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HomeMy Public PortalAboutAgreement 05-01-02 - 04-30-03AvMed Health Plan Group Medical and Hospital Service Contract AV G100 2001 MP 2153 (9/01) TABLE OF CONTENTS SERVICE AREAS 1 I GENERAL 1 II INTERPRETATION 1 III DEFINITIONS 2 IV ELIGIBILITY 7 V ENROLLMENT 9 VI EFFECTIVE DATE OF MEMBERSHIP 10 VII MONTHLY PAYMENTS AND COPAYMENTS 10 VIII CONVERSION 11 IX TERMINATION 13 X SCHEDULE OF BASIC BENEFITS 17 XI LIMITATIONS OF BASIC BENEFITS 24 XII EXCLUSIONS FROM BASIC BENEFITS 25 XIII COORDINATION OF BENEFITS 29 XIV REIMBURSEMENT 32 XV DISCLAIMER OF LIABILITY 32 XVI GRIEVANCE PROCEDURE 33 XVII MISCELLANEOUS 36 AV G100 2001 MP 2153 (9/01) AvMed CORPORATE OFFICE 9400 S DADELAND BLVD P O BOX 569004 MIAMI FL 33256-9004 SERVICE AREAS MIAMI 9400 South Dadeland Boulevard Post Office Box 569004 Miami, Flonda 33256-9004 (305) 671-5437 (800) 432-6676 FT LAUDERDALE 13450 W Sunnse Blvd Suite 370 Sunrise Florida 33323 2947 (954) 462-2520 (800) 368-9189 WEST PALM BEACH 3300 PGA Boulevard Suite 400 Palm Beach Gardens Florida 33410 (561) 622 0413 (800) 891-7768 JACKSONVILLE 1300 Riverplace Boulevard Suite 200 Jacksonville Florida 32207 (904) 858 1300 (800) 227-4184 GAINESVILLE 4300 N W 89th Boulevard Post Office Box 749 Gainesville, Florida 32606 0749 (352) 372-8400 (800) 346-0231 ORLANDO 541 South Orlando Avenue Suite 205 Maitland Florida 32751 (407) 539-0007 (800) 227-4848 TAMPA BAY 1511 North Westshore Boulevard, Suite 700 Tampa Florida 33607 (813) 281-5650 (800) 257-2273 TALLAHASSEE P 0 Box 15219 Tallahassee, Flonda 32317-5219 (850) 894-2004 (800) 677-8831 AVMED MEMBER SERVICES - ALL AREAS 1-800-88 AVMED (1-800-882-8633) I AV G100 2001 AvMed, INC D/B/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 corpdration d/b/a AvMed Health Plan (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 health care providers Said services are provided 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 1 AV G100 2001 III DEFINITIONS As used in this Contract, each of the following terms shall have the meaning indicated 3 01 "AvMed, Inc " otherwise known as "Health Plan" means a private not for profit Flonda corporation state licensed as a health maintenance organization under Chapter 641, Florida Statutes for the purpose of providing or arranging for prepaid health care services to its Members under the terms and conditions set forth in this Contract 3 02 "Contract" means this Group Medical and Hospital Service Contract AV -G100-2000 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 03 "Contract Year" means the period of twelve (12) consecutive months commencing on the effective date of this Contract 3 04 "Conversion Contract" means an individual Member or Subscriber Contract which shall be available to continue coverage (as provided for therein) of the Subscnber or the Dependent of the Subscnber 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 " 3 05 "Copayment" 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 covered Subscriber/Member is responsible for the payment of any Copayment charges directly to the provider of the health services at the time of service 3 06 "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 customanly provide for themselves, such as ostomy care measuring and recording urine and blood sugar levels, and administering insulin 3 07 "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 08 "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 2 AV G100 2001 3 09 "Durable Medical Equipment (DME), Orthotics, and/or Prosthetics" Coverage for DME Orthotics and Prosthetics is limited as outlined m Section(s) 10 18 01, 10 18 02 and 10 19 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 Health Care Financing Administration 3 10 "Emergency Medical Condition" means 3 1001 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) Senous impairment to bodily functions c) Serious dysfunction of any bodily organ or part 3 10 02 With respect to a pregnant woman 3 10 03 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 c) That there is evidence of the onset and persistence of uterine contractions or rupture of the membranes Examples of Emergency Medical Conditions include but are not limited to heart attack, stroke massive internal or external bleeding fractured limbs, or severe trauma 311 "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 11 01 3 11 02 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 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 3 AV G100 2001 be made by Health Plan and may be made retrospectively based upon all information known at the time patient was present for treatment 3 12 "Exclusion" means any provision of this Contract whereby coverage for a specific hazard or condition is entirely eliminated 3 13 "Full -Time Student" means one who is attending a recogmzed 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 14 "Group Health Insurance" (for purposes of Part XIII) 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 14 01 The terms "amount of insurance" and "insurance" include the benefits provided under a plan of self-insurance 3 14 02 The term "insurer" includes any person entity, or governmental unit providing a plan of self-insurance 3 14 03 The terms "policy" "insurance policy" "health insurance policy" and "Group Health Insurance policy" include plans of self insurance providing health insurance benefits 3 15 "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 provide or arrange for provision by the plan of prepaid health benefits and services covered by this Contract 3 16 "Health Professionals" means Physicians osteopaths podiatrists, chiropractors Physician assistants nurses social workers pharmacists optometnsts, 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 17 "Home Health Care Services" means services that are provided for a Member who is unable to receive medical care on an ambulatory outpatient basis and 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 3 18 "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 19 "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 "Plan Hospital " 4 AV G100 2001 3 20 "Hospital Services" (except as expressly limited or excluded by this Contract) means those services for registered bed patients which are 3 20 01 Generally and customarily provided by acute care general Hospitals within the Service Area, 3 20 02 Performed prescribed, or directed by Plan Providers and 3 20 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 21 "Hospitahst/Admittmg 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 22 "Limitation" means any provision other than an Exclusion which restricts coverage under this Contract 3 23 "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 24 "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 24 01 Consistent with the symptom, diagnosis and treatment of the Member's condition 3 24 02 The most appropriate level of supply and/or service for the diagnosis and treatment of the Member's condition 3 24 03 In accordance with standards of acceptable community practice 3 24 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 24 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 24 06 Prescribed directed authorized and/or rendered by a participating or authorized provider, except in the case of an emergency and 3 24 07 Not experimental or investigational 3 25 "Medical Office" means any outpatient facility or Physician's office in the Service Area utilized by a Participating Provider 5 AV G100 2001 3 26 "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 26 01 Generally and customarily provided in the Service Area 3 26 02 Performed, prescnbed or directed by Participating Providers, and 3 26 03 Medically Necessary (except for preventive services as stated herein) for the diagnosis and treatment of injury or illness 3 27 "Member" means any Subscriber or Dependent, as described in Part III Sections 3 08 and 3 35 of this Contract and shall at times be referred to as "Plan Member " 3 28 "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 and shall at times be referred to as "Non Plan Provider " 3 29 "Other Health Care Facility(ies)" means any licensed facility other than Ventilator Dependent Care Units and acute care Hospitals 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 3 30 "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 and shall at times be referred to as "Plan Provider " 3 31 "Physician" means any participating Physician licensed under Chapter 458 (physician), 459 (osteopath), 460 (chiropractor) or 461 (podiatrist) Florida Statutes, and shall at times be referred to as "Plan Physician" "Attending Physician" means the Participating Provider Physician primarily responsible for the care of a Member with respect to any particular injury or illness 3 32 "Primary Care Physician" means a Participating Provider Physician engaged in family practice, pediatrics, internal medicine obstetrics/gynecology, osteopathy, 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 33 "Service Area" means those counties in the State of Florida where AvMed has been approved to conduct business by the Florida Department of Insurance 3 34 "Specialty Health Care Professional" means a Health Professional other than the Member's chosen Pnmary Care Physician 3 35 "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 6 AV G100 2001 3 36 "Subscriber(ing) 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 37 "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 38 "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 for all inpatients who need continued care in an alternative setting (such as homecare or a skilled nursing facility) and for outpatients when deemed appropriate 3 39 "Ventilator Dependent Care Unit" means any facility which provides transitional