vary according to (lie selection made. Forgeneral questions about the plan, contact your benefits administrator. 13. Any care, treatment, services or supplies received outside of the service area, unless otherwise specified in the Group Plan. 14. Any treatment to reduce obesity including, but not limited to, surgical procedures. 15. Sickness or injury for which the member refuses to accept the recommended care and treatment of his or her physician when: a. the physician believes that no professionally acceptable alternative exists; and b. we have given the member written notice that we will only provide the physician's recommended care and treatment. The member has the right to appeal a decision of this nature by using the Grievance Procedure outlined in the Group Plan. 16. Services and supplies for treatment of temporomandibular joint disorder or dysfunction (TMJ) and craniomandibular jaw disorders (CMJ) which are recognized as dental procedures. This includes, but is not limited to, the extraction of teeth and the application of orthodontic devices and splints. LG /SG How the Rx4 Covered prescription drugs are assigned to one of four different levels with corresponding copayment structure works ainounts.The levels are organized as follows: • Level One: lowest copayment for low cost generic and brand -name drugs. • Level Two: higher copayment for higher cost generic and brand -name drugs. • Level Three: higher copayment than Level Two for higher cost, mostly brand -naive drugs that may have generic or brand -name alternatives on Levels One or Two. • Level Four: highest copayment for high - technology drugs (certain brand -name drugs, biotechnology drugs and self - administered injectable medications). Prescription drug products, or classes of certain prescription drug products, are generally reviewed on an ongoing basis by a Humana Pharmacy and Therapeutics committee which is composed of physicians and pharmacists. Drugs are reviewed for safety, effectiveness and cost- effectiveness prior to assignment or a change in assignment to one of the levels. Coverage of a prescription drug or placement of the drug within a level are subject to change throughout the year. In the event drugs are moved to categories with higher member cost, advance notice is provided based on past usage. Always discuss prescription drugs with your physician to determine appropriateness or clinical effectiveness with respect to you or any specific illness. Check our Website or contact Customer Service for the most up -to -date information about the Drug List. Some drugs in all levels may be subject to dispensing limitations, based on age, gender, duration or quantity. Additionally, some drugs may need prior authorization in order to be covered. In these cases, your physician should contact Humana Clinical Pharmacy Review at 1 -800- 555 -CLIN (2546). Members can visit Humana's Website, wwwhumana.com, to obtain information about their prescription drug and corresponding benefits and for possible lower cost alternatives, or they can call Humana's Customer Service with questions or to request a partial Humana Rx4 Drug List by mail. For a complete listing of participating pharmacies, please refer to our Website or your participating provider directory. Coverage at When you present your membership card at a participating pharmacy, you are required to make a copayment participating for each prescription based on the current assigned level of the drug. pharmacies Drugs assigned to: Copayment per prescription or refill Level One: $10 Level Two: $20 Level Three: $40 Level Four: 25 %* of the total required payment to the dispensing pharmacy per prescription or refill. * The total maximum out -of- pocket copayment costs for drugs in Level Four is limited to $2,500 per calendar year, per member. • If the dispensing pharmacy's charge is less than the corresponding copayment, you will only be responsible for the lower amount. • Your copayments for covered prescription drugs are made on a per prescription or refill basis and will not change if Humana receives any retrospective volume discounts or prescription drug rebates. • If you use a nonparticipating pharmacy, there is no coverage, except for prescriptions required during an emergency for treatment of an emergency medical condition. There are no claim forms to file if you use a participating pharmacy and present your membership card with each prescription. Coverage Your coverage includes the following: specifics • A 30 -day supply or the amount prescribed, whichever is less, for each prescription or refill. • Contraceptives. • Certain self - administered injectable drugs and related supplies approved by Humana. • Certain drugs, medicines or medications that, under federal or state law, may be dispensed only by prescription from a physician. Mai! -order For your convenience, you may receive a maximum 90 -day supply per prescription or refill through the benefit mail (maximum 30 -day supply for self - administered injectable drugs). The same requirements apply when purchasing medications through a participating mail -order pharmacy as apply when purchasing in person at a pharmacy. Members can call Customer Service or visit our Website for more information, including mail -order forms. GN- 12278 -HH 5/05 Definition • Drug List: a list of prescription drugs, medicines, medications and supplies specified by Humana. This list of terms identifies drugs as Level One, Level Two, Level Three or Level Four and indicates applicable dispensing limits and/or any prior authorization requirements. (This list is subject to change.) • Copayment: the amount to be paid by the member toward the cost of each separate prescription or refill of a covered drug when dispensed by a pharmacy. • Participating pharmacy: a pharmacy that has signed a direct agreement with us as an independent contractor or has been designated by us as an independent contractor to provide services to all covered persons • Nonparticipating pharmacy: a pharmacy that has not been designated by us to provide services to covered persons. Limitations and Unless specifically stated otherwise, no coverage is provided for the following: exclusions • Any drug prescribed for a sickness or bodily injury not covered under the master group contract. • Any drug, medicine or medication labeled "Caution- Limited by Federal Law to Investigational Use" or any experimental drug, medicine or medication, even though a charge is made to you. • Anorectic or any drug used for the purpose of weight control. • Any drug used for cosmetic purposes, including but not limited to: - Tretinoin, e.g. Retin A, except if you are under the age of 45 or are diagnosed as having adult acne; - Dermatologicals or hair growth stimulants; or Pigmenting or de- pigmenting agents, e.g. Solaquin. • Any drug or medicine that is: - Lawfully obtainable without a prescription (over the counter drugs), except insulin; or - Available in prescription strength without a prescription. • Abortifacients (drugs used to induce abortions). • Infertility services including medications. • Any drug prescribed for impotence and /or sexual dysfunction, e.g.Viagra. • Any drug for which prior authorization is requited, as determined by us, and not obtained. • Any service, supply or therapy to eliminate or reduce a dependency on, or addiction to tobacco and tobacco products, including but not limited to nicotine withdrawal therapies, programs, services or medications. • Treatment for onychomycosis (nail fungus). • Any portion of a prescription or refill that exceeds a 30 -day supply (or a 90 -day supply for a prescription or refill that is received from a mail order pharmacy). • Legend drugs which are not recommended and not deemed necessary by a health care practitioner. • Prescriptions filled at a non - network pharmacy except for prescriptions required during an emergency. (Unless specifically listed on this benefit summary.) This is only a partial list of limitations and exclusions. Please refer to the certificate of coverage for complete details regarding prescription drug coverage. HUMANA. Gudanee when you need it most Humana Plans are offered by the Family of Insurance and Health Plan Companies including Humana Employers Health Plan of Georgia, Inc., Humana Medical Plan, Inc., Humana Health Plan, Inc., Humana Health Benefit Plan of Louisiana, Inc,. Humana Health Plan of Ohio, Inc.,Humana Health Plans of Puerto Rico, Inc., Humana Wisconsin Health Organization Insurance Corporation, or Humana Health Plan of Texas, Inc. — A Health Maintenance Organization. Our Health Benefit Plans have limitations and exclusions. GN- 12274 -HH 5/05 HumanaHMO FLORIDA Plan 25, Option 40 physical exams (limited to one Preventive Care • Routine p y exam per calendar year) . Well -child care • Well -woman care (1) Physician services • Office visits in conjunction with a sickness or injury • Outpatient physician care • Diagnostic lab testing and X -rays • Emergency room visits sician's office • Surgery performed in a physician's • Allergy tests/serum Hospital Services • Inpatient care (semiprivate room and ancillary services) • Ancillary services . Preadmission testing • Emergency room Plan pays for services provided or arranged by your participating primary care physician 100% after a $10 primary care/ pediatrician copayment per visit (other specialists covered in full) 100% after a $10 primary care/ pediatrician copayment per visit (other specialists covered in full) 100% after a $10 primary care/ pediatrician copayment per visit (other specialists covered in full) 100% after $200 copayment per admission 100% outpatient Services • Outpatient surgical • Outpatient nonsurgical Prescription Drugs • See attached rider if applicable other Medical Services • Durable medical equipment (2) • Skilled nursing facility (limited to 100 days per lifetime) (2) • Ambulance physical • Therapy, (includes I - be determined and speech therapy,' must by primary care physician that the member's condition can improve within 60 days of the date significantly therapy begins.) (2) • Home health care (2) 100% after $50 copayment per visit (waived if admitted) 100% 100% Plan pays for services not provided or arranged by your participating primary care physician Not covered 70% after nonparticipating deductible 700/ after nonparticipating deductible 709/o after nonparticipating deductible 100% 100% after $50 copayment per visit (waived if admitted) 70% after nonparticipating dedudible 700/6 after nonparticipating dedudible ment per visit 70% after nonparticipating dedudible 100% after $10 copay 100% uo to $5,000 inpatient and outpatient combined maximum Hospice Services $0 Deductible •Individual • Family (two Etimes ndividual amount) $0 $1,500 Out -of- Pocket Maximum • Individual • Family (tw individual am ount) $3,000 Unlimited Lifetime Maximum Benefit Mental Health Services • Inpatient facility (limited to 30 days per calendar year) (3) • Inpatient professional services • Outpatient (maximum of 20 visits per calendar year) 100% after $200 copayment per admission 100% 1000/0 after $10 copayment per visit $400 $800 $2,500 $5,000 $1,000,000 70% after dedudible 70% after dedudible 700/6 after dedudible you to seek care from any provider without a referral. Care received from HumanaPOS allows y, , tin primary f care physician will be covered at a higher benefit level. or arranged by your participating p FL- 10011 -HH 4/04 - -- Alcohol and Drug Abuse Plan 25, Option 40 • Inpatient facility (3) • Inpatient professional services • Outpatient ( detox) • Outpatient (excluding detox) (limited to a lifetime maximum of 44 visits) Payments - Plan benefits are paid based on maximum allowable fees, as defined in your Certificate. Participating providers agree to accept maximum allowable fees as paid in full. For services rendered by nonparticipating providers, the member is responsible for amounts exceeding maximum allowable fees, as defined in your Certificate. Emergency services, or urgent services received while out of the service area, are covered at the referred level. Participating primary care and specialist physicians and other providers in Human's networks are not the agents, employees or partners of Humana or any of its affiliates or Limitations and Exclusions This is a partial and summarized list of limitations and exclusions.Your group may have specific limitations and exclusions not included on this list. Please check your Certificate for this complete 'isting.The Certificate is the document upon which enefit payment will be determined. Qniless stated otherwise, no coverage will be provided for the following situations. 