HomeMy Public PortalAbout22-022 - renewal contracts with Avmed and Metlife for Medical, Dental and Vision Insurance for city employeesSponsored by: City Manager
RESOLUTION NO. 22-022
A RESOLUTION OF THE CITY COMMISSION OF THE CITY OF OPA-
LOCKA, FLORIDA, AUTHORIZING THE INTERIM CITY MANAGER
TO ENTER INTO RENEWAL INSURANCE CONTRACTS WITH
AVMED, INC. AND METLIFE FOR MEDICAL, DENTAL, AND VISION
INSURANCE FOR CITY EMPLOYEES; PROVIDING FOR
INCORPORATION OF RECITALS; PROVIDING FOR AN EFFECTIVE
DATE
WHEREAS, there is a continued need for municipal health insurance coverage for
City of Opa-locka employees; and
WHEREAS, the Human Resources Department has worked with the City's Agent of
Record to assess the existing group insurance policies and proposed premium rated from
other carries (Policy Quote Presentations, attached hereto as Composite Exhibit "A"); and
WHEREAS, the City desires to renew its current agreements with AvMed, Inc. and
Metlife as policies for medical, dental, and vision insurance for City employees and their
dependents; and
WHEREAS, it is in the best interest of the City to renew the contracts with AvMed
and Metlife as the City's benefit providers.
NOW, THEREFORE, BE IT DULY RESOLVED BY THE CITY COMMISSION OF
THE CITY OF OPA- LOCKA, FLORIDA:
SECTION 1. The recitals to the preamble herein are incorporated by reference.
SECTION 2. The City Commission of the City of Opa-locka, Florida hereby authorizes
the City Manager to enter into Renewal Agreements, between the City of Opa-Locka,
AvMed, Inc., and Metlife for medical, dental, and vision insurance coverage for City
employees and dependents.
SECTION 3. The Interim City Manager and other proper City Officials are hereby
authorized to execute any required documents in order to carry out the intent of this
Resolution.
SECTION 4. Sections of this Resolution may be renumbered or re -lettered and
corrections of typographical errors which do not affect the intent may be authorized by
the Interim City Manager or the Interim City Manager's designee following review by
the City Attorney, without the need of a public hearing by filing a corrected copy of same
with the City Clerk.
Resolution No. 22-022
SECTION 5. This Resolution shall take effect upon the adoption and is subject to
the approval of the Governor or Governor's Designee.
PASSED and ADOPTED this 22nd day of August, 2022.
Veronica E. Williams, Mayor
ATTEST:
a Flores, City Clerk
APPROVED AS TO FORM AND
LEGAL SUFFICIENCY:
ye
Burnadette Norris -
City Attorney
Moved by: Commissioner Dominguez
Seconded by: Commissioner Davis
VOTE: 5-0
Commissioner Bass YES
Commissioner Davis YES
Commissioner Dominguez YES
Vice -Mayor Taylor YES
Mayor Williams YES
2
City of Opa-locka
Agenda Cover Memo
Department
Director:
Kierra Ward
Department
Director Signature:
'f&'( —j
City Manager:
Darvin Williams
CM Signature:
Commission
Meeting Date:
08.22.2022
Item Type:
(EnterX in box)
Resolution
Ordinance
Other
X
Fiscal Impact:
(Enter X in box)
Yes
No
Ordinance Reading:
(Enter X in box)
lst Reading
2nd Reading
X
X
Public Hearing:
(Enter X in box)
Yes
No
Yes
No
X
Funding Source:
Account# :
(Enter Fund &
Dept)
Ex:
Advertising Requirement:
(EnterX in box)
Yes
No
X
Contract/P.O.
Required:
(EnterX in box)
Yes
No
RFP/RFQ/Bi#:
X
Strategic Plan
Related
(EnterX in box)
Yes
No
Strategic Plan Priority Area:
Enhance Organizational
Bus. & Economic Dev
Public Safety
Quality of Education
Qual. of Life & City Image
Communication
MI
MI
El
•
III
IM
Strategic Plan Obj./Strategy:
(list the specific objective/strategy this
item will address)
X
Sponsor Name
City Manager
Department: Human Resources
City Manager
Short Title:
A resolution of the City of Opa-locka, Florida authorizing the City Manager to select AvMed Health Plan as the
provider for the City of Opa-locka Health Plan, Metlife as the provider for the City of Opa-locka's dental and
vision group plans, for the benefit year beginning October 1, 2022 expiring September 30, 2023.
