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HomeMy Public PortalAboutAgreement 05-01-06 - 04-30-07AvMed Health Plans Group Medical and Hospital Service Contract AV G100 2005 MP 3699 (10/05) TABLE OF CONTENTS SERVICE AREAS 1 I GENERAL 1 II INTERPRETATION 1 III DEFINITIONS 2 IV ELIGIBILITY 8 V ENROLLMENT 10 VI EFFECTIVE DATE OF MEMBERSHIP 10 VII MONTHLY PAYMENTS AND CO PAYMENTS 12 VIII CONVERSION 13 IX TERMINATION 15 X SCHEDULE OF BASIC BENEFITS 22 XI LIMITATIONS OF BASIC BENEFITS 30 XII EXCLUSIONS FROM BASIC BENEFITS 31 XIII COORDINATION OF BENEFITS 35 XIV REIMBURSEMENT 38 XV DISCLAIMER OF LIABILITY 38 XVI GRIEVANCE PROCEDURE 39 XVII MISCELLANEOUS 45 AV G100 2005 MP 3699 (10/05) AVMED CORPORATE OFFICE 9400 S DADELAND BLVD P O 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 Miami -Dade FT LAUDERDALE 13450 W Sunrise Boulevard Suite 370 Sunrise Florida 33323 2947 (954) 462-2520 (800) 368 9189 Broward Palm Beach JACKSONVILLE 1300 Riverplace Boulevard Suite 200 Jacksonville Florida 32207 (904) 858-1300 (800) 227-4184 Baker Clay Duval Nassau St Johns GAINESVILLE 4300 N W 89th Boulevard Post Office Box 749 Gainesville Florida 32606 0749 (352) 372 8400 (800) 346 0231 Alachua Bradford Citrus Columbia Dixie Gilchrist Hamilton Levy Marion Suwannee Union ORLANDO 541 South Orlando Avenue Suite 205 Maitland Florida 32751 (407) 539 0007 (800) 227-4848 Orange Osceola Seminole TAMPA BAY/ SOUTHWEST FLORIDA 1511 North Westshore Boulevard Suite 450 Tampa Florida 33607 (813) 281-5650 (800) 257-2273 Hernando Hillsboro Lee Pasco Pinellas Polk Sarasota AVMED MEMBER SERVICES - ALL AREAS 1-800-88 AVMED (1-800-882-8633) AV G100 2005 MP 3699 (10/05) AvMed, INC d/b/a AvMed HEALTH PLANS GROUP MEDICAL AND HOSPITAL SERVICE CONTRACT IN CONSIDERATION of the payment of monthly prepayment subscription charges as provided herein and of mutual promises and benefits hereinafter described AvMed Inc a Florida corporation d/b/a AvMed Health Plans (hereinafter referred to as "AvMed"), and (hereinafter referred to as "Subscribing Group") agree as follows I GENERAL The Subscribing Group engages AvMed Health Plans on behalf of the group health plan described herein (the Plan") to arrange for the provision of Medical Services or benefits which are Medically Necessary for the diagnosis and treatment of Members of the Subscribing Group through a network of contracted independent physicians and Hospitals and other independent health care providers who are not agents or employees of AvMed (see Section 15 04) AvMed in so arranging for the delivery of Medical Services or benefits, does not directly provide these Medical Services or benefits AvMed arranges for the provision of said services in accordance with the covenants and conditions contained in this Contract AvMed shall rely upon the statements of the Subscriber in his application in providing coverage and benefits hereunder This Contract is not intended to and does not cover or provide any Medical Services or benefits that are not Medically Necessary for the diagnosis and treatment of the Member The determination as to which services are Medically Necessary shall be made by AvMed subject to the terms and conditions of this Contract AvMed reserves the right to make changes in coverage criteria for covered products and services Coverage criteria are medical and pharmaceutical protocols used to determine payment of products and services and are based on independent clinical practice guidelines and standards of 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 Hospital and medical facilities and of the Participating Providers AvMed operates on a direct service rather than indemnity basis The interpretation of this Contract shall be guided by the direct service nature of AvMed's program and the definitions and other provisions contained herein 1 AV G100 2005 MP 3699 (10/05) 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 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 "AvMed, ' means a private not for profit Florida corporation, state licensed as a health maintenance organization under Chapter 641 Florida Statutes for the purpose of arranging for prepaid health care services to its Members under the terms and conditions set forth in this Contract 3 03 "Claim" means a request for benefits under this Contract made by a Member in accordance with AvMed s procedures for filing benefit claims, including Pre Service Claims and Post -Service Claims 3 04 "Claimant" means a Member or a Member s authorized representative acting on behalf of the Member AvMed may establish procedures for determining whether an individual is authorized to act on behalf of the Member If the Claim is an Urgent Care or Pre Service Claim a Health Professional with knowledge of the Member s medical condition shall be permitted to act as the Member's authorized representative and will be notified of all approvals on the Claimant s behalf In the event of an Adverse Benefit Determination, AvMed will notify both the Member and the Heath Professional 3 05 "Concurrent Care" means an ongoing course of treatment to be provided over a period of time or number of treatments that was previously approved by AvMed 3 06 "Contract" means this Group Medical and Hospital Service Contract which may at times be referred to as "Group Contract" or "Subscribing Group Contract" and all applications rate letters, face sheets, riders, amendments, addenda exhibits, supplemental agreements, and schedules which are or may be incorporated in this Contract from time to time 3 07 "Contract Year" means the period of 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 Conversion Contract " 3 09 "Co -payment" means the charge, in addition to the prepaid premium charges, which the Subscriber is required to pay at the time certain health services are provided under this Contract The Co -payment may be a specific dollar amount or a percentage of the cost The Member is responsible for the payment of any Co -payment charges directly to the provider of the health services at the time of service 2 AV G100 2005 MP 3699 (10/05) 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 medications "Custodial Care" also means services and supplies that can be safely and adequately provided by persons other than licensed health care professionals, such as dressing changes and catheter care, or that ambulatory patients customarily provide for themselves such as ostomy care administering insulin and measuring and recording urine and blood sugar levels 3 11 "Dental Care" means dental x-rays examinations and treatment of the teeth or any services supplies or charges directly related to (i) the care, filling removal or replacement of teeth, or (ii) the treatment of injuries to or disease of the teeth, gums or structures directly supporting or attached to the teeth that are customarily provided by dentists (including orthodontics reconstructive jaw surgery casts splints and services for dental malocclusion) 3 12 "Dependent" means any member of a Subscriber's family who meets all applicable requirements of Part IV and is enrolled hereunder and for whom the prepayment required by Part VII has actually been received by AvMed 3 13 "Durable Medical Equipment (DME), Orthotics, and/or Prosthetics" Coverage for DME orthotics and prosthetics is limited as outlined in Sections 10 20, 10 21 and 10 22 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 benefits 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 3 14 03 a) That there is inadequate time to effect safe transfer to another Hospital prior to delivery b) That a transfer may pose a threat to the health and safety of the patient or fetus or c) That there is evidence of the onset and persistence of uterine contractions or rupture of the membranes Examples of Emergency Medical Conditions include but are not limited to heart attack stroke, massive internal or external bleeding, fractured limbs or severe trauma 3 AV G100 2005 MP 3699 (10/05) 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 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 AvMed and may be made retrospectively based upon all information known at the time the 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 AvMed and may be made retrospectively based upon all information known at the time the patient was present for treatment 3 16 "Exclusion" means any provision of this Contract whereby coverage for a specific hazard or condition is entirely eliminated 3 17 "Full -Time Student" means one who is attending a recognized and/or accredited college, university vocational or secondary school and is carrying sufficient credits to qualify as a full time student in accordance with the requirements of the school (See Subsection 4 02 02(f)) 3 18 "Group Health Insurance" (for purposes of Part XIII) means that form of health insurance covering groups of persons under a master Group Health Insurance policy issued to any one of the groups listed in Sections 627 552 (employee groups) 627 553 (debtor groups), 627 554 (labor union and association groups) and 627 5565 (additional groups) Florida Statutes 3 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 Professionals" means physicians, osteopaths podiatrists, chiropractors, physician assistants nurses social workers, pharmacists optometrists, clinical psychologists nutritionists, occupational therapists physical therapists and other professionals engaged in the delivery of health care services who are licensed and practice under an institutional license, individual practice association or other authority consistent with State law and who are Participating Providers of AvMed Health Plans 3 20 "Home Health Care Services (Skilled Home Health Care)" means services that are provided for a Member who does not require confinement in a Hospital or Other Health Care Facility Such services include, but are not limited to, the services of professional visiting nurses or other health 4 AV G100 2005 MP 3699 (10/05) care personnel for services covered under this Contract See Section 10 08 regarding physical and occupational therapy Limitations 3 21 "Hospice" means a public agency or private organization that is duly licensed by the State to provide Hospice services and with whom AvMed has a current provider agreement Such licensed entity must be principally engaged in providing pain relief, symptom management, and supportive services to terminally ill Members 3 22 Hospital" means any general acute care facility which is licensed by the State and with which AvMed has contracted or established arrangements for inpatient Hospital Services and/or Emergency Medical Services and Care and shall at times be referred to as a "Participating Hospital " 3 23 "Hospital Services" (except as expressly limited or excluded by this Contract) means those services for registered bed patients that are a) Generally and customarily provided by acute care general Hospitals within the Service Area b) Performed, prescribed, or directed by Participating Providers, and c) 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 24 "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 25 "Injectable Drug" means a medication that has been approved by the Food and Drug Administration (FDA) for administration by one or more of the following routes intramuscular injection, intravenous injection, intravenous infusion subcutaneous injection intrathecal injection intrarticular injection intracavernous injection or intraocular injection Pre authorization is required for Injectable Drugs 3 26 "Limitation" means any provision other than an Exclusion which restricts coverage under this Contract 3 27 "Master Application" means the Subscribing Group application form entitled "Master Application" which becomes a part of the Contract when the Master Application has been completed and executed by the Subscribing Group and AvMed 3 28 "Medically Necessary" means the use of any appropriate medical treatment service equipment and/or supply as provided by a Hospital, skilled nursing facility, physician, or other provider which is necessary for the diagnosis, care and/or treatment of a Member's illness or injury and which is a) Consistent with the symptom diagnosis and treatment of the Member's condition b) The most appropriate level of supply and/or service for the diagnosis and treatment of the Member's condition c) In accordance with standards of acceptable community practice 5 AV G100 2005 MP 3699 (10/05) d) Not primarily intended for the personal comfort or convenience of the Member the Member's family, the physician, or other health care providers, e) Approved by the appropriate medical body or health care specialty involved as effective appropriate, and essential for the care and treatment of the Member's condition f) Not experimental or investigational 3 29 "Medical Office" means any outpatient facility or physician's office in the Service Area utilized by a Participating Provider 3 30 "Medical Services" (except as limited or excluded by this Contract) means those professional services of physicians and other Health Professionals, including medical, surgical, diagnostic therapeutic, and preventive services, that are a) Generally and customarily provided in the Service Area b) Performed prescribed or directed by Participating Providers and c) Medically Necessary (except for preventive services as stated herein) for the diagnosis and treatment of injury or illness 3 31 "Member" means any Subscriber or Dependent, as described in Part III, Sections 3 12 and 3 43, of this Contract 3 32 "Non -participating Provider" means any Health Professional or group of Health Professionals or Hospital Medical Office, or Other Health Care Facility with whom AvMed has neither made arrangements nor contracted to render the professional health services set forth herein as a Participating Provider 3 33 "Other Health Care Facihty(ies)" means any licensed facility, other than acute care Hospitals and those facilities providing services to ventilator dependent patients which provides inpatient services such as skilled nursing care or rehabilitative services for which AvMed has contracted or established arrangements for providing these services to Members Coverage is limited to 20 days per calendar year 3 34 "Participating Provider" means any Health Professional or group of Health Professionals or Hospital Medical Office, or Other Health Care Facility with whom AvMed has made arrangements or contracted to render the professional health services set forth herein 3 35 "Participating Physician" means any Participating Provider licensed under Chapter 458 (physician) 459 (osteopath), 460 (chiropractor) or 461 (podiatrist), Florida Statutes "Attending Physician" means the Participating Physician primarily responsible for the care of a Member with respect to any particular injury or illness 3 36 "Post -Service Claim" means any Claim for benefits under the Plan that is not a Pre Service Claim 3 37 "Pre -Service Claim" means any Claim for benefits under the Plan with respect to which in whole or in part a Member must obtain authorization from AvMed in advance of such services being provided to or received by the Member 6 AV G100 2005 MP 3699 (10/05) 3 38 Primary Care Physician" means a Participating Provider physician engaged in family practice pediatrics internal medicine obstetrics/gynecology or any specialty physician from time to time designated by AvMed as a "Primary Care Physician" in AvMed's current list of physicians and Hospitals 3 39 "Relevant Document" means any documentation that a) Was relied upon in making the benefit determination b) Was submitted considered or generated in the course of making the benefit determination, without regard to whether it was relied upon in making the determination, c) Demonstrates compliance with the administrative process and d) Constitutes a statement of policy or guidance with respect to the Plan concerning the Adverse Benefit Determination for the Claimant s diagnosis without regard to whether such advice or statement was relied upon in making the Adverse Benefit Determination 3 40 "Self -Administered Injectable Drug" means a medication that has been approved by the FDA for self -injection and is administered by subcutaneous injection or a medication for which there are instructions to the patient for self injection in the manufacturer s prescribing information (package insert) 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 Financial Services 3 42 "Specialty Health Care Physician" means any Participating Physician licensed under Chapter 458 (physician), 459 (osteopath) 460 (chiropractor) or 461 (podiatrist) Florida Statutes other than the Member's chosen Primary Care Physician 3 43 "Subscriber" means a person who meets all applicable requirements of Section 4 01 enrolls in the Plan and for whom the premium prepayment required by Part VII has actually been received by AvMed 3 44 "Subscribing Group" means a corporation partnership limited liability company or other legal entity (and its wholly owned subsidiaries) that negotiates and agrees to contract for the health services and benefits provided herein for its eligible employees 3 45 "Total Disability" means a totally disabling condition resulting from an illness or injury which prevents the Member from engaging in any employment or occupation for which he may otherwise become qualified by reason of education training or experience, and for which the Member is under the regular care of a physician 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 opinion of a physician with knowledge of the Member's medical condition would subject the Member to severe pain that cannot be adequately managed without the care or treatment requested Generally, the determination of whether a Claim is an Urgent Care Claim shall be 7 AV G100 