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Home My Public Portal AboutAgreement 05-01-03 - 04-30-04AvMed Health Plan Group Medical and Hospital Service Contract AV -G100 2001 MP -2153 (9/01) AvMed CORPORATE OFFICE 9400 S DADELAND BLVD P 0 BOX 569004 MIAMI, FL 33156-9004 SERVICE AREAS MIAMI 9400 South Dadeland Boulevard Post Office Box 569004 Miami, Florida 33156-9004 (305) 671-5437 (800) 432-6676 FT LAUDERDALE 13450 W Sunrise Boulevard Suite 370 Sunrise, Florida 33323-2947 (954) 462-2520 (800) 368-9189 WEST PALM BEACH Concourse Towers I 2000 Palm Beach Lakes Boulevard Suite 302 West Palm Beach, Florida 35409 (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/ SOUTHWEST FLORIDA 1511 North Westshore Boulevard Suite 700 Tampa, Florida 33607 (813) 281-5650 (800) 257-2273 AVMED MEMBER SERVICES - ALL AREAS 1-800-88 AVMED (1-800-882-8633) 1 AV -G100 2002 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 corporation, d/b/a AvMed Health Plan, (hereinafter referred to as "Health Plan"), and Village of Key B i s c a yn e (hereinafter referred to as "Subscribing Group") agree as follows I GENERAL The Subscribing Group engages Health Plan to arrange for the provision of Medical Services or benefits which are Medically Necessary for the diagnosis and treatment of Members of the Subscribing Group through a network of contracted independent Physicians and Hospitals and other independent health care providers, who are not agents or employees of the Health Plan (see Section 15 04) The Health Plan, in so arranging for the delivery of Medical Services or benefits, does not directly provide these Medical Services or benefits Health Plan arranges for the provision of said services in accordance with the covenants and conditions contained in this Contract Health Plan shall rely upon the statements of the Subscriber in his application in providing coverage and benefits hereunder This Contract is not mtended 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 A yr 1 nn 9nn2 III DEFINITIONS As used in this Contract, each of the following terms shall have the meaning indicated 3 01 "Adverse Benefit Determination" means a denial, reduction, or termination of, or a failure to provide or make payment, in whole or in part, for a benefit, including any such denial, reduction, termination, or failure to provide or make payment that is based on a determination of a Member's eligibility to participate in the Health Plan, a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) of, a benefit resulting from the application of any Utilization Management Program, as well as a failure to cover an item or service for which benefits are otherwise provided because it is determined to be Experimental and/or Investigational or not Medically Necessary 3 02 "AvMed, Inc" otherwise known as "Health Plan" means a pnvate, not for profit Flonda corporation, state licensed as a health maintenance organization under Chapter 641, Florida Statutes for the purpose of arranging for prepaid health care services to its Members under the terms and conditions set forth in this Contract 3 03 "Claim" means a request for benefits under the Health Plan made by a Member in accordance with the Health Plan's procedures for filing benefit claims, including Pre -Service Claims and Post -Service Claims 3 04 "Claimant" means a Member or a Member's authorized representative acting on behalf of the Member The Health Plan may establish procedures for determining whether an individual is authorized to act on behalf of the Member If the Claim is an Urgent Care Claim, a Health Care Professional, with knowledge of the Member's medical condition, shall be permitted to act as the Member's authorized representative 3 05 "Concurrent Care" means an ongoing course of treatment to be provided over a period of time or number of treatments that AvMed previously approved 3 06 "Contract" means this Group Medical and Hospital Service Contract which may at times be referred to as "Group Contract" and all applications, rate letters, face sheets, nders, amendments, addenda, exhibits, supplemental agreements, and schedules which are or may be incorporated in this Contract from time to time 3 07 "Contract Year" means the period of twelve (12) consecutive months commencing on the effective date of this Contract 3 08 "Conversion Contract" means an individual Member or Subscriber Contract which shall be available to continue coverage (as provided for therein) of the Subscriber or the Dependent of the Subscriber upon termination of the Subscribing Group Contract as provided in Part VIII of this Contract, and shall at times be referred to as the "Individual" or "Conversion Contract " 3 09 "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 tune of service 2 AV -G100 2002 3 10 "Custodial Care" means services and supplies that are furnished mainly to train or assist in the activities of daily living, such as bathing, feeding, dressing, walking, and taking oral medicines "Custodial Care" also means services and supplies that can be safely and adequately provided by persons other than licensed health care professionals, such as dressing changes and catheter care or that ambulatory patients customarily provide for themselves, such as ostomy care, measuring and recording urine and blood sugar levels, and administering insulin 3 11 "Dental Care" means dental x-rays, examinations and treatment of the teeth or structures directly supporting the teeth that are customarily provided by dentists, mcludmg orthodontics, reconstructive jaw surgery, casts, splints, and services for dental malocclusion 3 12 "Dependent" means any Member of a Subscriber's family who meets all applicable requirements of Part IV and is enrolled hereunder and for whom the prepayment required by Part VII has actually been received by Health Plan 3 13 "Durable Medical Equipment (DME), Orthotics, and/or Prosthetics" Coverage for DME, Orthotics and Prosthetics is limited as outlined in Section(s) 10 20 and 10 21 subject to specific Limitations and Exclusions as listed in Part XII The determination of whether a covered item will be paid under the DME, Orthotics or Prosthetics benefit will be based upon its classification as defined by the Centers for Medicare and Medicaid Services 3 14 "Emergency Medical Condition" means 3 14 01 A medical condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in any of the following a) Serious jeopardy to the health of a patient, including a pregnant woman or fetus b) Serious impairment to bodily functions c) Serious dysfunction of any bodily organ or part 3 14 02 With respect to a pregnant woman a) That there is inadequate time to effect safe transfer to another Hospital prior to delivery, b) That a transfer may pose a threat to the health and safety of the patient or fetus, or 3 14 03 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. 315 "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 AV -G100 2002 3 15 01 3 15 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 be made by Health Plan and may be made retrospectively based upon all information known at the time patient was present for treatment 3 16 "Exclusion" means any provision of this Contract whereby coverage for a specific hazard or condition is entirely eliminated 3 17 "Full -Time Student" means one who is attending a recognized and/or accredited college, university, vocational, or secondary school and is carrying sufficient credits to qualify as a Full - Time Student in accordance with the requirements of the school (See Subsection 4 02 02(0) 3 18 "Group Health Insurance" (for purposes of Part )CIII) means that form of health insurance covering groups of persons under a master Group Health Insurance pokey issued to any one of the groups listed in Sections 627 552 (employee groups), 627 553 (debtor groups), 627 554 (labor union and association groups), and 627 5565 (additional groups), Florida Statutes 3 18 01 The terms "amount of insurance" and "insurance" include the benefits provided under a plan of self-insurance 3 18 02 The term "insurer" includes any person, entity, or governmental unit providing a plan of self-insurance 3 18 03 The terms "policy," "insurance policy," "health insurance policy," and "Group Health Insurance policy" include plans of self-insurance providing health insurance benefits 3 19 "Health Care Professional" means a Physician or other Health Care Professional licensed, accredited, or certified to perform specified health services consistent with State law 3 20 "Health Plan" means AvMed, Inc , a not for profit Florida corporation, d/b/a AvMed Health Plan, which has been certified as a health maintenance organization by the Department of Insurance of the State of Florida to arrange for provision by the plan of prepaid health benefits and services covered by this Contract 3 21 "Health Professionals" means Physicians, osteopaths podiatrists, chiropractors, Physician assistants, nurses, social workers, pharmacists, optometnsts, clinical psychologists, nutntiomsts, 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 4 AV -G100 2002 3 22 "Home Health Care Services" means services that are provided for a Member who is homebound and 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 23 "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 24 "Hospital" means any general acute care facility which is hcensed by the state and with which Health Plan has contracted or established arrangements for inpatient Hospital Services and/or emergency services, and shall at times be referred to as "Participating Hospital " 3 25 "Hospital Services" (except as expressly limited or excluded by this Contract) means those services for registered bed patients which are 3 25 01 Generally and customarily provided by acute care general Hospitals within the Service Area, 3 25 02 Performed, prescribed, or directed by Participating Providers, and 3 25 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 26 "Hospitalist/Admitting Panelist" means a Physician who specializes in treating inpatients and who may coordinate a Member's health care when the Member has been admitted for a Medically Necessary procedure or treatment at a Hospital 3 27 "Limitation" means any provision other than an Exclusion which restricts coverage under this Contract 3 28 "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 29 "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 29 01 Consistent with the symptom, diagnosis, and treatment of the Member's condition, 3 29 02 The most appropriate level of supply and/or service for the diagnosis and treatment of the Member's condition, 3 29 03 In accordance with standards of acceptable community practice, 5 AV -G100 2002 3 29 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 29 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 29 06 Prescribed, directed, authorized, and/or rendered by a participating or authorized provider, except m the case of an emergency, and 3 29 07 Not experimental or investigational 3 30 "Medical Office" means any outpatient facility or Physician's office in the Service Area utilized by a Participating Provider 3 31 "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 31 01 Generally and customarily provided in the Service Area, 3 31 02 Performed, prescribed, or directed by Participating Providers, and 3 31 03 Medically Necessary (except for preventive services as stated herein) for the diagnosis and treatment of injury or illness 3 32 "Member" means any Subscriber or Dependent, as described in Part III, Sections 3 12 and 3 43 of this Contract 3 33 "Non -Participating Provider" means any Health Professional or group of Health Professionals dr 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 herem 3 34 "Other Health Care Facility(ies)" means any licensed facility, other than acute care Hospitals and those facilities providmg services to ventilator dependent patients, providing inpatient services such as skilled nursing care or rehabilitative services for which Health Plan has contracted or established arrangements for providmg these services to Members Coverage is limited to 20 days per Contract Year 3 35 "Participating Provider" means any Health Professional or group of Health Professionals or Hospital, Medical Office, or Other Health Care Facility with whom Health Plan has made arrangements or contracted to render the professional health services set forth herein 3 36 "Participating Physician" means any participating Physician licensed under Chapter 458 (physician), 459 (osteopath), 460 (chiropractor) or 461 (podiatrist), Florida Statutes "Attending Physician" means the Participating Provider Physician primarily responsible for the care of a Member with respect to any particular injury or illness 3 37 "Post -Service Claim" means any Claim for benefits under the Health Plan that is not a Pre - Service Claim 6 AV -6100 2002 3 38 "Pre -Service Claim" means any Claim for benefits under the Health Plan with respect to which, in whole or in part, a Member must obtain authorization from AvMed in advance of such services being provided to or received by the Member 3 39 "Primary Care Physician" means a Participating Provider Physician engaged in family practice, pediatrics, internal medicine, obstetncs/gynecology, osteopathy, or any specialty Physician from time to time designated by Health Plan as "Primary Care Physician" in Health Plan's current hst of Physicians and Hospitals 3 40 "Relevant Document" means any documentation that 3 40 01 Was relied upon in making the benefit determmation, 3 40 02 Was submitted, considered or generated in the course of making the benefit determination, without regard to whether it was relied upon in making the determination, 3 40 03 Demonstrates compliance with the administrative process, and 3 40 04 Constitutes a statement of policy or guidance with respect to the Health Plan concemmg the Adverse Benefit Determination for the Claimant's diagnosis, without regard to whether such advice or statement was relied upon m making the Adverse Benefit Determination 3 41 "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 42 "Specialty Health Care Professional" means a Health Professional other than the Member's chosen Primary Care Physician 3 43 "Subscriber" means a person who meets all applicable requirements of Part IV, enrolls in Health Plan, and for whom the premium prepayment required by Part VII has actually been received by Health Plan 3 44 "Subscribing Group" means an employer who negotiates and agrees to contract for the health services and benefits provided herein for its eligible employees, and shall at times be referred to herem as "Employer" or "Contract Holder " 3 45 "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, trammg, or experience, and for which the Member or Subscriber is under the regular care of a Physician 3 46 "Urgent Care Claim" means any Claim for medical care or treatment that could seriously jeopardize the Member's life or health or the Member's ability to regain maximum function or, in the opmion of a Physician with knowledge of the Member's medical condition, would subject the Member to severe pain that cannot be adequately managed without the care or treatment requested