1. Plastic, cosmetic or reconstructive surgery, except as specified in the Group Plan. 2. Any service, supply or treatment connected with custodial care. 3. Purchase or rental of supplies of common household use. 4. Investigational or experimental procedures or treatment methods. 5. Care for military service connected disabilities for which the member is legally entitled to services and for which facilities are reasonably available to the member. 6. Any service, supply, care or treatment provided to the member without the authorization of his or �' CR 4304 FL- 10011 -HH 4/04 Plan pays for services provided or Plan pays for services not provided or arranged by your participating arranged by your participating primary care physician primary care physician 100% after $200 copayment per admission 100% 100% not to exceed $35 per visit subsidiaries. They are independent contractors. Humana is not a provider of medical services. Humana does not endorse or control the clinical judgement or treatment recommendations made by the physicians or other providers listed in network directories or otherwise selected by you. To be covered, expenses must be medically necessary and specified as covered. Please see your Certificate for more information on medical necessity and other specific plan benefits. (1) insureds may self -refer to a participating specialist for an annual OB /GYN exam and for any medically necessary follow -up care identified at the annual her participating primary care physician, unless the member is receiving emergency services or unless such services have been expressly authorized under the terns of this Group Plan. 7. Rehabilitative services, unless we determine that the member's condition can be significantly improved by our provision of such services. 8. Drugs or medicines, prescription or nonprescription, provided to the member while he or she is not hospital- confined, unless otherwise covered by an outpatient prescription drug rider attached to the Group Plan. 9. In -vitro fertilization, sex change services or reversal of elective sterilization. 10. Care and treatment of the teeth or periodontium, unless otherwise specified in the Group Plan. 11. Elective abortion, except as specified in the Group Plan. 12. Eye refraction, the purchase or fitting of hearing aids, eyeglasses, contact lenses or advice on their care, except as specified in the Group Plan or otherwise provided by a vision care rider attached to the Group Plan. t ,�` HUMANA® 1 Guidance when you need it most Offered and insured by Humana Medical Plan, Inc. 70% after deductible 70% after deductible 70% after deductible (not to exceed $35 per visit) visit. Limited to one exam per insured per benefit year. (2) Failure to preauthorize may result in financial penalty or denial of payment. (3) Services require prior approval of plan or designee. Expenses do not apply toward out -of- pocket maximum. The amount of benefit provided depends upon the plan seceded. Premiums twill vary aanrding to the selection trade. For general questions about the plan, contact your benefits administrator. 13. Any care, treatment, set-vices or supplies received outside of the service area, unless otherwise specified in the Group Plan. 14. Any treatment to reduce obesity, including, but not limited to, surgical procedures. 15. Sickness or injury for which the member refuses to accept the recommended care and treatment of his or her physician when: a, the physician believes that no professionally acceptable alternative exists; and b, we have given the member written notice that we will only provide the physician's recommended care and treamhent.The member has the right to appeal a decision of this nature by using the Grievance Procedure outlined in the Group Plan. 16. Services and supplies for treatment of temporomandibular joint disorder or dysfunction (TMJ) and cmuiomandibular jaw disorders (CMJ) which are recognized as dental procedures. This includes, but is not limited to, the extraction of teeth and die application of orthodontic devices and splints. How the Rx4 Covered prescription drugs are assigned to one of four different levels with corresponding copayment structure works amounts. The levels are organized as follows: • Level One: lowest copayment for low cost generic and brand -name drugs. • Level Two: higher, copayment for higher cost generic and brand -name drugs. • Level Three: higher copayment than Level Two for higher cost, mostly brand -name drugs that may have generic or brand -name alternatives on Levels One or Two. • Level Four: highest copayment for high - technology drugs (certain brand -name drugs, biotechnology drugs and self - administered injectable medications). Prescription drug products, or classes of certain prescription drag products, are generally reviewed on an ongoing basis by a Humana Pharmacy and Therapeutics committee which is composed of physicians and pharmacists. Drugs are reviewed for safety, effectiveness and cost - effectiveness prior to assignment or a change in assignment to one of the levels. Coverage of a prescription drug or placement of the drug within a level are subject to change throughout the year. In the event drugs are moved to categories with higher member cost, advance notice is provided based on past usage. Always discuss prescription drugs with your physician to determine appropriateness or clinical effectiveness with respect to you or any specific illness. Check our Website or contact Customer Service for the most up -to -date information about the Drug List. Some drugs in all levels may be subject to dispensing limitations, based on age, gender, duration or quantity. Additionally, some drugs may need prior authorization in order to be covered. In these cases, your physician should contact Humana Clinical Pharmacy Review at 1- 800 - 555 -CLIN (2546). Members can visit Humana's Website, www.humana.com, to obtain information about their prescription drug and corresponding benefits and for possible lower cost alternatives, or they can call Human's Customer Service with questions or to request a partial Humana Rx4 Drug List by mail. For a complete listing of participating pharmacies, please refer to ou.r Website or your participating provider directory. ' Coverage at When you present your membership card at a participating pharmacy, you are required to make a copayment participating for each prescription based on the current assigned level of the drug. pharmacies Drugs assigned to: Copayment per prescription or refill Level One: $10 Level Two: $20 Level Three: $40 Level Four: 25 %* of the total required payment to the dispensing pharmacy per prescription or refill. * The total maximum out -of- pocket copayment costs for drugs in Level Four is limited to $2,500 per calendar year, per member. • If the dispensing pharmacy's charge is less than the corresponding copayment, you will only be responsible for the lower amount. • Your copayments for covered prescription drugs are made on a per prescription or refill basis and will not change if Humana receives any retrospective volume discounts or prescription drug rebates. There are no claim forms to file if you use a participating pharmacy and present your membership card with each prescription. Nonparticipating You may also purchase prescribed medications from a nonparticipating pharmacy.You will be required to pay pharmacy for your prescriptions according to the following rule. coverage • You pay 100 percent of the dispensing pharmacy's charges. — You file a claim form with Humana (address is on the back of ID card). — Claim is paid at 70 percent of the dispensing pharmacy's charges, after they are first reduced by the applicable copayment. • Your copayments for covered prescription drugs are made on a per prescription or refill basis and will not change if Humana receives any retrospective volume discounts or prescription drug rebates. GN- 12195 -HH 5/05 Coverage Your coverage includes the following. specifics • A 30 -day supply or the amount prescribed, whichever is less, for each prescription or refill. • Contraceptives. • Certain self - administered injectable drugs and related supplies approved by Humana. • Certain drugs, medicines or medications that, under federal or state law, may be dispensed only by - prescription from a physician. Mail -order For your convenience, you may receive a maximum 90 -day supply per prescription or refill through the benefit mail (maximum 30 -day supply for self - administered injectable drugs). The same requirements apply when purchasing medications through a participating mail -order pharmacy as apply when purchasing in person at a pharmacy. Members can call Customer Service or visit ourWebsite for more information, including mail -order forms. Definition • Drug List: a list of prescription drugs, medicines, medications and supplies specified by us.This list identifies of terms drugs as Level One, Level Two, Level Three or Level Four and indicates applicable dispensing limits and /or any prior authorization requirements. (This list is subject to change.) • Copayment: the amount to be paid by the member toward the cost of each separate prescription or refill of a covered drug when dispensed by a pharmacy. • Nonparticipating pharmacy: a pharmacy that has not been designated by us to provide services to covered persons • Participating pharmacy: a pharmacy that has signed a direct agreement with us as an independent contractor or has been designated by us as an independent contractor to provide services to all covered persons. Limitations and Unless specifically stated otherwise, no coverage is provided for the following: exclusions • Any drug prescribed for a sickness or bodily injury not covered under the master group contract. • Any drug, medicine or medication labeled "Caution- Limited by Federal Law to Investigational Use" or any experimental drug, medicine or medication, even though a charge is made to you. • Anorectic or any drug used for the purpose of weight control. • Any drug used for cosmetic purposes, including but not limited to: - Tretinoin, e.g. Retin A, except if you are under the age of 45 or are diagnosed as having adult acne; - Dermatologicals or hair growth stimulants; or - Pigmenting or de- pigmenting agents, e.g. Solaquin. • Any drug or medicine that is: - Lawfully obtainable without a prescription (over the counter drugs), except insulin; or - Available in prescription strength without a prescription. • Abortifacients (drugs used to induce abortions). • Infertility services including medications. • Any drug prescribed for impotence and /or sexual dysfunction, e.g.Viagra. • Any drug for which prior authorization is required, as determined by us, and not obtained. • Any service, supply or therapy to eliminate or reduce a dependency on, or addiction to tobacco and tobacco products, including but not limited to nicotine withdrawal therapies, programs, services or medications. • Treatment for onychomycosis (nail fungus). • Any portion of a prescription or refill that exceeds a 30 -day supply (or a 90 -day supply for a prescription or refill that is received from a mail order pharmacy). • Legend drugs which are not recommended and not deemed necessary by a health care practitioner. • Prescriptions filled at a non - network pharmacy except for prescriptions required during an emergency. (Unless specifically listed on this benefit summary.) This is only a partial list of limitations and exclusions. Please refer to the Certificate of Coverage for complete details regarding prescription drug coverage. HU-M-ANA Guidance when you need it most Humana Plans are offered by the Family of Insurance and Health Plan Companies including Humana Medical Plan, Inc., Humana Employers Health Plan of Georgia, Inc., Humana Health Plan, Inc., Humana Health Benefit Plan of Louisiana, Inc., Humana Health Plan of Ohio, Inc., Humana Health Plans of Puerto Rico, Inc., Humana