2005 MP 3699 (10/05) made by an individual acting on behalf of AvMed applying the judgment of a prudent layperson who possesses an average knowledge of health and medicine However, if a physician with knowledge of the Member's medical condition determines that the Claim is an Urgent Care Claim, it shall be deemed as such 3 47 "Urgent Care/Immediate Care" means medical screening, examination and evaluation received in an Urgent Care Center or Immediate Care Center or rendered in your Primary Care Physician's office after-hours and the covered services for those conditions which, although not life -threatening, could result in serious injury or disability if left untreated 3 48 "Utilization Management Program" means those comprehensive initiatives that are designed to validate medical appropriateness and to coordinate covered services and supplies These include but are not limited to (1) concurrent review of all patients hospitalized in acute care psychiatric rehabilitation and skilled nursing facilities, including on site review when appropriate, (2) case management and discharge planning for all inpatients and those requiring continued care in an alternative setting (such as home care or a skilled nursing facility) and for outpatients when deemed appropriate, and (3) the Benefit Coordination Program which is designed to conduct prospective reviews for select medical services to ensure that services are covered and Medically Necessary The Benefit Coordination Program may also advocate alternative cost effective settings for the delivery of prescribed care and may identify other options for non covered health care needs 3 49 "Ventilator Dependent Care Unit" means care received in any facility which provides services to ventilator dependent patients other than acute Hospital care including all types of facilities known as sub acute care units ventilator dependent units, alternative care units, sub acute care centers, and all other like facilities whether maintained in a free standing facility or maintained in a Hospital or skilled nursing facility setting Coverage is limited to 100 days lifetime maximum IV ELIGIBILITY 4 01 To be eligible to enroll as a Subscriber a person must be 4 01 01 An employee of the Subscribing Group who works the required number of hours per week as set forth in the Master Application for this Contract The employee must either work or reside in the Service Area Except as provided for Emergency Medical Services and Care, the covered services and benefits are available only from Participating Providers 4 01 02 Employed for the period of time required for eligibility as set forth in the Master Application, and 4 01 03 Entitled on his own behalf to participate in the medical and Hospital care benefits arranged by the Subscribing Group under this Contract 4 02 To be eligible to enroll as a Dependent a person must be 4 02 01 The spouse of the Subscriber, a new spouse must be enrolled within 31 days after marriage in order to be covered, or 4 02 02 A child of the Subscriber or a child of a covered Dependent of the Subscriber provided that the following conditions apply 8 AV G100 2005 MP 3699 (10/05) a) The child is the natural child or stepchild of the Subscriber, a legally adopted child in the custody of the Subscriber from the time of placement in the home (written evidence of adoption must be furnished to AvMed upon request) a child for whom the Subscriber 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 30 hours or more per week e) The child is not married 0 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 AvMed when full time attendance commences or terminates, and coverage shall commence or terminate upon such notification Termination of coverage will be retroactively applied if AvMed is not notified Subscriber agrees to provide documentation of Full Time Student status upon request by AvMed g) The child is age 19 or over and is wholly dependent on the Subscriber due to mental retardation or physical handicap (See Section 4 04) h) In the event an eligible Dependent child does not reside with the Subscriber coverage will be extended when the Subscriber is obligated to provide medical care by a qualified medical child support order You (or your beneficiaries) may obtain without charge copies of the Plan s procedures governing qualified medical child support orders and a sample qualified medical child support order by contacting the Plan Administrator i) In the case of a newborn child AvMed should be notified in writing prior to the scheduled delivery date of the Subscriber's intention to enroll the newborn child but such notice shall not be later than 31 days after the birth If timely notice is provided, no additional premium will be charged for the additional coverage of the newborn during the 31 day period following the birth of the child If timely notice is not provided the additional premium for the additional coverage of the newborn child will be charged from the child's date of birth If notice is not provided within 60 days of the birth the child may not be enrolled until the next open enrollment period of the Subscribing Group All services applicable for covered Dependent children under this Contract shall be provided to an enrolled newborn child of the Subscriber or to the enrolled newborn child of a covered Dependent of the Subscriber or to the newborn adopted child of the Subscriber provided that a written agreement to adopt such child has been entered into 9 AV G100 2005 MP 3699 (10/05) (prior to the birth of the child) from the moment of birth (as provided in Part X, Section 10 11) In the case of the newborn adopted child, however, coverage shall not be effective if the child is not ultimately placed in the Subscriber's residence in compliance with Florida law Coverage for the newborn child of a covered Dependent of the Subscriber (other than the spouse of the Subscriber) shall terminate 18 months after the birth of the newborn child 4 03 No person is eligible to enroll hereunder who has had his coverage previously terminated under Part IX Subsection 9 01 05 except with the written approval of AvMed 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 a) Incapable of self-sustaining employment by reason of mental retardation or physical handicap and b) Chiefly dependent upon the Subscriber for support and maintenance provided proof of such incapacity and dependency is furnished to AvMed by Subscriber within 31 days of the child's attainment of the limiting age and subsequently as may be required by AvMed but not more frequently than annually after the two year period following the child's attainment of the limiting age 4 05 During the term of this Contract no changes in the Subscribing Group eligibility or requirements of participation shall be permitted to effect eligibility or enrollment under this Contract unless such change is agreed to by AvMed V ENROLLMENT 5 01 Prior to the effective date of this Contract and at a proper time prior to each anniversary thereof AvMed may allow an open enrollment period of 31 days in which any eligible Subscriber on behalf of himself and his Dependents may elect to enroll in the Plan 5 02 Except as provided for newborns, eligible Subscribers and Dependents who meet the requirements of Part IV, Sections 4 01 and 4 02 must enroll within 31 days after becoming eligible by submitting application forms acceptable to or provided by AvMed 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 in the Plan outside of the initial enrollment and annual open enrollment periods if that individual within the immediately preceding 31 days was covered under another employer health benefit plan as an employee or the dependent of an employee at the time he was initially eligible to enroll for coverage under the Plan, and 5 03 01 Demonstrates that he or his Dependent has experienced one of the following status change events including a) Marriage, b) Birth, adoption or placement for adoption 10 AV G100 2005 MP 3699 (10/05) c) Legal separation, divorce or annulment, d) Change in legal custody or legal guardianship e) Death, f) Relocation into or out of the Service Area g) Termination/commencement of employment h) Reduction in the number of hours of employment, i) Commencement of or return from leave of absence, j) Change in employment status k) Change in worksite 1) Strike or lockout m) Termination of employer contributions toward such coverage, n) Exhaustion of COBRA coverage o) Attainment of lifetime maximum and 5 03 02 Requests enrollment within 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 AvMed will not be accepted if at the time of initial offering to Subscribing Group or following re enrollment the total enrollment does not result in a predetermined minimum enrollment as established by AvMed The required minimum group enrollment is included in the rate letter submitted to Subscribing Group VI EFFECTIVE DATE OF MEMBERSHIP Subject to the payment of applicable monthly premium charges set forth in Part VII and to the provisions of this Contract coverage under this Plan 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 covered under the Plan if within 31 days (or as 11 AV G100 2005 MP 3699 (10/05) 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 AvMed within the 31 day 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 in the case of marriage on the first day of the month following the date of marriage During this period you and your eligible spouse may also enroll for medical coverage under the Plan if not already covered However, if an enrollment request is not received by AvMed within the required time frame you and your eligible Dependents will be required to wait until the next open enrollment period to apply for coverage 6 03 If you or your Dependents originally declined medical coverage 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 the termination of employer contributions The effective date of any coverage provided by AvMed will be the first day of the month following the date you enroll If you fail to enroll within 31 days after the loss of other coverage you must wait until the next open enrollment period to apply for coverage 6 04 Coverage for the newborn child of the Subscriber or the 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 AvMed 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 AvMed 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 the premium due by the first of the month and not later than the end of the grace period (as provided in Section 7 02) shall result in retroactive termination of the Subscribing Group effective at 12 00 a m (midnight) on the last day of the month for which the premium was paid unless the payment of premiums has otherwise been contractually adjusted and specified by the parties in a fully executed addendum to this Contract An additional charge will apply to all late premium payments (See Section 17 14) 7 02 Grace Period This Contract has a ten-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 the premium will be retroactive to 12 00 a m (midnight) on the last day of the month for which the premium was paid Note Certain provisions in Section 7 01 may apply if the parties have executed an addendum affecting premium payments 7 03 Maximum Co payments Total annual Co -payments are limited as described in your Schedule of Benefits The Co -payment limits apply to Co -payments made for all core benefits contained in this Contract and do not apply to services provided under the Prescription Drug Mental Health Substance Abuse, Vision and other supplemental riders 12 AV G100 2005 MP 3699 (10/05) 7 04 Member shall pay premiums, applicable supplemental charges or Co payments as provided in this Contract If the Member fails to pay the applicable premiums, upon ten days written notice from AvMed to Member the Member's rights hereunder shall be terminated Consideration for reinstatement with AvMed shall require a new application, and any re enrollment shall be at the sole discretion of AvMed and shall not be retroactive 7 05 Refund of premiums paid to AvMed by the Subscribing Group for any Member after the date on which that Member's eligibility ceased or the Member was terminated shall be limited to the total excess premium amounts paid up to a maximum of 60 days from the date of such ineligibility or termination provided there are no claims incurred subsequent to the effective date of termination No retroactive terminations of Members will be made beyond 60 days from notification of the terminating event 7 06 In the event of the retroactive termination of an individual Member (as described in Subsections 9 01 02 and 9 02 01 of this Contract) AvMed shall not be responsible for medical expenses incurred by AvMed in providing benefits to the Member under the terms of this Contract after the effective date of termination (due to the Subscribing Group's nonpayment of premiums or failure to timely notify AvMed of Member ineligibility) At the discretion of AvMed and based on the facts available at the time AvMed may pursue either the Subscribing Group or the Member for payment VIII CONVERSION 8 01 A Subscriber or covered Dependent whose coverage under the Subscribing Group Contract has been terminated for any reason including discontinuance of the Subscribing Group Contract in its entirety or with respect to a covered class and who has been continuously covered under the Subscribing Group Contract, and under any group health maintenance contract providing similar benefits which it replaces for at least three months immediately prior to 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 31 days 8 01 01 8 01 02 The converting Subscriber and each of the eligible Dependents of the Subscriber who are converting must be Members of the Plan in good standing on the date when their coverage terminates under this Group Contract and all such Subscribers and Dependents after complying with Subsection 8 01 02 below, shall be covered under the Individual Conversion Contract A completed status change form requesting conversion shall be sent to AvMed or its designated administrator with the first applicable premium and shall be received by AvMed or its designated administrator not later than 63 days after the date of termination of this Group Contract 8 01 03 Dependents may not convert without the Subscriber except a) In the event of the death of the Subscriber Dependents are permitted an automatic conversion privilege and must comply with Subsection 8 01 02 above b) A spouse whose coverage would terminate or a spouse and children whose coverage would otherwise terminate at the same time or a child with respect to 13 AV G100 2005 MP 3699 (10/05) himself, by reason of ceasing to be a qualified family member, may convert and must comply with Subsection 8 01 02 above c) A former spouse whose coverage would otherwise terminate because of annulment or dissolution of marriage may convert if the former spouse is dependent for financial support The former spouse must comply with Subsection 8 01 02 above and must provide written evidence of financial dependence upon request of AvMed 8 01 04 Payment for health care services rendered to a Member after termination and prior to conversion shall be the responsibility of the Member When the conversion application has been timely completed (within 63 days after termination of the Group Contract) and the first premium due has been paid, AvMed 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 the premium on the day following the Member's termination from group coverage (due to ineligibility under the Group Contract) and continues through the end of the calendar year The Contract Year upon renewal shall be the calendar year 8 02 Individual Conversion Contracts may not include supplemental benefits notwithstanding the supplemental benefits included under this Subscribing Group Contract and may in other respects as determined by AvMed, 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 a) Failure to pay any required premium or contribution unless such nonpayment of premium was due to acts of an employer or person other than the individual, b) Replacement of any discontinued group coverage by similar group coverage within 31 days c) Fraud or material misrepresentation in applying for any benefits under this Contract, (See Subsection 9 01 05) d) Willful and knowing misuse of AvMed's identification card by the Subscriber e) Willfully and knowingly furnishing incorrect or incomplete information to AvMed for the purpose of fraudulently obtaining coverage or benefits from AvMed, or f) Termination from coverage under this Contract in accordance with Subsection 9 01 05 8 04 Conversion After Continuation Coverage When continuation coverage 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 this Part VIII The eligible Subscriber or Dependent must send a completed application and the applicable premium payment, postmarked not later than 63 days after the termination of COBRA coverage directly to 14 AV G100 2005 MP 3699 (10/05) AvMed Health Plans Accounts Receivable Department Suite 510 9400 South Dadeland Blvd Miami Florida 33156 The Subscriber or Dependent may obtain an application form and a statement of current premium rates for the Individual Conversion Contract by calling AvMed Member Services It is the responsibility of the Subscribing Group to notify Subscriber of Subscriber's rights under COBRA For any specific questions concerning COBRA, contact the Subscribing Group IX TERMINATION All rights and benefits under this Contract shall cease as of the effective date of termination unless otherwise provided herein This Contract shall continue in effect for one year from the effective date hereof and may be renewed from year to year thereafter subject to the following termination