Generally, the determination of whether a Claim is an Urgent Care Claim shall be made by an individual acting on behalf of the Health Plan applying the judgment of a prudent layperson who possesses an average knowledge of health and medicine However, if a Physician with knowledge of the Member's medical condition determines that the Claim is an Urgent Care Claim, it shall be deemed as such 7 AV -G100 2002 3 47 "Urgent Care/Immediate Care" means medical screening, examination, and evaluation received in an Urgent Care Center or Immediate Care Center or rendered in your pnmary care physician's office after-hours and the covered services for those conditions which, although not life -threatening, could result in serious injury or disability if left untreated 3 48 "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-authonzation 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 49 "Ventilator Dependent Care Unit" means care received in any facility which provides services to ventilator dependent patients other than acute Hospital care, including all types of facilities known as sub -acute care units, ventilator dependent units, alternative care units, sub -acute care centers, and all other like facilities whether maintained in a free standing facility or maintained in a Hospital or skilled nursing facility setting Coverage is limited to 100 days lifetime maximum N 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 from a worksite located within the Service Area as set forth m the Master Application for this Contract and either resides m the Service Area or in a county contiguous to the Service Area Except as provided for emergency services, the covered services and benefits are available only from Participating Providers 4 0102 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 or in a county contiguous to the Service Area (except for "f' below, also see Section 6 02) 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 8 AV -G100 2002 4 02 02 a child of the Subscriber, or a child of a covered Dependent of the Subscriber, provided that the following conditions apply a) The child is the natural child or stepchild of the Subscriber, a legally adopted child in the custody of the Subscriber from the time of placement in the home (written evidence of adoption must be furnished to Health Plan upon request), a child for whom the Subscriber is permanent legal guardian, or a newborn child of a covered Dependent of the Subscriber (such coverage terminates 18 months after the birth of the newborn child), b) The child resides with the Subscriber (except for "f and "h" below), c) The child is under the age of 19 (except for "f" and "g" below or Section 4 04 below), d) The child is principally dependent upon the Subscriber for maintenance and support and is not regularly employed by one or more employers for a total of thirty (30) hours or more per week, e) The child is not married, f) The child is age 19 or over but under the age of 23, or other limiting age as specified by the parties in a fully executed addendum to this Contract, and is enrolled as a Full -Time Student (See Section 3 17) at a college, university, vocational, or secondary school Subscriber is responsible for notifying Health Plan when full-time attendance commences or terminates, and coverage shall commence or terminate upon such notification Ceasing of coverage will be retroactively applied if Health Plan is not notified Subscriber agrees to provide documentation of Full -Tune Student status upon request of Health Plan, The child is age 19 or over and is wholly dependent on the Subscnber due to mental retardation or physical handicap (See Section 4 04) h) In the event an eligible Dependent child does not reside with the Subscriber, coverage will be extended where the Subscriber is obligated to provide medical care by Qualified Medical Support Order provided the eligible Dependent resides within the Service Area You (or your beneficiaries) may obtain, without charge, copies of the Plan's procedures governmg qualified medical support orders and a sample qualified medical support order by contacting the Plan Administrator i) In the case of a newborn child, Health Plan should be notified in writing prior to the scheduled delivery date of the Subscriber's intention to enroll the newborn child, but such notice shall not be later than thirty-one (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 g) AV -G100 2002 9 All services applicable for covered Dependent children under this Contract shall be provided to an enrolled newborn child of the Subscriber or to the enrolled newborn child of a covered Dependent of the Subscriber or to the newborn adopted child of the Subscriber provided that a written agreement to adopt such child has been entered into (prior to the birth of the child) from the moment of birth (as provided in Part X, Section 10 11) In the case of the newborn adopted child, however, coverage shall not be effective if the child is not ultimately placed in the Subscriber's residence m 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 0105, 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 tune 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, withm 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 10 AV -G100 2002 5 03 01 Demonstrates that he or his Dependent has experienced one of the following status change events, including a) mamage, b) birth, adoption or placement for adoption, c) legal separation, divorce or annulment, d) change in legal custody or legal guardianship, e) death, f) relocation into or out of a Service Area, g) termmation/commencement of employment, h) reduction in the number of hours of employment, i) commencement of or return from leave of absence, j) change in employment status, k) change in worksite, 1) strike or lockout, in) termination of coverage due to the termination of employer contributions toward such coverage, and 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 10) 5 05 This Contract, at the sole option of Health Plan, will not be accepted if at time of initial offering to Subscribing Group or following re -enrollment the total enrollment does not result in a predetermined minimum enrollment as established by Health Plan The required minimum group enrollment is included in the rate letter submitted to Subscnbmg Group 11 AV -G100 2002 VI EFFECTIVE DATE OF MEMBERSHIP Subject to the payment of applicable monthly membership charges set forth in Part VII and to the provisions of this Contract, coverage under this Contract shall become effective on the following dates 6 01 Eligible Subscribers and Dependents who enroll during the open enrollment period will be covered Members as of the effective date of this Contract or subsequent anniversary thereof 6 02 If a Subscriber acquires an eligible Dependent through birth, adoption, placement for adoption or marriage, such Dependent shall be treated as immediately covered under the Plan if, within 31 days (or as otherwise provided for newborns in Part IV) of acquiring the new dependent, you complete and submit an enrollment form on behalf of such dependent If received by the Plan within the 31 -clay time period (or 60 -days as permitted for newborns), the enrollment for such Dependent shall become effective on the date of the birth, adoption or placement for adoption, or for marriage, the first day of the month following the date you enroll your new spouse During this period, you and your eligible spouse may also enroll for medical coverage under the Plan, if not already covered However, if an enrollment is not received by the Plan within the required timeframe, you and your eligible Dependents will be required to wait until the next open enrollment period to apply for coverage 6 03 If you or your Dependents originally declined medical coverage under the Plan due to other health coverage, and that coverage is subsequently terminated as a result of either a loss of eligibility for such coverage or the termination of any employer contributions for such coverage, you and your Dependents will be eligible to enroll in the Plan To enroll, you must properly complete an enrollment form within 31 days of the loss of such other coverage or termination of employer contributions The effective date of any coverage provided under the Plan will be the first day of the month following the date you enroll If you fail to enroll within 31 days after the loss of other coverage, you must wait until the next open enrollment period to apply for coverage 6 04 Coverage for the newborn child of the Subscriber or the newborn child of the Subscriber's covered Dependent is effective at birth if Subsection 4 02 02(i) and Section 6 02 are complied with VII MONTHLY PAYMENTS AND CO PAYMENTS 7 01 On or before the first day of each month for which coverage is sought, Subscribing Group or its designated agent shall remit to Health Plan, on behalf of each Subscriber and his Dependents, the monthly premium based on the rate letter and Master Application Only Members for whom the stipulated payment is actually received by Health Plan shall be entitled to the health services covered under this Contract and then only for the period for which such payment is applicable Failure of the Subscribing Group to pay premiums for the group by the first of the month and not later than the end of the grace period (as provided m 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 nn a fully executed addendum to this Contract An additional charge will apply to all late premium payments (See Section 17 14) 12 AV -G100 2002 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 as described in your Schedule of Copayments The copayment limits apply to copayments made for all core benefits contained in this Contract, and do not apply to services provided under the Prescnptioii Drug, Mental Health, Substance Abuse, Vision and other supplemental riders 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 Subscribing Group for any Member after the date on which that Member's eligibility ceased or the Member was terminated shall be limited to the total excess premiums paid up to a maximum of sixty (60) days from the date of such ineligibility or termination, provided there are no claims incurred subsequent to the effective date of termination No retroactive terminations of Members will be made beyond 60 days from notification of the termmating 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 termmation (due to the Subscribing Group's nonpayment of premiums or failure to timely notify the Plan of Member ineligibility) At the discretion of Health Plan based on the facts available to Health Plan at the time, Health Plan may pursue either the Subscnbmg Group or the Member for payment VIII CONVERSION 8 01 A Subscriber or covered Dependent whose coverage under the Subscribing Group Contract has been terminated for any reason, including discontinuance of the Subscribing Group Contract in its entirety or with respect to a covered class, and who has been continuously covered under the Subscribing Group Contract, and under any group health maintenance Contract providing similar benefits which it replaces, for at least three (3) months immediately prior to termination, shall be entitled, subject to the exceptions contained herein, to have issued to him or her a Conversion Contract (See Section 3 08), unless there is a replacement of discontinued group coverage by similar group coverage within thirty-one (31) days 13 AV -6100 2002 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 0102 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 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 0102 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 0102 above and must provide wntten 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 8 01 05 A new Conversion Contract is established upon application and payment of premium on the day following the Member's termination from group coverage (due to ineligibility under the Group Contract) and continues through the end of the calendar year The Contract Year, upon renewal, shall be the calendar year 8 02 Individual Conversion Contracts may not include supplemental benefits, notwithstanding the supplemental benefits included under this Subscnbmg Group Contract, and may in other respects, as determined by Health Plan, differ from this Group Contract 8 03 The conversion privilege will not apply to a Subscriber or covered Dependent if termination of his coverage under this Contract occurred for any of the following reasons 8 03 01 Failure to pay any required premium or contribution unless such nonpayment of premium was due to acts of an employer or person other than the individual, 8 03 02 Replacement of any discontmued group coverage by similar group coverage within thirty-one (31) days, 14 AV -G100 2002 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 0105 8 04 Conversion After Continuation Coverage When continuation coverage as provided under the provisions of the Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA) expires, the Subscriber or covered Dependent may be eligible for conversion coverage and may apply by completing an application for an individual Conversion Contract, subject to the conditions described in Part VIII, above The eligible Subscriber or Dependent must send a completed application and the applicable premium payment, postmarked not later than sixty-three (63) days after the termination of COBRA coverage, directly to AvMed Health 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 AvMed Member Services It is the responsibility of the Subscribing Group to notify Subscriber of Subscriber's nghts 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 termmation, unless otherwise provided herein This Contract shall continue in effect for one year from the effective date hereof and may be renewed from year to year thereafter, subject to the following termination provisions All rights to benefits under this Contract shall cease at 12 00 a m (midnight) on the effective date of termination 9 01 Reasons for Termination 9 01 01 Loss of Eligibility - Subject to the conversion rights under Section 8 04 a) Upon a loss of the Subscriber's or Dependent's eligibility as defined in Part IV, including but not limited to the permanent relocation outside Health Plan Service Area, coverage shall automatically terminate on the last day of the month for which the monthly premium was paid and during which the Subscriber and/or Dependent was eligible for coverage 15 AV -6100 2002 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 m Part IV 9 01 02 9 01 03 9 01 04 Failure to Make Premium Payment - Upon failure of the Subscribing Group to make payment of the monthly premiums provided in Part VII within ten (10) days following the due date specified herein, benefits hereunder shall terminate, for all Subscribers and any Dependents for whom such payment has not been received, at 12 00 a m (midnight), on the last day of the month for which the monthly premium was paid Upon failure of the Subscriber to make payment of any premium contributions or applicable supplemental charges required by Section 704 of this