Wisconsin Health Organization Insurance Corporation, or Humana Health Plan of Texas, Inc. - A Health Maintenance Organization or insured by Humana Health Insurance Company of Florida, Inc., Humana Health Plan Inc., Humana Health Benefit Plan of Louisiana, Inc., Humana Insurance Company, Humana Insurance Company of Kentucky, or Humana Insurance of Puerto Rico, Inc. Our Health Benefit Plans have limitations and exclusions. GN- 12195 -HH 5/05 HumanaPOS YOUR BENEFITS UnitedHealthcare Choke Plan S56 Choice plan givesyou the freedom to see any Physician or other health care professional from our Network, including specialists, without a referral. With this plan, you will receive the highest level of benefits when you seek care from a network physician, facility or other health care professional. In addition, you do not have to worry about any claim forms or bills. Some of the Important Benefits You have access to a Network of physicians, facilities and other health care professionals, including specialists, without designating a Primary Physician or obtaining a referral. Benefits are available for office visits and hospital care, as well as inpatient and outpatient surgery. Care Coordinationsm services are available to help identify and prevent delays in care for those who might need specialized help. FLLEMS5602 of Your Plan: Emergencies are covered anywhere in the world. Pap smears are covered. Prenatal care is covered. Routine check -ups are covered. Childhood immunizations are covered. Mammograms are covered. Vision and hearing screenings are covered. Choice Benefits Summary Types of Coverage Network Benefits / Copayment Amounts This Benefit Summary is intended only to highlight Annual Deductible: No Annual Deductible. your Benefits and should not be relied upon to fully determine coverage. This benefit plan may not cover Out -of- Pocket Maximum: $2,500 per Covered Person, per calendar year, not to exceed $5,000 for all Covered all of your health care expenses. More complete Persons in a family. descriptions of Benefits and the terms under which they are provided are contained in the Certificate of Maximum Policy Benefit: No Maximum Policy Benefit. Coverage that you will receive upon enrolling in the Plan. $500 per Inpatient Stay If this Benefit Summary conflicts in any way with the $15 per visit Policy issued to your employer, the Policy shall Same as 8, 11, 12 and 13 prevail. No Copayment applies to Physician office visits for prenatal care after the first visit. Terms that are capitalized in the Benefit Summary are defined in the Certificate of Coverage. Benefits are payable for Covered Health Services $250 per surgical procedure provided by or under the direction of your Network For lab and radiology/Xray: No Copayment physician. $250 per test *Prior Notification is required for certain services. 1. Ambulance Services - Emergency only Ground Transportation: No Copayment 12. Physician's Office Services Air Transportation: 0% of Eligible Expenses 2. Dental Services - Accident only *Same as 8, 11, 12 and 13 care. *Prior notification is required before follow -up treatment begins. 3. Durable Medical Equipment No Copayment Benefits for Durable Medical Equipment are limited to $2,500 per calendar year. Limits do not apply to Durable Medical Equipment classified as diabetic equipment or supppies. 4. Emergency Health Services $150 per visit 5. Eye Examinations $15 per visit Refractive eye examinations are limited to one every other calendar year from a Network Provider. ' 6. Home Health Care No Copayment Benefits are limited to 60 visits for skilled care services per calendar year. 7. Hospice Care No Copayment Benefits are limited to 360 days during the entire period of time a Covered Person is covered under the Policy. S. Hospital - Inpatient Stay $500 per Inpatient Stay 9. Injections Received in a Physician's Office $15 per visit 10. Maternity Services Same as 8, 11, 12 and 13 No Copayment applies to Physician office visits for prenatal care after the first visit. 11. Outpatient Surgery, Diagnostic and Therapeutic Services Outpatient Surgery $250 per surgical procedure Outpatient Diagnostic Services For lab and radiology/Xray: No Copayment Outpatient Diagnostic /Therapeutic Services - CT $250 per test Scans, Pet Scans, MRI and Nuclear Medicine Outpatient Therapeutic Treatments No Copayment 12. Physician's Office Services $15 per visit except that the Copayment for a Specialist Physician office visit is $25. No Copayment applies Covered Health Services for preventive medical when a Physician charge is not assessed. care. Covered Health Services for the diagnosis and treatment of a Sickness or Injury received in a $15 per visit except that the Copayment for a Specialist Physician office visit is $25. No Copayment applies Physician's office. when a Physician charge is not assessed. 13. Professional Fees for Surgical and Medical No Copayment Services 14. Prosthetic Devices No Copayment Benefits for prosthetic devices are limited to $2,500 per calendar year. 15. Reconstructive Procedures Same as 8, 11, 12, 13 and 14 YOUR BENEFITS Types of Coverage Network Benefits /. Copayment Amounts 16. Rehabilitation Services - Outpatient Therapy $15 per visit Benefits are limited as follows: 20 visits of physical therapy; 20 visits of occupational therapy; 20 visits of speech therapy; 20 visits of pulmonary rehabilitation; and 36 visits of cardiac rehabilitation per calendar year. 17. Skilled Nursing Facility/Inpatient No Copayment Rehabilitation Facility Services Benefits are limited to 60 days per calendar year. 18. Transplantation Services *Same as 8 and 13 19. Urgent Care Center Services $50 per visit Additional Benefits Bones or Joints of the Jaw and Facial Region Same as 8, 11, 12 and 13 Child Health Supervision Services Same as 11, 12 and 13 Cleft Lip /Cleft Palate Treatment Same as 8, 11, 12, 13, and 16 Dental Procedures - Anesthesia and Hospitalization Same as 8, 11, and 13 Diabetes Treatment Same as 3, 11, 12 and 13 Mammography No Copayment Mastectomy Same as 8, 11, 12 and 13 Mental Health and Substance Abuse Services - $15 per individual visit; $10 per group visit Outpatient Must receive prior authorization through the Mental Health/Substance Abuse Designee. Benefits are limited to 30 visits per calendar year. Mental Health and Substance Abuse Services - $500 per Inpatient Stay Inpatient and Intermediate Must receive prior authorization through the Mental Health/Substance Abuse Designee. Benefits are limited to 30 days per calendar year. Osteoporosis Treatment Same as 11, 12 and 13 Prescription and Non - Prescription Enteral No Copayment Formulas Benefits for low protein food products for Covered Persons through age 24 are limited to $2,500 per calendar year. Spinal Treatment $15 per visit Benefits include diagnosis and related services and are limited to one visit and treatment per day. Benefits are limited to 24 visits per calendar year. Exclusions Except as maybe specifically provided in Section I of the Certificate of Coverage (COC) or through a Rider to the Policy, the following are not covered: A. Alternative Treatments Acupressurv, hypnotism; rolfing; massage therapy; aromatherapy; acupuncture; and other forms of alternative treatment. B. Comfort or Convenience Personal comfort or convenience items or services such as television; telephone; barber or beauty service; guest service; supplies, equipment and similar incidental services and supplies for personal comfort including air conditioners, air purifiers and filters, batteries and battery chargers, dehumidifiers and humidifiers; devices or computers to assist in communication and speech. C. Dental Except as specifically described as covered in Section I of the COC under the headings Dental Services - Accident only and Cleft Lip /Cleft Palate Treatment, dental services are excluded. There is no coverage for services provided for the prevention, diagnosis, and treatment of the teeth or gums (including extraction, restoration, and replacement of teeth and services to improve dental clinical outcomes). Dental implants and dental braces are excluded. Dental x -rays, supplies and appliances and all associated expenses arising out of such dental services (including hospitalizations and anesthesia) are excluded, except as might otherwise be required for transplant preparation, initiation of immunosuppressives, the direct treatment of acute traumatic Injury, cancer, or cleft palate, or as described in Section 1 of the COC under the heading of Dental Procedures - Anesthesia and Hospitalization. Treatment for congenitally missing, malpositioned, or super numerary teeth is excluded, even if part of a Congenital Anomaly except in connection with cleft lip or cleft palate. D. Drugs Prescription drug products for outpatient use that are filled by a prescription order or refill. Self - injectable medications except as described in Section 1 of the COC under the heading of Diabetes Treatment. Non - injectable medications given in a Physician's office except as required in an Emergency. Over - the - counter drugs and treatments. E. Experimental, Investigational or Unproven Services Experimental, Investigational or Unproven Services are excluded, except (a) bone marrow transplants and (b) medically appropriate medications prescribed for the treatment of cancer, for a particular indication, if that drug is recognized for the treatment of that indication in a standard reference compendium or recommended in medical literature. The fact that an Experimental, Investigational or Unproven Service, treatment, device or pharmacological regimen is the only available treatment for a particular condition will not result in Benefits if the procedure is considered to be Experimental, Investigational or Unproven in the treatment of that particular condition. F. Foot Care Routine foot care (including the cutting or removal of toms and calluses); nail trimming, cutting, or debriding; hygienic and preventive maintenance foot care; treatment of flat feet or subluxation of the foot; shoe orthotics. C. Medical Supplies and Appliances Devices used specifically as safety items or to affect performance primarily in sports - related activities. Prescribed or non - prescribed medical supplies and disposable supplies including but not limited to elastic stockings, . ace bandages, ostomy supplies, gauze and dressings. Orthotic appliances that straighten or re-shape a body part (including cranial banding and some types of braces). Tubings and masks are not covered except when used with Durable Medical Equipment as described in Section I of the COC. H. Mental Health /Substance Abuse Services performed in connection with conditions not classified in the current edition of the Diagnostic and Statistical Manual of the American Psychiatric Association. Services that extend beyond the period necessary for short-term evaluation, diagnosis, treatment, or crisis intervention. Mental Health treatment of insomnia and other sleep disorders, neurological disorders, and other disorders with a known physical basis. Treatment of conduct and impulse control disorders, personality disorders, paraphilias and other Mental Illnesses that will not substantially improve beyond the current level of functioning, or that are not subject to favorable modification or management according to prevailing national standards of clinical practice, as reasonably determined by the Mental Health/Substance Abuse Designee. Services utilizing methadone treatment as maintenance, L.A.A.M. (1- Alpha - Acetyl - Methadol), Cyelazocine, or their equivalents. Treatment provided in connection with or to comply with involuntary commitments, police detentions and other similar arrangements, unless authorized by the Mental Health/Substance. Abuse Designee. Residential treatment services. Services or supplies that in the reasonable judgment of the Mental Health/Substance Abuse Designee are not; for example, consistent with certain . national standards or professional research further described in Section 2 of the COC. I. Nutrition Megavitamin and nutrition based therapy; nutritional counseling for either individuals or groups. Enteral feedings and other nutritional and electrolyte supplements, including infant formula and donor breast milk, except