provisions All rights to benefits under this Contract shall cease at 12 00 a m (midnight) on the effective date of termination 9 01 Reasons for Termination 9 01 01 Loss of 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 the Service Area coverage shall automatically terminate on the last day of the month for which the monthly premium was paid and during which the Subscriber and/or Dependent was eligible for coverage b) Coverage for all Dependents shall automatically terminate on the last day of the month for which the monthly premium was paid upon a loss of the Subscriber's eligibility, as defined in Part IV 9 01 02 Failure to Make Premium Payment - Upon failure of the Subscribing Group to make payment of the monthly premium provided in Part VII within ten days following the due date specified herein benefits hereunder shall terminate for all Subscribers and any Dependents for whom such payment has not been received at 12 00 am (midnight) on the last day of the month for which the monthly premium was paid AvMed regarding cancellation or non renewal of this coverage, may retroactively cancel the policy to the date for which the Subscribing Group's premiums have been paid when AvMed provides notice of cancellation or non renewal to the Subscribing Group prior to 45 days after the date the premium was due AvMed will include a reason for the Contract termination in its written notification to the Subscribing Group The Subscribing Group will forward such notification to all Subscribers when 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 15 AV G100 2005 MP 3699 (10/05) 9 01 03 9 01 04 Termination of Group Contract by Subscribing Group — Subscribing Group may terminate this Group Contract on the anniversary date by giving written notice to AvMed 15 days prior to Contract anniversary date In such event, benefits hereunder shall terminate for all Members at 12 00 a m (midnight) on Contract expiration date Termination of Group Contract by AvMed - AvMed may non -renew or discontinue this Group Contract based on one or more of the conditions listed below In such event benefits hereunder shall terminate for all Members at 12 00 a m (midnight) on the Contract expiration date as described below a) Subscribing Group has failed to pay premiums or contributions in accordance with the terms of this Contract or AvMed has not received timely premium payments (See Part VII Monthly Payments and Co -payments and Subsection 9 01 02) Termination of coverage will be effective on the last day of the month for which payments were received by AvMed 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 Contract that relates to rules for employer contributions or group participation Termination will be effective upon 45 days written notice from AvMed to Subscribing Group d) There is no longer any enrollee in connection with the Plan who lives, resides, or works in the Service Area Termination of coverage will be effective on the last day of the month for which payments were received by AvMed e) AvMed ceases to offer coverage in the applicable market AvMed will provide written notice to Subscribing Group at least 180 days prior to such termination 9 01 05 Termination of Coverage for Cause AvMed 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 years from the issue date, only fraudulent misstatements in the Application may be used to void the policy or deny any claim for a loss occurred or disability starting after the two year period b) misuse of AvMed's identification card furnished to the Member c) furnishing to AvMed incorrect or incomplete information for the purpose of obtaining membership, coverage or benefits under this Contract d) behavior which is disruptive, unruly, abusive, or uncooperative to the extent that the Member's continuing coverage under this Contract seriously impairs AvMed's ability to administer this Contract or to arrange for the delivery of health care services to the Member or other Members after AvMed has attempted to resolve the Member's problem 16 AV G100 2005 MP 3699 (10/05) At the effective date of such termination premium payments received by AvMed on account of such termination shall be refunded on a pro rata basis, and AvMed shall have no further liability or responsibility for the Member under this Contract 9 02 Notification Requirements 9 02 01 Loss of eligibility of Subscriber It is the responsibility of Subscribing Group to notify AvMed in writing within 31 days from the effective date of termination regarding any Subscriber and/or Dependent who becomes ineligible to participate in the Plan Failure of the Subscribing Group to provide timely written notice as described above may lead to retroactive termination of the Subscriber and/or Dependent The effective date for such retroactive termination will be the last day of the month for which the 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 AvMed in writing within 31 days of the Dependent becoming ineligible 9 02 03 Contract Termination In the event this Contract is terminated the Subscribing Group agrees that it shall provide 45 days prior written notification of the date of such termination to its employee Subscribers who are covered under this Contract In no event will any retroactive termination of a Member be made beyond 60 days from notification of the terminating event 9 03 Certificates of Coverage If your coverage under the Plan ends, you will automatically receive a Certificate of Group Health Plan Coverage You may take this certificate to another health care plan to receive credit for your coverage under the Plan You will only need to do this if the other health care plan has a pre-existing condition limit You can request a Certificate of Group Health Plan Coverage anytime during the 24 -month period after the date your coverage under the Plan has ended 9 04 Continuation Coverage under COBRA Under certain provisions of COBRA the Subscriber or his Dependents may elect continued coverage under the Plan if coverage is lost due to a qualifying event 9 04 01 Eligibility You or your covered Dependents will become eligible for continuation coverage under COBRA after any of the following qualifying events result in the loss of Plan coverage a) loss of benefits due to a reduction in your hours of employment b) termination of your employment including retirement but excluding termination for gross misconduct, c) termination of employment following leave under the Family and Medical Leave Act of 1993 (FMLA) 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 17 AV G100 2005 MP 3699 (10/05) d) you or a Dependent first become entitled to Medicare or covered under another group health plan prior to your loss of coverage due to termination of employment or reduction in hours 9 04 02 In addition, your Dependents will become eligible for COBRA continuation coverage after any of the following qualifying events occur to cause a loss of Plan coverage a) your death b) your divorce or legal separation, c) you first become entitled to Medicare after your loss of coverage due to termination of employment or reduction in hours or d) your Dependent child no longer qualifies as a Dependent under the Plan A child who is born to or placed for adoption with a covered former employee during the continuation coverage period has the same continuation coverage rights as a Dependent child described above 9 04 03 Notification If a qualifying event other than divorce legal separation loss of Dependent status or entitlement to Medicare occurs, the Plan Administrator will be notified of the qualifying event by your employer and will send you an election form To continue Plan coverage, you must return the election form within 60 days from the later of the date you receive the form, or the date your coverage ends due to a qualifying event If divorce, legal separation loss of Dependent status or entitlement to Medicare under the Plan occurs, you or your covered Dependent must notify the Plan Administrator that a qualifying event has occurred This notification must be received by the Plan Administrator within 60 days after the later of the date of such event or the date you or your eligible Dependent would lose coverage on account of such event Failure to promptly notify the Plan Administrator of these events will result in loss of the right to continue coverage for you and your Dependents After receiving this notice, the Plan Administrator will send you an election form within 14 days If you or your Dependents wish to elect continuation coverage the election form must be returned to the Plan Administrator within 60 days from the later of the date you receive the form or the date your coverage ends due to the qualifying event 9 04 04 Cost If you elect to continue coverage you must pay the entire cost of coverage (the employer s contribution and the active employee portion of the contribution) plus a 2% administrative fee for the duration of COBRA continuation coverage If you or your Dependent is Social Security disabled (Social Security disability status must occur as defined by Title II or Title XVI of the Social Security Act) you may elect to continue coverage for the disabled person only or for some or all of COBRA eligible family members for up to 29 months if your employment is terminated or 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 18 AV G100 2005 MP 3699 (10/05) coverage for the 19th through the 29th months of coverage The Social Security disability date must occur within the first 60 days of loss of coverage due to your termination of employment or reduction in hours For COBRA coverage to remain in effect, payment must be received by the Plan Administrator by the first day of the month for which the premium is due (Your first payment is due no later than 45 days after your election to continue coverage and it must cover the period of time back to the first day of your COBRA continuation coverage ) 9 04 05 Duration COBRA Continuation Coverage can be extended for a) 18 months if coverage ended due to a reduction in your work hours or termination of your employment and you or one of your covered Dependents is not Social Security disabled within 60 days of the date you lose coverage due to termination of employment or reduction in hours the Medicare entitled person may elect up to 18 months of COBRA If you are that Medicare entitled person your Dependents may elect COBRA for the longer of 36 months from your prior Medicare entitlement date or 18 months from the date of your termination or reduction in hours b) 36 months for your Dependents if your Dependents lose eligibility for medical coverage due to your death your divorce or legal separation your entitlement to Medicare after your termination or reduction in hours or your Dependent child ceasing to qualify as a Dependent under the Plan c) 29 months if you lose coverage due to a termination of employment or reduction in hours and you or a Dependent is disabled as defined by Title II or Title XVI of the Social Security Act within 60 days of the original qualifying event In this case you may continue coverage for an additional 11 months after the original 18 month period either for the disabled person only or for one or all of your covered family members To be eligible for extended coverage due to Social Security disability, you must notify the Plan Administrator of the disability before the end of the initial 18 months of COBRA continuation coverage and within 60 days following the date you or a covered Dependent is determined to be disabled by the Social Security Administration If the disabled individual should no longer be considered to be disabled by the Social Security Administration you must notify the Plan Administrator within 30 days following the end of the disability Coverage that has exceeded the original 18 -month continuation period will end when the individual is no longer Social Security disabled If more than one qualifying event occurs no more than 36 months total of COBRA continuation coverage will be available The COBRA beneficiary must experience the second qualifying event during the first 18 months of COBRA continuation and must provide notice to the Plan 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 19 AV G100 2005 MP 3699 (10/05) 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 FMLA you may be entitled to up to a total of 12 weeks of unpaid job protected leave during each calendar year for the following a) the birth of your child, to care for your newborn child or for placement of a child in your home for adoption or foster care, b) to care for your spouse child or parent with a serious health condition or c) for your own serious health condition If your FMLA leave is a paid leave your pay will be reduced by your before -tax contributions as usual for the coverage level in effect on the date your FMLA leave begins If your FMLA leave is unpaid you will be required to pay your contributions directly to the employer until you return to active pay status If you notify your employer that you are terminating employment during your FMLA leave, your coverage will end on the date of your notification If you do not return to work on your expected FMLA return date and you do not notify your employer of your intent either to terminate your employment or to extend the period of leave, your 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 The Health Insurance Portability and Accountability Act of 1996 (HIPAA) 9 05 02 Military Leaves of Absence If you are absent from work due to military service you may elect to continue coverage under the 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 20 AV G100 2005 MP 3699 (10/05) 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 carrier elects to provide replacement coverage without limitation as to the disability condition or d) The maximum benefits payable under this Contract have been paid 9 07 02 In the case of maternity coverage when not covered by the succeeding carrier a reasonable extension of this Contract's benefits will be provided to cover maternity expenses for a covered pregnancy that commenced while the policy was in effect The extension shall be for the period of that pregnancy only and shall not be based upon Total Disability 9 07 03 Except as provided above no Subscriber is entitled to an extension of benefits if the termination by Avmed of this Contract is based upon one or more of the following reasons a) Fraud or intentional misrepresentation in applying for any benefits under this Contract b) Disenrollment for cause c) The Subscriber has left the geographic Service Area of AvMed with the intent to relocate or establish a new residence outside AvMed's Service Area X SCHEDULE OF BASIC BENEFITS AvMed is committed to arranging for comprehensive prepaid health care services rendered to its Subscribers through AvMed's network of contracted independent physicians and Hospitals and other independent health care providers under reasonable standards of quality health care The professional judgment of a physician licensed under 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 AvMed 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 AvMed Only services and benefits in conformity with Part III (Definitions), Part X (Schedule of Basic Benefits), Part XI (Limitations of Basic Benefits) Part XII (Exclusions from Basic Benefits) and the Schedule of 21 AV G100 2005 MP 3699 (10/05) Benefits, which by reference is incorporated herein, are covered by AvMed It is the Member's responsibility when seeking benefits under this Contract to identify himself as a Member of AvMed 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 advance authorization from AvMed, or when the service is beyond the scope of practice authorized for that provider under State law are not covered unless such services otherwise have been expressly authorized under the terms of this Contract or when required to treat an Emergency Medical Condition Except for Emergency Medical Services and Care, all services must be received from Participating Providers If a Member does not follow the access rules, he risks having the 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 The following services require authorization from AvMed's Benefit Coordination Department 1 Inpatient admissions 2 All Home Health Care Services 3 Complex diagnostic procedures performed in an outpatient Hospital Hospital affiliated diagnostic treatment facility, or free-standing diagnostic treatment facility 4 Surgical procedures or services performed in an outpatient Hospital Hospital -affiliated ambulatory surgery center or free standing ambulatory surgery center 5 All drugs administered in an outpatient Hospital or infusion therapy setting 6 Select drugs administered in a physician s office 7 Care rendered by Non participating Providers (except for Emergency Medical Services and Care) 8 Transplant services 9 Dialysis services Also Members must understand that services will not be covered if they are not in AvMed Health Plans' opinion, Medically Necessary Any and all decisions made by AvMed in 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 AvMed Any and all decisions that pertain to the medical need for or desirability of the provision or non provision of Medical Services or benefits including without limitation, the most appropriate level of such Medical Services or benefits, must be made solely by the Member and his physician, in accordance with the normal patient/physician relationship for purposes of determining what is in the best interest of the Member AvMed does not have the right of control over the medical decisions made by the 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 arranged or paid for by AvMed MEMBERS ARE RESPONSIBLE AND WILL BE LIABLE FOR CO -PAYMENTS WHICH MUST BE PAID TO