Contract, coverage shall automatically terminate for the Subscriber and all Dependents on the tenth day after written notice from Health Plan AvMed Health Plan, regarding cancellation or non -renewal of this coverage, may retroactively cancel the policy to the date for which the employer's premiums have been paid when AvMed provides notice of cancellation or non -renewal to the Subscribing Group prior to 45 days after the date premium was due AvMed will include a reason for the Contract termination in its written notification to the Subscribing Group The Subscribing Group will forward such notification to all Subscribers when AvMed has notified the Subscribing Group of the cancellation or non -renewal, and AvMed is deemed to have complied with its notification requirements by providing said notice to the Subscribing Group Termination of Group Contract by Subscribing Group - Group may terminate this Group Contract on the anniversary date by giving wntten 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 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 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 AV -G100 2002 16 9 01 05 d) There is no longer any enrollee in connection with the plan who lives, resides, or works m 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 Termination of Membership for Cause - Health Plan may terminate any Member immediately upon written notice for the following reasons which lead to a loss of eligibility of the Member a) fraud, material misrepresentation, or omission in applying for membership, benefits, or coverage under this Contract However, relative to a misstatement in the Application, after two (2) years from the issue date, only fraudulent misstatements in the Application may be used to void the policy or deny any claim for a loss occurred or disability starting after the two (2) year period, b) misuse of Health Plan's Membership Card furnished to the Member, c) furnishing to Health Plan incorrect or incomplete information for the purpose of obtaining Membership, coverage, or benefits under this Contract, d) behavior which is disruptive, unruly, abusive, or uncooperative to the extent that the Member's continuing coverage under this Contract seriously impairs the Health Plan's abihty to administer this Contract or to arrange for the delivery of health care services to the Member or other Members after Health Plan has attempted to resolve the Member's problem At the effective date of such termination, premium payments received by Health Plan on account of such termination shall be refunded on a pro rata basis, and Health Plan shall have no further liability or responsibility for the Member(s) under this Contract 9 02 Notification Requirements 9 02 01 Loss of eligibility of Subscriber - It is the responsibility of Subscnbmg Group to notify Health Plan in writing within thirty-one (31) days from the effective date of termmation regarding any Subscriber and/or Dependent who becomes ineligible to participate in Health Plan Failure of the Subscribing Group to provide timely written notice as described above may lead to retroactive termination of the Subscriber and/or Dependent The effective date for such retroactive termination will be the last day of the month for which premium was paid and during which the Subscriber and/or Dependent was eligible for coverage (See Section 7 06) 9 02 02 Loss of eligibility of Dependent - When a Dependent becomes ineligible for Dependent coverage, the Subscriber is required to notify Health Plan in wntmg withm thirty-one (31) days of the Dependent becoming ineligible 9 02 03 Contract Termination - In the event this Contract is terminated, the Subscnbmg Group agrees that it shall provide forty-five (45) days pnor written notification of the date of such termination to its employee Subscnbers who are covered under this Contract 17 AV -G100 2002 In no event will any retroactive termination of a Member be made beyond 60 days from notification of the terminating event 9 03 Certificates of Coverage If your coverage under the Plan ends, you will automatically receive a Certificate of Group Health Plan Coverage You may take this certificate to another health care plan to receive credit for your coverage under the Plan. You will only need to do this if the other health care plan has a pre-existing condition limit You can request a Certificate of Group Health Plan Coverage anytime during the 24 -month period after the date your coverage under the Plan has ended 9 04 Continuation Coverage under COBRA Under =tam provisions of the Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA), the Subscriber or his Dependent(s) may elect continued coverage under the Plan, if coverage is lost due to a qualifying event 9 04 01 Eligibility You or your covered Dependents will become eligible for continuation coverage under the Consolidated Omnibus Reconciliation Act of 1986, as amended (COBRA) after any of the following qualifying events result in the loss of plan coverage a) loss of benefits due to a reduction in your hours of employment, b) termination of your employment, including retirement but excluding termination for gross misconduct, c) termmation of employment following an FMLA leave, in which case the qualifying event will occur on the earlier of the date you indicated you were not returning to work or the last day of the FMLA leave, or d) you or a dependent first become entitled to Medicare or covered under another group health plan prior to your loss of coverage due to termination or employment or reduction in hours 9 04 02 In addition, your enrolled dependents will become eligible for COBRA continuation coverage after any of the following qualifying events occur to cause a loss of plan coverage a) your death, b) your divorce or legal separation, c) you first become entitled to Medicare after your loss of coverage due to termination of employment or reduction m hours, or d) your dependent child no longer qualifies as a dependent under the plan A child who is born to or placed for adoption with a covered former employee during the continuation coverage period has the same continuation coverage rights as a dependent child described above AV -6100 2002 18 9 04 03 Notification If a qualifying event other than divorce, legal separation, loss of dependent status or entitlement to Medicare occurs, the plan administrator will be notified of the qualifying event by your employer and will send you an election form To continue plan coverage, you must return the election form within 60 days from the later of the date you receive the form, or the date your coverage ends due to a qualifying event If divorce, legal separation, loss of dependent status or entitlement to Medicare under the plan occurs, you or your covered dependent must notify the plan admuustrator that a qualifying event has occurred This notification must be received by the plan administrator within 60 days after the later of the date of such event, or the date you or your eligible dependent would lose coverage on account of such event Failure to promptly notify the plan administrator of these events will result in loss of the right to continue coverage for you and your dependents After receiving this notice, the plan administrator will send you an election form within 14 days If you or your dependents wish to elect continuation coverage, the election form must be returned to the plan administrator within 60 days from the later of the date you receive the form, or the date your coverage ends due to the qualifying event 9 04 04 Cost If you elect to continue coverage, you must pay the entire cost of coverage (the employer's contribution and the active employee portion of the contribution), plus a 2% administrative fee for the duration of COBRA continuation coverage If you or your dependent is Social Security disabled (Social Security disability status must occur as defined by Title II or Title XVI of the Social Security Act), you may elect to continue coverage for the disabled person only or for some or all of COBRA eligible family members for up to 29 months if your employment is terminated or your hours are reduced You must pay 102% of the cost of coverage for the first 18 months of COBRA continuation coverage and 150% of the cost of coverage for the 19th through the 29th months of coverage The Social Secunty disability date must occur within the first 60 days of loss of coverage due to your termination of employment or reduction in hours For COBRA coverage to remam in effect, payment must be received by the plan administrator by the first day of the month for which the premium is due (Your first payment is due no later than 45 days after your election to continue coverage, and it must cover the period of time back to the first day of your COBRA continuation coverage ) 9 04 05 Duration COBRA Continuation Coverage can be extended for a) 18 months if coverage ended due to a reduction in your work hours or termination of your employment and you or one of your covered dependent(s) is not Social Security disabled within 60 days of the date you lose coverage due to termination of employment or reduction in hours the Medicare entitled person may elect up to 18 months of COBRA If you are that Medicare entitled person, your dependents may elect COBRA for the longer of 36 months from your prior Medicare entitlement date, or 18 months from the date of your termination or reduction in hours 19 AV -G100 2002 b) 36 months for your dependents, if your dependents lose eligibility for medical coverage due to your death, your divorce or legal separation, your entitlement to Medicare after your termination or reduction in hours, or your dependent child ceasing to qualify as a dependent under the plan c) 29 months if you lose coverage due to a termination of employment or reduction in hours and you or a dependent is disabled, as defined by Title II or Title XVI of the Social Security Act, within 60 days of the ongmal qualifying event In this case, you may continue coverage for an additional I1 months after the original 18 month period either for the disabled person only or for one or all of your covered family members To be eligible for extended coverage due to Social Security disability, you must notify the plan administrator of the disability before the end of the initial 18 months of COBRA continuation coverage and within 60 days following the date you or a covered dependent is determined to be disabled by the Social Security Administration. If the disabled individual should no longer be considered to be disabled by the Social Security Administration, you must notify the plan administrator within 30 days following the end of the disability Coverage that has exceeded the original 18 -month continuation period will end when the individual is no longer Social Security disabled If more than one qualifying event occurs, no more than 36 months total of COBRA continuation coverage will be available The COBRA beneficiary must experience the second qualifying event during the first 18 months of COBRA continuation, and must provide notice to the plan administrator within the required time period COBRA continuation coverage will end sooner if the plan terminates and the employer does not provide replacement medical coverage, or if a person covered under COBRA a) first becomes covered under another group health plan after the loss of coverage due to your termination or reduction in hours, unless the new group coverage is limited due to a pre-existing condition exclusion, this plan will be primary for the pre-existing condition and secondary for all other eligible health care expenses, provided contributions for COBRA coverage continue to be paid Coverage may only continue for the remainder of the original COBRA period, b) fails to make required contributions when due, c) first becomes entitled to Medicare benefits after the initial COBRA qualifying event, or d) is extending the 18 month coverage period because of disability and is no longer disabled as defined by the Social Security Act 9 05 Continuation Coverage During Leaves of Absence 9 05 01 Family and Medical Leaves of Absence (FMLA) Under the Family and Medical Leave Act of 1993, you may be entitled to up to a total of 12 weeks of unpaid, job - protected leave during each calendar year for the following a) the birth of your child, to care for your newborn child, or for placement of a child in your home for adoption or foster care, b) to care for your spouse, child or parent with a serious health condition, or c) for your own serious health condition 20 AV -G100 2002 If your FMLA leave is a paid leave, your pay will be reduced by your before -tax contributions as usual for the coverage level in effect on the date your FMLA leave begms If your FMLA leave is unpaid, you will be required to pay your contributions directly to the employer until you return to active pay status If you notify your employer that you are terminating employment during your FMLA leave, your coverage will end on the date of your notification If you do not return to work on your expected FMLA return date, and you do not notify your employer of your intent either to terminate your employment or to extend the period of leave, your Plan coverage will end on the date you were expected to return You may not change your Plan elections during your FMLA leave unless an open enrollment occurs, or unless you are on a paid FMLA leave and you have a change in status event or a special enrollment event under HIPAA 9 05 02 Military Leaves of Absence If you are absent from work due to mihtary service, you may elect to continue coverage under the Plan (including coverage for enrolled dependents) for up to 18 months from the first day of absence (or, if earlier, until the day after the date you are required to apply for or return to active employment with your employer under the Uniformed Services Employment and Reemployment Rights Act of 1994 ("USERRA")) Your contributions for continued coverage will be the same as for similarly situated active participants in the Plan Whether or not you continue coverage during military service, you may reinstate coverage under the Plan option you elected on your return to employment under USERRA The reinstatement will be without any waiting period otherwise required under the Plan, except to the extent that you had not fully completed any required waiting period prior to the start of the military service 9 06 Conversion After Continuation Coverage See Section 8 04 9 07 Extension of Benefits In the event this Contract is terminated for any reason, except nonpayment of premium or as set forth in 9 07 03, such termination shall be without prejudice to any continuous losses to a Subscriber or Member which commenced while this Contract was in force, but any extension of benefits beyond the date of termination shall be predicated upon the continuous Total Disability as defined in Section 3 45, of the Subscriber or Member and shall be limited to payment for the treatment of a specific accident or illness incurred while the Subscriber was a Member 9 07 01 The extension of benefits covered under this Contract shall be limited to the occurrence of the