as described in Section 1 of the COC under the heading Prescription and Non- prescription Enteral Formulas. United HealthCare Insurance Company J. Physical Appearance Cosmetic Procedures including, but not limited to, pharmacological regimens; nutritional procedures or treatments; salabrasion, chemosurgery and other such skin abrasion procedures associated with the removal of scars, tattoos, and/or which are performed as a treatment for acne. Replacement of an existing breast implant is excluded if the earlier breast implant was a Cosmetic Procedure. (Replacement of an existing breast implant is considered reconstructive if the initial breast implant followed mastectomy.) Physical conditioning programs such as athletic training, bodybuilding, exercise, fitness, flexibility, and diversion or general motivation. Weight loss programs for medical and non - medical reasons. Wigs, regardless of the reason for the hair loss. K. Providers Services performed by a provider with your same legal residence or who is a family member by birth or marriage, including spouse, brother, sister, parent or child. This includes any service the provider may perform on himself or herself. Services provided at a free - standing or Hospital -based diagnostic facility without an order written by a Physician or other provider as further described in Section 2 of the COC (this exclusion does not apply to mammography testing). L. Reproduction Health services and associated expenses for infertility treatments. Surrogate parenting. The reversal of voluntary sterilization. M. Services Provided under Another Plan Health services for which other coverage is paid under arrangements required by federal, state or local law. This includes, but is not limited to, coverage paid by workers' compensation, no -fault automobile insurance, or similar legislation. Health services for treatment of military service - related disabilities, when you are legally entitled to other coverage and facilities are reasonably available to you. Health services while on active military duty. N. Transplants Health services for organ or tissue transplants are excluded, except those specified as covered in Section 1 of the COC. Any solid organ transplant that is performed as a treatment for cancer. Health services connected with the removal of an organ or tissue from you for purposes of a transplant to another person. Health services for transplants involving mechanical or animal organs. Transplant services that are not performed at a Designated Facility. Any multiple organ transplant not listed as a Covered Health Service in Section 1 of the COC. O. Travel Health services provided in a foreign country, unless required as Emergency Health Services. Travel or transportation expenses, even though prescribed by i Physician. Some travel expenses related to covered transplantation services may be reimbursed at our discretion. P. Vision and Hearing Purchase cost of eye glasses, contact lenses, or hearing aids. Fitting charge for hearing aids, eye glasses or contact lenses. Eye exercise therapy. Surgery that is intended to allow you to see better without glasses or other vision correction including radial keratotomy, laser, and other refractive eye surgery. Q. Other Exclusions Health services and supplies that do not meet the definition of a Covered Health Service - see definition in Section 10 of the COC. Physical, psychiatric or psychological examinations, testing, vaccinations, immunizations or treatments otherwise covered under the Policy, when such services are: (1) required solely for purposes of career, education, sports or camp, travel, employment, insurance, marriage or adoption; (2) relating to judicial or administrative proceedings or orders; (3) conducted for purposes of medical research; or (4) to obtain or maintain a license of any type. Health services received as a result of war or any act of war, whether declared or undeclared or caused during service in the armed forces of any country. Health services received after the date your coverage under the Policy ends, including health services for medical conditions arising prior to the date your coverage under the Policy ends. Health services for which you have no legal responsibility to pay, or for which a charge would not ordinarily be made in the absence of coverage under the Policy. Charges in excess of Eligible Expenses or in excess of any specified limitation. Services for the evaluation and treatment of temporomandibular joint syndrome (TMJ), whether the services are considered to be medical or dental in nature, except as described in Section 1 of the COC under the heading Bones or Joints of the Jaw and Facial Region. Surgical treatment and non - surgical treatment of obesity (including morbid obesity). Surgical treatment and non- surgical treatment of obesity (including morbid obesity). Growth hormone therapy; sex transformation operations; treatment ofbenign gynecomastia (abnormal breast enlargement in males); medical and surgical treatment of excessive sweating (hyperhidrosis); medical and surgical treatment for snoring, except when provided as part of treatment for documented obstructive sleep apnea. Oral appliances for snoring. Custodial care; domiciliary care; private duty nursing; respite care; rest cures. Psychosurgery. Speech therapy except as required for treatment of a speech impediment or speech dysfunction that results from injury, stroke, cleft lip /cleft palate or Congenital Anomaly. This summary of Benefits is intended only to highlight your Benefits and should not be relied upon to fully determine coverage. This plan may not cover all your health care expenses. Please refer to the Certificate of Coverage for a complete listing of services, limitations, exclusions and a description of all the terms and conditions of coverage. If this description conflicts in any way with the Certificate of Coverage, the Certificate of Coverage prevails. Terms that are capitalized in the Benefit Summary are defined in the Certificate of Coverage. 02I_13S_Chc FLLEMS5602 OAH 213-11570604 YOUR BENEFITS UnitedHealtheare Pharmacy Management Program Plan 023 UnitedHealthcare's pharmacy management program provides clinical pharmacy services that promote choice, accessibility and value. The program offers a broad network of pharmacies (more than 56,000 nationwide) to provide convenient access to medications. While most pharmacies participate in our network, you should check first. Call your pharmacist or visit our online pharmacy service at www.myuhc.com. The online service offers you home delivery of prescriptions, ability to view personal benefit coverage, access health and well being information, and even location of network retail neighborhood pharmacies by zip code. Copayment per Prescription Order or Refill Your Copayment is determined by the tier to which the Prescription Drug List Management Committee has assigned the Prescription Drug Product. All Prescription Drug Products on the Prescription Drug List are assigned to Tier 1, Tier 2 or Tier 3. Please access www.myuhc.com through the Internet, or call the Customer Service number on your ID card to determine tier status. For a single Copayment, you may receive a Prescription Drug Product up to the stated supply limit. Some products are subject to additional supply limits. You are responsible for paying the lower of the applicable Copayment or the retail Network Pharmacy's Usual and Customary Charge, or the lower of the applicable Copayment or the Home Delivery Pharmacy's Prescription Drug Cost. Also note that some Prescription Drug Products require that you notify us in advance to determine whether the Prescription Drug Product meets the definition of a Covered Health Service and is not Experimental, Investigational or Unproven. Retail Network Home Delivery Network Pharmacy Pharmacy For up to a 31 day supply For up to a 90 day supply Tier 1 $10 $25 Tier 2 .$30 $75 Tier 3 $50 $125 FLNPP02304 Other Important Cost Sharing Information Annual Drug No Annual Drug Deductible Deductible Out -of- Pocket Drug No Out -of- Pocket Drug Maximum Maximum Exclusions Exclusions from coverage listed in the Certificate apply also to this Rider. In addition, the following exclusions apply: Outpatient Prescription Drug Products obtained from a non - Network Pharmacy. Coverage for Prescription Drug Products for the amount dispensed (days supply or quantity limit) which exceeds the supply limit. Prescription Drug Products dispensed outside the United States, except as required for Emergency treatment. Drugs which are prescribed, dispensed or intended for use while you are an inpatient in a Hospital, Skilled Nursing Facility, or Alternate Facility. Experimental, Investigational or Unproven Services and medications; medications used for experimental indications and/or dosage regimens determined by us to be experimental, investigational or unproven. Prescription Drug Products furnished by the local, state or federal government. Any Prescription Drug Product to the extent payment or benefits are provided or available from the local, state or federal government (for example, Medicare) whether or not payment or benefits are received, except as otherwise provided by law. Prescription Drug Products for any condition, Injury, Sickness or mental illness arising out of, or in the course of, employment for which benefits are available under any workers' compensation law or other similar laws, whether or not a claim for such benefits is made or payment or benefits are received. Any product dispensed for the purpose of appetite suppression and other weight loss products. A specialty medication Prescription Drug Product (such as immunizations and allergy serum) which, due to its characteristics as determined by us, must typically be administered or supervised by a qualified provider or licensed/certified health professional in an outpatient setting. This exclusion does not apply to Depo Provera and other injectable drugs used for contraception. United HealthCare Insurance Company Durable Medical Equipment. Prescribed and non - prescribed outpatient supplies, other than the diabetic supplies and inhaler spacers specifically stated as covered. General vitamins, except the following which require a Prescription Order or Refill: prenatal vitamins, vitamins with fluoride, and single entity vitamins. Unit dose packaging of Prescription Drug Products. Medications used for cosmetic purposes. Prescription Drug Products, including New Prescription Drug Products or new dosage forms, that are determined to not be a Covered Health Service. Prescription Drug Products as a replacement for a previously dispensed Prescription Drug Product that was lost, stolen, broken or destroyed. Prescription Drug Products when prescribed to treat infertility. Drugs available over - the - counter that do not require a Prescription Order or Refill by federal or state law before being dispensed. Any Prescription Drug Product that is therapeutically equivalent to an over - the - counter drug. Prescription Drug Products that are comprised of components that are available in over - the - counter form or equivalent. Prescription Drug Products for smoking cessation. Compounded drugs that do not contain at least one ingredient that requires a Prescription Order or Refill. Compounded drugs that contain at least one ingredient that requires a Prescription Order or Refill are assigned to Tier 3. New Prescription Drug Products and/or new dosage forms until the date they are reviewed by our Prescription Drug List Management Committee. Growth hormone therapy for children with familial short stature (short stature based upon heredity and not caused by a diagnosed medical condition). This summary of Benefits is intended only to highlight your Benefits for outpatient Prescription Drug Products and should not be relied upon to determine coverage. Your plan may not coverall your outpatient prescription drug expenses. Please refer to your Outpatient Prescription Drug Rider and the Certificate of Coverage for a complete listing of services, limitations, exclusions and a description of all the terms and conditions of coverage, if this description conflicts in any way with the Outpatient Prescription Drug Rider or the Certificate of Coverage, the Outpatient Prescription Drug Rider and Certificate of Coverage prevail. Capitalized terms in the Benefit Summary are defined in the Outpatient Prescription Drug Rider and/or Certificate of Coverage. 