care to 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 setting These units specifically do not include facilities known as skilled nursing facilities, rehabilitation facilities, or any other type of facility providing services similar to that of a skilled nursing facility or a rehabilitation facility Coverage is limited to 150 days per episode 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 and either resides in the Service Area or in a county contiguous to the Service Area In this instance the employee will also be required to complete a Waiver of Service Area form 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 reside in the Service Area (except for "f' below also see Section 6 03) and must be 4 02 01 the spouse of the Subscriber, a new spouse must be enrolled within thirty-one (31) days after marriage in order to be covered or 4 02 02 a child of the Subscriber or a child of a covered Dependent of the Subscriber provided that the following conditions apply 7 AV G100 2001 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 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 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 13) 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 court order provided the eligible Dependent resides within the Service Area 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 (31) days after the birth If timely notice is provided no additional premium will be charged for the additional coverage of the newborn during the thirty-one (31) day period following the birth of the child If timely notice is not provided the additional premium for the additional coverage of the newborn child will be charged from the child's date of birth If notice is not provided within 60 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 8 AV G100 2001 child has been entered into (prior to the birth of the child) from the moment of birth (as provided in Part X, Section 10 10) 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 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 (31) 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 (31) 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 lost coverage due to a loss of eligibility under the prior plan as a result of legal separation divorce death termination of 9 AV G100 2001 employment, reduction in the number of hours of employment, or termination of coverage due to the termination of employer contributions toward such coverage 5 03 02 Requests enrollment within thirty-one (31) 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 11) 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 m 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 Subscribers and/or their Dependents who become eligible to enroll after the open enrollment period of the Subscribing Group and who enroll as provided in Section 5 02 will become effective from the date of eligibility 6 03 If a Subscriber acquires an eligible Dependent the Dependent will be covered from the date of eligibility upon Health Plan's receipt of the required written notice and premium not later than thirty-one (31) days after the date the Dependent first became eligible (except in the case of a newborn child as described in Subsection 4 02 02 (i)) otherwise the Dependent may not be enrolled until the next open enrollment period of the Subscribing Group 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 03 are complied with VII MONTHLY PAYMENTS AND COPAYMENTS 7 01 On or before the first day of each month for which coverage is sought Subscriber 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 10 AV G100 2001 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 Subscriber 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 15) 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 Copayments Total annual Copayments are limited to a maximum of $1 500 00 for an individual or $3 000 00 for a couple or family It is the responsibility of the Subscnber/Member to retain receipts and to notify and document to the satisfaction of Health Plan when either of the Copayment limits has been reached 7 04 Member shall pay premiums applicable supplemental charges or Copayments 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 Subscriber 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 Subscriber 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 Subscriber Group or the Member for payment VIII CONVERSION 8 01 A Subscriber or covered Dependent whose coverage under the Subscriber Group Contract has been terminated for any reason including discontinuance of the Subscriber Group Contract in its 11 AV G100 2001 entirety or with respect to a covered class and who has been continuously covered under the Subscriber 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 04), unless there is a replacement of discontinued group coverage by similar group coverage within thirty-one (31) days 8 01 01 8 01 02 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 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 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 03 Dependents may not convert without the Subscriber except 8 01 04 8 01 05 a) In the event of the death of the Subscriber Dependents are permitted an automatic conversion privilege and must comply with Subsection 8 01 02 above b) A spouse whose coverage would terminate or a spouse and children whose coverage would otherwise terminate at the same time or a child with respect to himself by reason of ceasing to be a qualified family member may convert and must comply with Subsection 8 01 02 above c) A former spouse whose coverage would otherwise terminate because of annulment or dissolution of marriage may convert if the former spouse is dependent for financial support The former spouse must comply with Subsection 8 01 02 above and must provide written evidence of financial dependence upon request of Health Plan 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 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 Subscriber Group Contract and may in other respects as determined by Health Plan differ from this Group Contract 12 AV G100 2001 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 (31) days, 8 03 03 Fraud or material misrepresentation in applying for any benefits under this Contract, (See Subsection 9 01 05) 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 teijiunation of COBRA coverage, directly to AvMed Health Plan 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 the Service Area office 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 13 AV G100 2001 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 Eligibility - Subject to the conversion rights under Section 8 04 a) Upon a loss of the Subscriber's eligibility as defined in Part IV including but not limited to the Subscriber's permanent relocation outside Health Plan Service Area coverage shall automatically terminate on the last day of the month for which the monthly premium was paid unless otherwise agreed to by the parties 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 9 01 03 Failure to Make Premium Payment - Upon failure of the Subscriber 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 m 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 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 am (midnight) on Contract expiration date as described below 14 AV G100 2001 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 Copayments 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 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 senously 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 15 AV -G100 2001 9 02 01 Loss of eligibility 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 termination regarding any Subscriber and/or Dependent who becomes ineligible to participate in Health Plan Failure of the Subscriber 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 eligibility of Dependent - When a Dependent becomes ineligible for Dependent coverage due to age the Subscriber is required to notify Health Plan in wnting within thirty-one (31) days of the Dependent becoming ineligible 9 02 03 Contract Termination - In the event this Contract is terminated, the Subscribing Group agrees that it shall provide forty-five (45) days prior written notification of the date of such termination to its employee Subscnbers 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 Continuation Coverage Under certain provisions of the Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA) the Subscriber or his Dependent(s) may become eligible for continuation of coverage if one of the following qualifying events occurs 9 03 01 Death of the covered employee (Subscriber) 9 03 02 Termination of employment or reduction of work hours of a covered employee (except for employee's gross misconduct), 9 03 03 Divorce or legal separation of covered employee from spouse 9 03 04 Covered employee becomes entitled to benefits under Medicare, or 9 03 05 Dependent child of covered employee ceases to be a Dependent under Health Plan provisions The Subscribing Group shall immediately notify Health Plan if the event in Subsection 9 03 01 or 9 03 02 occurs The covered Subscriber is obligated to immediately notify his employer and Health Plan if the event in Subsection 9 03 03 9 03 04 or 9 03 05 occurs Continuation coverage will be administered in compliance with Federal laws and regulations currently in effect 9 04 Conversion After Continuation Coverage See Section 8 04 9 05 Extension of Benefits In the event this Contract is terminated for any reason except nonpayment of premium or as set forth in 9 05 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 37 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 16 AV G100 2001 9 05 