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Agreement 05-01-01 - 04-30-02
AvMnr HEAI TH PI AN 5- or -aoot - 4-30 --aqcrDc RENEWAL PROPOSAL Employee Health Coverage for Village of Key Biscayne Effective May 1, 2001 through April 30, 2002 AvMEnTm HEALTH PLAN AvMed Health Plan • About AvMed • Our Members i Our Network • Account Services a Value -Added Benefits AvMed Highlights ➢ One of only five HMO's in the nation to hold two full accreditations from both National Committee on Quality Assurance (NCQA) and Joint Commission on Accreditation of Healthcare Organization (JACO) statewide Accrediting factors include preventive health services, quality improvement, utilization management and physician credentialing ➢ Largest not -for-profit health plan in Florida with over 30 years of managed care experience ➢ HEDIS scores and members' satisfaction survey results are among the highest HMO satisfaction rates in the country ➢ Physician Bonus Incentive Plan rewards our physicians with annual bonuses based on the quality of care delivered to our members rather than applying any withholds or placing our physicians at risk financially based on utilization ➢ Member Service assistance available 24 hours a day, seven days a week ➢ AvMed's On Call Staffed by registered nurses provide assistance to members 24 hours a day, seven days a week Members may also listen to one of more than 430 topics from the Audio Health library ➢ Fully automated referrals allow 99%of all requests for specialty consultation to be approved within three minutes > Health Enhancement Programs Worksite programs involve employers in the health and well being of their employees Onsite programs include mammography screening, flu shots, cholesterol and glucose testing, blood pressure, portable bone density, and skin cancer screenings to name a few Programs are customized and results are provided to the employer > Specialty network available to all members (i e Mayo Clinic, Cleveland Clinic, Shands) I AvMED HL tl tli P1 zn AvMed Health Plan Our Mission To improve the health of our members and communities by making health care more accessible and affordable while operating within the not -for-profit humanitarian tradition Our Vision To achieve a recognized presence m the health care field as a leader m the delivery of health care services and contribute to knowledge m the field Our Philosophy To provide comprehensive, coordinated services to enhance the health of our members and communities using community and corporate resources which emphasize Quality, Accessibility, Affordability and User Satisfaction and which operates m keeping with our non -for-profit, humanitarian tradition and utilizes research m the latest approaches to health care components, delivery systems and health care decisions for the benefit of the member AVMED Our Tradition Created m 1969 as a prepaid health care system for pilots in Miami's aviation industry, today, AvMed is Florida's largest not - for -profit health plan AvMed, whose name is derived from "aviation medicine," became licensed as an HMO in 1973 and earned federal qualification in 1977 Our founders were not investors, but volunteers interested in better and more affordable health care Our mission directly reflects our tradition to improve the health of our members and the communities we serve AvMed serves more than 375,000 residents throughout the state AvMed offers Group HMO, Medicare HMO, Point -of -Service and other products which provide members with comprehensive health care coverage AvMed has offices in most major Florida cities, including Miami, Ft Lauderdale, Gainesville, Jacksonville, Orlando, Palm Beach, Port Charlotte, Tampa and Tallahassee As the Health Improvement Company, we are actively involved in improving the health of our members and communities AvMed is On -Line! Welcome to AvMed On -Line r What is it about ... • AvMed Profile All about AvMed • Health Information • Member Services Medicare and Employer Group Members • Brokers, Employers, and Benefit Managers • Health Providers Provider Directory Provider Surveys • Many more categories to choose from WWW.AvMed.COM Member Satisfaction 88.6% of AvMed members express overall satisfaction with AvMed as: Excellent Very Good Good Professional Research Corporation 1999 HMO Member Satisfaction Study �% C e n t r a l R e g i o n F t L a u d e r d a l e R e g i o n �% J a c k s o n v i l l e R e g i o n M i a m i R e g i o n 1 1 1 1 N o r t h C e n t r a l R e g i o n �% P a l m B e a c h R e g i o n �% P a n h a n d l e R e g i o n �% S o u t h w e s t R e g i o n �% T a m p a B a y R e g i o n ' C o m m e r c i a l o n l y ' C o m m e r c i a l a n d M e d i c a r e o f f e r e d ' U n d e r t h e t e r m s o f a S t r a t e g i c A l l i a n c e F l o r i d a H e a l t h C a r e P l a n s I n c i n V o l u s i a C o u n t y i s A v M e d s e x c l u s i v e p a r t n e r f o r t h e d e l i v e r y o f h e a l t h c a r e s e r v i c e s t o A v M e d m e m b e r s i n V o l u s i a C o u n t y * S e l e c t e d a r