earliest of the following events a) The expiration of 12 months, b) Such time as the Member is no longer totally disabled, c) A succeeding 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 07 02 In the case of maternity coverage, when not covered by the succeeding carrier, a reasonable extension of this Contract's benefits will be provided to cover maternity expenses for a covered pregnancy that commenced while the policy was in effect The extension shall be for the period of that pregnancy only and shall not be based upon Total Disability 21 AV -G100 2002 9 07 03 Except as provided above, no Subscriber is entitled to an extension of benefits if the termmation 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 is committed to arranging for comprehensive prepaid health care services rendered to its Subscribers through Health Plan's network of contracted independent Physicians and Hospitals and other independent health care providers, under reasonable standards of quality health care The professional judgment of a Physician licensed under Chapters 458 (physician), 459 (osteopath), 460 (chiropractor) or 461 (podiatrist), Florida Statutes, concerning the proper course of treatment of a Subscriber shall not be subject to modification by Health Plan or its Board of Directors, Officers, or Administrators However, this subsection is not intended to and shall not restrict any Utilization Management Program established by Health Plan Only services and benefits m 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, are covered by Health Plan It is the Member's responsibility when seeking benefits under this Contract to identify himself as a Health Plan Member and to assure that the services received by the Member are being rendered by Participating Providers Members should remember that services that are provided or received without having been authorized in advance by AvMed Health Plan's Medical Department, or if the service is beyond the scope of practice authorized for that Provider under state law, except in instances of Emergency Services and Care, are not covered unless such services otherwise have been expressly authorized under the terms of this Contract Except for Emergency Services and Care, all services must be received from Participating Providers on referral from AvMed If a Member does not follow the access rules, he risks having services and supplies received not covered under this Contract In such a circumstance, the Member will be responsible for reimbursing AvMed for the reasonable cost of the services and supplies received Also, Members must understand that services will not be covered if they are not, in AvMed Health Plan's opinion, Medically Necessary Any and all decisions made by Health Plan in administering the provisions of this Contract, including without limitation, the provisions of Part X (Schedule of Basic Benefits), Part XI (Limitations of Basic Benefits), and Part XII (Exclusions from Basic Benefits), are made only to determine whether payment for any benefits will be made by Health Plan Any and all decisions that pertain to the medical need for, or desirability of the provision or non -provision of Medical Services or benefits, including without limitation, the most appropriate level of such Medical Services or benefits, must be made solely by the Member and his Physician, in accordance with the normal patient/physician relationship for purposes of determining what is in the best interest of the Member The Health plan does not have the right of control over the medical decisions made by the Member's Physician or health care providers The ordering of a service by a Physician, whether Participating or Non -Participating, does not in itself make such service Medically Necessary Subscribing Group and Member acknowledge that it is possible that a Member and his Physician may determine that such services or supplies are appropriate even though such services or supplies are not covered and will not be paid for or arranged by AvMed Health Plan 22 AV -G100 2002 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 Participating Providers and Hospitals are set forth in a separate booklet which, by reference, is made a part hereof The list of Participating Providers, which may change from time to time, will be provided to all Subscribing Groups The list of Participating Providers may also be accessed from the AvMed website at www AvMed org Notwithstanding the punted booklet, the names and addresses of Participating Providers on file with Health Plan at any given time shall constitute the official and controlling list of Participating Providers 10 02 Within the Service Area, Members are entitled to receive the covered services and benefits only as herein specified, appropriately prescribed or directed -by Participating Physicians The covered services and benefits listed in the Schedule of Basic Benefits are available only from Participating Providers within the Service Area and, except for emergency services as provided in Section 10 12, Health Plan shall have no liability or obligation whatsoever on account of services or benefits sought or received by any Member from any nonparticipating Physician, health professional, Hospital or Other Health Care Facility, or other person, institution or organization, unless prior arrangements have been made for the Member and confirmed by written referral or authorization from Health Plan 10 03 Each Member shall select one Primary Care Physician upon enrollment If 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 The services of Specialty Health Care Professionals are covered only when Members are 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 14 and 3 15), either while temporarily outside the Service Area or within the Service Area but before they can reach a Participating Provider, may receive the Emergency benefits as specified in Section 10 12 10 05 Hospital Care Inpatient All Hospital inpatient services received at Participating Hospitals for non -mental illness or injury are provided when prescribed by Participating Physicians and pre - authorized by Health Plan Inpatient Services include semi -private room and board, birthing rooms, newborn nursery care, nursing care, meals and special diets when Medically Necessary, use of operating room and related facilities, intensive care unit and services, diagnostic imaging, laboratory and other diagnostic tests, drugs and medications, biologicals, anesthesia and oxygen supplies, physical therapy, radiation therapy, respiratory therapy, and administration of blood or blood plasma See Section 10 12 with regard to inpatient admission following emergency services Health Plan pre -authorization is required for inpatient Hospital Services for substance abuse, and these services are subject to the conditions set forth in the optional coverage selected (Also see Section 11 05) 23 AV -G100 2002 10 06 Physician Care Inpatient All Medical Services rendered by Participating Physicians and other Health Professionals when requested or directed by the Attending Physician, including surgical procedures, anesthesia, consultation and treatment by Specialists, laboratory and diagnostic imaging services, and physical therapy (See Section 10 08) are provided while the Member is admitted to a 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 Participating Physicians and other Health Professionals, as requested or directed by the Primary Care Physician, are covered when provided at Medical Offices, including surgical procedures, routine hearing examinations and vision examinations for glasses for children under age 18 (such examinations may be provided by optometrists licensed pursuant to Chapter 463, Florida Statutes or by ophthalmologists licensed pursuant to Chapter 458 or 459, Florida Statutes), and consultation and treatment by Specialty Health Care Professionals Also included are non -reusable materials and surgical supplies These services and materials are subject to the Limitations outlined in Part XI (Lunitations of Basic Benefits) See Part XII for Exclusions 10 07 02 Preventive and Health Maintenance Services The services of the Member's Primary Care Physician for illness prevention and health maintenance, including Child Health supervision services, and immunizations provided in accordance with prevailing medical standards consistent with the Recommendations for Preventive Pediatric Health Care of the American Academy of Pediatrics and/or the Advisory Committee on Immunization Practices, sterilization (See Schedule of Copayments), penodic health assessment, physical examinations, and voluntary family planning services are also covered These services are subject to Limitations as outlined in Part XI (Limitations of Basic Benefits) See Part XII for Exclusions 10 07 03 Outpatient Mental Health Services are covered only for diagnostic evaluation and crisis intervention These services are limited to a total of twenty (20) outpatient visits per Contract Year Referral for outpatient mental health services must be arranged by the Member's Participating Physician, and each visit requires a Copayment (See Schedule of Copayments) 10 08 Physical, Occupational or Speech Therapy Physical, Occupational or Speech Therapy provided in the Outpatient or Home Care setting is covered 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, m the judgment of Health Plan, such services are 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 calendar year for all services combined Long-term physical therapy, occupational therapy, speech therapy, rehabilitation, or other treatment of chronic conditions is not covered 24 AV -6100 2002 1009 Cardiac Rehabilitation Cardiac rehabilitation is covered for the following conditions acute myocardial infarction, percutaneous transluminal coronary angioplasty (PTCA), coronary artery bypass graft (CABG), repair or replacement of heart valve(s) or heart transplant Coverage is limited to a maximum of eighteen (18) visits per calendar year See Schedule of Copayments for detailed information regarding copayments and limitations 1010 Obstetrical and Gynecological Care Obstetrical care benefits as specified herein are covered and include Hospital care, anesthesia, diagnostic imaging, and laboratory services for conditions related to pregnancy unless such pregnancy is the result of a preplanned adoption arrangement, more commonly known as surrogacy The length of maternity stay in a Hospital will be that determined to be Medically Necessary in compliance with Florida law and in accordance with the _ Newborns' and Mothers' Health Protection Act, as follows 1) hospital stays of at least 48 hours following a normal vaginal delivery, or at least 96 hours following a cesarean section, 2) the - attending physician does not need to obtain authorization from the Plan to prescribe a hospital stay of this length or longer, except for the pre -authorization for the actual inpatient maternity stay prior to admission, and 3) shorter hospital stays are permitted if the attending health care provider, in consultation with the mother, determines that this is the best course of action Coverage for maternity care is subject to applicable copayments and all other Plan limits and requirements Newborn child care is covered as provided in Subsection 4 02 02 (i) and Section 10 11 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 1011 Newborn Care All services applicable for children under this Contract are covered for an enrolled newborn child of the Subscriber or the enrolled newborn child of a covered Dependent of the Subscriber or the newborn adopted child of the Subscriber (as described in Subsection 4 02 02 (i)), from the moment of birth, including the Medically Necessary care or treatment of medically diagnosed congenital defects, birth abnormalities or prematunty, and transportation costs to the nearest facility appropriately staffed and equipped to treat the newborn's condition, when such transportation is Medically Necessary Circumcisions are provided for up to one year from date of birth provided that newborn was continuously covered by Health Plan from date of birth 10 12 Emergency Services All necessary Physician and Hospital Services will be covered by Health Plan for emergency care (See Part III, Sections 3 14 and 3 15) In the event that Hospital inpatient services are provided following emergency services, Health Plan should be notified withm 24 hours or as soon as the Member is lucid and able to notify Health Plan of the inpatient admission Health Plan will pay the usual, reasonable, and customary charges to a non - Participating Physician or facility only for those services rendered before a Member's condition permits him to be reasonably able to travel to a Participatmg 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 1013 Urgent Care Services All necessary and covered services received in Urgent Care or Immediate Care Centers or rendered in your primary care physician's office after-hours for conditions as descnbed in Section 3 47 will be covered by Health Plan See Schedule of Copayments for details In addition, any Member requests for reimbursement (of payment made by the Member for services rendered) must be filed within ninety (90) days after the emergency or as soon as reasonably possible but not later than one (1) year unless the claimant was legally incapacitated 25 AV -G100 2002 1014 Ambulance Service For an emergency or when pre -authorized by Health Plan, ambulance service to the nearest Hospital appropriately staffed and equipped to treat the condition will be covered without charge to the Member 1015 Other Health Care Facihty(ies) All routine services of Other Health Care Facilities (see Section 3 34), mcluding Physician visits, physiotherapy, diagnostic imaging and laboratory work, are covered 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 1016 Diagnostic Imaging and Laboratory All prescribed diagnostic imaging and laboratory tests and services including diagnostic imaging, fluoroscopy, electrocardiograms, blood and urine and other laboratory tests, and diagnostic clinical isotope services are covered when Medically Necessary and ordered by a Participating Physician as part of the diagnosis and/or treatment of a covered illness or injury or as preventive health care services 10 17 Home Health Care Services With prior authorization by Health Plan, Home Health Care Services (as defined in Section 3 22) are covered when ordered by and under the direction of the Member's Attending Physician Physical, Occupational or Speech Therapy services provided m the home are limited as noted in 10 08 Homemaker or other Custodial Care services are not covered 10 18 Hospice Services With prior authorization by Health Plan, services are available from a Health Plan affiliated Hospice organization for a Member whose Participating Physician has determined the Member's illness will result in a remaining life span of six (6) months or less 1019 Second Medical Opinions The Member is entitled to a second medical opinion when he 1) disputes the appropriateness or necessity of a surgical procedure, or 2) is subject to a serious injury or illness With prior