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 earner 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 05 02 9 05 03 In the case of maternity coverage, when not covered by the succeeding earner, 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 Except as provided above no Subscnber 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 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 assures that the comprehensive prepaid health care services provided to its Subscribers will be rendered 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 untended to and shall not restrict any Utilization Management Program established by Health Plan All covered services and benefits shall be provided 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 Copayments which by reference is incorporated herein 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 17 AV G100 2001 authonzed 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 The ordenng 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 ) MEMBERS ARE RESPONSIBLE AND WILL BE LIABLE FOR COPAYMENTS WHICH MUST BE PAID TO HEALTH CARE PROVIDERS FOR CERTAIN SERVICES, AT THE TIME SERVICES ARE RENDERED, AS SET FORTH IN THE SCHEDULE OF COPAYMENTS 10 01 The names and addresses of Plan Providers and Hospitals are set forth in a separate booklet which by reference is made a part hereof The list of Plan Providers which may change from time to time, will be provided to all Subscribing Groups Notwithstanding the printed booklet the names and addresses of Plan 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 Within the Service Area the covered services and benefits listed in the Schedule of Basic Benefits are available only from Plan Providers and except for emergency services as provided in Section 10 11, 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 wntten referral or authorization from Health Plan 10 03 Each 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 must notify and receive approval by Health Plan prior to changing Primary Care Physicians The Member's change of Primary Care Physicians will become effective on the first day of the month after Member notifies Health Plan and cannot be changed more than once per month Members are entitled to receive the services of Specialty Health Care Professionals only when referred to them by their Primary Care Physician and approved by the Health Plan Health Professionals may from time to time cease their affiliation with Health Plan In such cases the Member will be required to select a new Primary Care Physician and/or will be referred to a new Specialty Health Care Professional 10 04 Any Member requiring medical Hospital or ambulance services for Emergencies (as described in Sections 3 10 and 3 11) either while temporanly outside the Service Area or within the Service Area but before they can reach a Plan Provider may receive the Emergency benefits as specified in Section 10 11 18 AV G100 2001 10 05 Hospital Care Inpatient All Hospital inpatient services received at Plan Hospitals for non mental illness or injury are provided when prescribed by Plan 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 11 with regard to inpatient emergency services 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 06) 10 06 Physician Care Inpatient All Medical Services rendered by Plan 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 Plan 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 Plan Physicians and other Health Professionals, as requested or directed by the Primary Care Physician are covered when provided at Medical Offices including surgical procedures routine hearing examinations and vision examinations for glasses for children under age 18 (such examinations may be provided by optometrists licensed pursuant to Chapter 463 Florida Statutes or by ophthalmologists licensed pursuant to Chapter 458 or 459 Florida Statutes) and consultation and treatment by Specialty Health Care Professionals 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 well baby care immunizations, sterilization (See Schedule of Copayments) periodic health assessment physical examinations and voluntary family planning services are provided 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 limited to diagnostic evaluation and crisis intervention only 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 Plan Physician and each visit requires a Copayment (See Schedule of Copayments) 10 08 Short -Term Rehabilitation (Physical Occupational or Speech Therapy) Short term therapy for acute conditions for which therapy applied for a consecutive two (2) month period can be expected to result in significant improvement Rehabilitation services for the acute phase of a chronic condition are covered only if in the judgment of Health Plan such services are 19 AV G100 2001 Medically Necessary and will result in significant improvement of a Member s condition through short-term therapy Coverage of outpatient short-term and rehabilitative services is limited to twenty-four (24) visits per condition whether services are provided in the office or in the home Long-term physical therapy, occupational therapy, speech therapy, rehabilitation or other treatment of chronic conditions is not covered 10 09 Obstetrical and Gynecological Care Covered obstetrical care benefits as specified herein are provided and include Hospital care, anesthesia diagnostic imaging, and laboratory services for conditions related to pregnancy The length of maternity stay in a Hospital will be that determined to be Medically Necessary in compliance with Florida law Newborn child care is covered as provided in Subsection 4 02 02 (i) and Section 10 10 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 10 Newborn Care All services applicable for children under this Contract shall be provided to 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 10 11 Emergency Services All necessary Physician and Hospital Services will be provided by Health Plan for emergency care (See Part III Sections 3 10 and 3 11) In the event that Hospital inpatient services are provided following an emergency admission Health Plan should be notified within 24 hours or as soon as the Member is lucid and able to notify Health Plan of the emergency admission Health Plan will pay the usual, reasonable, and customary charges to a non -Plan Physician or facility only for those services rendered before a Member's condition permits him to be reasonably able to travel to a Plan 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 12 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 provided without charge to the Member 10 13 Other Health Care Facihty(ies) All routine services of Other Health Care Facilities (see Section 3 29) including Physician visits physiotherapy diagnostic imaging and laboratory work are provided for a maximum of twenty (20) days per Contract 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 14 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 provided when Medically Necessary and ordered by a Plan Physician as part of the diagnosis and/or treatment of a covered illness or injury or as preventive health care services 10 15 Home Health Care Services With prior authorization by Health Plan Home Health Care Services (as defined in Section 3 17) are provided when ordered by and under the direction of the 20 AV G100 2001 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 16 Hospice Services With prior authorization by Health Plan services are available from a Health Plan affiliated Hospice organization for a Member whose Plan Physician has determined the Member's illness will result in a remaining life span of six (6) months or less 10 17 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 pnor notice to Health Plan, the Member may obtain the second medical opinion from any Plan or non -Plan Physician, chosen by the Member, who is within Health Plan's Service Area If a Plan Physician is chosen there is no cost to the Member other than any applicable Copayment If the Member chooses a non Plan 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 Plan Providers Once a second medical opinion has been rendered Health Plan shall review and determine the treatment obligations of Health Plan and that judgment is controlling Any treatment the Member obtains that is not authorized by Health Plan shall be at the Member's expense 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 18 Durable Medical Equipment and Orthotic Appliances 10 18 01 Durable Medical Equipment This Contract provides benefits when Medically Necessary for the purchase or rental of such Durable Medical Equipment 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 Durable Medical Equipment are hospital beds crutches wheelchairs, and infusion pumps Coverage of infusion pumps will apply toward the annual maximum Limitation but shall not be subject to the 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 The option of purchasing or renting the equipment will be determined based on cost Health Plan will require that the most economical option be selected Repair and/or replacement is not covered See Schedule of Copayments for any Copayments or Limitations See Part XII for Exclusions 21 AV G100 2001 10 18 02 Orthotic Appliances Coverage for orthotic appliances is limited to leg, arm back and neck custom made braces when related to a surgical procedure or when used in an attempt to avoid surgery and are 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 Copayments for any Copayments or Limitations See Part XII for Exclusions 10 19 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 cataract lenses is covered only if there is a change in prescnption which cannot be accommodated by e5 eglasses All other prosthetic devices are not covered