Staff Summary:
The Human Resources Department has worked diligently with the City's Agent of Records, Sapoznik Insurance
and Associates, Inc to assess the existing group insurance policies and proposed premium rates from two other
carriers. Staff has recommended to renew with the current insurance carriers. A resolution of the City
Commission of Opa-locka, Florida authorizes the City Manager to enter into an agreement with AvMed and
Metlife for the medical, dental, and vision group plans, respectively.
Staff has analyzed the results of the competitive Bid Process for Insurance Carriers facilitated by the City's
current Agent of Records Sapoznik Insurance and Associates. It has been determined that it would be in the
City's best interest to continue the current plans and renew the contract with the current carriers.
Metlife provided a 10.10% increase for the renewal of the dental and a rate pass vision insurance with no
increase.
Financial Impact: This item is estimated to present an annual cost of $935,234.64 and is subject to change
upon employee dependent coverage elections.
Proposed Action:
The packet attached identifies additional quotes and plans received and formal declination letters from
carriers that declined to provide a quote.
Attachment:
1. Plan Design and Insurance Bid Results
s zrik.
al AWORLD COMPANY
ALTER
CITY OF O. A-LOCKA
OCT OBER 2022
Carrie r N ame
Plan Name
AvMed
H MO 0A 7550
Re newal: HMO OA 7709/6278
ti5/ t
[} tY i
Av Med
Choice 7628
Re newal: Choic e 7809/7479
-- i.:1'1;.1
!\! rI:1 .. f .. v •'' ''ti'
HMO OA 7730/6218
H MO OA 7725/6218
Choice 7815/7479
Choice 7811/7479
Network Access
In Network Only
In Netw ork Only
In Network Only
In Netw ork I PHCS I Out of Network
In Network I PHCS I Out of Network
In N etwork I PHCS I Out of Network
Deductible
Deductible
$3500/$7000
$5000/510000
55000/$10000
$2500/55000
I 57500/$15000
$5000/510000
$15000/$30000
$3500/57000
$10500/521000
M ember Co -Insurance
20%
20%
20%
10%
40%
20%
50%
0%
40%
Max Benefits
Out of Pocket Maximu m
$6350/512700
07550/515100
$6850/$13700
$6500/$13000
1 $19500/$39000
$6350/512700
I $19050/$38100
07500/515000
$22500/545000
Lifetime max
Unlimited
Unlimited
.Unlimited
Unlimited
Unlimited
Unlimited
Physician Office Services
Physician
$25
$35
$25
$25
40% After Ded
$25
50% After Ded
$35
40% After Ded
Specialist
$50
$70
$50
$50
40% After Ded
$50
50% After Ded
570
40% After Ded
Preventive Care
Covered 100%
Cov ered 100%
Covered 100%
Covered 100%
40% After Ded
Co vered 100%
50% After Ded
Covered 100%
40% After Ded
Diagno stic Se rv ices
Indepen de nt Clinical Lab
Pardo: 100% / Indp: $100
Re newal: lndp: 8100 / All O ther: $200
lndp: $25
All O ther: $50
Indp: $25
All Other: $50
Parlic: Covered 100% / Indp: $50
Renewal: I ndp: 550 / All Other: $100
40% After Ded
Indp: $100
All Other: $200
50% Alter Ded
Indp: $50
All Other: 5150
40% After Ded
Diagnostic Testing Facility
MRI, MRA , CT 8 PET Scan s
Indp: $100
All Others: $200
Indp: $250
All O ther: $500/Ded
Indp: $250
All Other: $500
Indp: 5200
All Other: $400 After Ded
40% After Ded
Indp: 0100
All Other: $200
50% After Ded
Indp' $450
All Other: $600/Ded
40% After Ded
ER a nd Urgent Care
Emergency Room
$200
$500
$500
5350
$200
$600
Urgent Care
$40/525
$75/535
$75/$25
$75/$25 40% After Ded