04I BS RX NET FLNPP02304 H9 213- 1377_0804 YOUR BENEFITS UnitedHealthcare Choice Plus Plan S59 Choice Plus plan gives you the freedom to see any Physician or other health care professional from our Network, including specialists, without a referral. With this plan, you will receive the highest level of benefits when you seek care from a network physician, facility or other health care professional. In addition, you do not have to worry about any claim forms or bills. You also may choose to seek care outside the Network, without a referral. However, you should know that care received from a non - network physician, facility or other health care professional means a higher deductible and Cop�ayyment. In addition, if you choose to seek care outside the Network, UnitedHealthcare only pays a portion of those charges and it is your responsibility to pay the remainder. This amount you are required to pay, which could be significant, does not apply to the Out -of- Pocket Maximum. We recommend that you ask the non - network physician or health care professional about their billed charges before you receive care. Some of the Important Benefits You have access to a Network of physicians, facilities and other health care professionals, including specialists, without designating a Primary Physician or obtaining a referral. Benefits are available for office visits and hospital care, as well as inpatient and outpatient surgery. Care Coordinationsm services are available to help identify and prevent delays in care for those who might need specialized help. FLLGMS5902 of Your Plan: Emergencies are covered anywhere in the world. Pap smears are covered. Prenatal care is covered. Routine check -ups are covered. Childhood immunizations are covered. Mammograms are covered. Vision and hearing screenings are covered. Choice Plus Benefits Summary Types of Coverage Network Benefits / Copayment Amounts Non - Network Benefits / Copayment Amounts This Benefit Summary is intended only to highlight your Benefits and should not be relied upon to fully determine coverage. This benefit plan may not cover all of your health care expenses. More complete descriptions of Benefits and the terms under which they are provided are contained in the Certificate of Coverage that you will receive upon enrolling in the Plan. If this Benefit Summary conflicts in any way with the Policy issued to your employer, the Policy shall prevail. Terms that are capitalized in the Benefit Summary are defined in the Certificate of Coverage. Where Benefits are subject to day, visit and/or dollar limits, such limits apply to the combined use of Benefits whether in- Network or out -of- Network, except where mandated by state law. Network Benefits are payable for Covered Health Services provided by or under the direction of your Network physician. *Prior Notification is required for certain services. Annual Deductible: No Annual Deductible. Out -of- Pocket Maximum: $2,500 per Covered Person, per calendar year, not to exceed $5,000 for all Covered Persons in a family. Maximum Policy Benefit: No Maximum Policy Benefit. Annual Deductible: $750 per Covered Person per calendar year, not to exceed $1,500 for all Covered Persons in a family. Out -of- Pocket Maximum: $5,000 per Covered Person, per calendar year, not to exceed $10,000 for all Covered Persons in a family. The Out -of- Pocket Maximum does not include the Annual Deductible. Maximum Policy Benefit: $1,000,000 per Covered Person. 1. Ambulance Services - Emergency only Ground Transportation: No Copayment Same as Network Benefit Air Transportation: 0% of Eligible Expenses 2. Dental Services - Accident only *Same as 8, 11, 12 and 13 *Same as Network Benefit *Prior notification is required before follow -up *Prior notification is required before follow -up treatment begins. treatment begins. 3. Durable Medical Equipment No Copayment *40% of Eligible Expenses Network and Non - Network Benefits for Durable *Prior notification is required when the cost is more Medical Equipment are limited to $2,500 per than $1,000. calendar year. Limits do not apply to Durable Medical Equipment classified as diabetic equipment or supppies. 4. Emergency Health Services $150 per visit Same as Network Benefit *Notification is required if results in an Inpatient Stay. 5. Eye Examinations $15 per visit 40% of Eligible Expenses Refractive eye examinations are limited to one Eye Examinations for refractive errors are not covered. every other calendar year from a Network Provider. 6. Home Health Care No Copayment *40% of Eligible Expenses Network and Non - Network Benefits are limited to 60 visits for skilled care services per calendar year. 7. Hospice Care No Copayment *40% of Eligible Expenses Network and Non - Network Benefits are limited to 360 days during the entire period of time a Covered Person is covered under the Policy. 8. Hospital - Inpatient Stay $500 per Inpatient Stay *40% of Eligible Expenses 9. Injections Received in a Physician's Office $15 per visit 40% per injection 10. Maternity Services Same as 8, 11, 12 and 13 Same as 8, 11, 12 and 13 No Copayment applies to Physician office visits for *Notification is required if Inpatient Stay exceeds 48 prenatal care after the first visit. hours following a normal vaginal delivery or 96 hours following a cesarean section delivery. 11. Outpatient Surgery, Diagnostic and Therapeutic Services Outpatient Surgery $250 per surgical procedure 40% of Eligible Expenses Outpatient Diagnostic Services For lab and radiology/Xray: No Copayment 40% of Eligible Expenses Outpatient Diagnostic/Therapeutic Services - CT $250 per test 40% of Eligible Expenses Scans, Pet Scans, MRI and Nuclear Medicine Outpatient Therapeutic Treatments No Copayment 40% of Eligible Expenses 12. Physician's Office Services $15 per visit except that the Copayment for a Specialist 40% of Eligible Expenses. No Benefits for preventive Covered Health Services for preventive medical Physician office visit is $25. No Copayment applies care, except for Child Health Supervision Services. care. when a Physician charge is not assessed. 40% of Eligible Expenses Covered Health Services for the diagnosis and $15 per visit except that the Copayment for a Specialist treatment of a Sickness or Injury received in a Physician office visit is $25. No Copayment applies Physician's office. when a Physician charge is not assessed. 13. Professional Fees for Surgical and Medical No Copayment 40% of Eligible Expenses Services YOUR BENEFITS Types of Coverage Network Benefits / Copayment Amounts Non - Network Benefits / Copayment Amounts 14. Prosthetic Devices No Copayment 40% of Eligible Expenses Network and Non - Network Benefits for prosthetic devices are limited to $2,500 per calendar year. 15. Reconstructive Procedures Some as 8, 11, 12, 13 and 14 *Same as 8, 11, 12, 13 and 14 16. Rehabilitation Services - Outpatient Therapy $15 per visit 40% of Eligible Expenses Network and Non - Network Benefits are limited as Same as 11, 12 and 13 follows: 20 visits of physical therapy; 20 visits of Same as 8, 11, 12, 13, and 16 occupational therapy; 20 visits of speech therapy; 20 Dental Procedures - Anesthesia and Hospitalization visits ofpulmonary, rehabilitation; and 36 visits of *Same as 8, 11, and 13 cardiac rehabilitation per calendar year. Same as 3, 11, 12 and 13 17. Skilled Nursing Facility/Inpatient Rehabilitation No Copayment *40% of Eligible Expenses Facility Services Network and Non - Network Benefits are limited to 60 days per calendar year. year. 18. Transplantation Services *Same as 8 and 13 No Benefits 19. Urgent Care Center Services $50 per visit 40% of Eligible Expenses Additional Benefits Bones or Joints of the Jaw and Facial Region Same as 8, 11, 12 and 13 *Same as 8, 11, 12 and 13 Child Health Supervision Services Same as 11, 12 and 13 Same as 11, 12 and 13 Cleft Lip /Cleft Palate Treatment Same as 8, 11, 12, 13, and 16 *Same as 8, 11, 12, 13 and 16 Dental Procedures - Anesthesia and Hospitalization Same as 8, 11, and 13 *Same as 8, 11, and 13 Diabetes Treatment Same as 3, 11, 12 and 13 Same as 3, 11, 12 and 13 Mammography No Copayment Same as Network Benefit Mastectomy Same as 8, 11, 12 and 13 *Same as 8, 11, 12 and 13 Mental Health and Substance Abuse Services - $15 per individual visit; $10 per group visit 40% of Eligible Expenses Outpatient Must receive prior authorization through the Mental Health/Substance Abuse Designee. Network and Non - Network Benefits are limited to 30 visits per calendar year. Mental Health and Substance Abuse Services - $500 per Inpatient Stay 40% of Eligible Expenses Inpatient and Intermediate Must receive prior authorization through the Mental Health/Substance Abuse Designee. Network and Non - Network Benefits are limited to 30 days per calendar year. Osteoporosis Treatment Same as 11, 12 and 13 Same as 11, 12 and 13 Prescription and Non - Prescription Enteral Formulas No Copayment 40% of Eligible Expenses Benefits for low protein food products for Covered Persons through age 24 are limited to $2,500 per calendar year. Spinal Treatment $15 per visit 40% of Eligible Expenses Benefits include diagnosis and related services and are limited to one visit and treatment per day. Network and Non - Network Benefits are limited to 24 visits per calendar year. Exclusions Except as may be specifically provided in Section I of the Certificate of Coverage (COC) or through a Rider to the Policy, the following are not covered: A. Alternative Treatments Acupressure; hypnotism; rolling; massage therapy; aromatherapy; acupuncture; and other forms of alternative treatment. B. Comfort or Convenience Personal comfort or convenience items or services such as television; telephone; barber or beauty -- service; guest service; supplies, equipment and similar incidental services and supplies for personal comfort including air conditioners, air purifiers and filters, batteries and battery chargers, dehumidifiers and humidifiers; devices or computers to assist in communication and speech. C. Dental Except as specifically described as covered in Section 1 of the COC under the headings Dental Services - Accident only and Cleft DpXlefl Palate Treatment, dental services are excluded. There is no coverage for services provided for the prevention, diagnosis, and treatment of the teeth or gums (including extraction, restoration, and replacement of teeth and services to improve dental clinical outcomes). Dental implants and dental braces are excluded. Dental x -rays, supplies and appliances and all associated expenses arising out of such dental services (including hospitalizations and anesthesia) are excluded, except as might otherwise be required for transplant preparation, initiation of immunosuppressives, the direct treatment of acute traumatic Injury, cancer, or cleft palate, or as described in Section 1 of the COC under the heading of Dental Procedures - Anesthesia and Hospitalization. Treatment for congenitally missing, malpositioned, or supernumerary teeth is excluded, even if part of a Congenital Anomaly except in connection with cleft lip or cleft palate. D. Drugs Prescription drug products for outpatient use that are filled by a prescription order or refill. Self - injectable medications except as described in Section 1 of the COC under the heading of Diabetes Treatment. Non - injectable medications given in a Physician's office except as required in an Emergency. Over- the - counter drugs and treatments. E. Experimental, Investigational or Unproven Services Experimental, Investigational or Unproven Services are excluded, except (a) bone marrow transplants and (b) medically appropriate medications prescribed for the treatment of cancer, for a particular indication, if that drug is recognized for the treatment of that indication in a standard reference compendium or recommended in medical literature. The fact that an Experimental, Investigational or Unproven Service, treatment, device or pharmacological regimen is the only available treatment for a particular condition will not result in Benefits if the procedure is considered to be