See Schedule of Copayments for any Copayments or Limitations See Part XII for Exclusions 10 20 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 Plan 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 and customary charges for such covered services rendered by a Non Participating Provider will be made by Health Plan Charges for non Plan Hospital Services will be reimbursed in accordance with the covered benefits the Member would be entitled to receive in a Plan Hospital 10 21 Prescription Drug Benefits Allergy serums chemotherapy for cancer patients and covered medication administered by the Attending Physician are covered Coverage for insulin and other diabetic supplies is described in Section 10 24, below Other prescription drugs are a covered benefit only when the Subscribing Group Contract includes a supplemental Prescription Drug Rider 10 22 Ventilator Dependent Care Facilities With prior authorization by Health Plan Ventilator Dependent Care Facilities (See Section 3 39) are provided up to a total of 150 days per episode 10 23 Major Organ Transplants at a facility deemed appropriate and authorized by Health Plan, as well as associated immunosuppressant drugs are covered except those deemed expenmental (See Section 12 15) 10 24 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 Pnmary 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 1018 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 Prescnption Drug Rider In the event that a Subscribing Group does not purchase a 22 AV G100 2001 supplemental Prescnption Drug Rider, insulin, insulin syringes, lancets, and test strips are covered subject to a $12 Member Copayment per item for a 30 day supply 10 25 Mammograms are provided in accordance with Florida Statutes one baseline mammogram is available 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 10 26 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 27 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 24 and 3 38 No prior referral is required for these services 10 28 Mastectomy Surgery when performed for breast cancer 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 In addition coverage is provided for outpatient postsurgical follow-up care in keeping with prevailing medical standards This does not prohibit appropriate utilization review or case management by Health Plan Reconstructive surgery and prosthetic devices to re-establish symmetry between the two breasts following a mastectomy performed as a result of cancer while the Member was enrolled with Health Plan this coverage includes coverage for lymphedemas 10 29 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 30 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 23 AV G100 2001 XI LIMITATIONS OF BASIC BENEFITS The rights of Members and obligations of Plan 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 Plan Providers shall have no liability or obligation for delay or failure to provide or arrange for such services due to lack of available facilities or personnel if such lack is the result of any major disaster 11 02 In the event of circumstances not reasonably within the control of 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 If a Member is covered under more than one Contract with Health Plan he shall be covered under one but not both The refund of any premium payments made under such other Contract shall be limited to the smaller of the amount of overpayment or the amount overpaid during the ninety (90) days immediately preceding the date on which Health Plan received the notice of overpayment from the Subscriber Group or Member 11 05 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 06 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 07 Visits to Plan Physicians or dietitians/nutritionists for obesity control shall be limited to outpatient visits necessary to establish a program of obesity control and each visit requires a Copayment (See Schedule of Copayments and also Section 12 22) 11 08 Spinal manipulations will be provided only when Medically Necessary and prescribed by a Plan Physician or by self -referral to a Plan Physician 11 09 The total benefit for Ventilator Dependent Care Facilities is limited to 150 calendar days per episode 24 AV WOO 2001 11 10 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 emergency admission 11 11 Other Health Care Facility (ies) All routine services of Other Health Care Facilities (See Section 3 28) including Physician visits physiotherapy diagnostic imaging and laboratory work are provided for a maximum of twenty (20) days per Contract 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 12 Short -Term Rehabilitation Services (Physical, Occupational or Speech Therapy) shall be limited as explained in Section(s) 10 08 and 10 15 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) War or any act of war, whether declared or undeclared b) Insurrection or participation in a riot or rebellion c) Engagement in an illegal occupation d) 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, except reconstructive surgery necessary to correct and repair a functional disorder as a result of a disease injury, or congenital defect or initial implanted prosthesis and reconstructive surgery incident to a mastectomy for cancer of the breast 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 while an inpatient following birth), 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 Removal of warts, moles, skin tags, lipomas keloids scars and other benign lesions is not covered 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 Plan Participating Provider except for Emergency Services or not within the benefits covered by Health Plan 12 04 Dental Care as defined in 3 07 for any condition except 25 AV G100 2001 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 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- fabncated splints, and all bandages 12 08 Home monitoring devices and measuring devices, ventilator equipment inhalers 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 injectable drugs except chemotherapy for cancer patients, insulin and insulin syringes, allergy serums and any medications administered by the Attending Physician to treat the acute phase of an illness 12 11 Travel expenses including expenses for ambulance services to and from a Physician or Hospital except in accordance with Section 10 12 12 12 Treatment for chronic alcoholism and chronic drug addiction, except those services offered as a basic health service (See Section 11 06) 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 06) 12 15 Experimental and/or investigational procedures unless approved per Florida Administrative Code Section 59B-12 001 Experimental and/or investigational means for the purposes of this Contract a drug treatment device surgery or procedure that Health Plan in its sole discretion, determines a) cannot lawfully be marketed without the approval of the Food and Drug administration or other appropriate governmental agency, and such approval has not been granted at the time of use or proposed use, 26 AV G100 2001 b) that generally accepted or commonly and customarily recognized opinion among experts who regularly practice in the area of treatment of this particular disease or condition, is that usage should be substantially confined to research settings as set forth in the published authoritative literature, or c) that is being provided pursuant to a Phase I or Phase II clinical trial or as the experimental or research arm of a Phase III clinical trial 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 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) 12 19 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 20 Hearing examinations for Plan Members 18 years of age or older for the purpose of determining the need for hearing correction 12 21 Cosmetics, dietary supplements nutritional formulae, health or beauty aids 12 22 Gastric stapling, gastric bypass 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 23 Gender reassignment surgery as well as any service supply, or medical care associated with gender reassignment or gender identity disorders 12 24 All drugs, devices, and other forms of treatment related to a diagnosis of sexual dysfunction 12 25 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 antra -fallopian tube transfer or 27 AV G100 2001 cryogenic or other preservation techniques used in such or similar procedures Drugs for the treatment of infertility are not covered 12 26 Reversal of sterilization procedures 12 27 Immunizations and medications for the purpose of foreign travel or employment 12 28 Acupuncture biofeedback hypnotherapy massage therapy, sleep therapy sex therapy behavioral training cognitive therapy, and vocational rehabilitation 12 29 Foot supports are not covered These include shoe build-ups, shoe orthotics, shoe braces, and shoe supports Also excluded is routine foot care including trimming of corns, calluses, and nails 12 30 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 31 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 32 Emergency room services for non emergency purposes (See Sections 3 10 and 3 11) 12 33 Hospital Services that are associated with excluded surgery or Dental Care 12 34 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 10 and 3 11) 12 35 Physical speech, occupational, and all other therapies for chronic conditions Speech therapy for delayed or abnormal speech pathology is not covered 12 36 Alcohol or substance abuse rehabilitation vocational rehabilitation cardiac rehabilitation pulmonary rehabilitation, long term rehabilitation or any other rehabilitation program 12 37 Surgery for the reduction or augmentation of the size of the breasts except when Medically Necessary 12 38 