$40/025 50% After Ded
575/$35 40% After Ded
Outpatient & Inpatien t Services
Outpatient Surgery
Ambulatory Surgical Center/Hospital
20% After Ded
20% Alter DeU
20% After Ded
10% AlDed
40% After Ded
20%After Ded
50% After Ded
ASC: $1000
Hosp: $1000 After Dedter
40 % After Ded
In patient Hospital
20% After Ded
20% After Ded
20% After Ded
10% After Ded
40% After Ded
20% After Ded
50% After Ded
$1000 After Ded P er Admit
40 % Aft er Ded
Provider Serv ices Inpatient Ho spital
20% After De d
20% After Ded
20% After Ded
10% After Ded
40% After Ded
20% Aft er Ded
50% After Ded
Co vered 100%
40% After D ed
Pharmacy Services
Prescription
520/30/50/100/50%
$20/30/50/100/50%
$20/30/50/100/50%
$10/25/50/100; 30% After NC
$500/$1000 Ded
$10/25/50/100; 30% After
$500/$7000 Ded
NC
$10/25/50/100; 30 %
After $500/51000 D ed NC
tt.f Empl. yees
Employee
71
Cu rren t
5454. 15
Neg.liate d
$562.74
•It1
$520.28
7 y .v �,
5535.21
5
Cu rrent
$525. 76
Neg.li.tetl
$655.42
r' .-,;
}
all
$602 .99
$635.80
Employee/Spouse
9
5908. 31
$1,125. 47
$1,040. 55
$1,070. 42
1
$1,051.52
$1,310.84
$1,205.98
$1,271.60
Employee/Child(renl
13
$862.89
51,068. 97
$988. 32
$1,016. 68
1
$998.95
$1,245 .04
$1,145.44
51,207 .77
Employee/Family
8
$1,407.88
51,744. 48
51,612.86
51,659.15
4
$1,629.86
$2,031.80
51,869.27
51,970.99
Co mments
101
Current
23. 90%
14.56%
17. 84%
11
Current
24.66%
14.69%
20.93%
Mon thly Total
882,900.05
$77,938. 22
$72,055. 87
$74,123.73
511, 198.71
513,960.18
$12,843 .45
513,542.33
Current Monthly Total
Ne go tia te d Ml Mo nthly To tal
9 Y
Alternate 1 Mo nthly Total
Alternate 2 Monthly Total
574,098.76
$91,896.40 24. 02%
584,899.32 14.58%
$87,666. 06 18 31
Quotes are based on the ce nsus receiv ed. 9 tes could be adjusted based on final enrollment .
This da ta is provided for information purposes only. It is not intended to represent a bindin g o bligation. The governing document for this purp ose w ould be the COC issued by Inc carrier. Please s ee detailed be nefit s ummary.
2:46 PM
Information provided is proprietary. It ma y n ot be co pied, emulated or distributed without express permission.
8/16/2022
S -zni%c.
AWORLD COMP ANY
DHMO
CITY OF OPA-L OCH.,
OCTOBER 2022
Carrier Name
36
MetLife
Met290
r eye v
iEiitiW G?
LCDS700B
Plan Name
Network Access
In Network Only
In Network Only
De du ctible
No Ded
$5 Office Visits
No Ded
$0 Office Visits
Ded waived for Preventive
None
None
Prev entive
Some procedures
Covered 100%
Some procedures
Covered 100%
Basic
Co -Pays Apply
Co -Pays Apply
Majo r
Co -Pays Apply
Co -Pays Apply
Periodontics / Endodontics
Co -Pays Apply
Co -Pays Apply
Annual Maximu m Bene fit
None
None
Out of Network Reimbursement Lev el
In Network Only
In Network Only
Orthodontic
Co -Pays Apply
Co -Pays Apply
Orthodo ntic Eligibility
Adult & Child
Adult & Child
Ortho dontic Maximu m
None
None
Ra te Guarantee
Next Renewal: 10/01/2023
1 Year
$13.24
Premium Breakdown
Cu rrent
$11. 86
Renewal
$14. 15
Negotiated
$13 .06
Employee
Employee/Spouse
4
$20.75
$24. 75
$22.85
$23.16
Employee/Child(ren)
8
$24.90
$29/0
$27.41
$28.68
Employee/Family
4
$34.99
$41.73
$38.52
$36 .40
Co mments
52
Current
19. 29%
10.10%
11.21%
Mon thly Total
$849. 12
$1,012.92
$934.92
$944 .32
Quo tes are base d on the census received. Rates co uld be adju sted based on final enrollment.