e a s o f G a d s d e n C o u n t y H i l l s b o r o u g h ' M P 1 1 2 6 ( 4 / 0 0 ) AvMed Health Plan SERVICE TEAM Account Service Manager Evis Clavareza 1 Blanca Hernandez Account Service Representative (305) 671-6170 On -Site Visitation Contractual Issues Enrollment Presentations Renewal Negotiations 1 Michelle Townson Inside Account Service Representative (305) 6714791 Liaison to Benefits Complex Issues Elegibility Corrections Back-up to ASR Member Services Director Arlene Chejanovski Member Services, 24 hr,/7days 1-800-882-8633 AvMed's On Call, 24 hrfidays 1-888-86645432 Benefits / Procedural Questions Physician Selection Unplanned Admissions Other Emergency Situations Standard Option 0 Admit SCHEDULE OF LOPAYMENTh AVMED PRIMARY CARE PHYSICIAN Services at participating doctors offices include but are not limited to ROUTINE OFFICE VISITS/ANNUAL GYN VISIT MATERNITY OUTPATIENT VISITS 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 NUTRITIONIST ST TO EiBEF $10 PER VISIT AVMED SPECIALIST S I OFFICE VISITS SERVICES $10 PER VISIT HOSPITAL Inpatient care at prticipatIng hospitals includes NO CHARGE di ROOM & BOARD UNLIMITED DAYS (SEMI PRIVATE) 10 PHYSICIAN S SPECIALIST S & SURGEON S SERVICES Ti ANESTHESIA USE OF OPERATING & RECOVERY ROOMS OXYGEN DRUGS & MEDICATION KI INTENSIVE CARE UNIT & OTHER SPECIAL UNITS GENERAL & SPECIAL DUTY NURSING • LABORATORY & DIAGNOSTIC IMAGING REQUIRED SPECIAL DIETS a RADIATION & INHALATION THERAPIES SURGERY OUTPATIENT NO CHARGE EMERGENCY An emergency is the sudden and unexpected onset of 1 condition requiring SERVICES immediate medical or surgical care • EMERGENCY ROOM AT PARTICIPATING HOSPITALS Hi EMERGENCY SERVICES NON PARTICIPATING HOSPITALS FACILITIES & / OR PHYSICIANS PLAN MUST BE NOTIFIED WITHIN 24 HOURS OF EMERGENCY ADMISSION OR AS SOON AS REASONABLY POSSIBLE $30 COPAYMENT $50 COPAYMENT 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 TES AMBULANCE WHEN PRE AUTHORIZED OR IN THE CASE OF EMERGENCY NO CHARGF PHYSICAL SPEECH a SHORT TERM TREATMENT FOR ACUTE CONDITION FOR WHICH S. OCCUPATIONAL THERAPY APPLIED FOR A CONSECUTIVE TWO CALENDAR THERAPIES MONTH PERIOD CAN BE EXPECTED TO RESULT IN SIGNIFICANT IMPROVEMENT • COVERAGE IS LIMITED TO 24 VISITS PER CONDITION $10 PER VISIT AV STD OA 0 MP 3025 (6/00) SKILLED NURSING a UP TO 20 DAYS PER CONTRACT YEAR POST HOSPITALIZATION FACILITIES & CARE WHEN PRESCRIBED BY PHYSICIAN & AUTHORIZED BY -IABILITATION CENTERS AVMED $25 PER DAY HOME HEALTH CARE a PER OCCURRENCE NO CHARGE DURABLE MEDICAL EQUIPMENT INCLUDES )UIPMENT & ORTHOTIC m HOSPITAL BEDS APPLIANCES a WALKERS • CRUTCHES • 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 $50 PER EPISODE OF ILLNESS BENEFITS LIMITED TO $500 PER CONTRACT YEAR PROSTHETIC PROSTHETIC DEVICES ARE LIMITED TO DEVICES a ARTIFICIAL LIMBS • ARTIFICIAL JOINTS • OCULAR PROSTHESES REFER TO YOUR AVMED GROUP MEDICAL & HOSPITAL SERVICE CONTRACT FOR SPECIFIC EXCLUSIONS & LIMITATIONS NO CHARGE FOR FURTHER INFORMATION PLEASE CALL 1-800-88-AVMED (1-800-882-8633) THIS SCHEDULE OF COPAYMENTS IS NOT A CONTRACT FOR SPECIFIC INFORMATION ON BENEFITS EXCLUSIONS & LIMITATIONS, PLEASE SEE YOUR AVMED GROUP MEDICAL & HOSPITAL SERVICE CONTRACT " ) ; X 2 1 . ~ V , B r a n d n a m e d r u g m e a n s a P r e s c n p t i o n D r u g w h i c h i s m a n u f a c t u r e d a n d s o l d u n d e r a n a m e o r t r a d e m a r k b y a d r m a n u f a c t u r e r o r a d r u g w h i c h i s i d e n t i f i e d a s a B r a n d n a m e d r u g b y A v M e d G e n e n c d r u g m e a n s a d r u g w h i c h i s e q u i v a l e n t t o a B r a n d n a m e d r u g o r i s i d e n t i f i e d a s a G e n e r i c D r u g b y A v M e d M a n d a t o r y G e n e r i c P e n a l t y C h a r g e m e a n s t h e a d d i t i o n a l c h a r g e w h i c h m u s t b e p a i d i f y o u o r y o u r p h y s i c i a n c h o o s B r a n d n a m e d r u g w h e n a G e n e r i c i s a v a i l a b l e T h e c h a r g e i s t h e d i f f e r e n c e b e t w e e n t h e c o s t o f t h e B r a n d n a m e d r u g 2 t h e G e n e r i c d r u g T h i s p e n a l t y c h a r g e m u s t b e p a i d i n a d d i t i o n t o t h e a p p l i c a b l e B r a n d n a m e c o p a y m e n t ( P r e f e r r e d N o n - P r e f e r r e d ) P a r t i c i p a t i n g P h a r m a c y m e a n s a p h a r m a c y ( e i t h e r R e t a i l o r M a i l O r d e r ) w h i c h h a s e n t e r e d i n t o a n a g r e e m e n t v v A v M e d t o p r o v i d e P r e s c n p t i o n D r u g s t o A v M e d M e m b e r s a n d h a s b e e n d e s i g n a t e d b y A v M e d a s a P a r t i c i p a t i n g P h a r m a P r e f e r r e d D r u g L i s t m e a n s t h e l i s t o f P r e s c r i p t i o n D r u g s w h i c h a r e p r e f e r r e d b y A v M e d f o r d i s p e n s i n g t o i t s m e m b f T h e l i s t m a y b e o b t a i n e d b y c o n t a c t i n g A v M e d s M e m b e r S e r v i c e s D e p a r t m e n t T h e l i s t i s s u b j e c t t o p e r i o d i c r e v i e w m o d i f i c a t i o n b y A v M e d D r u g