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 12 39 Hospital Exclusion If a Member elects to receive Hospital care from a non -Plan attending Physician or a non -Plan Hospital then coverage is excluded for the entire episode of care, except when the admission was due to an Emergency or with pnor written authorization of Health Plan 28 AV G100 2001 12 40 Ventilator Dependent Care Facilities except for a maximum of 150 days per episode as provided in Part X (Schedule of Basic Benefits) Section 10 22 (Ventilator Dependent Care Facilities) 12 41 Private duty nursing services 12 42 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 over past or future Medical Services that are the subject of or related to that settlement 12 43 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 44 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 45 Services associated with autopsy or postmortem examinations including the autopsy 12 46 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 and similar equipment 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 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 29 AV G100 2001 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 deteiiiune the order of benefits 13 03 03 If two or more policies or plans cover a Dependent child of divorced or separated parents benefits for the child are determined in this order a) First, the policy or plan of the parent with custody of the child, b) Second the policy or plan of the spouse of the parent with custody of the child, and c) Third the policy or plan of the parent not having custody of the child However if the specific terms of a court order state that one of the parents is responsible for the health care expenses of the child and if the entity obliged to pay or provide the benefits of the policy or plan of that parent has actual knowledge of those terms, the benefits of that policy or plan are determined first This does not apply with respect to any claim determination period or plan or policy year during which any benefits are actually paid or provided before that entity has that actual knowledge 13 03 04 The benefits of a policy or plan which covers a person as an employee who is neither laid off nor retired or as that employee's Dependent are determined before those of a policy or plan which covers that person as a laid off or retired employee or as that employee's Dependent If the other policy or plan is not subject to this rule and if as a result the policies or plans do not agree on the order of benefits this Subsection shall not apply 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 30 AV G100 2001 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 c) 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 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 31 AV G100 2001 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 Plan 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 15 02 Neither Subscribers of Subscribing Group nor their Dependents shall be liable to Health Plan or Plan 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 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 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 Plan Physicians Plan 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 32 AV G100 2001 treatment or procedure recommended by the Plan Physician and if in the judgment of the Plan Physician, no professionally acceptable alternative exists or if an alternative treatment does exist but is not recommended by the Plan 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 Grievance Procedure Members are entitled to have any complaint regarding the services or benefits covered under this Contract reviewed by Health Plan which is obliged to resolve such complaint in an equitable fashion, according to Health Plan's Complaint/Gnevance Procedures then in effect The Primary Care Physician and/or the Medical Director shall participate in any Subscriber grievance where the appropriateness of treatment or quality of care is an issue The grievance must be submitted within one year from the date of occurrence of the action that initiated the grievance A grievance related to an adverse determination must be made within thirty (30) days of the receipt of the denial letter A Member with a complaint shall take the following steps a) Grievances related to complaints about the quality of service office waiting times Physician behavior adequacy of facilities or other Member concerns AvMed encourages the informal resolution of complaints (i e over the telephone) However if a Member complaint cannot be resolved in this manner, the Member may submit his or her grievance in writing to the AvMed Member Services Department AvMed shall acknowledge the written grievance and investigate the grievance A written response regarding the disposition of the complaint shall be provided within 60 days after receipt of the written grievance b) Grievance concerning an adverse determination An adverse determination means a coverage determination that an admission availability of care, continued stay or other health care service has been reviewed and based upon the information provided does not meet AvMed s requirements for medical necessity, appropriateness health care setting, level of care or effectiveness and coverage for the requested service is therefore denied reduced or terminated A grievance related to an adverse determination must be made within thirty (30) days of the receipt of the denial letter The Member may call AvMed's Member Services Department at 1-800-882-8633 (1-800 88AvMed) or submit the grievance in writing The request will be acknowledged in writing within five (5) working days A friend lawyer, or someone else may assist the Member with their grievance regarding an adverse determination AvMed will also assist For any questions or assistance call AvMed Member Services at 1 800-882-8633 AvMed is responsible for gathering all necessary medical information relevant to the request However, it may be helpful to provide additional information to clarify or support the request The request will be investigated including all aspects of clinical care involved 33 AV G100 2001 Persons who previously were not involved in the initial determination shall conduct an internal review A decision will be made within 30 working days Written notification of the decision will be provided to the Member If the initial request for reconsideration was verbal and the outcome of AvMed s internal review is unfavorable the Member may request a second -level review by calling or writing to AvMed Member Relations P O Box 749 Gainesville, Florida 32602-0749 1-800 346 0231 FAX 352-337-8794 If the initial request was in writing, and the outcome of AvMed s internal review is unfavorable, the request will be forwarded for a second -level review A panel will be appointed for the second -level review composed of a majority of representatives who were not involved in any previous decisions The second -level review will occur within 30 working days of receipt of the request For those whose initial request was in writing and automatically forwarded for a second level review, the resolution of the request will occur within 60 days after the initial receipt For requests regarding adverse determinations the majority of the persons reviewing the adverse determination will be providers who have appropriate expertise The Member has a right to appear before the panel in person or participate by conference call or other appropriate technology Written notification of the decision of the second -level review will be provided to the Member within five (5) working days of the completion of the review If the Member is not satisfied with AvMed s final decision he/she may contact the following State agency in writing within 365 days of receipt of the final decision letter This information will also be provided to the Member in the final decision letter Statewide Provider and Subscriber Assistance Panel (SPSAP) Agency for Health Care Administration HMO Section 2727 Mahan Drive Tallahassee Florida 32308 850 921 5458 c) Grievances involving denial of services excluded from the Member s benefit package, claims payment reimbursement of health care services, or other matters pertaining to the contractual relationship between a Member and AvMed A grievance related to denial of services excluded from the Member s benefit package claims payment, reimbursement, or other contractual matters must be made within thirty (30) days of the receipt of the denial letter The Member may call AvMed s Member Services Department at 1-800 882-8633 (1-800-88AvMed) or submit the grievance in writing The request will be acknowledged in writing within five (5) working days A friend lawyer, or someone else may assist the Member with the grievance requesting reconsideration AvMed will also assist For questions or assistance call AvMed Member Services at 1-800 882 8633 34 AV G100 2001 AvMed is responsible for gathering all necessary information relevant to the request However it may be helpful to provide additional information to clanfy or support the request The request will be investigated Persons who previously were not involved in the initial determination shall conduct an internal review A decision will be made within 30 working days Written notification of the decision will be provided to the Member If the initial request for reconsideration was verbal and the outcome of AvMed's internal review is unfavorable, the Member may request a second level review by calling or writing to AvMed Member Relations PO Box 749 Gainesville Florida 32602-0749 1 800 346-0231 FAX 352-337-8794 If the initial request was in writing and the outcome of AvMed's internal review is unfavorable the request will