HEALTH CARE PROVIDERS FOR CERTAIN SERVICES, AT THE TIME SERVICES ARE RENDERED, AS SET FORTH IN THE SCHEDULE OF BENEFITS 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 v NAAN. AvMed org Notwithstanding the printed booklet, the names and addresses of Participating Providers on file with AvMed at any 22 AV G100 2005 MP 3699 (10/05) given time shall constitute the official and controlling list of Participating Providers Pursuant to Florida Statute there is a link available on the AvMed website to view the performance outcome and financial data that is published by the Florida Agency for Health Care Administration 10 02 Within the Service Area Members are entitled to receive the covered services and benefits only as herein specified appropriately prescribed or directed by Participating Physicians The covered services and benefits listed in the section entitled Schedule of Basic Benefits are available only from Participating Providers within the Service Area and except for Emergency Medical Services and Care as provided in Section 10 12 AvMed shall have no liability or obligation whatsoever on account of services or benefits sought or received by any Member from any Non- participating Provider or other person, institution or organization, unless prior arrangements have been made for the Member and confirmed by written referral or authorization from AvMed 10 03 Each Member shall select one Primary Care Physician upon enrollment If you do not select a Primary Care Physician upon enrollment, AvMed will assign one for you You must notify and receive approval from AvMed prior to changing your Primary Care Physician Such change will become effective on the first day of the month after you notify AvMed You cannot change your Primary Care Physician selection more than once per month The services of Specialty Health Care Physicians are covered only when you are referred by your Primary Care Physician and as approved by AvMed Health Professionals may from time to time cease their affiliation with AvMed In such cases you will be required to receive services from another participating Health Professional 10 04 Any Member requiring medical Hospital or ambulance services for emergencies (as described in Sections 3 14 and 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 AvMed Inpatient services include semi private room and board birthing rooms newborn nursery care nursing care meals and special diets when Medically Necessary use of operating rooms and related facilities the intensive care unit and services, diagnostic imaging, laboratory and other diagnostic tests 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 Medical Services and Care Pre authorization from AvMed is required for inpatient Hospital Services for substance abuse and these services are subject to the conditions set forth in the optional coverage selected (Also see Section 11 05) 10 06 Physician Care Inpatient All Medical Services rendered by Participating Physicians and other Health Professionals when requested or directed by the Attending Physician, including surgical procedures anesthesia consultation and treatment by Specialty Health Care Physicians laboratory and diagnostic imaging services and physical therapy (See Section 10 08) are provided while the Member is admitted to a Participating Hospital as a registered bed patient When available and requested by the Member AvMed covers the services of a certified nurse anesthetist licensed under Chapter 464 Florida Statutes 23 AV G100 2005 MP 3699 (10/05) 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 Physicians Also included are non -reusable materials and surgical supplies These services and materials are subject to the Limitations outlined in Part XI (Limitations of Basic Benefits) See Part XII for Exclusions 10 07 02 Preventive and Health Maintenance Services The services of the Member's Primary Care Physician for illness prevention and health maintenance, including child health supervision services and immunizations provided in accordance with prevailing medical standards consistent with the Recommendations for Preventive Pediatric Health Care of the American Academy of Pediatrics and/or the Advisory Committee on Immunization Practices sterilization (See Schedule of Benefits) periodic health assessment physical examinations, and voluntary family planning services are also covered These services are subject to Limitations as outlined in Part XI (Limitations of Basic Benefits) See Part XII for Exclusions 10 07 03 Outpatient Mental Health Services are covered only for diagnostic evaluation and crisis intervention These services are limited to a total of 20 outpatient visits per Contract Year Referral for outpatient mental health services must be arranged by the Member's Participating Physician and each visit requires a Co payment (See Schedule of Benefits) 10 08 Physical, Occupational or Speech Therapy Short-term physical, occupational or speech therapy provided in an outpatient or home care setting is covered for acute conditions including exacerbation of previously treated conditions for which therapy applied for a consecutive two month period can be expected to result in significant improvement Coverage of outpatient short- term and rehabilitative services is limited as outlined on the Schedule of Benefits Long term physical therapy, occupational therapy speech therapy rehabilitation or other treatment is not covered 10 09 Cardiac Rehabilitation Cardiac rehabilitation is covered for the following conditions acute myocardial infarction, percutaneous transluminal coronary angioplasty (PTCA), coronary artery bypass graft (CABG), repair or replacement of heart valves or heart transplant Coverage is limited to a maximum of 18 visits per calendar year See Schedule of Benefits for detailed information regarding Co -payments and Limitations 10 10 Obstetrical and Gynecological Care Obstetrical care benefits as specified herein are covered and include Hospital care anesthesia, diagnostic imaging, and laboratory services for conditions related to pregnancy unless such pregnancy is the result of a preplanned adoption arrangement, more commonly known as surrogacy The length of maternity stay in a Hospital will be that determined to be Medically Necessary in compliance with Florida law and in accordance with the Newborns and Mothers' Health Protection Act, as follows 1) hospital stays of at least 48 hours following a normal vaginal delivery or at least 96 hours following a cesarean section 2) the Attending Physician does not need to obtain authorization from AvMed to prescribe a Hospital 24 AV G100 2005 MP 3699 (10/05) stay of this length, and 3) AvMed will cover an extended stay if Medically Necessary however your physician or your Hospital must precertify the extended stay and (4) shorter Hospital stays are permitted if the attending health care provider in consultation with the mother, determines that this is the best course of action Coverage for maternity care is subject to applicable Co - payments and all other Plan limits and requirements Newborn child care is covered as provided in Subsection 4 02 02 (i) and Section 10 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 10 11 Newborn Care All services applicable for children under this Contract are covered for an enrolled newborn child of the Subscriber or the enrolled newborn child of a covered Dependent of the Subscriber or the newborn adopted child of the Subscriber (as described in Subsection 4 02 02 (i)) from the moment of birth, including the Medically Necessary care or treatment of medically diagnosed congenital defects birth abnormalities or prematurity, and transportation costs to the nearest facility appropriately staffed and equipped to treat the newborn's condition, when such transportation is Medically Necessary Circumcisions are provided for up to one year from date of birth 10 12 Emergency Services All necessary physician and Hospital Services will be covered by AvMed for Emergency Medical Services and Care (See Part III Sections 3 14 and 3 15) In the event that Hospital inpatient services are provided following Emergency Medical Services and Care AvMed should be notified within 24 hours or as soon as the Member is lucid and able to notify AvMed of the inpatient admission AvMed will pay the usual, customary and reasonable charges to a Non participating Provider only for those services rendered before a Member's condition permits him to be reasonably able to travel to a participating facility In addition any Member requests for reimbursement (of payment made by the Member for services rendered) must be filed within 90 days after the emergency or as soon as reasonably possible but not later than one year unless the Claimant was legally incapacitated 10 13 Urgent Care Services All necessary and covered services received in Urgent Care or Immediate Care Centers or rendered in your Primary Care Physician s office after-hours for conditions as described in Section 3 47 will be covered by AvMed See Schedule of Benefits for details In addition, any Member requests for reimbursement (of payment made by the Member for services rendered) must be filed within 90 days after the emergency or as soon as reasonably possible but not later than one year unless the Claimant was legally incapacitated 10 14 Ambulance Services as follows (i) local professional air/ground ambulance transport for emergency services to the nearest emergency department appropriately staffed and equipped to treat a medical condition (ii) ground transportation to an alternative level of care when associated with an approved Hospital confinement, and (in) ground transportation to a Member s home will be covered when associated with an approved hospitalization or other confinement and the Member's condition requires the skill of medically trained personnel Transportation is not covered when the skill of medically trained personnel is not required and the Member can be safely transferred (or transported) by other means Air ambulance transportation is covered only when the point of pick up is inaccessible by land or when distance or other obstacles are involved in transporting the Member to the nearest emergency department equipped to adequately treat the medical condition See Part XII for Exclusions 10 15 Other Health Care Facihty(ies) All routine services of Other Health Care Facilities (see Section 3 33) including physician visits physiotherapy diagnostic imaging and laboratory work are covered for a maximum of 20 days per calendar year when a Member is admitted to such a 25 AV G100 2005 MP 3699 (10/05) facility following discharge from a Hospital, for a condition that cannot be adequately treated with Skilled Home Health Care Services or on an ambulatory basis 10 16 Diagnostic Imaging and Laboratory All prescribed diagnostic imaging and laboratory tests and services including diagnostic imaging, fluoroscopy, electrocardiograms blood and urine and other laboratory tests, and diagnostic clinical isotope services are covered when Medically Necessary and ordered by a Participating Physician as part of the diagnosis and/or treatment of a covered illness or injury or as preventive health care services 10 17 Skilled Home Health Care Services Home Health Care Services (as defined in Section 3 20) are covered as outlined on the Schedule of Benefits when ordered by and under the direction of the Member's Attending Physician Physical occupational or speech therapy services provided in the home are limited as noted in Section 10 08 Home Health Care Services that do not include a medical diagnostic, therapeutic or rehabilitative component, or that do not require the skill of a registered nurse, licensed practical (vocational) nurse or other healthcare personnel are not covered Homemaker or other Custodial Care services are not covered 10 18 Hospice Services Services are available from a participating Hospice organization for a Member whose Participating Physician has determined the Member's illness will result in a remaining life span of six months or less 10 19 Second Medical Opinions The Member is entitled to a second medical opinion when he disputes the appropriateness or necessity of a surgical procedure or is subject to a serious injury or illness The Member may obtain a second medical opinion from any physician who is within AvMed's Service Area If you chose a Participating Physician there is no prior authorization requirement You pay only the applicable Co -payment or Deductible and Co-insurance If you choose a non- participating physician the service is subject to prior authorization requirements You are also responsible for 40% of the amount of usual customary and reasonable charges associated with the consultation Any tests that may be required to render the second medical opinion must be arranged by AvMed and performed by Participating Providers Once a second medical opinion has been rendered, AvMed shall review and determine AvMed s obligations under the Contract and that judgment is controlling Any treatment the Member obtains that is not authorized by AvMed shall be at the Member's expense AvMed may limit second medical opinions in connection with a particular diagnosis or treatment to three per Contract Year, if AvMed deems additional opinions to be an unreasonable over utilization by the Member 10 20 Durable Medical Equipment This Contract provides benefits when Medically Necessary for the purchase or rental of such DME that a) Can withstand repeated use (i e could normally be rented and used by successive patients) b) Is primarily and customarily used to serve a medical purpose, c) Generally is not useful to a person in the absence of illness or injury, and 26 AV G100 2005 MP 3699 (10/05) d) Is appropriate for use in a patient's home Some examples of DME are hospital beds crutches canes walkers wheelchairs respiratory equipment apnea monitors and insulin pumps It does not include hearing aids or corrective lenses or the professional fee for fitting same It also does not include medical supplies and devices such as a corset which do not require prescriptions AvMed will pay for rental of equipment up to the purchase price Repair and/or replacements are not covered See Schedule of Benefits for any Co payments or Limitations See Part XII for Exclusions 10 21 Orthotic Appliances Coverage for orthotic appliances is limited to custom made leg, arm back and neck braces when related to a surgical procedure or when used in an attempt to avoid surgery and when necessary to carry out normal activities of daily living, excluding sports activities Coverage includes the initial purchase fitting or adjustment Replacements are covered only when Medically Necessary due to a change in bodily configuration All other orthotic appliances are not covered See Schedule of Benefits for any Co payments or Limitations See Part XII for Exclusions 10 22 Prosthetic Devices This Contract provides benefits when Medically Necessary for prosthetic devices Coverage for prosthetic devices is limited to artificial limbs artificial joints and ocular prostheses Coverage includes the initial purchase fitting, or adjustment Replacement is covered only when Medically Necessary due to a change in bodily configuration The initial prosthetic device following a covered mastectomy is also covered Replacement of intraocular lenses is covered only if there is a change in prescription that cannot be accommodated by eyeglasses All other prosthetic devices are not covered See Schedule of Benefits for any Co - payments or Limitations See Part XII for Exclusions 10 23 Payment to Non participating Providers When in the professional judgment of AvMed's Medical Director a Member needs covered Medical Services or Hospital Services which require skills or facilities not available from Participating Providers and it is in the best interest of the Member to obtain the needed care from a Non participating Provider upon authorization by the Medical Director payment not to exceed usual customary and reasonable charges for such covered services rendered by a Non participating Provider will be made by AvMed Charges for non participating Hospital Services will be reimbursed in accordance with the covered benefits the Member would be entitled to receive in a Participating Hospital 10 24 Prescription Drug Benefits Allergy serums and chemotherapy for cancer patients are covered Coverage for insulin and other diabetic supplies is described in Section 10 27 below Other retail prescription drugs are a covered benefit only when the Subscribing Group Contract includes supplemental Prescription Drug Benefits 10 25 Ventilator Dependent Care With prior authorization by AvMed Ventilator Dependent Care (See Section 3 49) is covered up to a total of 100 days lifetime maximum benefit 10 26 Major organ transplants at a facility deemed appropriate and authorized by AvMed as well as associated immunosuppressant drugs are covered except those deemed experimental (See Section 12 15) 10 27 Diabetes Treatment includes all Medically Necessary equipment supplies and services to treat diabetes This includes outpatient self management training and educational services if the Member's Primary Care Physician or the physician to whom the Member has been referred who specializes in diabetes treatment certifies the equipment supplies or services are Medically Necessary Insulin pumps are covered under Section 10 20 Diabetes outpatient self - 27 AV G100 2005 MP 3699 (10/05) management training and educational services must be provided under the direct supervision of a certified diabetes educator or a board certified endocrinologist under contract with AvMed In accordance with Florida Statutes, coverage of insulin pumps for the treatment of diabetes will not apply toward or be subject to