s o n t h e P r e f e r r e d D r u g L i s t a r e c a l l e d P r e f e r r e d D r u g s d r u g s n o t a p p e a n n g o n t h e a r e c a l l e d N o n - P r e f e r r e d D r u g s P r e s c n p t i o n D r u g m e a n s a m e d i c a t i o n w h i c h h a s b e e n a p p r o v e d b y t h e F o o d a n d D r u g A d m i n i s t r a t i o n a n d w h i c h i o n l y b e d i s p e n s e d p u r s u a n t t o a P r e s c r i p t i o n a c c o r d i n g t o s t a t e a n d f e d e r a l l a w P r e - A u t h o n z a t i o n m e a n s t h e p r o c e s s o f o b t a i n i n g a p p r o v a l f o r c e r t a i n P r e s c n p t i o n D r u g s ( p r i o r t o d i s p e n s i n g ) a c c o r d t o A v M e d s g u i d e l i n e s T h e a p p r o v a l m u s t b e o b t a i n e d f r o m A v M e d b y t h e p r e s c r i b i n g P h y s i c i a n T h e l i s t o f P r e s c n p t D r u g s r e q u i n n g P r e A u t h o n z a t i o n i s s u b j e c t t o p e r i o d i c r e v i e w a n d m o d i f i c a t i o n b y A v M e d H O W D O E S R E T A I L P R E S C R I P T I O N C O V E R A G E W O R K ' T h r o u g h y o u r c o v e r a g e w i t h A v M e d H e a l t h P l a n y o u r o r g a n i z a t i o n h a s e l e c t e d t o i n c l u d e p r e s c r i p t i o n d r u g c o v e r a g H o w t h e c o v e r a g e w o r k s 1 P r e s e n t y o u r A v M e d m e m b e r s h i p c a r d a t a n y P a r t i c i p a t i n g P h a r m a c y i n t h e S t a t e o f F l o r i d a w i t h a p r e s c r i p t i o n f i y o u r A v M e d p h y s i c i a n 2 P a y t h e f o l l o w i n g c o p a y m e n t ( t h e a d d i t i o n a l M a n d a t o r y G e n e n c P e n a l t y C h a r g e w i l l b e c h a r g e d i f y o u o r y p h y s i c i a n c h o o s e a B r a n d n a m e p r o d u c t w h e n a G e n e n c i s a v a i l a b l e ) G e n e r i c D r u g s P r e f e r r e d B r a n d N a m e D r u g s N o n - P r e f e r r e d B r a n d N a m e D r u g s $ 1 0 0 0 $ 2 0 0 0 $ 3 0 0 0 T h e p h a r m a c y w i l l d i s p e n s e t h e q u a n t i t y s u f f i c i e n t t o t r e a t a n a c u t e p h a s e o f i l l n e s s b u t n o t m o r e t h a n a 3 0 s u p p l y 3 R e c e i v e y o u r p r e s c r i b e d m e d i c a t i o n s C o n t a n u e d o n b a c k A V G 1 0 0 R X 3 T 1 R 9 9 M P 2 0 4 5 ( 5 / 9 9 ) ORDERING YOUR PRESCRIPTIONS THROUGH THE MAIL Through your coverage with AvMed Health Plan your prescription drug benefits include mail order prescription drugs provided by PCS Mail Service Mail Service is a benefit option for maintenance medications needed for chronic or long term health conditions It s 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 copayment (the additional Mandatory Generic Penalty Charge will be charged if you or your physician choose a Brand name product when a Generic is available) Pay the following copayment Generic Drugs Preferred Brand Name Drugs Non -Preferred Brand Name Drugs $ 20 00 $ 40 00 $ 60 00 HOW TO ORDER YOUR PRESCRIPTIONS THROUGH THE MAIL 1 For your first order fill out the patient profile sections of the PCS Mail Service Pharmacy Order Form A new order form will be sent to you with each delivery for future orders Send either a check payable to PCS Mail Service or provide your credit card number and expiration date (VISA MasterCard Discover and American Express are accepted) Please do not send cash through the mail 2 Enclose your maintenance prescription the order form and your payment in the pre addressed mail service envelope Mail your order to PCS Mail Service PO Box 961066 Fort Worth TX 76161-9854 3 Allow 10-14 business days from the date you mail your order for delivery of your medicine Overnight delivery is available for an additional charge 4 To order refills by phone call Pharmacy Customer Service at 1 800 966 5772 Please have your prescription number and credit card ready when you call Please note that a prescription will only be refilled after 60% of the previous prescription has been used 5 Check with your benefits coordinator if you are not sure whether a certain prescription medicine is covered under your plan Prescriptions for medicines not covered by your plan will be returned to you WHAT COPAYMENT DO YOU PAY GENERIC PREFERRED BRAND OR NON PREFERRED BRAND" You will pay the Generic copayment for Generic medication You will pay the applicable Brand name copayment for Preferred Brand name medication and Non -Preferred Brand name medication If the Brand name is dispensed at your or your physician s request when a Generic is available you will pay the pharmacy 100 percent of the difference between the cost of the Generic and Brand name prescription drug in addition to the applicable higher Brand name copayment (Preferred or Non Preferred) When ordering through the mail if the difference in cost totals less than $50 00 PCS Mail Service will enclose a bill for payment If the total cost difference exceeds $50 00 PCS Mail Service will contact you at the telephone number or address you provided on the order form