notice to Health Plan, the Member may obtain the second medical opinion from any Participating or non -Participating Physician, chosen by the Member, who is withm Health Plan's Service Area If a Participating Physician is chosen, there is no cost to the Member other than any applicable Copayment If the Member chooses a non -Participating Physician, the Member will be responsible for 40% of the amount of reasonable and customary charges for the second medical opinion Any tests that may be required to render the second medical opinion must be arranged by Health Plan and performed by Participating Providers Once a second medical opinion has been rendered, Health Plan shall review and determine Health Plan's obligations under the contract and that judgment is controlling Any treatment the Member obtains that is not authorized by Health Plan shall be at the Member's expense 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 26 AV -G100 2002 10 20 Durable Medical Equipment and Orthotic Appliances 10 20 01 Durable Medical Equipment This Contract provides benefits, when Medically Necessary, for the purchase or rental of such 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, canes, walkers, wheelchairs, respiratory equipment, apnea monitors and insulin pumps In accordance with Florida Statutes, coverage of insulin pumps for the treatment of diabetes will 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 10 20 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 21 Prosthetic Devices This Contract provides benefits, when Medically Necessary, for prosthetic devices Coverage for prosthetic devices is limited to artificial limbs, artificial joints, and ocular prostheses Coverage includes the initial purchase, fitting, or adjustment Replacement is covered only when Medically Necessary due to a change in bodily configuration The initial prosthetic device following a covered mastectomy is also covered Replacement of cataract lenses is covered only if there is a change in prescription which cannot be accommodated by eyeglasses All other prosthetic devices are not covered See Schedule of Copayments for any Copayments or Limitations See Part XII for Exclusions 10 22 Payment to Non -Participating Providers When, in the professional judgment of Health Plan's Medical Director, a Member needs covered medical or Hospital Services which require skills or facilities not available from Participating Providers and it is in the best interest of the Member to obtain the needed care from a Non Participating Provider, upon authorization by the Medical Director, payment not to exceed usual 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 Participating Hospital 27 AV -G100 2002 1023 Prescription Drug Benefits Allergy serums and chemotherapy for cancer patients are covered Coverage for insulin and other diabetic supplies is described in Section 10 26, below Other prescription drugs are a covered benefit only when the Subscribing Group Contract includes a supplemental Prescription Drug Rider 10 24 Ventilator Dependent Care With prior authonzation by Health Plan, Ventilator Dependent Care (See Section 3 49) is covered up to a total of 100 days lifetime maximum benefit 10 25 Major Organ Transplants at a facility deemed appropriate and authorized by Health Plan, as well as associated immunosuppressant drugs are covered except those deemed experimental (See Section 12 15) 10 26 Diabetes Treatment for all Medically Necessary equipment, supplies, and services to treat diabetes This includes outpatient self -management framing and educational services, if the Member's Primary Care Physician, or the Physician to whom the Member has been referred who specializes in diabetes treatment, certifies the equipment, supplies, or services are Medically Necessary Insulin pumps are covered under Section 10 20 Diabetes outpatient self - management training and educational services must be provided under the direct supervision of a certified diabetes educator or a board certified endocrinologist under contract with Health Plan Insulin, insulin syringes, lancets, and test strips are covered under the Subscribing Group's supplemental Prescription Drug Rider In the event that a Subscribing Group does not purchase a supplemental Prescription Drug Rider, insulin, insulin syringes, lancets, and test strips are covered subject to a $25 Member Copayment per item for a 30 -day supply 10 27 Mammograms are covered in accordance with Honda Statutes one baseline mammogram is covered for female Members between the ages of 35 and 39, a mammogram is available every two years for female Members between the ages of 40 and 49, and a mammogram is available every year for female Members aged 50 and older In addition, one or more mammograms a year are available when based upon a Physician's recommendation for any woman who is at risk for breast cancer because of a personal or family history of breast cancer, because of having a history of biopsy -proven benign breast disease, because of having a mother, sister, or daughter who has had breast cancer, or because a woman has not given birth before the age of 30 10 28 Osteoporosis Diagnosis and Treatment when Medically Necessary for high -risk individuals, e g estrogen -deficient individuals, individuals with vertebral abnormalities, individuals on long-term glucocorticoid (steroid) therapy, individuals with primary hyperparathyroidism, and individuals with a family history of osteoporosis 10 29 Dermatological Services Health Plan will cover up to five (5) office visits per calendar year to a Plan Dermatologist for Medically Necessary covered services subject to Sections 3 29 and 3 48 No prior referral is required for these services 28 AV -G100 2002 10 30 Mastectomy Surgery when performed for breast cancer Coverage for Post -Mastectomy Reconstructive Surgery shall include 1) reconstruction of the breast on which the mastectomy has been performed, 2) surgery and reconstruction on the other breast to produce a symmetrical appearance, and 3) prostheses and physical complications during all stages of mastectomy including lymphedemas The length of stay will not be less than that determined by the treating Physician to be Medically Necessary in accordance with prevailing medical standards and after consultation with the covered patient. Coverage is subject to any applicable copayments and will require pre -authorization of services as applicable to other surgical procedures or hospitalizations under the Plan 10 31 General anesthesia and hospitalization services to a Member who is under 8 years of age and is determined by a licensed dentist and the Member's Physician to require necessary dental treatment in a Hospital or ambulatory surgical center due to a significantly complex dental condition or a developmental disability in which patient management in the dental office has proved to be ineffective, or if the Member has one or more medical conditions that would create significant or undue medical risk for the Member in the course of delivery of any necessary dental treatment or surgery if not rendered in a Hospital or ambulatory surgical center Pre - authorization by Health Plan is required There is no coverage for diagnosis or treatment of dental disease 10 32 Coverage for cleft hp and cleft palate for Members under 18 years of age The coverage provided by this section is subject to the terms and conditions applicable to other benefits XI LIMITATIONS OF BASIC BENEFITS The rights of Members and obligations of Participating Providers hereunder are subject to the following Limitations 11 01 In the event of any major disaster, Participating Providers shall render Hospital and Medical Services provided under this Contract msofar as practical, according to their best judgment, within the Limitations of such facilities and personnel as are then available, but Health Plan and Participating Providers shall have no liability or obligation for delay or failure to provide or arrange for such services due to lack of available facilities or personnel if such lack is the result of any major disaster 11 02 In the event of circumstances not reasonably withm 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 29 AV -G100 2002 1104 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 1105 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 1106 Visits to Participating 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 21) 1107 Spinal manipulations will be covered only when Medically Necessary and prescribed by a Participating Physician or by self -referral to a Participating Physician 1108 The total benefit for Ventilator Dependent Care is limited to 100 calendar days lifetime maximum 11 09 Inpatient Hospital care for a medical "Emergency," m -area or out -of -area, will only be covered when authorized by Health Plan, after the Member or the Hospital notifies Health Plan within 24 hours of admission or as soon as the Member is lucid and able to notify Health Plan of the admission following emergency care and services 11 10 Other Health Care Facility (ies) All routme inpatient services of Other Health Care Facilities (See Section 3 34), including Physician visits, physiotherapy, diagnostic unagmg 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 11 Physical, Occupational or Speech Therapy Physical, Occupational or Speech therapies shall be limited as explained in Section(s) 10 08 and 10 17 11 12 Surgical or non -surgical procedures which are undertaken to improve or otherwise modify the Member's external appearance shall be limited to reconstructive surgery to correct and repair a functional disorder as a result of a disease, injury, or congenital defect or initial implanted prosthesis and reconstructive surgery incident to a mastectomy for cancer of the breast 11 13 Hyperbanc Oxygen Treatments are limited to forty (40) treatments per condition as appropriate pursuant to the Centers for Medicare and Medicaid Services (CMS) guidelines subject to applicable copayments as listed for Physical, Speech and Occupational Therapies 30 AV -G100 2002 XII EXCLUSIONS FROM BASIC BENEFITS Medical Services and benefits for the following classifications and conditions are not covered and are excluded from the Schedule of Basic Benefits provided under this Contract 12 01 Treatment of a condition resulting from a) Participation in a not or rebellion, b) Engagement in an illegal occupation, c) Commission of or attempted commission of an assault, commission or attempted commission of a crime punishable as a felony, — — -- - - - 12 02 Cosmetic, surgical or non -surgical procedures which are undertaken primarily to improve or otherwise modify the Member's external appearance Also excluded are surgical excision or reformation of any sagging skin of any part of the body, including, but not limited to the eyelids, face, neck, abdomen, aims, legs, or buttocks, any services performed in connection with the enlargement, reduction, implantation or change in appearance of a portion of the body, including, but not limited to the face, lips, jaw, chin, nose, ears, breasts, or genitals (including circumcision, except newborns for up to one year from date of birth, see also Section 10 11), hair transplantation, chemical face peels or abrasion of the skin, electrolysis depilation, removal of tattoomg, or any other surgical or non -surgical procedures which are prnnanly 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 Participatmg Provider, except for Emergency Services, or not within the benefits covered by Health Plan 12 04 Dental Care, aS defined in 3 11, for any condition except 12 04 01 When such services are for the treatment of trauma related fractures of the jaw or facial bones or for the treatment of tumors, 12 04 02 Reconstructive jaw surgery for the treatment of deformities that are present and apparent at birth, provided the Member was continuously covered by Health Plan from date of birth to date of surgery, or 12 04 03 Full mouth extraction when required before radiation therapy 12 05 Services related to the diagnosis/treatment of temporomandibular joint (TMJ) dysfunction except when Medically Necessary, all dental treatment for TMJ 12 06 Mandibular and maxillary osteotomies except when Medically Necessary to treat conditions caused by congenital or developmental deformity, disease, or injury 12 07 Medical supplies including, but not limited to ostomy supplies, urinary catheter bags, pre- fabricated splints, Thromboemboletic/Support hose and all bandages 31 AV -G100 2002 12 08 Home monitoring devices and measuring devices (other than apnea monitors), and any other equipment or devices for use outside the Hospital 12 09 Surgically implanted devices and any associated external devices, except for cardiac pacemakers, intraocular lenses, artificial joints and orthopedic hardware, and vascular grafts Dental appliances, other corrective lenses and hearing aids, including the professional fee for fitting them are not covered 12 10 Over-the-counter medications, all contraceptives (including drugs and devices), hypodermic needles and syringes and 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 1012 12 12 Treatment for chronic alcoholism and chronic drug addiction, except those services offered as a basic health service (See Section 11 05) 12 13 Treatment for armed forces service -connected medical care (for both sickness and injury) 12 14 Custodial Care (as defined in Part III, Section 3 10) 1215 Experimental and/or investigational procedures unless approved per Honda Administrative Code, Section 59B-12 001 For the purposes of this Contract, a drug, treatment, device, surgery or procedure may be determined to be experimental and/or investigational if any of the following applies a) the Food and Drug Administration (FDA) has not granted the approval for general use, or b) there are insufficient outcomes data available from controlled clinical teals published in peer - reviewed literature to substantiate its safety and effectiveness for the disease or injury involved, or c) there is no consensus among practicing physicians that the drug, treatment, therapy, procedure or device is safe or effective for the treatment in question or such drug, treatment, therapy, procedure or device is not the standard treatment, therapy, procedure or device utilized by practicing physicians in treating other patients with the same or similar condition, or d) such drug, treatment, procedure or device is the subject of an ongoing Phase I or Phase II clinical investigation, or experimental or research arm of a Phase III clinical investigation, or under study to determine maximum tolerated dosage(s), toxicity, safety, efficacy, or efficacy as compared with the standard means for treatment or diagnosis of the condition in question 12 16 Personal comfort items not Medically Necessary for proper medical care as part of the therapeutic plan to treat or arrest the progression of an illness or injury This Exclusion includes, but is not limited to wigs (including partial hair pieces, weaves, and toupees), personal care kits, guest meals and accommodations, maid service, television/radio, telephone charges, photographs, complimentary meals, birth