be forwarded for a second level review A panel will be appointed for the second level review composed of a majority of representatives who were not involved in any previous decisions The second -level review will occur within 30 working days of receipt of the request For those whose initial request was in writing and automatically forwarded for a second -level review the resolution of the request will occur within 60 days after the initial receipt The Member has a right to appear before the panel in person or participate by conference call or other appropnate technology Written notification of the decision of the second - level review will be provided to the Member within five (5) working days of the completion of the review If the Member is not satisfied with AvMed's final decision he/she may contact the following State agency in writing and within 365 days of receipt of the final decision letter This information will also be provided in the final decision letter sent to the Member Statewide Provider and Subscnber Assistance Panel (SPSAP) Agency for Health Care Administration HMO Section 2727 Mahan Drive Tallahassee, Florida 32308 850-921-5458 d) Grievances involving expedited review of an urgent adverse determination An urgent adverse determination is an adverse determination when the standard timeframe of the grievance procedure would seriously jeopardize the life or health of a Member or would jeopardize the Member s ability to regain maximum function A request for an urgent adverse determination may be submitted orally or in writing Requests for expedited determinations will be reviewed by the Medical Department to determine if the request meets the criteria for an urgent adverse determination If the request does not meet the criteria for an expedited review the request will be processed through the standard grievance procedure The Member will be informed in writing that the 35 AV G100 2001 request is not an urgent adverse determination and will be processed through the standard grievance procedures An appropriate clinical peer or peers will evaluate all expedited reviews The clinical peer or peers will not have been involved in the initial adverse determination A decision will be made and the Member notified as expeditiously as the Member s medical condition requires but in no event more than 72 hours after receipt of the request for expedited review If the expedited review is a concurrent review determination, services shall be continued without liability to the Member until the Member has been notified of the decision AvMed will provide written confirmation of its decision within two (2) working days after providing notification of the decision if the initial notification was not in writing AvMed will not provide an expedited review for a retrospective adverse determination If the Member is not satisfied with AvMed s final decision, he/she may contact the following State agency in writing and within 365 days of receipt of the final decision letter This information will also be provided to the Member in the final decision letter Statewide Provider and Subscriber Assistance Panel (SPSAP) Agency for Health Care Administration HMO Section 2727 Mahan Drive Tallahassee, Florida 32308 850-921-5458 XVII 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 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 36 AV G100 2001 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 nght 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 Physical Examination Although Health Plan does not impose a pre-existing condition Limitation on Members, Health Plan at its own expense shall have the right and opportunity to physically examine the Member when and as often as it may reasonably require during the pendency of a claim hereunder 17 06 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 07 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 08 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 09 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 Plan P 0 Box 749 Gainesville Flonda 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 17 10 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 11 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 37 AV G100 2001 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 12 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 13 Premium Tax 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 14 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 15 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 16 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 17 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 18 Statute of Limitations A claim which has not been timely filed with Health Plan shall be considered waived if, on the date notice of it is received by Health Plan, that claim would otherwise have been barred by any Florida Statute of Limitations if asserted in a civil court 17 19 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 17 20 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 is not the plan administrator or named fiduciary of the welfare plan as those terms are used in ERISA If a Member has questions about the welfare plan the Member should contact the Subscribing Group 38 AV G100 2001 AvMEDm HEALTH PLAN AVMED, INC d/b/a AVMED Health Plan Group Medical and Hospital Service Contract Group Master Application Contract Number (s) Subscriber Group Name x+515 Village of Key Biscayne Effective Date May 1, 2002 Group Contract This Group Contract provides the benefits checked below Benefit Designs HIGH OPTION ❑ $0 per Admission ❑ $100 per Admission ❑ $100 per Day Days 1-5 ❑ $250 per Admission STANDARD OPTION ($10 Specialist) 21 $0 per Admission ❑ $100 per Admission 0 $100 per Day Days 1-5 ❑ $250 per Admission STANDARD OPTION ($20 Specialist) ❑ $100 per Day Days 1-5 0 $250 per Admission BASIC OPTION ($15 Specialist) ❑ $0 per Admission 0 $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 Form AV- STD —OA -0 BASIC OPTION ($30 Specialist) ❑ $250 per Day Days 1 5 0 $250 per Admission BASIC OPTION ($35 Specialist) C $250 per Day Days 1-5 C $250 per Admission C $300 per Day Days 1-5 If selected the following optional and supplemental coverage is also provided as described in the endorsements/riders to this contract ❑ Prescription Coverage Form AV- G100—RX-3T-10/20/30—R-01 El Vision Coverage Form AV VISION —R-99 ❑ Dental Coverage (ADP) Form AV - (All Dental Plans are administered by American Dental Plan) Elective Termination of Pregnancy Form AV- G100—ETP—R-97 E Mental Health Form AV-G100—MH—OIP—R-99 C Group declines mental health benefits (Section 627 668 Florida Statutes) 1 Substance Abuse Form AV -SA -98 ❑ Group declines substance abuse benefits (Section 627 669 Florida Statutes) ❑ Durable Medical Equipment Other E Domestic Partner k injectable Drug Rider x Durable Medical $2,000 AV G100 APP 01 MP 2027 (9 01) Form AV - Form AV- DPartner—R-98 Form AV-G100—IDB—R-01 Form Av—G100—DME-2000—E-01 ELIGIBILITY A full-time employee of the Subscribing Group must be employed a minimum of 35 hours per week to become eligible for coverage under this Contract A full-time 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 30 consecutive days after the date of hire other TERMINATION Termination of employee coverage under this Contract shall become effective ❑ on the date the employee s employment is terminated Ei on the last date of the month in which the employees 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 Subscnbing 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 Plan and the Subscribing Group This Contract shall remain in effect for a period of twelve (12) months from the effective date of May 1, 2002 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 May 1, 2002 day of each month thereafter Subsequent payments are due on the first 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 Subscriber Only Subscriber plus Spouse Subscriber plus One Dependent (No Spouse) Subscriber plus Two or More Dependents Subscriber plus Spouse and One or More Dependents C Other $ 223 72 $ 447 44 $ 447 44 $ 648 79 $ 648 79 $ The provisions contained in the Schedule of Copayments 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 May 1, 2002 Subscribing Group Village of Key Biscayne AVMED Inc d/b/a AVM s!i Health By By Signature Signature Evis Clavareza Name Name Account Service Manager Title Title Date Date )1 — (0 d')-- AvMEDTm HEALTH PLAN PRESCRIPTION DRUG BENEFITS POLICY ENDORSEMENT $10/20/30 COPAYMENT DEFINITIONS Brand name" drug means a Prescription Drug which is manufactured and sold under a name or trademark by a drug manufacturer or a drug which is identified as a Brand name drug by AvMed Brand Additional Charge means the additional charge which must be paid if you or your physician choose a Brand name drug when a Generic is available The charge is the difference between the cost of the Brand name drug and the Generic drug This additional charge must be paid in addition to the applicable Brand name copayment (Preferred or Non Preferred) Genenc" drug means a drug which is equivalent to a Brand name drug or is identified as a Genenc drug by AvMed "Participating Pharmacy" means a pharmacy (either Retail or Mail Order) which 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 list of Prescription Drugs which are preferred by AvMed for dispensing to its members Drugs on the Preferred Drug List are called Preferred Drugs " drugs not appearing on the list are called "Non Preferred Drugs "Prescription Drug" means a medication which has been approved by the Food and Drug Administration and which can only be dispensed pursuant to a Prescnption according to state and federal law Quantities are limited to a manufacturers package size per copayment Pre -Authorization