The Florida Boards of Medicine and Pharmacy pursuant to Chapter 465 Florida Statutes have established a negative drug formulary No drug substitution shall be allowed for the following drugs Digoxin Digitoxin Warfarin Conjugated estrogen Quinidine gluconate Dicumarol Phenytoin Chloropromazine (solid oral dosage forms) Theophylline (controlled release) Levothyroxine sodium Pancrelipase (oral dosage forms) No mandatory Generic penalty is applied to Brand name drugs on the Florida Negative Formulary UNTIL YOU RECEIVE YOUR NEW MEMBERSHIP CARD Normally there is a brief period of time between the date your coverage becomes effective and the date you receive your new card If you need a prescription before your new card arrives you can fill the prescription at a participating pharmacy and submit the receipt and a copy of the prescription to AvMed for reimbursement The copayment amount will be subtracted from the reimbursement Please indicate your Social Security Number on the receipt I IN AN EMERGENCY Always present your AvMed membership card to allow the doctor or hospital to verify coverage with AvMed Your coverage with AvMed includes prescriptions written during emergency situations 1 r 4 WHAT IS COVERED" • Your prescription drug coverage includes outpatient medications which 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 copayment The amount of medication per copayment is limited to the amount which will be sufficient to treat an acute phase of illness or up to a 30 day supply • Your mail-order prescription drug coverage includes up to a 90 -day supply of a maintenance medication for the listed copayment If the amount of medication is less than a 90 day supply you will still be charged the listed mail order copayment QUESTIONS" Call your AvMed Member Services Department at 1-800-88-AvMed (1-800-882-8633) EXCLUSIONS AND LIMITATIONS Medications available without a prescription or where there is a non prescription equivalent available Therapeutic devices dressings or appliances Support garments and other medical or non -medical supplies Prescription medications which are reimbursable under other insurance programs or which may be properly received under local state or federal programs including worker s compensation SPECIFIC EXCLUSIONS INCLUDE • Over the counter medications • Drugs or medications which do not require a prescription or when a non-prescription equivalent is available • Diaphragms and other contraceptive devices • Oral injectable and implantable contraceptive products • Fertility drugs • Drugs or other forms of treatment related to the diagnosis of sexual dysfunction • Fluoride products • Prescription and non-prescription vitamins and minerals except prenatal vitamins • Nutritional supplements given as a medicine between meals to boost protein caloric intake or the mainstay of a daily nutritional plan • Immunization drugs • Hypodermic needles and syringes (except insulin syringes) • Injectable drug products (except chemotherapy for cancer patients insulin for diabetic patients allergy serums and any medications administered by the attending physician) • Investigational and experimental drugs (except as required by Florida statute) • Hair growth products (e g Minoxidil) • Nicotine suppressants and smoking cessation products and services • Prescription and non prescription appetite suppressants and products for the purpose of weight loss • Transdermal scopolamine for recreational purposes • Tretinoin products used for cosmetic purposes (e g Retin A) • Prescription drugs when ordered from a government (local state or federal) funded program including Worker s Compensation HEALTH PLAN INPATIENT ENTAL HEALTH BENEFITS As of the effective date, Inpatient Mental Health 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 Plan Hospital or Plan Health Care Facility as a registered bed patient AV G100-MH-OIP R 99 MP 2029 (5/99) AvMmm' HEALTH PLAN ATE RIDER 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 AVSA98 MP 1527 (7/98) 11 ET"A L T it' PLAN 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 Definttton 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 las duration • is not related by blood or marriage, • is at least eighteen years of age, • is mentally competent to consent to a contract, • has cohabited with you and intends to continue doing so indefinitely • has filed a Domestic Partnership agreement or registration with the Employer if available in the star (and/or city) of residence • has shared financial obligations including basic living expenses for the twelve month period prior to enrollment in the plan, and • will provide documentation that will be satisfactory to the Employer as evidence of a Domestic Part] relationship, • meets the dependent eligibility requirements of the Employer's health benefits plan AV DPartner R 98 MP 1995 (1/99) ALTERNATE PLAN Standard Option 250 Admit ChEDULE OF COPAYMENTS COST TO MEMBER AVMED PRIMARY CARE Services at participating doctors offices include but are not limited to PHYSICIAN ROUTINE OFFICE VISITS/ANNUAL