the annual DME maximum limitation Insulin insulin syringes lancets and test strips are covered under the Subscribing Group's supplemental Prescription Drug Benefits In the event that a Subscribing Group does not purchase supplemental Prescription Drug Benefits, insulin, insulin syringes, lancets, and test strips are covered subject to a $25 Co payment per item for a 30 -day supply 10 28 Mammograms are covered in accordance with Florida Statutes One baseline mammogram is covered for female Members between the ages of 35 and 39 A mammogram is available every two years for female Members between the ages of 40 and 49 and a mammogram is available every year for female Members aged 50 and older In addition one or more mammograms a year are available when based upon a physician's recommendation for any woman who is at risk for breast cancer because of a personal or family history of breast cancer, because of having a history of biopsy proven benign breast disease because of having a mother sister or daughter who has had breast cancer, or because a woman has not given birth before the age of 30 10 29 Osteoporosis Diagnosis and Treatment when Medically Necessary for high -risk individuals e g estrogen deficient individuals individuals with vertebral abnormalities individuals on long-term glucocorticoid (steroid) therapy, individuals with primary hyperparathyroidism and individuals with a family history of osteoporosis 10 30 Dermatological Services AvMed will cover up to five office visits per calendar year to a participating dermatologist for Medically Necessary covered services subject to Sections 3 28 and 3 48 No prior referral is required for these services 10 31 Mastectomy surgery when performed for breast cancer Coverage for post -mastectomy reconstructive surgery shall include 1) reconstruction of the breast on which the mastectomy has been performed 2) surgery and reconstruction on the other breast to produce a symmetrical appearance and 3) prostheses and physical complications during all stages of mastectomy including lymphedemas The length of stay will not be less than that determined by the Attending Physician to be Medically Necessary in accordance with prevailing medical standards and after consultation with the covered patient Coverage is subject to any applicable Co - payments and will require pre -authorization of services as applicable to other surgical procedures or hospitalizations under the Plan 10 32 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 AvMed is required There is no coverage for diagnosis or treatment of dental disease 28 AV G100 2005 MP 3699 (10/05) 10 33 Coverage for cleft lip and cleft palate for Members under 18 years of age The coverage provided by this Section is subject to the terms and conditions applicable to other benefits 10 34 Outpatient therapeutic services Covered health services for therapeutic treatments received on an outpatient basis in your home physician s office Other Health Care Facility or Hospital including intravenous chemotherapy or other intravenous infusion therapy and Injectable Drugs Injectable Drugs that are approved for self injection are only a covered benefit when included in the supplemental Prescription Drug Benefits (See Section 12 10) 10 35 Ostomy supplies and urinary catheter bags are covered when Medically Necessary Provisions of ostomy and urostomy supplies are limited to a one month supply every 30 days Items which are not medical supplies or which could be used by the Member or a family member for purposes other than ostomy care are not covered 10 36 Wound care supplies as part of an approved treatment plan, when one of the following criteria is met (i) treatment of a wound caused by or treated by a surgical procedure (u) treatment of a wound that required debridement or (iii) participation in AvMed's wound care program Provision of wound care supplies is limited to a one month supply every 30 days XI LIMITATIONS OF BASIC BENEFITS The rights of Members and obligations of Participating Providers hereunder are subject to the following Limitations 11 01 In the event of any major disaster Participating Providers shall render Hospital and Medical Services provided under this Contract insofar as practical according to their best judgment within the limitations of such facilities and personnel as are then available but AvMed and Participating Providers shall have no liability or obligation for delay or failure to provide or arrange for such services due to lack of available facilities or personnel if such lack is the result of any major disaster 11 02 In the event of circumstances not reasonably within the control of AvMed such as complete or partial destruction of facilities an act of God war riot civil insurrection disability of a significant part of Hospital or participating medical personnel or similar causes if the rendition of Medical Services and Hospital Services provided under this Contract is delayed or rendered impractical neither AvMed Participating Providers nor any physician shall have any liability or obligation on account of such delay or failure to provide services however AvMed 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 that in the judgment of the Member's Primary Care Physician, are essential to the maintenance of the Member's good health 11 04 A Member shall select one Primary Care Physician upon enrollment If you do not select a Primary Care Physician upon enrollment a Primary Care Physician will be assigned to you by AvMed You may obtain assistance in making a selection by contacting AvMed 29 AV G100 2005 MP 3699 (10/05) 11 05 Substance Abuse Hospital Limitation Inpatient services for alcohol and drug abuse shall be provided but only for acute detoxification and the treatment of other medical sequelae of such abuse Inpatient alcohol or drug rehabilitation services are not covered 11 06 Visits to licensed dietitians/nutritionists for treatment of diabetes, renal disease or obesity control shall be limited to three outpatient visits per calendar year and each visit requires a Co -payment (See Schedule of Benefits and also Section 12 21) 11 07 Spinal manipulations will be covered only when Medically Necessary and prescribed by a Participating Physician or by self -referral to a Participating Physician 11 08 The total benefit for Ventilator Dependent Care is limited to 100 calendar days lifetime maximum 11 09 Inpatient Hospital care for a medical "emergency," in -area or out of -area, will only be covered when authorized by AvMed after the Member or the Hospital notifies AvMed within 24 hours of admission or as soon as the Member is lucid and able to notify AvMed of the admission following Emergency Medical Services and Care 11 10 Other Health Care Facility(ies) All routine inpatient services of Other Health Care Facilities (See Section 3 33), including physician visits, physiotherapy, diagnostic imaging and laboratory work are covered for a maximum of 20 days per calendar year when a Member is admitted to such a facility following discharge from a Hospital for a condition that cannot be adequately treated with Home Health Care Services or on an ambulatory basis 11 11 Physical Occupational or Speech Therapy Physical, occupational or speech therapies shall be limited as explained in Sections 10 08 and 10 17 11 12 Surgical or non -surgical procedures which are undertaken to improve or otherwise modify the Member s external appearance 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 Hyperbaric oxygen treatments are limited to 40 treatments per condition as appropriate pursuant to the Centers for Medicare and Medicaid Services (CMS) guidelines subject to applicable Co - payments as listed for physical, speech and occupational therapies XII EXCLUSIONS FROM BASIC BENEFITS Medical Services and benefits for the following classifications and conditions are not covered and are excluded from the Schedule of Basic Benefits provided under this Contract 12 01 Treatment of a condition resulting from a) Participation in a riot or rebellion b) Engagement in an illegal occupation, c) Commission or attempted commission of an assault, commission or attempted commission of a crime punishable as a felony 30 AV G100 2005 MP 3699 (10/05) 12 02 Cosmetic, surgical or non -surgical procedures which are undertaken primarily to improve or otherwise modify the Member's external appearance Also excluded are surgical excision or reformation of any sagging skin of any part of the body including but not limited to the eyelids face neck abdomen arms legs, or buttocks any services performed in connection with the enlargement, reduction, implantation or change in appearance of a portion of the body including but not limited to the face lips, jaw chin nose ears breasts or genitals (including circumcision except newborns for up to one year from date of birth see also Section 10 11) hair transplantation chemical face peels or abrasion of the skin electrolysis depilation, removal of tattooing or any other surgical or non surgical procedures which are primarily for cosmetic purposes or to create body symmetry Additionally, all medical complications as a result of cosmetic surgical or non surgical procedures are excluded 12 03 Medical care or surgery not authorized by a Participating Provider except for Emergency Medical Services and Care or not within the benefits covered by AvMed 12 04 Dental Care, as defined in 3 11, for any condition except a) When such services are for the treatment of trauma related fractures of the jaw or facial bones or for the treatment of tumors, b) Reconstructive jaw surgery for the treatment of deformities that are present and apparent at birth or c) 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 Except as provided in Sections 10 35 and 10 36, medical supplies including, but not limited to pre fabricated splints Thromboemboletic/Support hose and all other bandages 12 08 Home monitoring devices and measuring devices (other than apnea monitors) and any other equipment or devices for use outside the Hospital 12 09 Surgically implanted devices and any associated external devices except for cardiac pacemakers intraocular lenses artificial joints and orthopedic hardware and vascular grafts Dental appliances other corrective lenses and hearing aids including the professional fee for fitting them are not covered 12 10 Over -the counter medications, all contraceptives (including drugs and devices) hypodermic needles and syringes and Self Administered Injectable Drugs except insulin and insulin syringes for the treatment of diabetes as outlined in Section 10 27 12 11 Travel expenses including expenses for ambulance services to and from a physician or Hospital except in accordance with Section 10 14 12 12 Treatment for chronic alcoholism and chronic drug addiction except those services offered as a basic health service (See Section 11 05) 31 AV G100 2005 MP 3699 (10/05) 12 13 Treatment for armed forces service connected medical care (for both sickness and injury) 12 14 Custodial Care (as defined in Part III, Section 3 10) 12 15 Experimental and/or investigational procedures, except for bone marrow transplants as approved per Florida Administrative Code, Section 59B-12 001 For the purposes of this Contract, a drug, treatment device, surgery or procedure may be determined to be experimental and/or investigational if any of the following applies a) The FDA has not granted the approval for general use b) There are insufficient outcomes data available from controlled clinical trials published in peer reviewed literature to substantiate its safety and effectiveness for the disease or injury involved 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 a 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 dosages toxicity safety efficacy or efficacy as compared with the standard means for treatment or diagnosis of the condition in question 12 16 Personal comfort items not Medically Necessary for proper medical care as part of the therapeutic plan to treat or arrest the progression of an illness or injury This Exclusion includes but is not limited to wigs (including partial hair pieces, weaves and toupees) personal care kits guest meals and accommodations, maid services televisions/radios telephone charges, photographs complimentary meals birth announcements, take home supplies travel expenses (other than Medically Necessary ambulance services that are provided for in Section 10 14) air conditioners humidifiers dehumidifiers, and air purifiers or filters 12 17 Physical examinations or tests such as premarital blood tests or tests for continuing employment education licensing, or insurance or that are otherwise required by a third party 12 18 Eye care including a) Eye examinations for Members 18 years of age or older for the purpose of determining the need for sight correction (such as eye glasses or contact lenses) b) Training or orthoptics including eye exercises or c) Radial keratotomy refractory keratoplasty Lasik surgery or any other corneal surgical procedure to correct refractive error 12 19 Hearing examinations for 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 32 AV G100 2005 MP 3699 (10/05) 12 21 Gastric stapling gastric bypass, gastric banding gastric bubbles, and other procedures for the treatment of obesity or morbid obesity as well as any related evaluations or diagnostic tests Ongoing visits other than establishing a program of obesity control 12 22 Gender reassignment surgery as well as any service supply or medical care associated with gender reassignment or gender identity disorders 12 23 All drugs devices and other forms of treatment related to a diagnosis of sexual dysfunction 12 24 Infertility diagnosis treatment and supplies including infertility testing treatment of infertility diagnostic procedures and artificial insemination to determine or correct the cause or reason for infertility or inability to achieve conception This includes artificial insemination in vitro fertilization ovum or embryo placement or transfer gamete intra-fallopian tube transfer or cryogenic or other preservation techniques used in such or similar procedures Also excluded are obstetrical benefits when such pregnancy is the subject of a preplanned adoption arrangement or surrogacy as defined under Chapter 63 Florida Statutes Drugs for the treatment of infertility are not covered 12 25 Reversal of sterilization procedures 12 26 Immunizations and medications for the purpose of foreign travel or employment 12 27 Acupuncture biofeedback hypnotherapy massage therapy sleep therapy sex therapy behavioral training, cognitive therapy and vocational rehabilitation 12 28 Foot supports are not covered These include orthopedic or specialty shoes, shoe build ups, shoe orthotics shoe braces and shoe supports Also excluded is routine foot care, including trimming of corns calluses and nails 12 29 The Medical Services and Hospital Services for a donor or prospective donor who is an AvMed Member when the recipient of an organ transplant is not an AvMed Member Coverage is provided for costs associated with the bone marrow donor -patients to the 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 Hyperactivity Disorder (ADHD) 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 treatment or service from a Non -participating Provider except in the case of an emergency or when specifically pre authorized by AvMed (See Sections 3 14 and 3 15) 12 34 Speech therapy for delayed or abnormal speech pathology 12 35 Alcohol or substance abuse rehabilitation, vocational rehabilitation, pulmonary rehabilitation long term rehabilitation, or any other rehabilitation program 33 AV G100 2005 MP 3699 (10/05) 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 amendment to the Subscribing Group Contract 12 38 Hospital Exclusion If a Member elects to receive Hospital care from a non participating Attending Physician or a non participating Hospital, then coverage is excluded for the entire episode of care except when the admission was due to an emergency or with the prior written authorization of AvMed 12 39 Ventilator Dependent Care, except as provided in Part X (Schedule of Basic Benefits) for 100 days lifetime maximum benefit 12 40 Private duty nursing services 12 41 Any sickness or injury for which the covered person is paid benefits, or may be paid benefits if claimed if the covered person is covered or required to be covered by Workers' Compensation In addition if the covered person enters into a settlement giving up rights to recover past or future medical benefits under a Workers' Compensation law AvMed shall not cover past or future Medical Services that are the subject of or related to that settlement Furthermore if the covered person is covered by a Worker s Compensation program that limits benefits if other than specified health care providers are used and the covered person receives care or services from a health care provider not specified by the program AvMed shall not cover the balance of any costs remaining after the program has paid 12 42 Complications of any non -covered service including the evaluation or treatment of any condition that arises as a complication of a non -covered service 12 43 Any service or supply to eliminate or reduce dependency on or addiction to tobacco, including but not limited to nicotine withdrawal programs, facilities and supplies (e g transdermal patches, Nicorette gum) 12 44 Services associated with autopsy or postmortem examinations, including the autopsy 12 45 Exercise programs gym memberships or exercise equipment of any kind including, but not limited to exercise bicycles, treadmills, stairmasters rowing machines free weights or resistance equipment Also excluded are massage devices portable whirlpool pumps hot tubs Jacuzzis sauna baths swimming