This data is provide d fo r information purposes only. It is not intende d to represent a binding obligatio n. The governin g document for this purpose would be the COC issued by the carrier . Pl ease see detailed benefit summary .
2:39 PM Information provided is pro prietary. It may not be copied, emulated or distributed without express permission.
8/16/2022
AWORLD COMPANY
Carrier Name
Plan Name
Network Access
Deductible
Ded waived fo r Preventive
Preventive
Basic
Major
Perio do ntics / Endodo ntics
Annual Maximum Benefit
Out of Netwo rk
Reimbursement Level
Orthodontic
O rtho dontic Eligibility
Orthodo ntic Maximum
Rate Gu aran tee
Emplo yee
34
DPPO
MetLife
DPPO
CITY OF OPA-L OCKA
OCT OBER 2022
Lincoln
DPPO
In Network Member Cost Out of Network Member Cost
In Network Member Cost Out of Netw ork Member Cost
$50/$150
$50/$150
$50/$150
$50/$150
Yes
No
Yes
Yes
0%
10%
0%
10%
10% 30%
10% 30%
40% 60%
40% 60%
Major
Simple Extractions: Basic
Major
Simple Extractions: Basic
$3,000 $1,500
$3,000 $1,500
Fee
Fee
Fee
UCR
50%
50%
Child(ren) to age 19
Child(ren) to age 19
$1,000
$1,000
Next Renewal: 10/01/2023
Current
$40.42
$38.40
1 Year
$34 .34
Employee/Spouse
8
$80.83
$76.79
$68 .69
Employee/Child(ren)
9
$97.48
$92. 61
$82.83
Employee/Family
11
$145. 48
$138.21
$123 .61
Comments
62
Current
-5.00%
-15.03%
Monthly Total
$4,498. 52
$4,273.72
$3,822 .26
Quo tes are base d on the c ensus receiv ed. Rates could be adjusted based on final enrollment.
This data is provided fo r information purpo ses only. It is no t intended to represent a binding obligation. The governing document for this purpo se would be the COC issued by the carrier. Please see detailed benefit summary.
2:39 PM Information pro vided is proprietary. It may no t be copied, emulated or distributed without e xpress permission. 8/16/2022
CITY OF OPA-L CKA
OCTOBER 2022
VISION
Carrier Name
MetLife
*Must be sold with D ental*
M130D - 10/10
Ey eMed
li-ilil fli
.1MtWf T :5.01 ,i1�i11! iit{: f'
Plan Name
Option 1
LVC8
Network Access
In Network
Allowance
Out of Netw ork
Reimbursement
In Netw ork
Allowance
Out of Network
Reimbursement
In Network
Allowance
Out of Network
Reimbursement
Eye Care Co -pay
Eye Exam
$10 I
Up to $45
$10
Up to $40
$10
Up to $40
Fre qu ency
12 Months
12 Months
12 Months
Materials Co -pay
$10 I
N/A
$10
N/A
$10
N/A
Lenses
Single
$0 After Co -pay
Up to $30
$0 After Co -pay
Up to $30
$0 After Co -pay
Up to $40
Bifocal
$0 After Co -pay
Up to $50
$0 After Co -pay
Up to $50
$0 After Co -pay
Up to $60
Trifocal
$0 After Co -pay
Up to $65
$0 After Co -pay
Up to $70
$0 After Co -pay
Up to $80
Lenticular
$0 After Co -pay
Up to $100
$0 After Co -pay
Up to $70
$0 After Co -pay
Up to $80
Frequency
12 Mon ths
12 Months
12 Months
Frames
Frames
Up to $130 +
20% off Balance
Up to $70
Up to $130 +
20% off Balance
Up to $91
Up to $130 +
30% off Balance
Up to $45
Freque ncy