Experimental, Investigational or Unproven in the treatment of that particular condition. F. Foot Care Routine foot care (including the cutting or removal of cores and calluses); nail trimming, cutting, or debriding; hygienic and preventive maintenance foot care; treatment of flat feet or subluxation ofthe foot; shoe orthotics. G. Medical Supplies and Appliances Devices used specifically as safety items or to affect performance primarily in sports - related activities. Prescribed or non - prescribed medical supplies and disposable supplies including but not limited to elastic stockings, ace bandages, ostomy supplies, gauze and dressings. Orthotic appliances that straighten or re -shape a body part (including cranial banding and some types of braces). Tubings and masks are not covered except when used with Durable Medical Equipment as described in Section 1 of the COC. H. Mental Health /Substance Abuse Services performed in connection with conditions not classified in the current edition of the Diagnostic and Statistical Manual of the American Psychiatric Association. Services that extend beyond the period necessary for short-term evaluation, diagnosis, treatment, or crisis intervention. Mental Health treatment of insomnia and other sleep disorders, neurological disorders, and other disorders with a known physical basis. Treatment of conduct and impulse control disorders, personality disorders, paraphilias and other Mental Illnesses that will not substantially improve beyond the current level of functioning, or that are not subject to favorable modification or management according to prevailing national standards of clinical practice, as reasonably determined by the Mental Health/Substance Abuse Designee. Services utilizing methadone treatment as maintenance, L.A.A.M. (1- Alpha- Acetyl- Methadol), Cyclazocine, or their equivalents. Treatment provided in connection with or to comply with involuntary commitments, police detentions and other similar arrangements, unless authorized by the Mental Health/Substance Abuse Designee. Residential treatment services. Services or supplies that in the reasonable judgment of the Mental Health/Substance Abuse Designee are not, for example, consistent with certain national standards or professional research further described in Section 2 of the COC. I. Nutrition Megavitamin and nutrition based therapy; nutritional counseling for either individuals or groups. Enteral feedings and other nutritional and electrolyte supplements, including infant formula and donor breast milk, except as described in Section 1 of the CDC under the heading Prescription and Non- prescription Enteral Formulas. United HealthCare Insurance Company J. Physical Appearance Cosmetic Procedures including, but not limited to, pharmacological regimens; nutritional procedures or treatments; salabrasion, chemosurgery and other such skin abrasion procedures associated with the removal of scars, tattoos, and/or which are performed as a treatment for acne. Replacement of an existing breast implant is excluded if the earlier breast implant was a Cosmetic Procedure. (Replacement of an existing breast implant is considered reconstructive if the initial breast implant followed mastectomy.) Physical conditioning programs such as athletic training, bodybuilding, exercise, fitness, flexibility, and diversion or general motivation. Weight loss programs for medical and non - medical reasons. Wigs, regardless of the reason for the hair loss. K. Providers Services performed by a provider with your same legal residence or who is a family member by birth or manage, including spouse, brother, sister, parent or child. This includes any service the provider may perform on himself or herself. Services provided at a free - standing or Hospital -based diagnostic facility without an order written by a Physician or other provider as further described in Section 2 of the COC (this exclusion does not apply to mammography testing). L. Reproduction Health services and associated expenses for infertility treatments. Surrogate parenting. The reversal of voluntary sterilization. M. Services Provided under Another Plan Health services for which other coverage is paid under arrangements required by federal, state or local law. This includes, but is not limited to, coverage paid by workers' compensation, no -fault automobile insurance, or similar legislation. Health services for treatment of military service - related disabilities, when you are legally entitled to other coverage and facilities are reasonably available to you. Health services while on active military duty. N. Transplants Health services for organ or tissue transplants are excluded, except those specified as covered in Section 1 of the COC. Any solid organ transplant that is performed as a treatment for cancer. Health services connected with the removal of an organ or tissue from you for purposes of a transplant to another person. Health services for transplants involving mechanical or animal organs. Any multiple organ transplant not listed as a Covered Health Service in Section I of the COC. O. Travel Health services provided in a foreign country, unless required as Emergency Health Services. Travel or transportation expenses, even though prescribed by a Physician. Some travel expenses related to covered transplantation services may be reimbursed at our discretion. P. Vision and Hearing Purchase cost of eye glasses, contact lenses, or hearing aids. Fitting charge for hearing aids, eye glasses or contact lenses. Eye exercise therapy. Surgery that is intended to allow you to see better without glasses or other vision correction including radial keratotomy, laser, and other refractive eye surgery. Q. Other Exclusions Health services and supplies that do not meet the definition of a Covered Health Service - see definition in Section 10 of the COC. Physical, psychiatric or psychological examinations, testing, vaccinations, immunizations or treatments otherwise covered under the Policy, when such services are: (1) required solely for purposes of career, education, sports or camp, travel, employment, insurance, manage or adoption; (2) relating to judicial or administrative proceedings or orders; (3) conducted for purposes of medical research; or (4) to obtain or maintain a license of any type. Health services received as a result of war or any act of war, whether declared or undeclared or caused during service in the armed forces of any country. Health services received after the date your coverage under the Policy ends, including health services for medical conditions arising prior to the date your coverage under the Policy ends. Health services for which you have no legal responsibility to pay, or for which a charge would not ordinarily be made in the absence of coverage under the Policy. In the event that a Non - Network provider waives Copayments and/or the Annual Deductible for a particular health service, no Benefits are provided for the health service for which Copayments and/or the Annual Deductible are waived. Charges in excess of Eligible Expenses or in excess of any specified limitation. Services for the evaluation and treatment of temporomandibular joint syndrome (TMJ), whether the services are considered to be medical or dental in nature, except as described in Section 1 of the COC under the heading Bones or Joints of the Jaw and Facial Region. Surgical treatment and non - surgical treatment of obesity (including morbid obesity). Surgical treatment and non - surgical treatment of obesity (including morbid obesity). Growth hormone therapy; sex transformation operations; treatment of benign gynecomastia (abnormal breast enlargement in males); medical and surgical treatment of excessive sweating (hyperhidrosis); medical and surgical treatment for snoring, except when provided as part of treatment for documented obstructive sleep apnea: Oral appliances for snoring. Custodial care; domiciliary care; private duty nursing; respite care; rest cures. Psychosurgery. Speech therapy except as required for treatment of a speech impediment or speech dysfunction that results from Injury, stroke, cleft lip /cleft palate or Congenital Anomaly. This summary of Benefits is intended only to highlight your Benefits and should not be relied upon to fully determine coverage. This plan may not cover all your health care expenses. Please refer to the Certificate of Coverage for a complete listing of services, limitations, exclusions and a description of all the terms and conditions of coverage. If this description conflicts in anyway with the Certificate of Coverage, the Certificate of Coverage prevails. Terms that are capitalized in the Benefit Summary are defined in the Certificate of Coverage. 02I_BS_ChePls FLLGMS5902 OBE 213 -1151 0604 Rev01 YOUR BENEFITS UnitedHealthcare Pharmacy Management Program Plan 023 UnitedHealthcare's pharmacy management program provides clinical pharmacy services that promote choice, accessibility and value. The program offers a broad network of pharmacies (more than 56,000 nationwide) to provide convenient access to medications. While most pharmacies participate in our network, you should check first. Call your pharmacist or visit our online pharmacy service at www.myuhc.com. The online service offers you home delivery of prescriptions, ability to view personal benefit coverage, access health and well being information, and even location of network retail neighborhood pharmacies by zip code. Copayment per Prescription Order or Refill Your Copayment is determined by the tier to which the Prescription Drug List Management Committee has assigned the Prescription Drug Product. All Prescription Drug Products on the Prescription Drug List are assigned to Tier 1, Tier 2 or Tier 3. Please access www.myghe.com through the Internet, or call the Customer Service number on your ID card to determine tier status. For a single Copayment, you may receive a Prescription Drug Product up to the stated supply limit. Some products are subject to additional supply limits. You are responsible for paying the lower of the applicable Copayment or the retail Network Pharmacy's Usual and Customary Charge, or the lower of the applicable Copayment or the Home Delivery Pharmacy's Prescription Drug Cost. Also note that some Prescription Drug Products require that you notify us in advance to determine whether the Prescription Drug Product meets the definition of a Covered Health Service and is not Experimental, Investigational or Unproven. Retail Network Home Delivery Network Pharmacy Pharmacy For up to a 31 day supply For up to a 90 day supply Tier 1 $10 $25 Tier 2 $30 $75 Tier 3 $50 $125 FLNPP02304 Other Important Cost Sharing Information Annual Drug Deductible No Annual Drug Deductible Out -of- Pocket Drug No Out -of- Pocket Drug Maximum Maximum Exclusions Exclusions from coverage listed in the Certificate apply also to this Rider. In addition, the following exclusions apply: Outpatient Prescription Drug Products obtained from a non - Network Pharmacy. Coverage for Prescription Drug Products for the amount dispensed (days supply or quantity limit) which exceeds the supply limit. Prescription Drug Products dispensed outside the United States, except as required for Emergency treatment. Drugs which are prescribed, dispensed or intended for use while you are an inpatient in a Hospital, Skilled Nursing Facility, or Alternate Facility. Experimental, Investigational or Unproven Services and medications; medications used for experimental indications and/or dosage regimens determined by us to be experimental, investigational or unproven. Prescription Drug Products furnished by the local, state or federal government. Any Prescription Drug Product to the extent payment or benefits are provided or available from the local, state or federal government (for example, Medicare) whether or not payment or benefits are received, except as otherwise provided by law. Prescription Drug Products for any condition, Injury, Sickness or mental illness arising out of, or in the course of, employment for which benefits are available under any workers' compensation law or other similar laws, whether or not a claim for such benefits is made or payment or benefits are received. Any product dispensed for the purpose of appetite