announcements, take home supplies, travel expenses other than Medically Necessary ambulance services that are provided for in the covered benefits section, air conditioners, humidifiers, dehumidifiers, and air purifiers or filters 32 AV -G100 2002 1217 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 1218 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 1219 Hearing examinations for Plan Members 18 years of age or older for the purpose of determining the need for hearing correction 12 20 Cosmetics, dietary supplements, nutritional formulae, health or beauty aids 12 21 Gastric stapling, gastric bypass, gastric banding, gastric bubbles, and other procedures for the treatment of obesity or morbid obesity, as well as any related evaluations or diagnostic tests Ongomg visits other than establishing a program of obesity control 12 22 Gender reassignment surgery as well as any service, supply, or medical care associated with gender reassignment or gender identity disorders 12 23 All drugs, devices, and other forms of treatment related to a diagnosis of sexual dysfunction 12 24 Infertility diagnosis, treatment, and supplies, including infertility testing, treatment of infertility, diagnostic procedures and artificial insemination, to determine or correct the cause or reason for infertility or inability to achieve conception This includes artificial insemination, in -vitro fertilization, ovum or embryo placement or transfer, gamete mtra-fallopian tube transfer, or cryogenic or other preservation techniques used in such or similar procedures Also excluded are obstetrical benefits when such pregnancy is the subject of a Preplanned Adoption Arrangement or Surrogacy as defined under Chapter 63, Florida Statutes Drugs for the treatment of infertility are not covered 12 25 Reversal of sterilization procedures 12 26 Immunizations and medications for the purpose of foreign travel or employment 12 27 Acupuncture, biofeedback, hypnotherapy, massage therapy, sleep therapy, sex therapy, behavioral trammg, cognitive therapy, and vocational rehabilitation 12 28 Foot supports are not covered These include orthopedic or specialty shoes, shoe build-ups, shoe orthotics, shoe braces, and shoe supports Also excluded is routine foot care, including trunmmg of corns, calluses, and nails 33 AV -6100 2002 12 29 The Medical and Hospital Services for a donor or prospective donor who is a Health Plan Member when the recipient of an organ transplant is not a Health Plan Member Coverage is provided for costs associated with the bone marrow donor -patients to the same extent as the insured recipient The reasonable costs of searching for the bone marrow donor is limited to immediate family members and the National Bone Marrow Donor Program 12 30 Diagnostic testing and treatment related to mental retardation or deficiency, learning disabilities, behavioral problems, developmental delays, Autism Spectrum Disorder or Attention Deficit Disorder Expenses for remedial or special education, counseling, or therapy including evaluation and treatment of the above -listed conditions or behavioral training whether or not associated with manifest mental disorders or other disturbances 12 31 Emergency room services for non -emergency purposes (See Sections 3 14 and 3 15) 12 32 Hospital Services that are associated with excluded surgery or Dental Care 12 33 Any non -Plan treatment received by a Member, except in the case of an Emergency or when specifically pre-authonzed by Health Plan (See Sections 3 14 and 3 15) 12 34 Physical, speech, occupational, and all other therapies for chronic conditions Speech therapy for delayed or abnormal speech pathology is not covered 12 35 Alcohol or substance abuse rehabilitation, vocational rehabilitation, pulmonary rehabilitation, long term rehabilitation, or any other rehabilitation program 12 36 Surgery for the reduction or augmentation of the size of the breasts except as required for the comprehensive treatment of breast cancer 12 37 Termination of pregnancy unless deemed Medically Necessary by the Medical Director, subject to applicable state and federal laws or as specified in the Elective Termination of Pregnancy supplement to the Subscribing Group Contract 12 38 Hospital Exclusion If a Member elects to receive Hospital care from a non -Participating attending Physician or a non-Participatmg 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 12 39 Ventilator Dependent Care, except as provided in Part X (Schedule of Basic Benefits) for 100 days lifetime maximum benefit 12 40 Private duty nursing services 12 41 Any sickness or injury for which the covered person is paid benefits, or may be paid benefits if claimed, if the covered person is covered or required to be covered by Workers' Compensation In addition, if the covered person enters into a settlement giving up rights to recover past or future medical benefits under a Workers' Compensation law, Health Plan shall not cover past or future Medical Services that are the subject of or related to that settlement 12 42 Complications of any non -covered service, including the evaluation or treatment of any condition which arises as a complication of a non -covered service 34 AV -G100 2002 12 43 Any service or supply to eliminate or reduce dependency on or addiction to tobacco, including but not limited to nicotine withdrawal programs, facilities, and supplies (e g transdermal patches, Nicorette gum) 12 44 Services associated with autopsy or postmortem examinations, including the autopsy 12 45 Exercise programs, gym memberships, or exercise equipment of any kind, including, but not limited to exercise bicycles, treadmills, staumasters, rowing machuies, 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 pnmary 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 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 tune 35 AV -G100 2002 However, if a policy or plan subject to the rule based on the birthday of the parent a stated above coordinates with an out-of-state policy or plan winch coat i provisions under which the benefits of a policy or plan which covers a person as Dependent of a male are determined before those of a policy or plan which covers th person as a Dependent of a female and if, as a result, the policies or plans do a agree on the order of benefits, the provisions of the other policy or plan s_1] determine the order of benefits 13 03 03 If two or more policies or plans cover a Dependent child of divorced or separ 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 chic 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 paren responsible for the health care expenses of the child and if the entity obliged to pay i provide the benefits of the policy or plan of that parent has actual knowledge of t1.1 terms, the benefits of that policy or plan are determined first This does not c with respect to any claim determination period or plan or policy year during with any benefits are actually paid or provided before that entity has that actu knowledge 13 03 04 The benefits of a policy or plan which covers a person as an employee who is neith laid off nor retired, or as that employee's Dependent, are determmed before those ►1 policy or plan which covers that person as a laid off or retired employee or a lr employee's Dependent If the other policy or plan is not subject to this rule, and if, a result, the policies or plans do not agree on the order of benefits, this Subse-'1 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 determine the order of benefits, the benefits of the policy or plan which cover employee, Member, or Subscriber for a longer period of time are determined b,..Le 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 pole , excess insurance policy as defined in Section 627 635, Florida Statutes a policy a coverage limited to specified illnesses or accidents, or a Medicare supplement r 1 However, if the person is also a Medicare beneficiary, and if the rule estab l under the Social Security Act of 1965, as amended, makes Medicare secondary to plan covering the person as a Dependent of an active employee, the order of bin. determination is a) First, benefits of a plan covering a person as an employee, Member, Subscriber b) Second, benefits of a plan of an active worker covering a person as a Depende d) Third, Medicare benefits 36 AV -6100 2002 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 i 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 m 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 )(Iv 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 nghts 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 37 AV -G100 2002 XV DISCLAIMER OF LIABILITY 15 01 Neither Subscribing Group nor its agents, servants or employees, nor any Member is the agent or representative of Health Plan, and none of them shall be liable for any acts or omissions of Health Plan, its agents or employees or of a Plan Hospital, or a Participating Physician, or any other person or organization with which Health Plan has made or hereafter shall make arrangements for the performance of services under this Contract 15 02 Neither Subscribers of Subscribing Group nor their Dependents shall be liable to Health Plan or Participating Providers except as specifically set forth herein, provided all procedures set forth herein are followed 15 03 Neither Health Plan nor its agents, servants or employees, nor any Member is the agent or representative of the Subscriber Group, and none of them shall be liable for any acts or omissions of Subscriber Group, its agents or employees or any other person representing or acting on behalf of Subscriber Group 15 04 Health Plan does not directly employ any practicing Physicians nor any Hospital personnel or Physicians These health care providers are independent contractors and are not the agents or employees of Health Plan Health Plan shall be deemed not to be a health care provider with respect to any services performed or rendered by any such independent contractors Participating providers maintain the physician/patient relationship with members and are solely responsible for all Medical Services which Participating Providers render to Members Therefore, Health Plan shall not be liable for any negligent act or omission committed by any independent practicing Physicians, nurses, or medical personnel, nor any Hospital or health care facility, its personnel, other health care professionals or any of their employees or agents who may, from time to time, provide Medical Services to a Member of the Health Plan Furthermore, Health Plan shall not be vicariously liable for any negligent act or omission of any of these independent health care professionals who treat a Member(s) of Health Plan 15 05 Certain Members may, for personal reasons, refuse to accept procedures or treatment recommended by Participating Physicians Participating Physicians may regard such refusal to accept their recommendations as incompatible with the continuance of the Physician/patient relationship and as obstructing the provision of proper medical care If a Member refuses to accept the medical treatment or procedure recommended by the Participating Physician and if, in the judgment of the Participating Physician, no professionally acceptable alternative exists or if an alternative treatment does exist but is not recommended by the Participating Physician, the Member shall be so advised If the Member continues to refuse the recommended treatment or procedure, Health Plan may terminate the Member's coverage under this Contract as set forth in Part IX, Subsection 9 0105 38 AV -G100 2002 XVI GRIEVANCE PROCEDURE 16 01 Urgent Care Clauns 16 0101 Initial Claim An Urgent Care Claim shall be deemed to be filed on the date received by Health Plan. AvMed shall notify the Claimant of the Health Plan's benefit determination (whether adverse or not) as soon as possible, taking into account the medical exigencies, but not later than 72 hours after the Health Plan receives, either orally or in writing, the Urgent Care Claim, unless the Claimant fails to provide sufficient information to determine whether, or to what extent, benefits are covered or payable under the Health Plan If such information is not provided, AvMed shall notify the Claimant as soon as possible, but not later than 24 hours after the Health Plan receives the Claim, of the specific information necessary to complete the Claim The Claimant shall be afforded a reasonable amount of time, taking into account the circumstances, but not less than 48 hours, to provide the specified information AvMed shall notify the Claimant of the Health Plan's benefit determination as soon as possible, but in no case later than 48 hours after the earlier of 1) The Health Plan's receipt of the specified information, or 2) The end of the period afforded the Claimant to provide the specified additional information If the Claimant fails to supply the requested information within the 48 -hour period, the Claim shall be denied AvMed may notify the Claimant of its benefit determination orally or in writing If the notification is provided orally, a written or electronic notification, meeting the requirements of Section 16 05 shall be provided to the Claimant no later than 3 days after the oral notification 16 0102 Appeal A Claimant may appeal an Adverse Benefit Determination with respect to an Urgent Care Claim withm 180 days of receiving the Adverse Benefit Determination AvMed shall notify the Claimant, in accordance with Section 16 07, of the Health Plan's benefit determination on review as soon as possible, taking into account the medical exigencies, but not later than 72 hours after the Health Plan receives the Claimant's request for review of an Adverse Benefit Determination You may submit an appeal to AvMed Member Services — North PO Box823 Gainesville, Florida 32602-0823 Telephone 1-800-882-8633 Fax (352) 337-8612 AvMed Member Services — South P 0 Box 569008 Miami, Florida 33256-9906 Telephone 1-800-882-8633 Fax (305) 671-4736 If you are not satisfied with AvMed's final decision, you may contact the Florida Agency for Health Care Administration (AHCA) or the Department of Insurance (DOI) in writing within 365 days of receipt of the final decision letter If you appeal AvMed's decision, your grievance will be reviewed by the Statewide Provider and Subscriber Assistance Program You also have the right to contact the AHCA or DOI at any time to inform them of an unresolved grievance 39 AV -G100-2002 The Statewide Provider and Subscriber Assistance Program will not hear a grievance if the Member has not completed the entire AvMed Grievance process nor if the member has instituted an action pending in the state or federal court. If you need further assistance, you may contact Statewide Provider and Subscriber Assistance Panel (SPSAP) Agency for Health Care Administration HMO Section 2727 Mahan Drive, Mail Stop 26 Tallahassee, Florida 32308 Telephone 1-888-419-3456 or 850-921-5458 The Florida Department of Insurance 200 East Gaines Street Tallahassee, Honda 32399 Telephone 1-800-342-2762 16 02 Pre -Service Claims 16 02 01 Initial Claim — A Pre -Service Claim shall be deemed to be