GYN VISIT MATERNITY OUTPATIENT VISITS 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 NUTRITIONIST $10 PER VISIT AVMED SPECIALIST S ,>.1 OFFICE VISITS $10 PER VISIT SERVICES HOSPITAL Inpatient care at participating hospitals includes A $250 PER ADMISSION ROOM & BOARD UNLIMITED DAYS (SEMI PRIVATE) 100% COVERAGE PHYSICIAN S SPECIALIST S & SURGEON S SERVICES THEREAFTER ANESTHESIA USE OF OPERATING & RECOVERY ROOMS OXYGEN DRUGS & MEDICATION OE INTENSIVE CARE UNIT & OTHER SPECIAL UNITS GENERAL & SPECIAL DUTY NURSING IP LABORATORY & DIAGNOSTIC IMAGING Si REQUIRED SPECIAL DIETS RADIATION & INHALATION THERAPIES SURGERY E OUTPATIENT $250 COPAYMENT EMERGENCY An emergency is the sudden and unexpected onset of a condition requiring SERVICES immediate medical or surgical care (Copayment waived if admitted ) • EMERGENCY ROOM AT PARTICIPATING HOSPITALS • EMERGENCY SERVICES NON PARTICIPATING HOSPITALS FACILITIES & / OR PHYSICIANS PLAN MUST BE NOTIFIED WITHIN 24 HOURS OF EMERGENCY ADMISSION OR AS SOON AS REASONABLY POSSIBLE $30 COPAYMENT $50 COPAYMENT MENTAL HEALTH d 20 OUTPATIENT VISITS $25 PER VISIT FAMILY PLANNING M VOLUNTARY FAMILY PLANNING SERVICES $10 PER VISIT STERILIZATION $100 COPAYMENT ALLERGY TREATMENTS INJECTIONS $10 PER VISIT • SKIN TESTING $50 PER COURSE OF'1'ES AMBULANCE M WHEN PRE AUTHORIZED OR IN THE CASE OF EMERGENCY NO CHARGE PHYSICAL SPEECH SHORT TERM TREATMENT FOR ACUTE CONDITION FOR WHICH $10 PER VISIT & OCCUPATIONAL THERAPY APPLIED FOR A CONSECUTIVE TWO CALENDAR THERAPIES MONTH PERIOD CAN BE EXPECTED TO RESULT IN SIGNIFICANT IMPROVEMENT • COVERAGE IS LIMITED TO 24 VISITS PER CONDITION AV STD 250A 00 MP 3028 (6/00) SKILLED NURSING FACILITIES & -HABILITATION CENTERS UP TO 20 DAYS PER CONTRACT YEAR POST HOSPITALIZATION CARE WHEN PRESCRIBED BY PHYSICIAN & AUTHORIZED BY AVMED $25 PER DAY HOME HEALTH CARE a PER OCCURRENCE NO CHARGE DURABLE MEDICAL EQUIPMENT INCLUDES lUIPMENT & ORTHOTIC a HOSPITAL BEDS APPLIANCES a WALKERS • CRUTCHES • 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 $50 PER EPISODE OF ILLNESS BENEFITS LIMITED TO $500 PER CONTRACT YEAR PROSTHETIC PROSTHETIC DEVICES ARE LIMITED TO DEVICES a ARTIFICIAL LIMBS • ARTIFICIAL JOINTS ▪ OCULAR PROSTHESES REFER TO YOUR AVMED GROUP MEDICAL & HOSPITAL SERVICE CONTRACT FOR SPECIFIC EXCLUSIONS & LIMITATIONS NO CHARGE FOR FURTHER INFORMATION PLEASE CALL 1 800-88-AVMED (1-800-882-8633) THIS SCHEDULE OF COPAYMENTS IS NOT A CONTRACT FOR SPECIFIC INFORMATION ON BENEFITS EXCLUSIONS & LIMITATIONS PLEASE SEE YOUR AVMED GROUP MEDICAL & HOSPITAL SERVICE CONTRACT $20 z DE IMinoi''s Brand name drug means a Prescription Drug which is manufactured and sold under a name or trademark by a d manufacturer or a drug which is identified as a Brand name drug by AvMed Generic drug means a drug which is equivalent to a Brand name drug or is identified as a Generic Drug by AvMec Mandatory Generic Penalty Charge means the additional charge which must be paid if you or your physician choo Brand name drug when a Generic is available The charge is the difference between the cost of the Brand name drug the Generic drug This penalty charge must be paid in addition to the applicable Brand name copayment (Preferrec Non -Preferred) Participating Pharmacy means a pharmacy (either Retail or Mail Order) which has entered into an agreement v AvMed to provide Prescription Drugs to AvMed Members and has been designated by AvMed as a Participating Pharm, Preferred Drug List means the list of Prescription Drugs which are preferred by AvMed for dispensing to its membi The list may be obtained by contacting AvMed s Member Services Department The list is subject to periodic review modification by AvMed Drugs on the Preferred Drug List are called Preferred Drugs drugs not appearing on the are called Non -Preferred Drugs ' Prescription Drug means a medication which has been approved by the Food and Drug Administration and which only be dispensed pursuant to a Prescription according to state and federal law Pre-Authonzation means the process of obtaining approval for certain Prescription Drugs (prior to dispensing) accord to AvMed s guidelines The approval must be obtained from AvMed by the prescribing Physician The list of Prescript Drugs requiring Pre-Authonzation is subject to periodic review and modification by AvMed HOW DOES RETAIL PRESCRIPTION COVERAGE WORK' Through your coverage with AvMed Health Plan your organization has elected to include prescription drug coverag How the coverage works 1 Present your AvMed membership card at any Participating Pharmacy in the State of Florida with a prescription fr your AvMed physician 2 Pay the following copayment (the additional Mandatory Generic Penalty Charge will be charged if you or y physician choose a Brand name product when a Generic is available) Generic Drugs Preferred Brand Name Drugs Non -Preferred Brand Name Drugs $1000 $20 00 $3000 The pharmacy will dispense the quantity sufficient to treat an acute phase of illness but not more than a 30 - supply 3 Receive your prescribed medications Continued