24 Mo nths
24 Mo nths
24 Months
Contact Lens Co -pay
In lieu of any o the r eye wear benefits
In li eu of any other eyewear b enefits
In lieu of any other eyewe ar be nefits
Elective
Up to $130
Up to $105
Up to $130
Up to $91
Up to $125
Up to $125
Medically Necessary
$0 After Co -pay
Up to $210
$0 After Co -pay
Up to $300
$0 After Co -pay
Up to $210
Frequency
12 Months
12 Months
12 Months
Rate Guarantee
Next Renewa l:10/01/2023
4 Years
2 Years
Premium Breakdo wn
■
Current/Renewal
Employee
53
$6.80
$6.75
$7.62
Employee/Spouse
12
$13.62
$13.52
$14.47
Employee/Childlren)
12
$14.02
$13.91
$16 .98
Employee/Family
14
$21. 79
$21.63
$23 .87
Comments
91
Rate Pass
-0.74%
11 .86%
Total Mon thly
$997.14
$989.73
$1,115 .44
Quotes are based on the censu s received. Rates cou ld be adjusted based on final enrollment.
This data is provided for info rmatio n purposes only. 11 is no t intended to represent a binding obligation. The governing document for this purpo se would be the COC issued by th e carrier. Please see detailed benefit summary .
2:39 PM Info rmation provided is proprietary. It may not be co pied, emulated or distributed without express permissi on.
8/16/2022
AvMed
Embrace
better health:'
Large Group Choice Plan
Medical and Hospital Service Contract
with Point of Service Rider
James M. Repp
President & COO
AV-LG-COC-21 Choice-LG-7638 (07/21)
TABLE OF CONTENTS
Service Area ii
I. INTRODUCTION 1
II. DEFINITIONS 2
III. ELIGIBILITY FOR COVERAGE 12
IV. ENROLLMENT AND EFFECTIVE DATE OF COVERAGE 14
V. TERMINATION 16
VI. PREMIUMS, COPAYMENTS, COINSURANCE, DEDUCTIBLES AND OTHER EXPENSES 22
VII. PHYSICIANS, HOSPITALS AND OTHER PROVIDERS 24
VIII. ACCESSING COVERED BENEFITS AND SERVICES 25
IX. COVERED MEDICAL SERVICES 28
X. LIMITATIONS OF COVERED MEDICAL SERVICES 41
XI. EXCLUSIONS FROM COVERED MEDICAL SERVICES 43
XII. PRESCRIPTION MEDICATION BENEFITS, LIMITATIONS AND EXCLUSIONS 50
XIII. REVIEW PROCEDURES AND HOW TO APPEAL A CLAIM (BENEFIT) DENIAL 51
XIV. COORDINATION OF BENEFITS 56
XV. SUBROGATION AND RIGHT OF RECOVERY 59
XVI. DISCLAIMER OF LIABILITY AND RELATIONSHIPS BETWEEN THE PARTIES 60
XVII. GENERAL PROVISIONS 61
AV-LG-COC-21 i Choice-LG-7638 (07/21)
AVMED CORPORATE OFFICE
9400 S. DADELAND BOULEVARD
MIAMI, FL 33156-9004
AVMED MEMBER ENGAGEMENT CENTER - ALL AREAS
1-800-88 AVMED
(1-800-882-8633)
Alachua
Baker
Bradford
Broward
Citrus
Clay
Columbia
Dixie
Duval
Gilchrist
SERVICE AREA
Hamilton
Hernando
Hillsborough
Lake
Lee
Levy
Manatee
Marion
Miami -Dade
Nassau
Orange
SERVICE AREA OFFICES
MIAMI
9400 South Dadeland Boulevard
Miami, Florida 33156-9004
(305) 671-5437
(800) 432-6676
Osceola
Palm Beach
Pasco
Pinellas
Polk
St. Johns
Sarasota
Seminole
Suwannee
Union
GAINESVILLE
4300 Northwest 89th Boulevard
Post Office Box 749
Gainesville, Florida 32627-0749
(352) 372-8400
(800) 346-0231
AV-LG-COC-21 ii Choice-LG-7638 (07/21)
AVMED, INC.