means the process of obtaining approval for certain Prescription Drugs (prior to dispensing) according to AvMed s guidelines The approval must be obtained from AvMed by the prescribing Physician The list of Prescnption Drugs requiring Pre-Authonzation is subject to periodic review and modification by AvMed HOW DOES RETAIL PRESCRIPTION COVERAGE WORK? To obtain your prescription take to or have your physician call an AvMed Pharmacy Network Provider Present your prescnption along with your AvMed membership card Pay the following copayment (as well as the Brand Additional Charge if you or your physician choose a Brand name product when a Generic is available) Generic Drugs Preferred Brand Name Drugs Non Preferred Brand Name Drugs $10 00 $ 20 00 $ 30 00 ORDERING YOUR PRESCRIPTIONS THROUGH THE MAIL 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 prescnption 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 (as well as the Brand Additional Charge if you or your physician choose a Brand name product when a Generic is available) Generic Drugs Preferred Brand Name Drugs Non Preferred Brand Name Drugs $ 20 00 $ 40 00 $ 60 00 WHAT COPAYMENT DO YOU PAY- GENERIC PREFERRED BRAND OR NON PREFERRED BRAND? You will pay the Generic copayment for Generic medications You will pay the applicable Brand name copayment for Preferred Brand name medication and Non Preferred Brand name medications If you or your physician request or require a Brand drug when a Generic drug is available you will be responsible for paying the cost difference between the Brand and Generic plus the Brand drug copayment AV G100 RX 3T 10/20/30 E 01 MP 2044 (9/01) 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 cntena 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 pharmacy will dispense the quantity sufficient to treat an acute phase of illness or within the drug manufacturer s recommended dosages but not more than a 30 -day supply per copayment If your prescription is for a drug on the Preferred Drug List or is for a drug that is not within the classes of Preferred Drugs no prior authorization is needed However prior authonzation is needed for drugs that are not on the Preferred Drug List and for drugs with quantity limitations once the limit is reached Your mail-order prescription drug coverage includes up to a 90 -day supply of a routine 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 Over the counter medications Drugs or medications which do not require a prescription or when a non-prescription equivalent is available Medical supplies including therapeutic devices dressings appliances and support garments Oral injectable implantable contraceptive medications 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 Blood biologicals and immunizations Hypodermic needles syringes injectable and self -injectable medications except insulin and insulin syringes glucagon epinephnne and low molecular weight hepann Injectable drug products (except chemotherapy for cancer patients insulin for diabetic patients allergy serums and any medications administered by the attending physician to treat an acute phase of an illness) - Investigational and experimental drugs (except as required by Florida statute) Cosmetic products including 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 Transdermal scopolamine for non -business related purposes - Compounded prescriptions except pediatric preparations Medications for non -business related travel Agreed to and Accepted by the parties hereto effective for the contract term of May 1, 2002 to April 30, 2003 , Subscribing Group Village of Key Biscayne AvMed Inc d/b/a AvMed Health Plan 1 By By Signature Name Title Date Account Service Manager 4ut1e Date Li t I 0 02- AvMEDThA HEALTH PLAN OUTPATIENT VISION BENEFITS POLICY ENDORCEMENT As of the effective date, the following benefits are added for an additional premium The Plan provides one routine vision examination per contract year with no age limitation subject to a member copayment of $10 per visit No pre -authorization or referral is necessary, but services must be provided by a Plan Physician The Plan provides one (1) pair eyeglasses per contract year subject to a member copayment of $10 The eyeglasses must be non -treated standard single or bifocal lenses only, with standard frame from the available selection (designer frames are not covered) Agreed to and Accepted by the parties hereto, effective for the contract term of May 1, 2002 to April 30, 2003 Subscribing Group Village of Key AvMed Inc d/b/a AvMed Health Plan Biscayne By By Signature Signatur Evls Clavareza Name Name Account Service Manager Title Title Date Date " 4-1---/0-0-2__ AV VISION E 99 MP 2042 (5/99) AvMED HEALTH PLAN Elective Termination of Pregnancy If selected, the following optional coverage is hereby added The AvMed Health Plan Group Medical and Hospital Service Contract is amended to state Elective termination of pregnancy will be a covered benefit if the services and treatment are provided by an AvMed participating provider in an AvMed participating facility There shall be a physician copayment of $100 00 in addition to the applicable facility copayment AGREED TO AND ACCEPTED by the parties hereto, effective for the contract term of May 1, 2002 to April 30, 2003 20 Subscribing Group Village of Key Biscayne AvMed, Inc d/b/a AvMed Health Plan By By Signature Signature Evis Clavareza Name Name Date Account Service Manager Title Title AV G 100-ETP-97 MP -1640 (6/97) Date 4/- /0 02_ A. AvMnr INPATIENT HEALTH PLAN MENTAL HEALTH BENEFITS POLICY ENDORSEMENT 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 Agreed to and Accepted by the parties hereto effective for the contract term of May 1, 2002 to April 30, 2003 Subscribing Group Vallage -of Key Biscayne By Signature AvMed Inc d/b/a AvMed Health Plan By Sig ture Evis Clavareza Name Name Account Service Manager Title Title Date Date `/ /a c AVG100MHOIPE99 MP 2028 (5/99) TM AvMED HEALTH PLA N SUBSTANCE ABUSE BENEFITS POLICY ENDORSEMENT As of the effective date, the Outpatient Substance Benefits have been added for an additional premium The Inpatient Substance Abuse Benefits remain as stated in the Contract INPATIENT Inpatient treatment of alcohol and drug abuse is not provided except for acute detoxification OUTPATIENT • An mtensive 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 Agreed to and Accepted by the parties hereto, effective for the contract term of May 1, 2002 to April 30, 2003 Subscribing Group Village of Key Biscayne By Signature AvMed, Inc d/b/a AvMed Health Plan By AS -L40 Signatu Name Evls Clavareza. Date Name Title Account Service Representative Title AV -G100 -SA -E-98 Date U /U O Date AV G100 IDB E 01 MP 3062 (9/01) AvMnr HEALTH PLAN INJECTABLE DRUG BENEFITS POLICY ENDORSEMENT $75 COPAYMENT DEFINITIONS Injectable drug means a Prescription Drug that has been approved by the Food and Drug Administration (FDA) for subcutaneous intramuscular intradermal intravenous injection or infusion or administration under the skin WHAT IS COVERED'? - Your injectable drug coverage extends to many injectable drugs approved by the FDA for injection or infusion These drugs must be prescribed by an AvMed physician and dispensed by an AvMed Pharmacy Network Provider or Home Health Agency AvMed reserves the right to make changes in coverage cntena for covered products and related services Coverage cntena 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 - Pre -authorization is required for most injectable drugs - Your injectable drug prescription coverage includes the quantity sufficient to treat the acute phase of an illness or established by the manufacturers dosing guidelines but not more than a 30 day supply per copayment of $75 or actual cost whichever is less - If you request a brand drug when a generic equivalent is available you will be responsible for paying the cost difference between the brand and generic drugs in addition to the applicable copayment Discuss your prescription with your AvMed Physician or Pharmacist to be sure that you know what the prescription is for how to administer it correctly what results are expected and in what timeframe EXCLUSIONS AND LIMITATIONS All exclusions and limitations listed on your Prescription Drug coverage remain in force unless specifically addressed by this rider Agreed to and Accepted by the parties hereto, effective for the contract term of May 1, 2002 to April 30, 2003 , Subscribing Group Village Of Key Biscayne AvMed, Inc d/b/a AvMed H h Pla By By P4'h ni—. Signature Signature Evis Clavareza Name Name Account Service Manager Title Title Date � — /O Ca Z AvMED-m HEALTH PLAN POLICY ENDORSEMENT 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 unmarred 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 manage, • 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 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, and • will provide documentation that will be satisfactory to the Employer as evidence of a Domestic Partner relationship, • meets the dependent eligibility requirements of the Employer's health benefits plan Agreed to and Accepted by the parties hereto, effective for the contract term of May 1, 2002 to April 30., 2003 Subscribing Group Village of Icy Biscayne Signature allte eAcio I By Name ‘-Detovi-ty�f•�,� n � ( rye c- f' Title AvMed, Inc d/b/a AvMed Health Plan By Evis Clavareza Name Account Service Manager Title Date Date 4-10 U2_. AV DPartner E 98 MP 1994 (1/99) AvMmM HEALTH PLAN Durable Medical Equipment (DME) Policy Endorsement 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 m 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 Agreed to and Accepted by the parties hereto, effective for the contract term of May 1., 2002 to April 30, 2003 , Subscnbmg Group