on back AV G100-RX 3T1 R 99 MP 2045 (5/99) ORDERING YOUR PRESCRIPTIONS THROUGH THE MAIL Through your coverage with AvMed Health Plan your prescription drug benefits include mail order prescription drugs provided by PCS Mail Service Mail Service is a benefit option for maintenance medications needed for chronic or long term health conditions It s 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 copayment (the additional Mandatory Generic Penalty Charge will be charged if you or your physician choose a Brand name product when a Generic is available) Pay the following copayment Generic Drugs Preferred Brand Name Drugs Non -Preferred Brand Name Drugs $ 20 00 $ 40 00 $ 60 00 HOW TO ORDER YOUR PRESCRIPTIONS THROUGH THE MAIL 1 For your first order fill out the patient profile sections of the PCS Mail Service Pharmacy Order Form A new order form will be sent to you with each delivery for future orders Send either a check payable to PCS Mail Service or provide your credit card number and expiration date (VISA MasterCard Discover and American Express are accepted) Please do not send cash through the mail 2 Enclose your maintenance prescription the order form and your payment in the pre addressed mail service envelope Mail your order to PCS Mail Service PO Box 961066 Fort Worth TX 76161-9854 3 Allow 10-14 business days from the date you mail your order for delivery of your medicine Overnight delivery is available for an additional charge 4 To order refills by phone call Pharmacy Customer Service at 1 800-966 5772 Please have your prescription number and credit card ready when you call Please note that a prescription will only be refilled after 60% of the previous prescription has been used 5 Check with your benefits coordinator if you are not sure whether a certain prescription medicine is covered under your plan Prescriptions for medicines not covered by your plan will be returned to you WHAT COPAYMENT DO YOU PAY GENERIC PREFERRED BRAND OR NON PREFERRED BRAND You will pay the Generic copayment for Generic medication You will pay the applicable Brand name copayment for Preferred Brand name medication and Non -Preferred Brand name medication If the Brand name is dispensed at your or your physician s request when a Generic is available you will pay the pharmacy 100 percent of the difference between the cost of the Generic and Brand name prescription drug in addition to the applicable higher Brand name copayment (Preferred or Non -Preferred) When ordering through the mail if the difference in cost totals less than $50 00 PCS Mail Service will enclose a bill for payment If the total cost difference exceeds $50 00 PCS Mail Service will contact you at the telephone number or address you provided on the order form The Florida Boards of Medicine and Pharmacy pursuant to Chapter 465 Florida Statutes have established a negative drug formulary No drug substitution shall be allowed for the following drugs Digoxin Digitoxin Warfarin Conjugated estrogen Quinidine gluconate Dicumarol Phenytoin Chloropromazine (solid oral dosage forms) Theophylline (controlled release) Levothyroxine sodium Pancrelipase (oral dosage forms) No mandatory Generic penalty is applied to Brand name drugs on the Florida Negative Formulary UNTIL YOU RECEIVE YOUR NEW MEMBERSHIP CARD Normally there is a brief period of time between the date your coverage becomes effective and the date you receive your new card If you need a prescription before your new card arrives you can fill the prescription at a participating pharmacy and submit the receipt and a copy of the prescription to AvMed for reimbursement The copayment amount will be subtracted from the reimbursement Please indicate your Social Security Number on the receipt IN AN EMERGENCY Always present your AvMed membership card to allow the doctor or hospital to verify coverage with AvMed Your coverage with AvMed includes prescriptions written during emergency situations WHAT IS COVERED' • Your prescription drug coverage includes outpatient medications which 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 copayment The amount of medication per copayment is limited to the amount which will be sufficient to treat an acute phase of illness or up to a 30 -day supply • Your mail order prescription drug coverage includes up to a 90 -day supply of a maintenance medication for the listed copayment If the amount of medication is less than a 90 -day supply you will still be charged the listed mail order copayment QUESTIONS' Call your AvMed Member Services Department at 1 800-88-AvMed (1 800 882-8633) EXCLUSIONS AND LIMITATIONS Medications available without a prescription or where there is a non prescription equivalent available Therapeutic devices dressings or appliances Support garments and other medical or non medical supplies Prescription medications which are reimbursable under other insurance programs or which may be properly received under local state or federal programs including worker s compensation SPECIFIC EXCLUSIONS INCLUDE • Over the counter medications • Drugs or medications which do not require a prescription or when a non-prescription equivalent is available • Diaphragms and other contraceptive devices • Oral injectable and implantable contraceptive products • Fertility drugs • Drugs or other forms of treatment related to the diagnosis of sexual dysfunction • Fluoride products • Prescription and non prescription vitamins and minerals except prenatal vitamins • Nutritional supplements given as a medicine between meals to boost protein caloric intake or the mainstay of a daily nutritional plan • Immunization drugs • Hypodermic needles and syringes (except insulin syringes) • Injectable drug products (except chemotherapy for cancer patients insulin for diabetic patients allergy serums and any medications administered by the attending physician) • Investigational and experimental drugs (except as required by Florida statute) • Hair growth products (e g Minoxidil) • Nicotine suppressants and smoking cessation products and services • Prescription and non prescription appetite suppressants and products for the purpose of weight loss • Transdermal scopolamine for recreational purposes • Tretinoin products used for cosmetic purposes (e g Retin A) • Prescription drugs when ordered from a government (local state or federal) funded program including Worker s Compensation AvMnm HEALTH PLAN Tat HEALTH BENEFITS As of the effective date, Inpatient Mental Health Benefits are being provided for an additional premium • Inpatient treatment of mental/nervous disorders for up to 30 days per patient, subject to a member copayment of $250 per admission, shall be provided by the Plan when a member is admitted to a Plan Hospital or Plan Health Care Facility as a registered bed patient AV G100 MH 250/AIP R 99 MP 2035 (5/99) ic+ Sac CERTIFICATE RIDER 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 AVSA98 MP 1527 (7/98) 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 las duration, • is not related by blood or marriage • is at least eighteen years of age, • is mentally competent to consent to a contract, • has cohabited with you and intends to continue doing so indefinitely, • has filed a Domestic Partnership agreement or registration with the Employer if available in the star (and/or city) of residence, • has shared financial obligations including basic living expenses for the twelve month period prior to enrollment in the plan, and • will provide documentation that will be satisfactory to the Employer as evidence of a Domestic Part] relationship • meets the dependent eligibility requirements of the Employer's health benefits plan AV DPartner R 98 MP 1995 (1/99) AvMed Member Services We're here for you... 24 hours a day, 1 days a week. For answers to any questions regarding your AvMed membership. 1 -800-88-AvMed 1-800-882-8633 No one offers service like AvMed. Round -the -Clock Phone Lines: AvMed members can reach a Member Services Representative 24 hours a day, seven days a week by calling 1-800-88AvMed Health Information Line: When you have a specific health question, call AvMed toll free at 1-888-866-5432 You can listen to tapes on more than 430 topics or speak personally with a registered nurse Anytime! AvMe and Weight Watchers Want to lose weight? ...Establish a healthy lifestyle? AvMed will help. If you meet your goal weight and complete your maintenance program while enrolled in Weight Watchers, AvMed will reimburse all fees you paid to Weight Watchers. Write to AvMed's Health Promotions Department at the address below to receive your reimbursement check Be sure to include the following information. or Number of pounds lost or Your AvMed membership Number or A copy of your Weight Watchers Lifetime Card or attendance booklet or Amount of reimbursement requested t+ '- Your current mailing address cw Send to: AvMed Health Promotions Department PD BOX 749 Gainesville, FL 32602-0749 To contact the Weight Watchers nearest you, call 1-800-651.6000, in Dade County (305) 221-9411 and in Broward County (954) 525-7233 Questions? Call 352.337.8549 MP 1 (9/99) AvMed and Smokenders As an AvMed member you receive a reduced price for the Smokenders booklet/videotape and you get your money back when you quit smoking! To order, call 1-800-828-4357, ext. 3 For reimbursement, write to AvMed Health Promotions stating that you have successfully quit smoking Include the following information ate- Your name and AvMed membership number air How many years you smoked ate- Your comments on the Smokenders program * Your current mailing address Send to AvMed Health Promotions PO Box 749 Gainesville, FL 32602-0749 AvMui HEALTH PLAN IT'S IMPORTANT TO HAVE A MAMMOGRAM Dear AVMED Member AVMED Health Plan will provide mammography (breast) screenings as a preventative care measure to females age 40 and over A baseline mammogram will be provided once between the ages of 35 and 40 There is NO CHARGE to AVMED Members for the screenings (The average cost in a hospital/ clinic is from $65 00 to $95 00) A prescription is required from your Primary Care OB or GYN