suppression and other weight loss products. A specialty medication Prescription Drug Product (such as immunizations and allergy serum) which, due to its characteristics as determined by us, must typically be administered or supervised by a qualified provider or licensed/certified health professional in an outpatient setting. This exclusion does not apply to Depo Provera and other injectable drugs used for contraception. United Healthcare Insurance Company Durable Medical Equipment. Prescribed and non - prescribed outpatient supplies, other than the diabetic supplies and inhaler spacers specifically stated as covered. General vitamins, except the following which require a Prescription Order or Refill: prenatal vitamins, vitamins with fluoride, and single entity vitamins. Unit dose packaging of Prescription Drug Products. Medications used for cosmetic purposes. Prescription Drug Products, including New Prescription Drug Products or new dosage forms, that are determined to not be a Covered Health Service. Prescription Drug Products as a replacement for a previously dispensed Prescription Drug Product that was lost, stolen, broken or destroyed. Prescription Drug Products when prescribed to treat infertility. Drugs available over - the - counter that do not require a Prescription Order or Refill by federal or state law before being dispensed. Any Prescription Drug Product that is therapeutically equivalent to an over - the - counter drug. Prescription Drug Products that are comprised of components that are available in over - the - counter form or equivalent. Prescription Drug Products for smoking cessation. Compounded drugs that do not contain at least one ingredient that requires a Prescription Order or Refill. Compounded drugs that contain at least one ingredient that requires a Prescription Order or Refill are assigned to Tier 3. New Prescription Drug Products and/or new dosage forms until the date they are reviewed by our Prescription Drug List Management Committee. Growth hormone therapy for children with familial short stature (short stature based upon heredity and not caused by a diagnosed medical condition). This summary of Benefits is intended only to highlight your Benefits for outpatient Prescription Drug Products and should not be relied upon to determine coverage. Your plan may not cover all your outpatient -.. prescription drug expenses. Please refer to your Outpatient Prescription Drug Rider and the Certificate of Coverage for a complete listing of services, limitations, exclusions and a description of all the terms and conditions of coverage. if this description conflicts in any way with the Outpatient Prescription Drug Rider or the Certificate of Coverage, the Outpatient Prescription Drug Rider and Certificate of Coverage prevail. Capitalized terms in the Benefit Summary are defined in the Outpatient Prescription Drug Rider and/or Certificate of Coverage. 04I_BS_RX NET FLNPP02304 H9 213-13770804 ')XAetw, . Health Maintenance Organization Program Final Proposal for 11 ! i 1 r� : \► i1 Effective Date: 1011105 FL Single t$351.68 Parent/Child(ren) $654.12 Couple $735.01 Family $1,040.97 Referred Care Primary Office Visit Copay: $10 Specialist Copay: $10 Outpatient (SPU) Surgery Copay: $0 Hospitalization Copay /A: $0 Bariatric Surgery: Not Covered Emergency Room Copay: $75 Urgent Care Copay: $35 MH O/P Copay: $25 20v /cal Routine Eye Exam Copay: $10 Routine GYN Exam Copay: $10, Weal Rehab I/P Copay/D: ($0) 30d/cal Rehab O/P Copay: $10 30v /cal Prescription Copay: $10/$20/$35, 30 Day Oral Contraceptives: $10/$20/$35, 30 Day 31 -90 Day Supply: 2 Copays (Retail and MOD) Chiropractic Copay: $10 20v /cal DUE Item Copay: $0 Out of Pocket Limit: $1500/$3000 In Net Lifetime Maximum Benefit: Unlimited The foregoing rates apply in the Service Area specified above. Rates will vary for other service areas. Service Area is determined by location of the subscriber's primary care doctor. Quote Conditions Assumed Dependent Eligibility Dependent children to the end of the billable year in which he /she tums 25 or full -time students to the end of the billable year in which he/she turns 25. Coverage will continue for dependents who become mentally /physically handicapped prior to the end of the billable year they reach age 25. Rates are pending approval by state regulators and are subject to adjustment based on regulatory determinations. These monthly quoted rates are valid as of the Effective Date and apply only to the benefit level and conditions stated above and are subject to the terms and conditions as are set forth in the HMO's Group Master Contract and/or the Corporate Health Insurance Policy. Any changes in benefit level or conditions stated above may require a change in rates. This proposal is subject to change at any time prior to the acceptance by AETNA of employees offer. Final Rates Please see Rating Conditions, Assumptions and Information Requests document for quote details. WVE® PRIMARY CARE Services at participating doctors' offices include, but are not PHYSICIAN limited to: ■ ROUTINE OFFICE VISITS / ANNUAL GYN VISIT WHEN PERFORMED BY PRIMARY CARE PHYSICIAN ® MATERNITY- OUTPATIENT VISITS $10 PER VISIT ® PEDIATRIC CARE & WELL -BABY CARE ® PERIODIC HEALTH EVALUATION & IMNIUNIZATIONS ■ DIAGNOSTIC IMAGING, LABORATORY OR OTHER DIAGNOSTIC SERVICES ■ MINOR SURGICAL PROCEDURES ■ VISION & HEARING EXAMINATIONS FOR CHILDREN UNDER 18 AVMED SPECIALIST'S ■ OFFICE VISITS $10 PER VISIT SERVICES ■ ANNUAL GYN EXAMINATION WHEN PERFORMED BY PARTICIPATING SPECIALIST HOSPITAL Inpatient care at participating hospitals includes: NO CHARGE ® ROOM & BOARD - UNLIMITED DAYS (SEMI - PRIVATE) _ ® PHYSICIANS, SPECIALIST'S & SURGEON'S SERVICES ■ ANESTHESIA, USE OF OPERATING &RECOVERY ROOMS, OXYGEN, DRUGS & MEDICATION ® INTENSIVE CARE UNIT & OTHER SPECIAL UNITS, GENERAL & SPECIAL DUTY NURSING ■ LABORATORY & DIAGNOSTIC IMAGING ■ REQUIRED SPECIAL DIETS ® RADIATION & INHALATION THERAPIES OUTPATIENT SURGERY ■ OUTPATIENT SURGERIES, INCLUDING CARDIAC NO CHARGE CATHETERIZATIONS AND ANGIOPLASTY OUTPATIENT DIAGNOSTIC ® CAT Scan, PET Scan, MRI $25 PER TEST TESTS E OTHER DIAGNOSTIC IMAGING TESTS $10 PER TEST EMERGENCY ERVICES An emergency is the sudden & unexpected onset of a condition requiring immediate medical or surgical care. • EMERGENCY ROOM AT PARTICIPATING $75 COPAYMENT HOSPITALS • EMERGENCY SERVICES - NON - PARTICIPATING $100 COPAYMENT HOSPITALS, FACILITIES, & /OR PHYSICIANS PLAN 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 FACILITY OR SERVICES RENDERED AFTER HOURS IN YOUR PRIMARY CARE PHYSICIAN'S OFFICE ■ MEDICAL SERVICES AT A NON- PARTICIPATING URGENTAMMEDIATE CARE FACILITY $40 COPAYMENT $60 COPAYMENT 1 `' ' t Summary, REFER TO YOUR AVMED GROUP MEDICAL & HOSPITAL SERVICE CONTRACT FOR SPECIFIC EXCLUSIONS & LIMITATIONS. PROSTHETIC DEVICES Prosthetic devices are limited to: NO CHARGE • ARTIFICIAL LIMBS • ARTIFICIAL JOINTS • OCULAR PROSTHESES REFER TO YOUR AVMED GROUP MEDICAL & HOSPITAL SERVICE CONTRACT FOR SPECIFIC EXCLUSIONS & LIMITATIONS. FOR ADDITIONAL INFORMATION, PLEASE CALL: 1-800-88-AVMED (1- 800 -882 ®0653) THIS SCHEDULE OF COPAYMENTS IS NOT A CONTRACT. - FOR SPECIFIC INFORMATION ON BENEFITS, EXCLUSIONS & LIMITATIONS, PLEASE SEE YOUR AVMED GROUP MEDICAL & HOSPITAL SERVICE CONTRACT. AV- STD -OA -03 MP- 3410 (10/03) ■ COVERAGE IS LIMITED TO 24 VISITS PER MENTAL HEALTH ■ 20 OUTPATIENT VISITS $25 PER VISIT FAMILY PLANNING ■ VOLUNTARY FAMILY PLANNING SERVICES $10 PER VISIT ■ STERILIZATION $100 COPAYMENT ALLERGY TREATMENTS a INJECTIONS $10 PER VISIT ■ SKIN TESTING $50 PER COURSE OF SKILLED NURSING UP TO 20 DAYS PER CONTRACT YEAR POST- TESTING AMBULANCE ■ WHEN PRE - AUTHORIZED OR IN THE CASE OF NO CHARGE REHABILITATION CENTERS EMERGENCY PHYSICAL, SPEECH® M SHORT -TERM PHYSICAL, SPEECH OR $10 PER VISIT OCCUPATIONAL THERAPIES OCCUPATIONAL THERAPY FOR ACUTE CONDITIONS BENEFITS LIMITED TO REFER TO YOUR AVMED GROUP MEDICAL & HOSPITAL SERVICE CONTRACT FOR SPECIFIC EXCLUSIONS & LIMITATIONS. PROSTHETIC DEVICES Prosthetic devices are limited to: NO CHARGE • ARTIFICIAL LIMBS • ARTIFICIAL JOINTS • OCULAR PROSTHESES REFER TO YOUR AVMED GROUP MEDICAL & HOSPITAL SERVICE CONTRACT FOR SPECIFIC EXCLUSIONS & LIMITATIONS. FOR ADDITIONAL INFORMATION, PLEASE CALL: 1-800-88-AVMED (1- 800 -882 ®0653) THIS SCHEDULE OF COPAYMENTS IS NOT A CONTRACT. - FOR SPECIFIC INFORMATION ON BENEFITS, EXCLUSIONS & LIMITATIONS, PLEASE SEE YOUR AVMED GROUP MEDICAL & HOSPITAL SERVICE CONTRACT. AV- STD -OA -03 MP- 3410 (10/03) ■ COVERAGE IS LIMITED TO 24 VISITS PER CALENDAR YEAR FOR ALL SERVICES COMBINED REFER TO YOUR AVMED GROUP MEDICAL & HOSPITAL SERVICE CONTRACT FOR SPECIFIC EXCLUSIONS & LIMITATIONS. SKILLED NURSING UP TO 20 DAYS PER CONTRACT YEAR POST- $25 PER DAY FACILITIES & HOSPITALIZATION CARE WHEN PRESCRIBED REHABILITATION CENTERS BY PHYSICIAN & AUTHORIZED BY AVMED CARDIAC REHABILITATION Cardiac Rehabilitation is covered for the following conditions: $20 PER VISIT • ACUTE MYOCARDIAL INFARCTION • PERCUTANEOUS TRANSLUMINAL CORONARY BENEFITS LIMITED TO ANGIOPLASTY (PTCA) $1,500 PER CONTRACT • REPAIR OR REPLACEMENT OF HEART VALVE(S) YEAR. • CORONARY ARTERY BYPASS GRAFT (CABG), or • HEART TRANSPLANT COVERAGE IS LIMITED TO 18 VISITS PER YEAR _ HOME HEALTH CARE ■ PER OCCURRENCE NO CHARGE DURABLE MEDICAL Equipment includes: $50 PER EPISODE OF EQUIPMENT & ORTHOTIC ■ HOSPITAL BEDS ILLNESS. BENEFITS APPLIANCES M WALKERS LIMITED TO $500 PER ■ CRUTCHES CONTRACT YEAR. ■ WHEELCHAIRS Orthotic appliances are limited to: ■ LEG, ARM, BACK, AND NECK CUSTOM -MADE BRACES REFER TO YOUR AVMED GROUP MEDICAL & HOSPITAL SERVICE CONTRACT FOR SPECIFIC EXCLUSIONS & LIMITATIONS. PROSTHETIC DEVICES Prosthetic devices are limited to: NO CHARGE • ARTIFICIAL LIMBS • ARTIFICIAL JOINTS • OCULAR PROSTHESES REFER TO YOUR AVMED GROUP MEDICAL & HOSPITAL SERVICE CONTRACT FOR SPECIFIC EXCLUSIONS & LIMITATIONS. FOR ADDITIONAL INFORMATION, PLEASE CALL: 1-800-88-AVMED (1- 800 -882 ®0653) THIS SCHEDULE OF COPAYMENTS IS NOT A CONTRACT. - FOR SPECIFIC INFORMATION ON BENEFITS, EXCLUSIONS & LIMITATIONS, PLEASE SEE YOUR AVMED GROUP MEDICAL & HOSPITAL SERVICE CONTRACT. AV- STD -OA -03 MP- 3410 (10/03) v Erg I E A L T H P L A N S Bene t Summary POINT= F ®SERVICE RIDER SCHEDULE YOUR COST BENEFITS OUT-OF-METWORK BENEFITS CASH DEDUCTIBLE INDIVIDUAL/FAMILY $500 /$1,500 ANNUALLY COINSURANCE OUT-OF- INDIVIDUAL/FAMILY $3,000/6,000 ANNUALLY POCKET MAXIMUM LIFETIME MAXIMUM $2,000,000 PER MEMBER PRICK AUTHORIZATION REQUIRED FOR SPECIFIC COVERED SERVICES. THE PENALTY FOR NOT OBTAINING PRIOR AUTHORIZATION IS A 20% REDUCTION IN BENEFITS. PHYSICIAN Services at doctors' offices include, but are not limited to: ELIGIBLE EXPENSE, • ROUTINE OFFICE VISITS /ANNUAL GYN VISIT SUBJECT TO THE CASH • MATERNITY- OUTPATIENT VISITS DEDUCTIBLE AND 30% • PEDIATRIC CARE & WELL -CHILD CARE COINSURANCE • DIAGNOSTIC IMAGING, LABORATORY OR OTHER DIAGNOSTIC SERVICES • MINOR SURGICAL PROCEDURES • VISION &HEARING EXAMINATIONS FOR CHILDREN UNDER 18 SPECIALIST'S SERVICES OFFICE VISITS ELIGIBLE EXPENSE, SUBJECT TO THE CASH DEDUCTIBLE AND 30% COINSURANCE HOSPITAL Inpatient care at hospitals includes: ELIGIBLE EXPENSE, ■ ROOM & BOARD — UNLIMITED DAYS (SEMI - PRIVATE) SUBJECT TO THE CASH ■ PHYSICIAN'S, SPECIALIST'S & SURGEON'S SERVICES DEDUCTIBLE AND 30% • ANESTHESIA, USE OF OPERATING & "RECOVERY ROOMS, COINSURANCE OXYGEN, DRUGS & MEDICATION ■ INTENSIVE CARE UNIT & OTHER SPECIAL UNITS, GENERAL & SPECIAL DUTY NURSING ■ LABORATORY & DIAGNOSTIC IMAGING ■ REQUIRED SPECIAL DIETS ■ RADIATION & INHALATION THERAPIES OUTPATIENT SURGERY ■ OUTPATIENT SURGERIES, INCLUDING CARDIAC ELIGIBLE EXPENSE, CATHETERIZATIONS AND ANGIOPLASTY SUBJECT TO THE CASH DEDUCTIBLE AND 30% COINSURANCE OUTPATIENT DIAGNOSTIC ■ CAT SCAN, PET SCAN, MRI ELIGIBLE EXPENSE, TESTS OTHER DIAGNOSTIC IMAGING TESTS SUBJECT TO THE CASH DEDUCTIBLE AND 30% COINSURANCE MENTAL HEALTH ■ 20 OUTPATIENT VISITS ELIGIBLE EXPENSE; SUBJECT TO THE CASH (20 VISITS IS THE TOTAL NUMBER OF COVERED VISITS DEDUCTIBLE AND 30% FOR BOTH IN AND OUT OF NETWORK, COMBINED) COINSURANCE IF MENTAL HEALTH/SUBSTANCE ABUSE BENEFIT RIDER IS ELECTED, BENEFITS ARE SUBJECT TO POS RIDER DEDUCTIBLE AND COINSURANCE ARRANGEMENTS WHEN USING NON- PARTICIPATING PROVIDERS. SPECIFIED SERVICE LIMITS ARE THE TOTAL NUMBER OF COVERED VISITS FOR