pools and similar equipment 12 46 Removal of warts moles skin tags lipomas keloids, scars and other benign lesions is not covered XIII COORDINATION OF BENEFITS 13 01 The services and benefits provided under this Contract are not intended to 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 34 AV G100 2005 MP 3699 (10/05) 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 AvMed coverage will be primary to Medicaid benefits 13 02 If any covered person is eligible for services or benefits under two or more plans as set forth in Section 13 01 the coverage under those plans will be coordinated so that up to but not more than 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 AvMed Failure to do so will result in nonpayment of claims Requested information should be provided to AvMed within 30 days of request or Member will be responsible for payment of claim Information received after one 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 the benefits of the policy or plan of the parent whose birthday excluding year of birth falls later in the year but b) If both parents have the same birthday the benefits of the policy or plan which covered the parent for a longer period of time are determined before those of the policy or plan which covered the parent for a shorter period of time However if a policy or plan subject to the rule based on the birthday of the parents as stated above coordinates with an out of -state policy or plan which contains provisions under which the benefits of a policy or plan which covers a person as a dependent of a male are determined before those of a policy or plan which covers the person as a dependent of a female and if as a result the policies or plans do not agree on the order of benefits the provisions of the other policy or plan shall determine the order of benefits 13 03 03 If two or more policies or plans cover a dependent child of divorced or separated parents, benefits for the child are determined in this order a) First the policy or plan of the parent with custody of the child, b) Second the policy or plan of the spouse of the parent with custody of the child, and c) Third the policy or plan of the parent not having custody of the child However if the specific terms of a court order state that one of the parents is responsible for the health care expenses of the child and if the entity obliged to pay or 35 AV G100 2005 MP 3699 (10/05) provide the benefits of the policy or plan of that parent has actual knowledge of those terms the benefits of that policy or plan are determined first This does not apply with respect to any claim determination period or plan or policy year during which any benefits are actually paid or provided before that entity has that actual knowledge 13 03 04 The benefits of a policy or plan which covers a person as an employee who is neither laid off nor retired or as that employee's dependent are determined before those of a policy or plan which covers that person as a laid off or retired employee or as that employee's dependent If the other policy or plan is not subject to this rule, and if, as a result the policies or plans do not agree on the order of benefits, this Subsection shall not apply 13 03 05 If none of the rules in Subsections 13 03 01, 13 03 02, 13 03 03, or 13 03 04 determine the order of benefits, the benefits of the policy or plan which covered an employee member or subscriber for a longer period of time are determined before those of the policy or plan which covered that person for the shorter period of time 13 03 06 Coordination of benefits shall not be permitted against an indemnity type policy an excess insurance policy as defined in Section 627 635 Florida Statutes a policy with coverage limited to specified illnesses or accidents or a Medicare supplement policy However if the person is also a Medicare beneficiary, and if the rule established under the Social Security Act of 1965, as amended makes Medicare secondary to the plan covering the person as a dependent of an active employee the order of benefit determination is a) First benefits of a plan covering a person as an employee member or subscriber b) Second, benefits of a plan of an active worker covering a person as a dependent c) Third Medicare benefits 13 03 07 If an individual is covered under a COBRA continuation plan as a result of the purchase of coverage as provided under the Consolidation Omnibus Budget Reconciliation Act of 1987 (Pub L No 99-272), and also under another Group Health Insurance plan, the following order of benefits applies a) First, the plan covering the person as an employee, or as the employee's dependent b) Second the coverage purchased under the plan covering the person as a former employee, or as the former employee's dependent provided according to the provisions of COBRA 13 04 For the purpose of determining the applicability and implementing the terms of the Coordination of Benefits provision of this Contract AvMed may, without the consent of or notice to any person release to or obtain from any other insurance company, organizations or person any information, with respect to any Subscriber or applicant for subscription, which AvMed deems to be necessary for such purposes 13 05 Whenever payments which should have been made under this Plan in accordance with this provision have been made under any other plans, AvMed shall have the right, exercisable alone 36 AV G100 2005 MP 3699 (10/05) and in its sole discretion to pay over to any organizations making such other payments any amounts AvMed shall determine to be warranted in order to satisfy the intent of this provision and amounts so paid shall be 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 AvMed is secondary to other coverage and the treatment is covered under the other coverage XIV REIMBURSEMENT In the event that AvMed 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, AvMed is entitled to reimbursement from the Subscriber in accordance with Section 768 76(4) Florida Statutes If the Subscriber recovers all or part of such medical benefits, payments or expenses from the third party AvMed may take any action it deems necessary to protect its rights to recover the amount of any payments made by AvMed including the right to bring suit in Member's name if the Member chooses not to file suit In that case Member shall provide a written assignment to AvMed of Member s rights to all claims demands, and rights to recovery that Member may have against the third party Should Member file suit Member is required to notify AvMed as required by Section 768 76 Florida Statutes In any suit Member shall bring a separate claim for reimbursement of amounts paid by AvMed and shall not enter into any settlement that does not provide for reimbursement of the amounts paid by AvMed Member shall execute and deliver any and all instruments and papers as may be required by AvMed and do whatever else is necessary to secure and protect the recovery rights of AvMed In the event of any recovery Member shall hold such proceeds in trust for the benefit of AvMed and pay them to AvMed upon demand if the proceeds have been paid directly to the Member In the event of a trial Member shall present evidence of the amounts paid by AvMed and shall seek a separate special verdict for reimbursement of such amounts in favor of AvMed At any time AvMed shall be allowed to intervene in any suit brought by Member against any third party and if Member opposes such intervention Member shall pay all costs and attorney fees incurred by AvMed in the process of seeking the order of the court for such intervention over Member s objections XV DISCLAIMER OF LIABILITY 15 01 Neither Subscribing Group nor its agents servants or employees nor any Member is the agent or representative of AvMed and none of them shall be liable for any acts or omissions of AvMed its agents or employees or of a Participating Hospital or a Participating Physician or any other person or organization with which AvMed has made or hereafter shall make arrangements for the performance of services under this Contract 15 02 Neither Subscribers of Subscribing Group nor their Dependents shall be liable to AvMed or Participating Providers except as specifically set forth herein provided all procedures set forth herein are followed 15 03 Neither AvMed nor its agents servants or employees nor any Member is the agent or representative of the Subscribing Group and none of them shall be liable for any acts or omissions of Subscribing Group, its agents or employees or any other person representing or acting on behalf of Subscribing Group 37 AV G100 2005 MP 3699 (10/05) 15 04 AvMed does not directly employ any practicing physicians nor any Hospital personnel or physicians These health care providers are independent contractors and are not the agents or employees of AvMed AvMed shall be deemed not to be a health care provider with respect to any services performed or rendered by any such independent contractors Participating Providers maintain the physician/patient relationship with Members and are solely responsible for all Medical Services which Participating Providers render to Members Therefore AvMed 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 AvMed Furthermore AvMed shall not be vicariously liable for any negligent act or omission of any of these independent health care professionals who treat a Member of AvMed 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 AvMed may terminate the Member's coverage under this Contract as set forth in Part IX Subsection 9 01 05 XVI GRIEVANCE PROCEDURE 16 01 Urgent Care Claims 16 01 01 Initial Claim An Urgent Care Claim shall be deemed to be filed on the date received by AvMed AvMed shall notify the Claimant of AvMed's benefit determination (whether adverse or not) as soon as possible taking into account the medical exigencies but not later than 72 hours after AvMed receives, either orally or in writing the Urgent Care Claim unless the Claimant fails to provide sufficient information to determine whether or to what extent, benefits are covered or payable under the Plan If such information is not provided AvMed shall notify the Claimant as soon as possible but not later than 24 hours after AvMed 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 benefit determination as soon as possible but in no case later than 48 hours after the earlier of 1) AvMed 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 38 AV G100 2005 MP 3699 (10/05) of Section 16 05, shall be provided to the Claimant no later than three days after the oral notification 16 01 02 Appeal A Claimant may appeal an Adverse Benefit Determination with respect to an Urgent Care Claim within 180 days of receiving the Adverse Benefit Determination AvMed shall notify the Claimant in accordance with Section 16 07 of AvMed s benefit determination on review as soon as possible taking into account the medical exigencies but not later than 72 hours after AvMed receives the Claimant s request for review of an Adverse Benefit Determination You may submit an appeal to AvMed Member Services — North P O Box 823 Gainesville, Florida 32602 0823 Telephone 1 800 882-8633 Fax (352) 337 8612 AvMed Member Services — South P O Box 569008 Miami, Florida 33156 9906 Telephone 1-800 882 8633 Fax (305) 671 4736 If you are not satisfied with AvMed's final decision you may contact the Florida Agency for Health Care Administration (AHCA) or the Department of Financial Services (DFS) in writing within 365 days of receipt of the final decision letter If you appeal AvMed s decision your grievance will be reviewed by the Subscriber Assistance Program You also have the right to contact the AHCA or DFS at any time to inform them of an unresolved grievance The Subscriber Assistance Program will not hear a grievance if you have not completed the entire AvMed grievance process nor if you have instituted an action pending in State or Federal court If you need further assistance you may contact Subscriber Assistance Panel (SAP) Agency for Health Care Administration HMO Section 2727 Mahan Drive Mail Stop 26 Tallahassee Florida 32308 Telephone 1 888 419 3456 or 850 921-5458 The Florida Department of Financial Services 200 East Gaines Street Tallahassee Florida 32399 Telephone 1-800 342 2762 16 02 Pre -Service Claims 16 02 01 Initial Claim — A Pre Service Claim shall be deemed to be filed on the date received by AvMed AvMed shall notify the Claimant of the benefit determination (whether adverse or not) within a reasonable period of time appropriate to the medical circumstances but not later than 15 days after AvMed receives the Pre -Service Claim AvMed may extend this period one time for up to 15 days, provided that AvMed determines that such an extension is necessary due to matters beyond AvMed s control and notifies the Claimant before the expiration of the initial 15 day period of the circumstances requiring the extension of time and the date by which AvMed 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 39 AV G100 2005 MP 3699 (10/05) 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 AvMed'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 days following such failure AvMed's period for making the benefit determination shall be tolled from the date on which the notification of the extension is sent to the Claimant until the date on which the Claimant responds to the request for additional information If the Claimant fails to supply the requested information within the 45 day period the Claim shall be denied 16 02 02 Appeal A Claimant may appeal an Adverse Benefit Determination with respect to a Pre -Service Claim within 180 days of receiving the Adverse Benefit Determination AvMed shall notify the Claimant, in accordance with Section 16 07 of it s determination on review within a reasonable period of time Such notification shall be provided not later than 30 days after AvMed receives the Claimant s request for review of the Adverse Benefit Determination You may submit an appeal to AvMed Member Services — North P O Box 823 Gainesville, Florida 32602-0823 Telephone 1 800 882 8633 Fax (352) 337 8612 AvMed Member Services — South P O Box 569008 Miami, Florida 33156-9906 Telephone 1 800-882 8633 Fax (305) 671-4736 If you are not satisfied with AvMed s final decision, you may contact AHCA or DFS in writing within 365 days of receipt of the final decision letter If you appeal AvMed s decision your grievance will be reviewed by the Subscriber Assistance Program You also have the right to contact AHCA or DFS at any time to inform them of an unresolved grievance The Subscriber Assistance Program will not hear a grievance if you have not completed the entire AvMed grievance process nor if you have instituted an action pending in State or Federal court it you need further assistance you may contact Subscriber Assistance Panel (SAP) Agency for Health Care Administration HMO Section 2727 Mahan Drive, Mail Stop 26 Tallahassee, Florida 32308 Telephone 1 888 419 3456 or 850 921 5458 The Florida Department of Financial Services 200 East Gaines Street Tallahassee Florida 32399 Telephone 1 800 342-2762 16 03 Post Service Claims 16 03 01 Initial Claim — A Post -Service Claim shall be deemed to be filed on the date received by AvMed AvMed shall notify the Claimant in accordance with Section 16 05 of AvMed s Adverse Benefit Determination within a reasonable period of time but not later than 30 days after AvMed receives the Post Service Claim AvMed may extend 40 AV G100 2005 MP 3699 (10/05) this period one time for up to 15 days provided that AvMed determines that such an extension is necessary due to matters beyond AvMed'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 AvMed 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 AvMed's period for making the benefit determination shall be tolled from the date on which the notification of the extension is sent to the Claimant until the date on which the Claimant responds to the request for additional information If the Claimant fails to supply the requested information within the 45 -day period the Claim shall be denied 16 03 02 Appeal A Claimant may appeal an Adverse Benefit Determination with respect to a Post Service Claim within 180 days of receiving the Adverse Benefit Determination AvMed shall notify the Claimant in accordance with Section 16 07 of AvMed s determination on review within a reasonable period of time Such notification shall be provided not later than 60 days after AvMed receives the Claimant s request for review of the Adverse Benefit Determination You may submit an appeal to AvMed Member Services — North 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 33156 9906 Telephone 1 800-882 8633 Fax (305) 671 4736 If you are not satisfied with AvMed's final decision you may contact AHCA or DFS in writing within 365 days of receipt of the final decision letter If you appeal AvMed's decision your grievance will be reviewed by the Subscriber Assistance Program You also have the right to contact the AHCA or DFS at any time to inform them of an unresolved grievance The Statewide Provider and Subscriber Assistance Program will not hear a grievance if you have not completed the entire AvMed grievance process nor if you have instituted an action pending in State or Federal court If you need further assistance, you may contact Subscriber Assistance Panel (SAP) Agency for Health Care Administration HMO Section 2727 Mahan Drive, Mail Stop 26 Tallahassee Florida 32308 Telephone 1 888 419 3456 or 850-921 5458 The Florida Department of Insurance 200 East Gaines Street Tallahassee Florida 32399 Telephone 1 800 342 2762 41 AV G100 2005 MP 3699 (10/05) 16 04 Concurrent Care Claims 16 04 01 Any reduction or termination by AvMed of Concurrent Care (other than by Plan amendment