filed on the date received by Health Plan AvMed shall notify the Claimant of the Health Plan's benefit determination (whether adverse or not) within a reasonable period of tune appropriate to the medical circumstances, but not later than 15 days after the Health Plan receives the Pre -Service Claim The Health Plan may extend this period one tune for up to 15 days, provided that AvMed determmes that such an extension is necessary due to matters beyond the Health Plan's control and notifies the Claimant, before the expiration of the initial 15 -day period, of the circumstances requiring the extension of tune and the date by which the Health Plan expects to render a decision If such an extension is necessary because the Claimant failed to submit the information necessary to decide the Claim, the notice of extension shall specifically describe the required information, and the Claimant shall be afforded at least 45 days from receipt of the notice within which to provide the specified information In the case of a failure by a Claimant to follow the Plan's procedures for filing a Pre -Service Claim, the Claimant shall be notified of the failure and the proper procedures to be followed in filing a Claim for benefits not later than five (5) days following such failure The Plan's period for making the benefit determination shall be tolled from the date on which the notification of the extension is sent to the Claimant until the date on which the Claimant responds to the request for additional information If the Claimant fails to supply the requested information within the 45 -day period, the Claim shall be denied 16 02 02 Appeal — A Claimant may appeal an Adverse Benefit Determination with respect to a Pre -Service Claim within 180 days of receiving the Adverse Benefit Determmation AvMed shall notify the Claimant, in accordance with Section 16 07, of the Health Plan's determination on review within a reasonable period of time Such notification shall be provided not later than 30 days after the Health Plan receives the Claimant's request for review of the Adverse Benefit Determination 40 AV -G100 2002 You may submit an appeal to AvMed Member Services —North P O Box 823 Gainesville, Florida 32602-0823 Telephone 1-800-882-8633 Fax (352) 337-8612 AvMed Member Services — South P O Box 569008 Miami, Florida 33256-9906 Telephone 1-800-882-8633 Fax (305) 671-4736 If you are not satisfied with AvMed's final decision, you may contact the Florida Agency for Health Care Administration (AHCA) or the Department of Insurance (DOI) in writing within 365 days of receipt of the final decision letter If you appeal AvMed's decision, your grievance will be reviewed by the Statewide Provider and Subscriber Assistance Program You also have the right to contact the MICA or DOI at any time to inform them of an unresolved grievance The Statewide Provider and Subscriber Assistance Program will not hear a grievance if the Member has not completed the entire AvMed Grievance process nor if the member has instituted an action pending m the state or federal court If you need further assistance, you may contact Statewide Provider and Subscriber Assistance Panel (SPSAP) Agency for Health Care Administration HMO Section 2727 Mahan Drive, Mail Stop 26 Tallahassee, Florida 32308 Telephone 1-888-419-3456 or 850-921-5458 The Florida Department of Insurance 200 East Games Street Tallahassee, Florida 32399 Telephone 1-800-342-2762 16 03 Post -Service Claims 16 03 01 Initial Claim — A Post -Service Claim shall be deemed to be filed on the date received by Health Plan AvMed shall notify the Claimant, in accordance with Section 16 05 of the Health Plan's Adverse Benefit Determination within a reasonable period of time, but not later than 30 days after the Health Plan receives the Post -Service Claim The Health Plan may extend this period one tune for up to 15 days, provided that AvMed determines that such an extension is necessary due to matters beyond the Health Plan's control and notifies the Claimant, before the expiration of the initial 30 -day period, of the circumstances requiring the extension of time and the date by which the Health Plan expects to render a decision If such an extension is necessary because the Claimant failed to submit the information necessary to decide the Post -Service Claim, the notice of extension shall specifically describe the required information, and the Claimant shall be afforded at least 45 days from receipt of the notice within which to provide the specified information The Plan's period for making the benefit determination shall be tolled from the date on which the notification of the extension is sent to the Claimant until the date on which the Claimant responds to the request for additional information If the Claimant fails to supply the requested information within the 45 -day period, the Claim shall be denied 41 AV -G100-2002 16 03 02 Appeal — A Claimant may appeal an Adverse Benefit Determination with respect to a Post -Service Claim within 180 days of receiving the adverse Benefit Determination AvMed shall notify the Claimant, in accordance with Section 16 07, of the Health Plan's determination on review within a reasonable period of tune Such notification shall be provided not later than 60 days after the Health Plan receives the Claimant's request for review of the Adverse Benefit Deterimiiation You may submit an appeal to AvMed Member Services —North P O Box 823 Gainesville, Florida 32602-0823 Telephone 1-800-882-8633 Fax (352) 337-8612 AvMed Member Services — South P O Box 569008 Miami, Florida 33256-9906 Telephone 1-800-882-8633 Fax (305) 671-4736 If you are not satisfied with AvMed's final decision, you may contact the Florida Agency for Health Care Administration (AHCA) or the Department of Insurance (DOI) in writing within 365 days of receipt of the final decision letter If you appeal AvMed's decision, your grievance will be reviewed by the Statewide Provider and Subscriber Assistance Program You also have the right to contact the AHCA or DOI at any time to inform them of an unresolved grievance The Statewide Provider and Subscriber Assistance Program will not hear a grievance if the Member has not completed the entire AvMed Gnevance process nor if the member has instituted an action pending in the state or federal court If you need further assistance, you may contact Statewide Provider and Subscriber Assistance Panel (SPSAP) Agency for Health Care Administration HMO Section 2727 Mahan Drive, Mail Stop 26 Tallahassee, Florida 32308 Telephone 1-888-419-3456 or 850-921-5458 The Florida Department of Insurance 200 East Games Street Tallahassee, Florida 32399 Telephone 1-800-342-2762 1604 Concurrent Care Claims 16 04 01 Any reduction or termination by the Health Plan of Concurrent Care (other than by plan amendment or termination) before the end of an approved period of time or number of treatments, shall constitute an Adverse Benefit Determination AvMed shall notify the Claimant, in accordance with Section 16 05, of the Adverse Benefit Determination at a time sufficiently in advance of the reduction or termination to allow the Claimant to appeal and obtain a determination on review of the Adverse Benefit Determination before the benefit is reduced or terminated AV -G100 2002 42 1604 02 Any request by a Claimant to extend the course of treatment beyond the period of time or number of treatments that relates to an Urgent Care Claim shall be decided as soon as possible, taking into account the medical exigencies, and AvMed shall notify the Claimant of the benefit determination, whether adverse or not, within 24 hours after the Health Plan receives the Claim, provided that any such Clain is made to the Plan at least 24 hours before the expiration of the prescribed period of time or number of treatments Notification and appeal of any Adverse Benefit Determination concerning a request to extend the course of treatment, whether involving an Urgent Care Claim or not, shall be made in accordance with the remainder of Section XVL 16 05 Manner and Content of Initial Claims Determination Notification AvMed shall provide a Claimant with wntten or electronic notification of any Adverse Benefit Determination The notification shall set forth, in a manner calculated to be understood by the Claimant, the following 16 05 01 The specific reason(s) for the Adverse Benefit Determmation 16 05 02 Reference to the specific Health Plan provisions on which the determination is based 16 05 03 A description of any additional material or information necessary for the Claimant to perfect the claim and an explanation of why such material or information is necessary 16 05 04 A description of the Health Plan's review procedures and the tune limits applicable to such procedures, including, when applicable a statement of the Claimant's right to bring a civil action under section 502(a) of the Employee Retirement Income Security Act of 1974, as amended (ERISA), following an Adverse Benefit Determination on final review 16 05 05 If an internal rule, guideline, protocol, or other similar criterion was relied upon in making the Adverse Benefit Determmation, either the specific rule, guideline, protocol, or other similar criterion or a statement that such rule, guideline, protocol or other similar criterion was relied upon in making the Adverse Benefit Determination and that a copy shall be provided free of charge to the Claimant upon request 16 05 06 If the Adverse Benefit Determination is based on whether the treatment or service is Experimental and/or Investigational or not Medically Necessary, either an explanation of the scientific or clinical judgment for the determmation, applying the terms of the Health Plan to the Claimant's medical circumstances, or a statement that such explanation shall be provided free of charge upon request 16 05 07 In the case of an Adverse Benefit Determination involving an Urgent Care Claim, a description of the expedited review process applicable to such Claim 16 06 Review Procedure Upon Appeal The Health Plan's appeal procedures shall include the following substantive procedures and safeguards 16 06 01 Claimant may submit written comments, documents, records, and other information relating to the claim 43 AV -6100-2002 16 06 02 Upon request and free of charge, the Claimant shall have reasonable access to and copies of any Relevant Document. 1606 03 The appeal shall take into account all comments, documents, records, and other information the Claimant submitted relating to the Claim, without regard to whether such information was submitted or considered in the initial Adverse Benefit Determination 16 06 04 The appeal shall be conducted by an appropriate named fiduciary of the Health Plan who is neither the individual who made the initial Adverse Benefit Determination nor the subordinate of such individual Such person shall not defer to the initial Adverse Benefit Determination. 16 06 05 In deciding an appeal of any Adverse Benefit Determination that is based in whole or in part on a medical judgment, including determinations with regard to whether a particular treatment, drug, or other item is Experimental and/or Investigational or not Medically Necessary, the appropriate named fiduciary shall consult with a Health Care Professional who has appropriate training and experience in the field of medicine involved in the medical judgment 16 06 06 The appeal shall provide for the identification of medical or vocational experts whose advice was obtained on behalf of the Health Plan in connection with a Claimant's Adverse Benefit Determination, without regard to whether the advice was relied upon in making the Adverse Benefit Determination 16 06 07 The appeal shall provide that the Health Care Professional engaged for purposes of a consultation in Subsection 16 06 05 shall be an individual who is neither an individual who was consulted in connection with the initial Adverse Benefit Determination that is the subject of the appeal, nor the subordinate of any such individual 1606 08 In the case of an Urgent Care Claim, there shall be an expedited review process pursuant to which a) a request for an expedited appeal of an Adverse Benefit Determination may be submitted orally or in writing by the Claimant, and b) all necessary information, including the Health Plan's benefit determination on review, shall be transmitted between the Health Plan and the Claimant by telephone, facsimile, or other available similarly expeditious methods 16 07 Manner and Content of Appeal Notification AvMed shall provide a Claimant with written or electronic notification of the Health Plan's benefit determination upon review 16 07 01 In the case of an Adverse Benefit Determination, the notification shall set forth, in a manner calculated to be understood by the Claimant, all of the following, as appropriate a) The specific reason(s) for the Adverse Benefit Determination b) Reference to the specific Health Plan provisions on which the Adverse Benefit Determination is based c) A statement that the Claimant is entitled to receive, upon request, and free of charge, reasonable access to, and copies of any Relevant Document 44 AV -G100 2002 d) A statement describing any voluntary appeal procedures offered by the Health Plan and the Claimant's right to obtain the information about such procedures and a statement of the Claimant's right to bring an action under ERISA Section 502(a) - when applicable e) If an internal rule, guideline, protocol, or other similar criterion was relied upon in making the Adverse Benefit Determination, either the specific rule, guideline, protocol, or other similar criterion or a statement that such rule, guideline, protocol, or other similar criterion was relied upon in making the Adverse Benefit Determination and that a copy shall be provided free of charge to the Claimant upon request. f) If the Adverse Benefit Determination is based on whether the treatment or service is Experimental and/or Investigational or not Medically Necessary, either an explanation of the scientific or clinical judgment for the determmation, applying the terms of the Health Plan to the Claimant's medical circumstances, or a statement that such explanation shall be provided free of charge upon request 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 N 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 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 containmg any false, incomplete, or misleading information is guilty of a felony, punishable as provided by Florida Statutes 17 04 Membership Cards Cards issued by Health Plan to Members pursuant to this Contract are for purposes of identification only Possession of a Health Plan identification card confers no right to health services or other benefits under this Contract To be entitled to such services or benefits the holder of the card must, in fact be a Member on whose behalf all applicable charges under this Contract have actually been paid and accepted by Health Plan 45 AV -G100 2002 17 05 Waiver A claim which has not been timely filed with Health Plan within one (1) year of date of service, shall be considered waived 17 06 Non Waiver The failure of Health Plan to enforce any of the provisions of this Contract or to exercise any options herein provided or to require timely performance by any Member or Subscriber Group of any of the provisions herein, shall not be construed to be a waiver of such provisions nor shall it affect the validity of this Contract or any part thereof or the right of Health Plan to thereafter enforce each and every such provision 17 07 Plan Administration Health Plan may from time to time adopt reasonable policies, procedures, rules, and interpretations to promote the orderly and efficient administration of this Contract 17 08 Notice. Any notice intended for and directed to a party to this Contract, unless otherwise expressly provided, should be sent by United States mail, postage prepaid, addressed as follows If to Health Plan, to AvMed Health Plan P 0 Box 749 Gainesville, Florida 32602-0749 (OR if from a Member to Health Plan see the Member's Service Area address listed on Page i ) If to a Member To the last address provided by the Member and actually received by Health Plan on the enrollment or change of address notification If to Subscribing Group To the address provided in the Group Master Application. 