Village of Key AvMed, Inc d/b/a AvMed Health Plan Biscayne By By Signature Signatui< Evis Clavareza Name Name Title Date AV-G100-DME-2000-E-01 MP -2148 (9/01) Account Service Manager Title Date '/- /0 ©2._ Standard Option 0 Admit SCHEDULE OF COPAYMENTS COST TO MEMBER 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 a DIAGNOSTIC IMAGING LABORATORY OR OTHER DIAGNOSTIC SERVICES ■ MINOR SURGICAL PROCEDURES ■ VISION & HEARING EXAMINATIONS FOR CHILDREN UNDER 18 ■ NUTRITIONIST $10 PER VISIT AVMED SPECIALIST S a OFFICE VISITS $10 PER VISIT SERVICES HOSPITAL Inpatient care at participating hospitals includes a 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 a LABORATORY & DIAGNOSTIC IMAGING a REQUIRED SPECIAL DIETS ■ RADIATION & INHALATION THERAPIES NO CHARGE SURGERY a OUTPATIENT NO CHARGE EMERGENCY SERVICES An emergency is the sudden and unexpected onset of a condition requiring immediate medical or surgical care ✓ 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 a 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 a SKIN TESTING $50 PER COURSE OF TESTING AMBULANCE a WHEN PRE AUTHORIZED OR IN THE CASE OF EMERGENCY NO CHAR( F PHYSICAL SPEECH a SHORT TERM TREATMENT FOR ACUTE CONDITION FOR WHICH & 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 REHABILITATION CENTERS AVMED $25 PER DAY HOME HEALTH CARE m PER OCCURRENCE NO CHARGE DURABLE MEDICAL EQUIPMENT INCLUDES EQUIPMENT & ORTHOTIC 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 n ARTIFICIAL LIMBS • ARTIFICIAL JOINTS M. 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 AvMEDm HEALTH PLAN PRESCRIPTION DRUG BENEFITS CERTIFICATE RIDER $10/20/30 COPAYMENT DEFINITIONS Brand name drug means a Prescription Drug which is manufactured and sold under a name or trademark by a drug manufacturer or a drug which is identified as a Brand name drug by AvMed Brand Additional Charge means the additional charge which must be paid if you or your physician choose a Brand name drug when a Genenc is available The charge is the difference between the cost of the Brand name drug and the Generic drug This additional charge must be paid in addition to the applicable Brand name copayment (Preferred or Non Preferred) Generic drug means a drug which is equivalent to a Brand name drug or is identified as a Generic drug by AvMed Participating Pharmacy' means a pharmacy (either Retail or Mail Order) which 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 list of Prescription Drugs which are preferred by AvMed for dispensing to its members Drugs on the Preferred Drug List are called Preferred Drugs drugs not appearing on the list are called Non Preferred Drugs Prescription Drug means a medication which has been approved by the Food and Drug Administration and which can only be dispensed pursuant to a Prescription according to state and federal law Quantities are limited to a manufacturers package size per copayment Pre Authorization means the process of obtaining approval for certain Prescription Drugs (prior to dispensing) according to AvMed s guidelines The approval must be obtained from AvMed by the prescribing Physician The list of Prescription Drugs requiring Pre Authonzation is subject to periodic review and modification by AvMed HOW DOES RETAIL PRESCRIPTION COVERAGE WORK? To obtain your prescription take to or have your physician call an AvMed Pharmacy Network Provider Present your prescription along with your AvMed membership card Pay the following copayment (as well as the Brand Additional Charge if you or your physician choose a Brand name product when a Generic is available) Generic Drugs Preferred Brand Name Drugs Non -Preferred Brand Name Drugs $10 00 $20 00 $30 00 ORDERING YOUR PRESCRIPTIONS THROUGH THE MAIL Mail service is a benefit option for maintenance medications needed for chronic or long term health conditions Its best to get an initial prescription filled at your retail pharmacy Ask your physician for an additional prescnption 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 (as well as the Brand Additional Charge if you or your physician choose a Brand name product when a Generic is available) Generic Drugs Preferred Brand Name Drugs Non Preferred Brand Name Drugs $20 00 $40 00 $60 00 WHAT COPAYMENT DO YOU PAY GENERIC PREFERRED BRAND OR NON PREFERRED BRAND'S You will pay the Genenc copayment for Generic medications You will pay the applicable Brand name copayment for Preferred Brand name medication and Non Preferred Brand name medications If you or your physician request or require a Brand drug when a Generic drug is available you will be responsible for paying the cost difference between the Brand and Generic plus the Brand drug copayment AV G100 RX 3T 10/20/30 R 01 MP 2045 (9 01) 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 pharmacy will dispense the quantity sufficient to treat an acute phase of illness or within the drug manufacturer s recommended dosages but not more than a 30 -day supply per copayment If your prescnption is for a drug on the Preferred Drug List or is for a drug that is not within the classes of Preferred Drugs no prior authorization is needed However prior authorization is needed for drugs that are not on the Preferred Drug List and for drugs with quantity limitations once the limit is reached - Your mail order prescription drug coverage includes up to a 90 -day supply of a routine 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 Over the counter medications Drugs or medications which do not require a prescription or when a non-prescription equivalent is available Medical supplies including therapeutic devices dressings appliances and support garments Oral injectable implantable contraceptive medications 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 Blood biologicals and immunizations Hypodermic needles syringes injectable and self -injectable medications except insulin and insulin syringes glucagon epinephrine and low molecular weight heparin Injectable drug products (except chemotherapy for cancer patients insulin for diabetic patients allergy serums and any medications administered by the attending physician to treat an acute phase of an illness) Investigational and experimental drugs (except as required by Florida statute) Cosmetic products including 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 Transdermal scopolamine for non business related purposes Compounded prescriptions except pediatric preparations Medications for non -business related travel II F N. I I II P I k As of the effective date, the following benefits are added for an additional premium • The plan provides one routine vision examination per contract year with no age limitation subject to a member copayment of $10 per visit No pre - authorization or referral is necessary, but services must be provided by a Plan Physician • The plan provides one (1) pair eyeglasses per contract year subject to a member copayment of $10 The eyeglasses must be non -treated standard single or bifocal lenses only, with standard frame from the available selection (designer frames are not covered) AV VISION R 99 MP 2043 (5/99) AvMnr Ht 1 L i ti PLAN a 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 (6/97) AVMED HE Al I H P 1 4N CERTIFICATE RIDER INPATIENT MENTAL 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 G 100-M H O I P R 99 MP -2029 (5/99) AvMEV HEALTH PLAN SUBSTANCE ABUSE BENEFITS CERTIFICATE RIDER As of the effective date the Outpatient 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 98 MP 1527 (7/98) AvMrn H F A L T H 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 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 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 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, and • will provide documentation that will be satisfactory to the Employer as evidence of a Domestic Partner relationship, • meets the dependent eligibility requirements of the Employer s health benefits plan AV DPartner R 98 MP 1995 (1/99) AvMEu HEALTH PLAN INJECTABLE DRUG BENEFITS CERTIFICATE RIDER $75 COPAYMENT DEFINITIONS Injectable drug means a Prescription Drug that has been approved by the Food and Drug Administration (FDA) for subcutaneous intramuscular intradermal intravenous injection or infusion or administration under the skin WHAT IS COVERED? Your injectable drug coverage extends to many injectable drugs approved by the FDA for injection or infusion These drugs must be prescribed by an AvMed physician and dispensed by an AvMed Pharmacy Network Provider or Home Health Agency AvMed reserves the right to make changes in coverage criteria for covered products and related services Coverage cntena 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 Pre authorization is required for most injectable drugs Your injectable drug prescription coverage includes the quantity sufficient to treat the acute phase of an illness or established by the manufacturers dosing guidelines but not more than a 30 day supply per copayment of $75 or actual cost whichever is less If you request a brand drug when a generic equivalent is available you will be responsible for paying the cost difference between the brand and generic drugs in addition to the applicable copayment Discuss your prescription with your AvMed Physician or Pharmacist to be sure that you know what the prescription is for how to administer it correctly what results are expected and in what timeframe EXCLUSIONS AND LIMITATIONS All exclusions and limitations listed on your Prescription Drug coverage remain in force unless specifically addressed by this rider AV G100 1DB R 01 MP 3063 (9/01) AvMEDThi HEALTH PLAN Durable Medical Equipment (DME) Certificate Rider 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 AV -G 100-DME-2000-R-01 MP -2149 (9/01)