or termination) before the end of an approved period of time or number of treatments shall constitute an Adverse Benefit Determination 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 16 04 02 Any request by a Claimant to extend the course of treatment beyond the period of time or number of treatments that relates to an Urgent Care Claim shall be decided as soon as possible taking into account the medical exigencies, and AvMed shall notify the Claimant of the benefit determination, whether adverse or not within 24 hours after AvMed receives the Claim, provided that any such Claim is made to AvMed at least 24 hours before the expiration of the prescribed period of time or number of treatments Notification and appeal of any Adverse Benefit Determination concerning a request to extend the course of treatment whether involving an Urgent Care Claim or not shall be made in accordance with the remainder of Part XVI 16 05 Manner and Content of Initial Claims Determination Notification AvMed shall provide a Claimant with written or electronic notification of any Adverse Benefit Determination The notification shall set forth in a manner calculated to be understood by the Claimant, the following a) The specific reasons for the Adverse Benefit Determination b) Reference to the specific Plan provisions on which the determination is based c) 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 d) A description of AvMed's review procedures and the time limits applicable to such procedures, including, when applicable a statement of the Claimant s right to bring a civil action under Section 502(a) of the Employee Retirement Income Security Act of 1974 as amended (ERISA) following an Adverse Benefit Determination on final review e) If an internal rule guideline protocol or other similar criterion was relied upon in making the Adverse Benefit Determination either the specific rule guideline, protocol or other similar criterion or a statement that such rule guideline protocol or other similar criterion was relied upon in making the Adverse Benefit Determination and that a copy shall be provided free of charge to the Claimant upon request f) If the Adverse Benefit Determination is based on whether the treatment or service is experimental and/or investigational or not Medically Necessary either an explanation of the scientific or clinical judgment for the determination, applying the terms of the Plan to the Claimant s medical circumstances or a statement that such explanation shall be provided free of charge upon request g) In the case of an Adverse Benefit Determination involving an Urgent Care Claim a description of the expedited review process applicable to such Claim 42 AV G100 2005 MP 3699 (10/05) 16 06 Review Procedure Upon Appeal AvMed s appeal procedures shall include the following substantive procedures and safeguards a) Claimant may submit written comments documents records and other information relating to the Claim b) Upon request and free of charge, the Claimant shall have reasonable access to and copies of any Relevant Document c) 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 d) The appeal shall be conducted by an appropriate named fiduciary of AvMed who is neither the individual who made the initial Adverse Benefit Determination nor the subordinate of such individual Such person shall not defer to the initial Adverse Benefit Determination e) In deciding an appeal of any Adverse Benefit Determination that is based in whole or in part on a medical judgment including determinations with regard to whether a particular treatment drug or other item is experimental and/or investigational or not Medically Necessary the appropriate named fiduciary shall consult with a Health Professional who has appropriate training and experience in the field of medicine involved in the medical Judgment f) The appeal shall provide for the identification of medical or vocational experts whose advice was obtained on behalf of AvMed in connection with a Claimant s Adverse Benefit Determination without regard to whether the advice was relied upon in making the Adverse Benefit Determination g) The appeal shall provide that the Health Professional engaged for purposes of a 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 h) In the case of an Urgent Care Claim there shall be an expedited review process pursuant to which (i) request for an expedited appeal of an Adverse Benefit Determination may be submitted orally or in writing by the Claimant and (ii) all necessary information including AvMed's benefit determination on review shall be transmitted between AvMed 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 AvMed 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 reasons for the Adverse Benefit Determination 43 AV G100 2005 MP 3699 (10/05) b) Reference to the specific Plan provisions on which the Adverse Benefit Determination is based c) A statement that the Claimant is entitled to receive, upon request, and free of charge, reasonable access to and copies of any Relevant Document d) A statement describing any voluntary appeal procedures offered by AvMed and the Claimant's right to obtain the information about such procedures and a statement of the Claimant s right to bring an action under ERISA Section 502(a) when applicable e) If an internal rule, guideline, protocol, or other similar criterion was relied upon in making the Adverse Benefit Determination, either the specific rule, guideline protocol or other similar criterion or a statement that such rule guideline protocol or other similar criterion was relied upon in making the Adverse Benefit Determination and that a copy shall be provided free of charge to the Claimant upon request f) If the Adverse Benefit Determination is based on whether the treatment or service is experimental and/or investigational or not Medically Necessary either an explanation of the scientific or clinical judgment for the determination applying the terms of the 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 AvMed agree to make the Medical Services and Hospital Services specified herein available to persons who are eligible under the provisions of Part IV However the delivery of benefits and services covered in this Contract shall be subject to the provisions Limitations, and Exclusions set forth herein and any amendments modifications, and Contract termination provisions specified herein and by the mutual agreement between AvMed and Subscribing Group, without the consent or concurrence of the Members By electing or accepting Medical Services and Hospital or other benefits hereunder all Members legally capable of contracting and the legal representatives of all Members incapable of contracting agree to all terms conditions and provisions hereof No changes or amendments to this Contract shall be valid unless approved by an executive officer of AvMed and endorsed herein or attached hereto No agent has authority to change this Contract or to waive any of its provisions 17 02 Certificate of Coverage AvMed shall provide a copy of the Certificate of Coverage for each Subscriber 17 03 Membership Application Members or applicants for membership shall complete and submit to AvMed such applications or other forms or statements as AvMed may reasonably request If Member or applicant fails to provide accurate information which AvMed deems material then upon ten days written notice AvMed may deny coverage and/or membership to such individual Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of Claim or an application containing any false incomplete or misleading information is guilty of a felony punishable as provided by the Florida Statutes 44 AV G100 2005 MP 3699 (10/05) 17 04 Identification Cards Cards issued by AvMed to Members pursuant to this Contract are for purposes of identification only Possession of an AvMed 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 AvMed 17 05 Waiver A Claim that has not been timely filed with AvMed within one year of date of service shall be considered waived 17 06 Non -Waiver The failure of AvMed to enforce any of the provisions of this Contract or to exercise any options herein provided or to require timely performance by any Member or Subscribing Group of any of the provisions herein shall not be construed to be a waiver of such provisions nor shall it affect the validity of this Contract or any part thereof or the right of AvMed to thereafter enforce each and every such provision 17 07 Plan Administration AvMed 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 AvMed, to AvMed Health Plans P O Box 749 Gainesville Florida 32602 0749 (OR if from a Member to AvMed see the Member's Service Area address listed on Page i ) If to a Member To the last address provided by the Member and actually received by AvMed on the enrollment application or change of address notification If to Subscribing Group To the address provided in the Group Master Application 17 09 Gender Whenever used the singular shall include the plural and the plural the singular and the use of any gender shall include all genders 17 10 Clerical Errors Clerical errors 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 17 11 Contract Review Subscribing Group may if this Contract is not satisfactory for any reason, return this Contract within three days after receipt and receive a full refund of the deposit paid if any unless the services of AvMed were utilized during the three days If this Contract is not returned within three days after receipt then this Contract shall be deemed to have been accepted 17 12 Premium Tax/Surcharge If any government entity shall impose a premium tax or surcharge then the sums due from the Subscribing Group under the terms of this Contract shall be increased by the amount of such premium tax or surcharge 45 AV G100 2005 MP 3699 (10/05) 17 13 Entirety of Contract This Agreement and all applicable Schedules Exhibits Riders and any other attachments and endorsements, constitute the entire Contract between the Subscribing Group and AvMed No modification (or oral representation) of this Group Contract shall be of any force or effect unless it is in writing and signed by both parties 17 14 Rate Letter The "rate letter" is AvMed's formal notice to the Subscribing Group of the premium rates applicable to the Subscribing 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 AvMed'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 AvMed the applicable employer employee contribution to the premium payment and the charge for other optional, supplemental benefits selected by the Subscribing Group if any 17 15 Third Party Beneficiary This Contract is entered into exclusively between the Subscribing Group and AvMed This Contract is intended only to benefit the Subscribing Group and the Members and does not confer any rights on any other third parties 17 16 Assignment This Contract, and all rights and benefits related thereto, may not be assigned by the Subscribing Group or the Members without written consent of AvMed 17 17 Applicability of Law The provisions of this Contract shall be deemed to have been modified by the parties and shall be interpreted so as to comply with the laws and regulations of the State of Florida and the United States 17 18 ERISA When this Contract is purchased by the Subscribing Group to provide benefits under a welfare plan governed by ERISA, AvMed shall be considered a fiduciary to the extent that it performs any discretionary functions on behalf of the Plan If a Member has questions about the group's welfare plan the Member should contact the Subscribing Group 46 AV G100 2005 MP 3699 (10/05) AVMED HEALTH PLANS Contract Number (s) Subscribing Group Name Effective Date AVMED, INC d/b/a AVMED Health Plans Group Medical and Hospital Service Contract Group Master Application 004515 Village of Key Biscayne May 1 2006 Group Contract This Group Contract provides the benefits checked below BASIC OPTION ($15 Specialist) ❑ $0 per Admission ❑ $100 per Admission O $250 per Admission O $250 per Day Days 1 5 BASIC OPTION ($25 Specialist) O $0 per Admission O $100 per Admission O $250 per Admission O $250 per Day Days 1 5 BASIC OPTION ($30 Specialist) ❑ $250 per Day Days 1 5 ❑ $250 per Admission Benefit Designs BASIC OPTION ($35 Specialist) ❑ $250 per Day Days 1 5 O $250 per Admission ❑ $300 per Day Days 1 5 STANDARD OPTION ($10 Specialist) ❑ $0 per Admission ❑ $100 per Admission ❑ $100 per Day Days 1 5 O $250 per Admission STANDARD OPTION ($20 Specialist) O $100 per Day Days 1 5 ® $250 per Admission Form AV STD/20 250A 05 If selected the following optional and supplemental coverage is also provided O El IZI 0 El El IZI Open Access Prescription Coverage Vision Coverage Dental Coverage (ADP) (All Dental Plans are administered by American Dental Plan) Elective Termination of Pregnancy Form Form Form Form OTHER LARGE GROUP BENEFITS O $15/$250 PER Day Days 1 5 O $25/$500 PER Day Days 1 5 O $20/$250/10% ❑ $20/$250/20% ❑ $25/$500/20% ❑ $25/$750/20% ❑ $30/$750/20% CORE ❑ $15/$250/25 40% ❑ $15/$500/15 30% O $25/$250/25 40% O $15/$1000/10 25% ❑ $15/$100/30 40% O $25/$100/30 40% CDHP ❑ Consumer 1A O Consumer 1B O Consumer 1C as described in the amendments to this contract AV AV G100 RX 15/30/50/75 OC 05 AV VISION R 99 AV Form AV G100 ETP R 97 Mental Health/Partial Hospitalization Form AV G100 MH/PH $250 per admit 04 0 Group declines mental health benefits (Section 627 668 Florida Statutes) Substance Abuse Form AV SA R 98 0 Group declines substance abuse benefits (Section 627 669 Florida Statutes) Durable Medical Equipment Waiver of Co payment — Coverage for Mammograms Other ® Domestic Partner Form AV DP 12 R 02 0 Form AV Form AV G100 DME 2000 R 06 Form AV Mammogram 05 AVMED, INC d/b/a AVMED Health Plans Group Medical and Hospital Service Contract Group Master Application, continued ELIGIBILITY An employee of the Subscribing Group must be employed a minimum of 30 hours per week to become eligible for coverage under this Contract An employee becomes eligible for coverage under this Contract (Check and/or fill in as appropriate) ❑ on the date of hire ❑ consecutive days after the date of hire ® on the first day of the month following 30 consecutive days after the date of hire ❑ other TERMINATION Termination of coverage under this Contract shall become effective ® on the date the employee s employment is terminated El on the last date of the month in which the employee s employment is terminated ❑ on the date the Group Contract is terminated El other AGREEMENT This Contract is issued in consideration of the Master Application of the Subscribing Group for group medical and hospital services and the monthly prepayment subscription charges and the mutual promises and benefits between AVMED Inc d/b/a AVMED Health Plans and the Subscribing Group This Contract shall remain in effect for a period of twelve (12) months from the effective date of May 1 2006 and may be renewed annually not later than the anniversary date upon mutual agreement of the parties The Contract period begins at 12 01 a m Eastern Standard Time on the effective date or on the anniversary date if a renewal This Contract shall be governed by Chapter 641 Florida Statutes and other applicable State and Federal laws The first monthly payment is due on May 1 2006 Subsequent payments are due on the first day of each month thereafter ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE DEFRAUD OR DECEIVE ANY INSURER FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE AVMED, INC d/b/a AVMED Health Plans Group Medical and Hospital Service Contract Group Master Application, continued MONTHLY CHARGES Monthly Membership Charges Subscriber Only $ 295 42 Subscriber plus Spouse $ 590 83 Subscriber plus One Dependent (No Spouse) $ 590 83 Subscriber plus Two or More Dependents $ 856 71 Subscriber plus Spouse and One or More Dependents $ 856 71 0 Other $ The provisions contained in the Schedule of Co payments applicable to this Contract and all Exhibits and Amendments executed by the parties and attached hereto are by reference made a part of this Contract AGREED TO AND ACCEPTED BY the parties the day and year hereinafter written The Effective Date of this Contract is May 1 2006 Subscribing Group Or Name 1 l &1 e ei _.._ � teti:AIACI )ate 0 APP 04 ' (12/04) AVMED Inc d/• _ _ VMED Health Plans By Signa Evis Clavareza, Name Director, Client Service �Itie Date AvMED H EAI r ii P I ANS STANDARD OPTION/20 250 ADMIT benefit Summary SCHEDULE OF BENEFITS COST TO MEMBER OUT OF POCKET MAXIMUM Per Calendar Year AVMED PRIMARY CARE PHYSICIAN AVMED SPECIALISTS' SERVICES Services at Participating Physicians offices include but are not limited to • Routine office visits / annual gynecological examination when performed by Primary Care Physician • Maternity outpatient visits • Pediatric care and well child care ■ Periodic health evaluation and immunizations • Diagnostic imaging laboratory or other diagnostic services ■ Minor surgical procedures • Vision and hearing examinations for children under 18 • Office visits • Annual gynecological examination when performed by a participating Specialty Health Care Physician $1 500 INDIVIDUAL $3 000 FAMILY $10 per visit $20 per visit HOSPITAL OUTPATIENT SERVICES OUTPATIENT DIAGNOSTIC TESTS Inpatient care at Participating Hospitals includes • Room and board unlimited days (semi private) • Physicians specialists and surgeons services • Anesthesia use of operating and recovery rooms oxygen drugs and medication • Intensive care unit and other special units general and special duty nursing ■ Laboratory and diagnostic imaging • Required special diets • Radiation and inhalation therapies • Outpatient surgeries including cardiac catheterizations and angioplasty ■ Outpatient therapeutic services including • Drug infusion therapy • Injectable Drugs (Co payment for Injectable Drug waived if incidental to same day drug infusion therapy) • CAT Scan PET Scan MRI • Other diagnostic imaging tests $250 per admission 100% coverage thereafter $250 Co payment $100 Co payment $75 Co payment $25 per test $10 per test EMERGENCY SERVICES An emergency is the sudden and unexpected onset of a condition requiring immediate medical or surgical care (Co payment waived if admitted) ■ Emergency services at Participating Hospitals ■ Emergency services at non participating Hospitals facilities and/or physicians AvMed must be notified within 24 hours of inpatient admission following emergency services or as soon as reasonably possible $75 Co payment $100 Co payment AV STD/20 250A 05 MP 3413 (10/05) Benefit Summary, continued URGENT/IMMEDIATE CARE • Medical Services at a participating Urgent/Immediate Care facility or services rendered after hours in your Primary Care Physician s office • Medical Services at a non participating Urgent/Immediate Care facility $40 Co payment $60 Co payment MENTAL HEALTH ■ 20 outpatient visits $25 per visit FAMILY PLANNING • Voluntary family planning services • Sterilization $10 per visit $100 Co payment ALLERGY TREATMENTS AMBULANCE PHYSICAL, SPEECH, AND OCCUPATIONAL THERAPIES • Injections • Skin testing • Ambulance transport for emergency services • Non emergent ambulance services are covered when the skill of medically trained personnel is required and the Member cannot be safely transported by other means • Short term physical speech or occupational therapy for acute conditions Coverage is limited to 30 visits per calendar year for all services combined $10 per visit $50 per course of testing $100 Co payment $10 per visit SKILLED NURSING FACILITIES AND REHABILITATION CENTERS • Up to 20 days post hospitalization care per Contract Year when prescribed by physician and authorized by AvMed $25 per day CARDIAC REHABILITATION Cardiac rehabilitation is covered for the following conditions • Acute myocardial infarction • Percutaneous transluminal coronary angioplasty (PTCA) • Repair or replacement of heart valves • Coronary artery bypass graft (CABG) or • Heart transplant Coverage is limited to 18 visits per Contract Year $20 per visit Benefits limited to $1,500 per Contract Year HOME HEALTH CARE • Limited to 60 skilled visits per calendar year NO CHARGE DURABLE MEDICAL EQUIPMENT AND ORTHOTIC APPLIANCES Equipment includes • Hospital beds • Walkers • Crutches • Wheelchairs Orthotic appliances are limited to ■ Leg arm back and neck custom made braces $50 per episode of illness Benefits limited to $500 per Contract Year PROSTHETIC DEVICES Prosthetic devices are limited to • Artificial limbs • Artificial joints • Ocular prostheses NO CHARGE FOR ADDITIONAL INFORMATION, PLEASE CALL 1 800 88 AVMED (1 800 882 8633) THIS SCHEDULE OF BENEFITS IS NOT A CONTRACT FOR SPECIFIC INFORMATION ON BENEFITS EXCLUSIONS AND LIMITATIONS PLEASE SEE YOUR AVMED GROUP MEDICAL AND HOSPITAL SERVICE CONTRACT AV STD/20 250A 05 MP 3413 (10/05) Av] HEALTH P LAN S Prescription Drug Benefits $15/30/50/75 CO PAYMENT with Contraceptives DEFINITIONS Bland drug means a Prescription Drug that is usually manufactured and sold under a name or trademark by a drug manufacturer or a drug that is identified as a Brand drug by AvMed AvMed delegates determination of Generic/Brand status to our Pharmacy Benefits Manger Bvind Add!ttonn.l (hai ge means the additional charge that must be paid if you or your physician choose a Brand drug when a Generic equivalent is available The charge is the difference between the cost of the Brand drug and the Generic drug This charge must be paid in addition to the applicable Brand Co payment (Preferred or Non Preferred) Generic drug means a drug that has the same active ingredient as a Brand drug or is identified as a Generic drug by AvMed s Pharmacy Benefits Manager Injectable Dru., is a medication that has been approved by the Food and Drug Administration (FDA) for administration by one or more of the following routes intramuscular injection intravenous injection intravenous infusion subcutaneous injection intrathecal injection intrarticular injection intracavernous injection or intraocular injection Pre Authorization is required for all Injectable Drugs P urtiLipatmg Phnr m1cs means a pharmacy (either retail mail order or specialty pharmacy) that has entered into an agreement with AvMed to provide Prescription Drugs to AvMed Members and has been designated by AvMed as a Participating Pharmacy PraLlicd Diug Lost means the listing of preferred medications as determined by AvMed s Pharmacy and Therapeutics Committee based on clinical efficacy relative safety and cost in comparison to similar medications within a therapeutic class This multi tiered list establishes different levels of Co payment for medications within therapeutic classes As new medications become available they may be considered excluded until they have been reviewed by AvMed s Pharmacy and Therapeutics Committee Prescription Drui, means a medication that has been approved by the FDA and that can only be dispensed pursuant to a prescription according to state and federal law Pie Author iz ition means the process of obtaining approval for certain Prescription Drugs (prior to dispensing) according to AvMed s guidelines The prescribing physician must obtain approval from AvMed The list of Prescription Drugs requiring Pre Authorization is subject to periodic review and modification by AvMed A copy of the list of medications requiring Pre Authorization and the applicable criteria are available from Member Services or from the AvMed website Self Administered lnlectlble Drug is a medication that has been approved by the FDA for self injection and is administered by subcutaneous injection or a medication for which there are instructions to the patient for self injection in the manufacturer s prescribing information (package insert) Pre Authorization is required for all Self Administered Injectable Drugs HOW DOES YOUR RETAIL PRESCRIPTION COVERAGE WORK' To obtain your Prescription Drug take your prescription to or have your physician call an AvMed Participating Pharmacy Your physician should submit prescriptions for Self Administered Injectable Drugs to AvMed s specialty pharmacy Present your prescription along with your AvMed identification card Pay the following Co payment (as well as the Brand Additional Charge if you or your physician choose a Brand product when a Generic equivalent is available) Tier 1 Tier 2 Tier 3 Tier 4 Preferred Generic Drugs Preferred Brand Drugs Non Preferred Brand or Generic Drugs Self Administered Injectable Drugs $ 15 00 Co payment $ 30 00 Co payment $ 50 00 Co payment $ 75 00 Co payment ORDERING YOUR PRESCRIPTIONS THROUGH THE MAIL Mail service is a benefit option for maintenance medications needed for chronic or long term health conditions It is best to get an initial prescription filled at your retail pharmacy Ask your physician for an additional prescription for up to a 90 day supply of your medication to be ordered through mail service Up to 3 refills are allowed per prescription Pay the following Co payment (as well as the Brand Additional Charge if you or your physician choose a Brand product when a Generic equivalent is available) Tier 1 Tier 2 Tier 3 Tier 4 Preferred Generic Drugs $ 45 00 Co payment Preferred Brand Drugs $ 90 00 Co payment Non Preferred Brand or Generic Drugs $150 00 Co payment Self Administered Injectable Drugs are not available through mail service Prescription Drug Renef its, continued WHAT IS COVERED' • Your Prescription Drug coverage includes outpatient medications (including contraceptives) that require a prescription and are prescnbed by your AvMed physician in accordance with AvMed s coverage criteria AvMed reserves the right to make changes in coverage cntena for covered products and services Coverage criteria are medical and pharmaceutical protocols used to determine payment of products and services and are based on independent clinical practice guidelines and standards of care established by government agencies and medical/pharmaceutical societies • Your retail Prescription Drug coverage includes up to a 30 day supply of a medication for the listed Co payment Your prescription may be refilled via retail or mail order after 75% of your previous fill has been used You also have the opportunity to obtain a 90 day supply of medications used for chronic conditions including but not limited to asthma cardiovascular disease and diabetes from the retail pharmacy for the applicable Co payment per 30 day supply However Pre Authorization may be required for covered medications • Your mail order Prescription Drug coverage includes up to a 90 day supply of a routine maintenance medication for the listed Co payment If the amount of medication is less than a 90 day supply you will still be charged the listed mail order Co payment • Your Self Administered Injectable Drug coverage extends to many injectable drugs approved by the FDA These drugs must be prescribed by a physician and dispensed by a retail or specialty pharmacy The Co payment levels for Self Administered Injectable Drugs apply regardless of provider This means that you are responsible for the appropriate Co payment whether you receive your Self Administered Injectable Drug from the pharmacy at the doctor s office or during home health visits Self Administered Injectable Drugs are limited to a 30 day supply • Your prescription drug coverage includes coverage for injectable contraceptives There is a Co payment of $30 for each injection If there is an office visit associated with the injection there will be an additional Co payment required for the office visit • Quantity limits are set in accordance with FDA approved prescribing limitations general practice guidelines supported by medical specialty organizations and/or evidence based statistically valid clinical studies without published conflicting data This means that a medication specific quantity limit may apply for medications that have an increased potential for over utilization or an increased potential for a Member to expenence an adverse effect at higher doses QUESTIONS' Call your AvMed Member Services Department at 1 800 88 AvMed (1 800 882 8633) EXCLUSIONS AND LIMITATIONS • Drugs or medications which do not require a prescription (i e over the counter medications) or when a non prescription alternative is available • Medical supplies including therapeutic devices dressings appliances and support garments • Replacement Prescription Drug products resulting from a lost stolen expired broken or destroyed prescription order or refill • Diaphragms and other contraceptive devices • Fertility drugs • Medications or devices for the diagnosis or treatment of sexual dysfunction • Medications for dental purposes including fluonde medications • Prescription and non prescnption vitamins and minerals except prenatal vitamins • Nutritional supplements • Immunizations • Allergy serums medications administered by the Attending Physician to treat the acute phase of an illness and chemotherapy for cancer patients are covered in accordance with the Group Medical and Hospital Service Contract and may be subject to Co payments or Co insurance as outlined on the Schedule of Benefits • Investigational and experimental drugs (except as required by Florida statute) • Cosmetic products including but not limited to hair growth skin bleaching sun damage and anti wrinkle medications • Nicotine suppressants and smoking cessation products and services • Prescription and non prescnption appetite suppressants and products for the purpose of weight loss • Compounded prescriptions except pediatric preparations • Medications and immunizations for non business related travel including Transdermal Scopolamine Filling a prescription at a pharmacy is not a claim for benefits and is not subject to the Claims and Appeals procedures under ERISA However any medicines that require Pre Authorization will be treated as a claim for benefits subject to the Claims and Appeals Procedures as outlined in the Group Medical and Hospital Service Contract AV G100 RX 15/30/50/75 OC 05 MP 3450 (10/05) AvMED HEALTH PLANS OUTPATIENT VISION BENEFITS Amendment As of the effective date the following benefits are added for an additional premium The Plan provides one routine vision examination per contract year with no age limitation subject to a member copayment of $10 per visit No pre authorization or referral is necessary but services must be provided by a Plan Physician The Plan provides one (1) pair eyeglasses per contract year subject to a member copayment of $10 The eyeglasses must be non treated standard single or bifocal lenses only with standard frame from the available selection (designer frames are not covered) AV VISION R 99 MP 2043 (1/04) AVMED HEALTH PLANS ELECTIVE TERMINATION OF PREGNANCY Amendment If selected the following optional coverage is hereby added The AvMed Health Plan Group Medical and Hospital Service Contract is amended to state • Elective termination of pregnancy will be a covered benefit if the services and treatment are provided by an AvMed participating provider in an AvMed participating facility There shall be a physician copayment of $100 00 in addition to the applicable facility copayment AV G100 ETP R 97 MP 1321 (1/04) AvMED HEALTH PLNNS Amendment Inpatient Mental Health and Partial Hospitalization Benefits As of the effective date Inpatient Mental Health and Partial Hospitalization Benefits are being provided for an additional premium ■ Inpatient treatment of mental/nervous disorders for up to 30 days per patient subject to a member copayment of $250 per admit shall be provided by the Plan when a member is admitted to a Participating Hospital or Participating Health Care Facility as a registered bed patient • Partial Hospitalization for mental health services is a Covered Service when it is provided in lieu of inpatient hospitalization and is combined with the inpatient hospital benefit Two days of Partial Hospitalization will count as one day toward the inpatient Mental Health Benefit subject to member copayment as noted above AV G100 ME/PH $250 per admit 04 MP 3522 (10/04) AvMED HEALTH P L a N s Substance Abuse Benefits Amendment As of the effective date the following Substance Abuse Benefits have been added for an additional premium • INPATIENT Inpatient treatment of alcohol and drug abuse is not provided except for acute detoxification • OUTPATIENT An intensive treatment program(s) of one or more weeks by Plan Physicians subject to a member copayment of $50 per week Coverage is limited to a maximum of six weeks per contract year AV SA R 98 MP 1527 (1/04) AVMED HEALTH Dui able Medical Fquipnient Amendment If selected, the following coverage is hereby modified, for an additional premium DURABLE MEDICAL EQUIPMENT • Benefits are limited to a maximum of $2,000 per contract year* All other coverage provisions, including co -payment, limitations and exclusions remain as stated in the Certificate of Coverage or Schedule of Co -Payments *For the treatment of diabetes, coverage for an infusion pump will not apply toward the annual maximum limitation and shall not be subject to the durable medical equipment benefit limitation AV G100 DME 2000 R 06 MP 2149 (4 06) AVMED _ HEALTH PLANS Addendum Coverage for Mammograms — Waiver of Co -payment If selected the following provision is hereby modified for an additional premium Section 10 28 of the AvMed Health Plans Group Medical and Hospital Service Contract is amended to state Mammograms are covered in accordance with Florzda 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 This coverage will not be subject to diagnostic imaging Co payments AV Mammogram 05 MP -3228 (12/05) AVMED HEALTH PLAYS DOMESTIC PARTNER Amendment 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 Fhgibility %Sill be added tot a Domestic Par trier and his of het children Definition of Domestic Partner A Domestic Partner means an unmarried adult who • Cohabits with you in an emotionally committed and affectional relationship that is meant to be of lasting duration • Is not related by blood or marriage • Is at least eighteen years of age • Is mentally competent to consent to a contract • Has filed a Domestic Partnership agreement or registration with the Employer if available in the state (and/or city) of residence • Has shared financial obligations including basic living expenses for the twelve month period prior to enrollment in the plan • Will provide documentation that will be satisfactory to the Employer as evidence of a Domestic Partner relationship and • Meets the dependents eligibility requirements of the Employer s health benefits plan AV DP 12 R 02 MP 3147 (1/04) AvMED HEALTH PLANS VILLV'0E OE KEI xISCAY\E, 5e1ec tic,ri Arnendzrent As of the Effective Date the above named Subscribing Group has selected the following Amendments Identifier AV G100 RX 15/30/50/75 OC 05 AV VISION R 99 AV G100 ETP R 97 AV MH/PH $250 per admit 04 AV SA R 98 AV G l 00 DME 2000 R 06 AV Mammogram 05 AV DP12R02 Amendment Name Prescription Drug Benefit Vision Benefit Elective Termination of Pregnancy Mental Health Benefit Substance Abuse Durable Medical Equipment Coverge for Mammograms Domestic Partner The provisions contained in the Schedule of Co payments applicable to this Contract and all Exhibits and Riders attached hereto are by reference made a part of this Contract AGREED TO AND ACCEPTED BY the parties the day and year hereinafter written The Effective Date of this Contract is May 1 2006 Subscribing Group VILLAGE OF KEY BISCAYNE By Signature Name Title Date AV- -SELECTION AMENDMENT -03 AVMED Inc d/b/a AVMED Health Plan By Evis Clavareza Name Director of Client Service Title Date