BOTH IN AND OUT OF NETWORK; COMBINED Benefit , continued ALLERGY TREATMENTS ■ INJECTIONS ELIGIBLE EXPENSE, ■ SKIN TESTING SUBJECT TO THE CASH DEDUCTIBLE AND 30% COINSURANCE PHYSICAL, SPEECH, & ■ SHORT -TERM PHYSICAL, SPEECH OR OCCUPATIONAL ELIGIBLE EXPENSE, OCCUPATIONAL THERAPIES THERAPY FOR ACUTE CONDITIONS SUBJECT TO THE CASH DEDUCTIBLE AND 30% COVERAGE IS LIMITED TO 24 VISITS PER CALENDAR COINSURANCE YEAR FOR ALL SERVICES COMBINED. SKILLED NURSING I°A ILIT0 ■ UP TO 20 DAYS PER CONTRACT YEAR POST- ELIGIBLE EXPENSE, REHABILITATION CENTERS HOSPITALIZATION CARE WHEN PRESCRIBED BY SUBJECT TO THE CASH PHYSICIAN & AUTHORIZED BY AVMED DEDUCTIBLE AND 30% COINSURANCE CARDIAC REHABILITATION Cardiac Rehabilitation is covered for the following. conditions: $20 PER VISIT • ACUTE MYOCARDIAL INFARCTION • PERCUTANEOUS TRANSLUMINAL CORONARY BENEFITS LIMITED TO ANGIOPLASTY (PICA) $1,500 PER CONTRACT • REPAIR OR REPLACEMENT OF HEART VALVE(S) YEAR. • CORONARY ARTERY BYPASS GRAFT (CABG), or • HEART TRANSPLANT COVERAGE IS LIMITED TO 18 VISITS PER YEAR. HOME HEALTH CAR ■ PER OCCURRENCE ELIGIBLE EXPENSE, SUBJECT TO THE CASH DEDUCTIBLE AND 30% COINSURANCE DURABLE MEDICAL Equipment includes: $50 PER EPISODE OF .1 EQUIPMENT & ■ HOSPITAL BEDS ILLNESS. BENEFITS BIITIIOTIC APPLIANCES • WALKERS LIMITED TO $500 PER ■ CRUTCHES CONTRACT YEAR. ■ WHEELCHAIRS Orthotic appliances are limited to: ■ LEG, ARM; BACK, AND NECK CUSTOM -MADE BRACES PROSTHETIC DEVICES Prosthetic devices are limited to: ELIGIBLE EXPENSE, • ARTIFICIAL LIMBS SUBJECT TO THE CASH • ARTIFICIAL JOINTS DEDUCTIBLE AND 30% • OCULAR PROSTHESES COINSURANCE THIS SCHEDULE IS NOT A CONTRACT. FOR SPECIFIC INFORMATION ON BENEFITS, EXCLUSIONS AND LIMITATIONS PLEASE CONSULT YOUR AVMED HMO MEDICAL AND HOSPITAL SERVICE CONTRACT AND POINT -OF- SERVICE RIDER. AV- POS-500_ -30- 3000 -03 MP- 3440 (9/03) .0 Health Maintenance Organization Program Final Proposal for ! 1 Effective Date: 10 11105 FL Single 1$351.68 Parent'Child(ren) $654.12 Couple $735.01 Family $1,040.97 Referred Care Primary Office Visit Copay: $10 Specialist Copay: $10 Outpatient (SPU) Surgery Copay: $0 Hospitalization Copay /A: $0 Bariatric Surgery: Not Covered Emergency Room Copay: $75 Urgent Care Copay: $35 MH O/P Copay: $25 20v /cal Routine Eye Exam Copay: $10 Routine GYN Exam Copay: $10, Iv /cal Rehab I/P Copay/D: ($0) 30d/cal Rehab O/P Copay: $10 30v /cal Prescription Copay: $10/$20/$35, 30 Day Oral Contraceptives: $10 /$20/$35, 30 Day 31 -90 Day Supply: 2 Copays (Retail and MOD) Chiropractic Copay: $10 20v /cal DME Item Copay: $0 Out of Pocket Limit: $1500/$3000 In -Net Lifetime Maximum Benefit: Unlimited The foregoing rates apply in the Service Area specified above. Rates will vary for other service areas. Service Area is determined by location of the subscriber's primary care doctor. Ouote Conditions Assumed Dependent Eligibility Dependent children to the end of the billable year in which he /she turns 25 x full -time students to the end of the billable year in which he /she turns 25. Coverage will continue for dependents who become mentally /physically handicapped prior to the end of the billable year they reach age 25. Rates are pending approval by state regulators and are subject to adjustment based on regulatory determinations These monthly quoted rates are valid as of the Effective Date and apply only to the benefit level and conditions stated above and are subject to the terms and conditions as are set forth in the HMO's Group Master Contract and/or the Corporate Health Insurance Policy. Any changes in benefit level or conditions stated above may require a change in rates. This proposal is subject to change at any time prior to the acceptance by AETNA of employer's offer. Final .Rates Please see Rating Conditions, Assumptions and Information Requests document for quote details. City of South Miami Human Resources Department Health Insurance Selection July 12, 2005 Please select one vendor: AvMed Blue Cross / Blue Shield Cigna Health Care • Humana Neighborhood Health Partnership United Health Care ' Vista e�M R Oro Employee Name lease Print No Declined to quote Declined to quote /tt( Declined to quote Declined to quote dploye ie Sign., ui< - Date South Miami ne-lA&IMcib 'I► 3001 City of South Miami 6130 Sunset Drive, South Miami, Florida 33143 X11 .' � i City of South Miami Human Resources Department Health Insurance Selection July 12, 2005 Please select one vendor: AvMed Blue Cross / Blue Shield Cigna Health Care Humana Neighborhood Health Partnership United Health Care Vista Employee Name - Please Print Declined to quote Declined to quote 1 ("111) Declined to quote Decl' to : uote f p mployee Signature - D e ! (� 5 South Miami AWiMMIM p I I if 2001 City of South Miami 6130 Sunset Drive, South Miami, Florida 33143 �4 City of South Miami Human Resources Department Health Insurance Selection July 12, 2005 Please select one vendor: AvMed Blue Cross / Blue Shield Cigna Health Care Humana Neighborhood Health Partnership United Health Care Vista CE ployee Name - Please Print 9401 Declined to quote Declined to quote A l 01 Declined to quote e lined to quote "` C' E ployee Signature - Date South Miami AD- AmedcaMy 11r 2001 City of South Miami 6130 Sunset Drive, South Miami, Florida 33143 tk P PV 'AT..[ A €-7 C.3 Lz, # City of South Miami Human Resources Department Health Insurance Selection July 12, 2005 Please select one vendor: AvMed Blue Cross / Blue Shield Cigna Health Care Humana Neighborhood Health Partnership United Health Care Vista Employee Name - Please Print j, Declined to quote Declined to quote Declined to quote Declined to quote t 7 1 mployee Sig ture -Date South Miami MAMNICaCRY 11[f 2001 City of South Miami 6130 Sunset Drive, South Miami, Florida 33143 r A R s City of South Miami Human Resources Department Health Insurance Selection July 125, 2005 Please select one vendor: AvMed Blue Cross / Blue Shield Cigna Health Care Humana Neighborhood Health Partnership United Health Care Vista =Ame& MSC wK Employee Name - Please Print 1'1� Declined to quote Declined to quote Declined to quote N C) Declined to quote mployee Signature - Date South Miami A a Wcacnt I[r 3001 City of South Miami 6130 Sunset Drive, South Miami, Florida 33143 Y b City of South Miami Human Resources Department Health Insurance Selection July I2, 2005 Please select one vendor: AvMed Blue Cross / Blue Shield Cigna Health Care Humana Neighborhood Health Partnership United Health Care Vista 1 Employee Name - Please Print Declined to quote Declined to quote Declined to quote j Declined to quote . �41A � Employee Signature - Date South Miami AO*= CfiY 2001 City of South Miami 6130 Sunset Drive, South Miami, Florida 33143 _i a v City of South MiamiHuman Resources Department Health Insurance Selection July 12, 2005 Please select one vendor: AvMed Blue Cross / Blue Shield Cigna Health Care Humana Neighborhood Health Partnership United Health Care Vista Employee Name - Please Print Declined to quote Declined to quote O Declined to quote V o Declined to quote Employee Signature - Date South Miami 'III► 2001 City of South Miami 6130 Sunset Drive, South Miami, Florida 33143 F City of South Miami Human Resources Department Health Insurance Selection .July 12, 2005 Please select one vendor: AvMed Blue Cross / Blue Shield Cigna Health Care Humana Neighborhood Health Partnership United Health Care Vista Nv,tlo.. f -�kkf-/ Employee Name - Please Print J Declined to quote Declined to quote Declined to quote kv Declined to quote Employee Signature -Date South Miami AHRzftChy 11[F 2001 City of South Miami 6130 Sunset Drive, South Miami, Florida 33143 City of South Miami Human Resources Department Health Insurance Selection July 12, 2005 Please select one vendor: AvMed Blue Cross 1 Blue Shield Cigna Health Care Humana Neighborhood Health Partnership United Health Care Vista Oeo re EmployeeName - Please Print Declined to quote Declined to quote (k) o Declined to quote u0 Declined to quote f Employee Sign ture - Date South Miami AMUMCky 11►r 2001 City of South Miami 6130 Sunset Drive, South Miami, Florida 33143 AvMED I E A L T 14 P L A N S 0 , 3 A7 114,340,111f r ne S r SCHEDULE OUT -OF -MET O K BENEFITS CASH DEDUCTIBLE INDIVIDUAL/FAMILY YOUR COST $500 1$1,500 ANNUALLY COINSURANCE OUT -OF- INDIVIDUAL/FAMILY $3,000/6,000 ANNUALLY POCKET MAXIMUM LIFETIME MAXIMUM $2,000,000 PER MEMBER PRIOR AUTHORIZATION REQUIRED FOR SPECIFIC COVERED SERVICES. THE PENALTY FOR NOT OBTAINING PRIOR AUTHORIZATION IS A 20% REDUCTION IN BENEFITS. Inpatient care at hospitals includes: PHYSICIAN Services at doctors' offices include, but are not limited to: ELIGIBLE EXPENSE, • ROUTINE OFFICE VISITS /ANNUAL GYN VISIT SUBJECT TO THE CASH • MATERNITY- OUTPATIENT VISITS DEDUCTIBLE AND 30% • PEDIATRIC CARE & WELL -CHILD CARE COINSURANCE • DIAGNOSTIC IMAGING, LABORATORY OR OTHER - DIAGNOSTIC SERVICES OXYGEN, DRUGS & MEDICATION • MINOR SURGICAL PROCEDURES • VISION & HEARING EXAMINATIONS FOR CHILDREN UNDER 18 GENERAL & SPECIAL DUTY NURSING SPECIALIST'S SERVICES ° OFFICE VISITS ELIGIBLE EXPENSE, ■ LABORATORY & DIAGNOSTIC IMAGING SUBJECT TO THE CASH DEDUCTIBLE AND 30% COINSURANCE HOSPITAL Inpatient care at hospitals includes: ELIGIBLE EXPENSE, ■ ROOM & BOARD — UNLIMITED DAYS (SEMI - PRIVATE) SUBJECT TO THE CASH ■ PHYSICIAN'S, SPECIALIST'S & SURGEON'S SERVICES DEDUCTIBLE AND 30% ■ ANESTHESIA, USE OF OPERATING & RECOVERY ROOMS, COINSURANCE OXYGEN, DRUGS & MEDICATION ■ INTENSIVE CARE UNIT & OTHER SPECIAL UNITS, GENERAL & SPECIAL DUTY NURSING ■ LABORATORY & DIAGNOSTIC IMAGING ■ REQUIRED SPECIAL DIETS ■ RADIATION & INHALATION THERAPIES OUTPATIENT SURGERY ■ OUTPATIENT SURGERIES, INCLUDING CARDIAC ELIGIBLE EXPENSE, CATHETERIZATIONS AND ANGIOPLASTY SUBJECT TO THE CASH DEDUCTIBLE AND 30% COINSURANCE OUTPATIENT DIAGNOSTIC ■ CAT SCAN, PET SCAN, MRI ELIGIBLE EXPENSE, TESTS ■ OTHER DIAGNOSTIC IMAGING TESTS SUBJECT TO THE CASH DEDUCTIBLE AND 30% COINSURANCE MENTAL HEALTH ■ 20 OUTPATIENT VISITS ELIGIBLE EXPENSE, SUBJECT TO THE CASH (20 VISITS IS THE TOTAL NUMBER OF COVERED VISITS DEDUCTIBLE AND 30% FOR BOTH IN AND OUT OF NETWORK, COMBINED) COINSURANCE IF MENTAL HEALTH/SUBSTANCE ABUSE BENEFIT RIDER IS ELECTED, BENEFITS ARE SUBJECT TO POS RIDER DEDUCTIBLE AND COINSURANCE ARRANGEMENTS WHEN USING NON - PARTICIPATING PROVIDERS. SPECIFIED SERVICE LIMITS ARE THE TOTAL NUMBER OF COVERED VISITS FOR BOTH IN AND OUT OF NETWORK, COMBINED. Summary Aw`f`�rr�vr HEALTH PLANS Benefit STANDARD OPTION SCHEDULE OF COPAYME TS COST TO MEMBER G-A6 IT OUT -OF- POCKET MAXIMUM $1,500 INDIVIDUAL $3,000 FAMILY AVMED PRIMARY CARE Services at participating doctors' offices include, but are not PHYSICIAN limited to: ■ ROUTINE OFFICE VISITS / ANNUAL GYN VISIT WHEN PERFORMED BY PRIMARY CARE PHYSICIAN ® MATERNITY- OUTPATIENT VISITS $10 PER VISIT PEDIATRIC CARE & WELL -BABY CARE ® PERIODIC HEALTH EVALUATION & IMMUNIZATIONS ■ DIAGNOSTIC IMAGING, LABORATORY OR OTHER DIAGNOSTIC SERVICES ■ MINOR SURGICAL PROCEDURES ■ VISION & HEARING EXAMINATIONS FOR CHILDREN UNDER 18 AYMED SPECIALIST'S e OFFICE VISITS $10 PER VISIT SERVICES ■ ANNUAL GYN EXAMINATION WHEN PERFORMED BY PARTICIPATING SPECIALIST HOSPITAL Inpatient care at participating hospitals includes: NO CHARGE ® ROOM & BOARD - UNLIMITED DAYS (SEMI- PRIVATE) ® PHYSICIAN'S, SPECIALIST'S & SURGEON'S SERVICES ® ANESTHESIA, USE OF OPERATING & RECOVERY ROOMS, OXYGEN, DRUGS & MEDICATION ■ INTENSIVE CARE UNIT & OTHER SPECIAL UNITS, GENERAL & SPECIAL DUTY NURSING ■ LABORATORY & DIAGNOSTIC IMAGING ® REQUIRED SPECIAL DIETS ® RADIATION & INHALATION THERAPIES OUTPATIENT SURGERY a OUTPATIENT SURGERIES, INCLUDING CARDIAC NO CHARGE CATHETERIZATIONS AND ANGIOPLASTY OUTPATIENT DIAGNOSTIC . CAT Scan, PET Scan, MRI $25 PER TEST TESTS w OTHER DIAGNOSTIC IMAGING TESTS $10 PER TEST EMERGENCY SERVICES An emergency is the sudden & unexpected onset of a condition requiring immediate medical or surgical care. ■ EMERGENCY ROOM AT PARTICIPATING $75 COPAYMENT HOSPITALS ■ EMERGENCY SERVICES - NON - PARTICIPATING $100 COPAYMENT HOSPITALS, FACILITIES, & /OR PHYSICIANS PLAN 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 $40 COPAYMENT URGENT/IMMEDIATE CARE FACILITY OR SERVICES RENDERED AFTER HOURS IN YOUR PRIMARY CARE PHYSICIAN'S OFFICE ■ MEDICAL SERVICES AT A NON - PARTICIPATING $60 COPAYMENT URGENT/IMMEDIATE CARE FACILITY