LARGE GROUP CHOICE PLAN
MEDICAL AND HOSPITAL SERVICE CONTRACT
WITH POINT OF SERVICE RIDER
IN CONSIDERATION of the payment of pre -paid monthly Premiums as provided herein, AvMed, Inc., a
private Florida not -for-profit corporation, state licensed as a health maintenance organization under
Chapter 641, Florida Statutes (hereinafter, "AvMed"), and the Subscribing Group as named on the Group
Master Application (hereinafter "Subscribing Group"), agree as follows:
I. INTRODUCTION
1.1 Provision of Health Care Services and Benefits. The Subscribing Group engages AvMed, on behalf
of the group health plan described in this Contract, to arrange for the provision of Covered Benefits
or Covered Services which are Medically Necessary for the diagnosis and treatment of Members of
the Subscribing Group. AvMed arranges for the delivery of Covered Services in accordance with
the covenants and conditions contained in this Contract, and does not directly provide these
Covered Services. AvMed will rely upon the statements of the Subscriber in his application in
arranging for the provision of Covered Services under this Contract.
1.2 Interpretation. In order to provide the advantages of Hospital and medical facilities and of In -
Network Providers, AvMed operates on a direct service rather than indemnity basis. The
interpretation of this Contract will be guided by the direct service nature of AvMed's program and
the definitions and other provisions contained herein.
1.3 Important Considerations. When reading your Contract, please remember:
a. You should read this Contract in its entirety in order to determine if a particular Health Care
Service is covered.
b. Many of the provisions of this Contract are interrelated. Therefore, reading just one or two
provisions may give you a misleading impression. Many words used in this Contract have special
meanings (see Part II. DEFINITIONS).
c. The headings of Parts and Sections contained in this Contract are for reference purposes only
and will not affect in any way the meaning or interpretation of particular provisions.
1.4 References in this Contract
a. References to "you" or "your" throughout refer to you as the Subscriber and to your Covered
Dependents, unless expressly stated otherwise or unless, in the context in which the term is used,
it is clearly intended otherwise. Any references which refer solely to you as the Subscriber or
solely to your Covered Dependents will be noted as such.
b. References to "we", "us" and "our" throughout refer to AvMed.
c. Whenever used, the singular will include the plural and the plural the singular, and the use of
any gender will include all genders.
d. References to the "Plan" refer to this AvMed Large Group Choice Plan.
e. If a word or phrase starts with a capital letter, it is either the first word in a sentence, a proper
name, a title, or a defined term. If a word or phrase has a defined meaning, it will either be in
Part II. DEFINITIONS or defined within the particular section where it is used.
1.5 Shared Savings Incentive Program. This Contract is eligible for the Shared Savings Incentive Program
per Section 641.31076, F.S. This voluntary program allows Members to participate in the savings
generated from Shoppable Health Care Services located at providers on the AvMed's shared
savings list.
a. AvMed's shared savings list is available at www.avmed.org/smartshopger. This list includes all
available Shoppable Health Care Services and their Shared Savings Incentive amount. Be
aware, this list may change. Please check frequently to ensure you have accurate information.
AV-LG-COC-21 1 Choice-LG-7638 (07/21)
b. When you qualify for a reward, your Shared Saving Incentive will be sent to you by check
approximately 30 days after we confirm that you received care at an incentive eligible location.
c. AvMed must notify you, and the Office of Insurance Regulation, at least 30 days before
termination of this program.
1.6 Contract Renewal. This Contract is guaranteed renewable and will stay in effect as long as the
Subscribing Group meets and continues to meet the eligibility guidelines set forth in the Group
Master Application and Premiums are paid on time. Subscribing Group and Members are subject
to all terms, conditions, Limitations, and Exclusions in this Contract and to all of the rules and
regulations of the Plan. By paying Premiums or having Premiums paid on your behalf, you accept
the provisions of this Contract.