Physician You will have to present this at the time you receive the exam at one of our participating facilities Preventive health care is the cornerstone of the AVMED philosophy Please take a moment to read the current facts which affect women 35 years and older in the 1990 s • BREAST CANCER IS THE SECOND LEADING CAUSE OF CANCER DEATH IN WOMEN AFTER LUNG CANCER • ONE IN TEN WOMEN WILL DEVELOP BREAST CANCER • IN 1989 APPROXIMATELY 43 000 WOMEN DIED FROM THE DISEASE INCLUDING APPROXIMATELY 2 500 FROM FLORIDA • THE FIVE YEAR SURVIVAL RATE FOR WOMEN WITH LOCALIZED CANCER HAS RISEN TO 90% TODAY IN LARGE PART DUE TO ROUTINE MAMMOGRAPHY • ONLY 15% OF ELIGIBLE WOMEN NATIONWIDE HAVE EVER HAD A MAMMOGRAM It is a documented and statistical fact that early detection of breast cancer by mammography screen ings significantly reduces the mortality and morbidity of the disease process TAKE ADVANTAGE OF THIS SCREENING - CONTACT YOUR PRIMARY CARE PHYSICIAN AND REQUEST A PRESCRIPTION FOR YOUR MAMMOGRAM To your good health, AVMED Health Plan MP 1 107 (6/96) Expecting? Give your baby the greatest chance of being born strong and healthy. Call AvMed's Member Services Department at 1-800-88-AvMed to select an obstetrician or other prenatal care provider as your primary care provider and to register for AvMed's free pregnancy program. AvMed's pregnancy program includes personal interviews with a maternity care specialist and 24 -hour access to a toll -free telephone line to answer any questions you may have. � Call AvMed at 1-800-88-AvMed. 1690 (5/97) 1 1 AvMed's Disease Management Program f you have congestive heart failure, asthma or are at risk for a problem pregnancy, we can help our registered nurses will work with you to develop a personal program based on your needs our initial evaluation includes one-on-one counseling on medication, nutrition, exercise and your home environment We can help you by providing Personal care coordination, evaluation and follow-up Regular telephone updates Home visits within four hours of the sudden onset of symptoms Coordination of home health services one-on-one education on preventive care For more information on AvMed's Disease Management Program, call: North Florida 1.800.34fi-0231, ext. 41955; �A N South Florida 1.800.432.6616, ext. 26111. Village of Key Biscayne Monthly Rates Effective May 1 2001 through April 30 2002 (HMO) - Current Benefit Plan Standard Option Hospitalization 100% $10 PCP Office Visit/$10 Specialist Visit co -payment Rx $10/20/30 Prescription Plan mail order 20/40/60/for 90 day supply Mental Health and Substance Abuse Domestic Partner Employee Only $ 203 04 Employee + One (1) $406 09 Employee + Family $ 588 83 (HMO) - Alternate Plan Design Standard Option Hospitalization $250 per Admission $10 PCP Office Visit/$10 Specialist Visit co -payment Rx $10/20/30 Prescription Plan Mail Order $20/40/60 for a 90 -day supply Mental Health $250 per admission and Substance Abuse Domestic Partner Employee Only Employee + One (1) Employee + Family $ 198 25 $ 396 53 $ 574 98 ♦ Please refer to the respective Summary of Benefits ♦ Retirees Not included ♦ Employer Contribution 100% of single employee premium ♦ Required Minimum Participation 75% of all eligible employees ♦ New Hire Waiting Period 1st of the month following 30 days ♦ The proposal is based upon the data supplied in the specifications received by AvMed Health Plan, and is pending final approval by AvMed Health Plan The rates and final acceptance of each case are subject to change, should census data vary from that specified or provided Please check the HMO Options selected Current Benefits Plan Design X Alternate Plan Design If you find these conditions acceptable, please indicate by having signed in the space provided below and forward a copy back to our office for our records Corporate Approv \\C3 aQ`ta� Nca`t� Q�ar `. C CC\G�, `.,tNca�tcatcQ�� `�c k\°t��a VtC3 Cr°,CC FC ttda N 0\ \t �° ea�tr Dept e k t,°pti ,�C vt�i Stka\th©S' &�'` 9 Ne ea\tr ©fit p S°`,t,�e{ c\of\ �c N `trQ\ 1trQ`ap o Q\ap �� c © cx c \\ea b Q`a `r va� � N ,Q lea N�e�,ca arc t��`� �r tb a,�� ape ,ANN \t\�Q a1th4 as �pc apa Qvar ea e c da may° boy vo ar °C Q`°tQ�ar� tray VW �e��b e\trQ� rcare \mac c Ge��°�`v��, S e C o \�C AvMed is one of only six HMOs in Florida, and the only statewide HMO, to �ceive a five-star **-0(4r* * rating in member *: * * satisfaction from the *�*.��Ageacy for Health Care **,Administration. Five *attarf iidicate the b$t ran possible. Tile categ y of OeraIl Pla' Sat1faction hows the ,tirrcentag of memb�r.s,givin an z'� Nea Q�a'� �� ac of Op c�a°S �ca\ e lac ■ vt Ca s ove ra Q teeCCea ea�t�Ct Ga�eQ a��`nc �a`�pa a -an ratan of QQ aeptxt a` " b Ga e V;(` p `mac ca` °°�d aep ca ace �e� st 10(best healthplan � ep °pass�ble) on a s al Qt`�`daepta� � Groce� �`ot`aaa',�c GS°�t`�,F� vta\feat ea\trcaCe o{ ��cJa `pc teaN �t��ai tF�° of 1 to 10. v`tee. a\tbca`e 1,�c nt �Qr1QUrY td �O ‘)1\\e'Gate ��s to e z1P1� ct?a late \°�,Ja S °� ap Sct J,c` da \( C 'Ca\t\1 111 MP -2104 (,/00) AVME D� MEDICAL EXCELLENCE