17 09 Gender Whenever used, the singular shall include the plural and the plural the singular and the use of any gender shall include all genders 17 10 Clerical Errors Clerical error(s) shall neither deprive any individual Member of any benefits or coverage provided under this Group Contract nor shall such errors) act as authorization of benefits or coverage for the Member that is not otherwise validly in force Retroactive adjustments in coverage, for clerical errors or otherwise -will only be done for up to a 60 day period from the date of notification Refunds of premiums are done for up to a 60 day period from the date of notification Refunds of premiums are limited to a total of 60 days from the date of notification of the event, provided there are no claims incurred subsequent to the effective date of such event 1711 Contract Review Subscnbmg Group may, if this Contract is not satisfactory for any reason, return this Contract within three (3) days after receipt and receive a full refund of the deposit paid, if any, unless the services of Health Plan were utilized during the three (3) days If this Contract is not returned within three (3) days after receipt, then this Contract shall be deemed to have been accepted 17 12 Premium Tax/Surcharge. If any government entity shall impose a premium tax or surcharge, then the sums due from the Subscribing Group under the terms of this Contract shall be increased by the amount of such premium tax or surcharge 46 AV -G100 2002 1713 Entirety of Contract. This Agreement and all applicable Schedules, Exhibits, Riders and any other attachments and endorsements, constitute the entire Contract between the Subscnbing 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 1714 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 1715 Third Party Beneficiary This Contract is entered into exclusively between the Subscnbmg 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 1716 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 1717 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 18 ERISA When this Contract is purchased by the Subscribing Group to provide benefits under a welfare plan governed by the Employee Retirement Income Security Act (ERISA), AvMed shall be considered a fiduciary to the extent that it performs any discretionary functions on behalf of the plan If a Member has questions about the group's welfare plan, the Member should contact the Subscribing Group 47 AV -G100 2002 AVMED, INC d/b/a AVMED Health Plan Group Medical and Hospital Service Contract Group Master Application Contract Number (s) Subscriber Group Name Effective Date 004515 Village of Key Biscayne May 1 2003 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) El $0 per Admission ❑ $100 per Admission ❑ $100 per Day Days 1 5 ❑ $250 per Admission STANDARD OPTION ($20 Specialist) ❑ $100 per Day Days 1-5 ❑ $250 per Admission BASIC OPTION ($15 Specialist) ❑ $0 per Admission ❑ $100 per Admission ❑ $250 per Admission ❑ $250 per Day Days 1 5 BASIC OPTION ($25 Specialist) ❑ $0 per Admission ❑ $100 per Admission ❑ $250 per Admission ❑ $250 per Day, Days 1-5 Form AV STD -OA -02 BASIC OPTION ($30 Specialist) ❑ $250 per Day, Days 1 5 ❑ $250 per Admission BASIC OPTION ($35 Specialist) ❑ $250 per Day Days 1 5 O $250 per Admission ❑ $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 El Prescription Coverage Form AV G100-RX 3T 10/20/30 E 02 Vision Coverage Form AV- VISION -E 99 Dental Coverage Form Elective Termination of Pregnancy Form El El Eu ci AV AV G100-ETP 97 Mental Health Form AV G100-MH-01P E 99 ['Group declines additional mental health benefits (Section 627 668 Florida Statutes) © Substance Abuse Form AV G100 -SA E 98 ['Group declines additional substance abuse benefits (Section 627 669 Florida Statutes) Durable Medical Equipment Form AV G100 DME 2000E 01 Waiver of Copayment — Coverage for Mammograms Form AV - 13 O El Other El Domestic Partner El Injectable Drug Benefits Form AV DP 12-E 02 Form AV G100-IDB-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) 0 0 12 0 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 ® on the last date of the month in which the employee s employment is terminated ❑ on the date the Group Contract is terminated ❑ other AGREEMENT This Contract is issued in consideration of the Master Application of the Subscribing Group for group medical and hospital services and the monthly prepayment subscription charges and the mutual promises and benefits between AVMED, Inc d/b/a AVMED Health 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 , 2003 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 day of each month thereafter May 1 2003 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 $ 256 84 Subscnber plus Spouse $ 513 68 Subscriber plus One Dependent (No Spouse) $ 513 68 Subscnber plus Two or More Dependents $ 744 84 Subscriber plus Spouse and One or More Dependents $ 744 84 0 Other $ 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 Subscnbing Group Vdla•e oe Bisca e AVMED Inc d/b/a AVMED Health Plan Signature Signature Evis Clavareza May 1 2003 By Name Name Account Service Manager Date Title Title AV G100 APP 02 MP 2027 (9/02) �7 Date hl� HEALTH PLAN STANDARD OPTION 0 -ADMIT Benefit Summary SCHEDULE OF COPAYIINTS COST TO MEER 011T -OF -POCKET MAXI $1 500 INDIVIDUAL $3 000 FAMILY A'VMED PRIMARY CARE PHYSICIAN Services at participating doctors' offices mclude but are not limited to • ROUTINE OFFICE VISITS / ANNUAL GYN VISIT • MATERNITY -OUTPATIENT VISITS ■ PEDIATRIC CARE & WELL -BABY CARE ■ PERIODIC HEALTH EVALUATION & IMMUNIZATIONS • DIAGNOSTIC IMAGING LABORATORY OR OTHER DIAGNOSTIC SERVICES • MINOR SURGICAL PROCEDURES • VISION & HEARING EXAMINATIONS FOR CHILDREN UNDER 18 • NUTRITIONIST $10 PER VISIT AVMED SPECIALIST'S SERVICES • OFFICE VISITS $10 PER VISIT HOSPITAL Inpatient care at participatmg hospitals mcludes • ROOM & BOARD UNLIMITED DAYS (SEMI PRIVATE) • PHYSICIAN'S SPECIALIST'S & SURGEON'S SERVICES • ANESTHESIA USE OF OPERATING & RECOVERY ROOMS OXYGEN DRUGS & MEDICATION • INTENSIVE CARE UNIT & OTHER SPECIAL UNITS GENERAL & SPECIAL DUTY NURSING • LABORATORY & DIAGNOSTIC IMAGING • REQUIRED SPECIAL DIETS • RADIATION & INHALATION THERAPIES NO CHARGE SURGERY ■ OUTPATIENT NO CHARGE OUTPATIENT DIAGNOSTIC TESTS • CAT Scan, PET Scan MRI • OTHER DIAGNOSTIC IMAGING TESTS $25 PER TEST $10 PER TEST EMERGENCY SERVICES An emergency is the sudden & unexpected onset of a condition requirmg 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 INPATIENT ADMISSION FOLLOWING EMERGENCY SERVICES OR AS SOON AS REASONABLY POSSIBLE $75 COPAYMENT $100 COPAYMENT URGENVIMMEDIATE CARE • MEDICAL SERVICES AT A PARTICIPATING URGENT/IMMEDIATE CARE FACILITY OR SERVICES RENDERED AFTER HOURS IN A PHYSICIANS OFFICE • MEDICAL SERVICES AT A NON PARTICIPATING URGENT/IMMEDIATE CARE FACILITY $40 COPAYMENT $60 COPAYMENT Benefit Summary, continued MENTAL HEALTH ■ 20 OUTPATIENT VISITS $25 PER VISIT FAMILY rUUMINa • VOLUNTARY FAMILY PLANNING SERVICES • STERILIZATION $10 PER VISIT $100 COPAYMENT ALLERGY TREATMENTS • INJECTIONS • SKIN TESTING $10 PER VISIT $50 PER COURSE OF TESTING AMBULANCE • WHEN PRE -AUTHORIZED OR IN THE CASE OF EMERGENCY NO CHARGE PHYSICAL, SPEECH, S OCCUPATIONAL THERAPIES • SHORT-TERM PHYSICAL SPEECH OR OCCUPATIONAL THERAPY FOR ACUTE CONDITIONS ■ COVERAGE IS LIMITED TO 24 VISITS PER CALENDAR YEAR FOR ALL SERVICES COMBINED REFER TO YOUR AVMED GROUP MEDICAL & HOSPITAL SERVICE CONTRACT FOR SPECIFIC EXCLUSIONS & LIMITATIONS $10 PER VISIT SWUM MSG F1 S A REHABN.RATION CENTERS • UP TO 20 DAYS PER CONTRACT YEAR POST HOSPITALIZATION CARE WHEN PRESCRIBED BY PHYSICIAN & AUTHORIZED BY AVMED $25 PER DAY CARDIAC REHABBJTATION Cardiac Rehabilitation is covered for the following conditions • ACUTE MYOCARDIAL INFARCTION • PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY (PTCA) • REPAIR OR REPLACEMENT OF HEART VALVE(S) • CORONARY ARTERY BYPASS GRAFT (CABG) or • HEART TRANSPLANT COVERAGE IS LIMITED TO 18 VISITS PER YEAR $20 PER VISIT BENEFITS LIMITED TO $1 500 PER CONTRACT YEAR HOME HEALTH CARE • PER OCCURRENCE NO CHARGE DURABLE N EDI & EQUIPMENT & DEMOTIC APPLIANCES Equipment includes • HOSPITAL BEDS • 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 PROSTHETIC DEVICES Prosthetic devices are limited to • ARTIFICIAL LIMBS • ARTIFICIAL JOINTS • OCULAR PROSTHESES 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 NO CHARGE FOR ADDITIONAL INFORMATION, PLEASE CALL 1-800-88-AVMED (1-800-482-8633) THIS SCHEDULE OF COPAYMENTS IS NOT A CONTRACT FOR SPECIFIC INFORMATION ON BENEFITS EXCLUSIONS & LIMITATIONS PLEASE SEE YOUR AVMED GROUP MEDICAL & HOSPITAL SERVICE CONTRACT AV STD -OA 02 MP 3181 (7/02) 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) Generic' drug means a drug which is equivalent to a Brand name drug or is identified as a Generic drug by AvMed Participatmg 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 Participatmg Pharmacy Pieferred 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 Prc, 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 Authorization is subject to penodic review and modification by AvMed HOW DOES RETAIL PRESCRIPTION COVERAGE WORK? To obtain your prescnption, 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 $ 1000 $ 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 prescription for up to a 90 -day supply of your medication to be ordered through mail service Up to 3 refills are allowed per prescnption. 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 $ 30 00 $ 60 00 $ 90 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 Date Prescrition Drug Benefits, continued 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 cntena 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 gundelmes 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 • 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 mcludmg therapeutic devices dressings appliances and support gannents • 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, epmephrme 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 Agreed to and Accepted by the parties hereto effective for the contract term of May 1, 2001) April 30 2004 Subscribing Group AvMed, Inc AvMed Health Plan By By .r L,. Signature Signature Name Evis Clavareza Name Account Service Manager Title Title Date -7 // CY 3 AV G100 RX 3T 10/20/30 E-02 MP 3185 (7/02) AvMnT HEALTH PLAN INPATIENT 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, 2003 to April 30, 2004 Subsc - i ng Gro AvMed, Inc d/b/a AvMed Health Plan By Br qt_c_n.CC:co?r Signatu " Signa e t: & L, v i e ,q Na I Title Evis Clavareza Name Account Service Manager Title Date Date 7 // AV G100-MH OIP-E 99 MP 2028 (5/99) AvMnr HEALTH PLAN SUBSTANCE ABUSE BENEFITS POLICY ENDORSEMENT As of the effective date, the Outpatient Substance Abuse 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 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 Agreed to and Accepted by the parties hereto, effective for the contract term of May 1, 2003 to April 30, 2004 Subscnbing Group AvMed, Inc d/b/a AvMed Health Plan I By By 6, i .,,_ .� Signature Signatue Evis Clavareza Name Name Title hi' Account Service Manager Title Date Date 7 /1 03 AV G100 -SAE 98 MP -1659 (8/98) AvMn m HEALTH PLAN OUTPATIENT VISION BENEFITS POLICY ENDORCEMENT As of the effective date, the followmg 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, 2003 Subsc • Png Grou / By Signa to April 30, 2004 Name Title AvMed, Inc d/b/a AvMed Health Plan By Evis Clavareza Name Account Service Manager Title Date Date —77,1 r�`� mi, AV VISION E-99 MP 2042 (5/99) HEALTH PLAN Policy Endorsement DOMESTIC PARTNER As of the Effective Date, Part IV ELIGIBILITY of the Group Medical and Hospital Service Contract is amended by the addition of the following provision Dependent Eligibility will be added for a Domestic Partner and his or her children Definition of Domestic Partner A Domestic Partner means an 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 mamage • Is at least eighteen years of age • Is mentally competent to consent to a contract • Has filed a Domestic Partnership agreement or registration with the Employer if available m the state (and/or city) of residence • Has shared financial obligations including basic living expenses for the twelve month penod pnor to enrollment in the plan • Will provide documentation that will be satisfactory to the Employer as evidence of a Domestic Partner relationship and • Meets the dependents ehgibility requirements of the Employer s health benefits plan Agreed to and Accepted by the parties hereto effective for the contract term of May 1, 2003 to April 30, 2004 Subscribing Group AvMed Inc d/b/a AvMed Health Plan By By Signature Signatur Evis Clavareza Name Name Account Service Manager Title Title Date Date 7 et' %--)3 AV DP 12 E-02 MP 3146 (3/02) AvMru HEALTH PLAN Durable Medical Equipment (DME) Pohcy 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, mcludmg 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 mfusion 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, 2003 to April 30 2004 Subscribing Group AvMed, Inc d/b/a AvMed Health Plan By By Signature Evis Clavareza Name Name Title Date Date 7 </ c 2) Account Service Manager AV-G100-DME-2000-E-01 MP -2148 (9/01) Title AvMnr HEALTH PLAN ELECTIVE TERMINATION OF PREGNANCY POLICY ENDORSEMENT 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, 2003 to April 30, 2004 Subsc ► g Grou By Name / Signatur('-' Title AvMed, Inc d/b/a AvMed Health Plan By Evis Clavareza Name Account Service Manager Date Date '7 // AV G100-ETP 97 MP 1640 (6/97) Title AvMEDTm 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 criteria for covered products and related 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 - Pre-authonzation 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, 2003 to April 30 00 2004 AvMed, Inc d/b/a AvMed He n _, ,c.r., tit/ By Signature Evis Clavareza Name Name Title Date AV G100 1DB E 01 MP 3062 (9/01) Account ServirP MAnajer Title Date 7 // <713