1.7 You must notify us immediately of any address change (or email us if you have opted for electronic
communications).
II. DEFINITIONS
As used in this Contract, each of the following terms will have the meaning indicated. For further definitions,
go to www.healthcare.gov/glossary to review the Uniform Glossary provided as a result of the Affordable
Care Act.
2.1 Accidental Dental Injury means an injury to Sound Natural Teeth (not previously compromised by
decay) caused by a sudden, unintentional, and unexpected event or force. This term does not
include injuries to the mouth, structures within the oral cavity, or injuries to Sound Natural Teeth
caused by biting or chewing, surgery or treatment for a disease or illness.
2.2 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; and including:
a. a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in
part) for, 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 or Investigational, or not Medically Necessary; and
b. a cancellation or discontinuance of coverage that has retroactive effect, unless attributable to
a failure to timely pay required Premiums or contributions toward the cost of coverage.
2.3 Allowed Amount means the maximum amount established by AvMed upon which payment will
be based for Covered Services rendered by In -Network Providers. The Allowed Amount may be
changed at any time without notice to you or your consent.
2.4 Ambulatory Surgery Center means a facility licensed pursuant to Chapter 395, Florida Statutes (or
if outside Florida, applicable state law), the primary purpose of which is to provide surgical care to
a patient admitted to, and discharged from, such facility within 24 hours.
2.5 Applied Behavior Analysis means the design, implementation, and evaluation of environmental
modifications, using behavioral stimuli and consequences, to produce socially significant
improvement in human behavior, including the use of direct observation, measurement, and
functional analysis of the relations between environment and behavior. Applied Behavior Analysis
services will be provided by an individual certified pursuant to Section 393.17, Florida Statutes, or an
individual licensed under Chapter 490 or Chapter 491, Florida Statutes.
2.6 Attending Physician means the Physician primarily responsible for the care of a Member with
respect to any particular Condition.
2.7 Autism Spectrum Disorders means any of the following disorders as defined in the most recent
edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric
Association:
a. Autistic disorder;
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b. Asperger's syndrome;
c. Pervasive developmental disorder not otherwise specified.
2.8 AvMed Provider Network or AvMed Network means the Health Care Providers with whom AvMed
has contracted or made arrangements to provide Covered Benefits and Covered Services to
Choice Plan Members.
2.9 Benefit Level means:
a. For AvMed Choice Plan In -Network Providers and PHCS providers, the Copayment or
Coinsurance percentage of the Allowed Amount for Covered Services, after any applicable
Calendar Year Deductible is met. Benefits for Covered Services from AvMed In -Network
Providers inside the Service Area, and PHCS providers outside the Service Area, are payable at
the high Benefit Level. NOTE: Covered Services from PHCS providers are payable at the high
Benefit Level only when received outside the Service Area.
b. For Out -of -Network Providers, the Copayment or Coinsurance percentage of the Maximum
Allowable Payment for Covered Services, after the applicable Calendar Year Deductible is met.
Benefits for Covered Services from Out -of -Network Providers are payable at the low Benefit
Level.
2.10 Birthing Center means a facility licensed pursuant to Chapter 383, Florida Statutes (or if outside
Florida, applicable state law), which is freestanding, and is not a Hospital or in a Hospital, in which
births are planned to occur away from the mother's usual residence following a normal,
uncomplicated, low -risk pregnancy. Birthing Centers must provide facilities for obstetrical delivery
and short-term recovery after delivery, care under the full-time supervision of a Physician and either
a registered nurse (R.N.) or a licensed nurse midwife, and have a written agreement with a Hospital
in the same locality for immediate acceptance of patients who develop complications or require
pre- or post- delivery confinement.
2.11 Breast Reconstructive Surgery means surgery to reestablish symmetry between the two breasts
following breast cancer treatment.
2.12 Calendar Year Deductible means the first payments up to a specified dollar amount that a Member
must make in the applicable calendar year for Covered Benefits. It is the amount you owe for
certain Covered Services before AvMed begins to pay, and must be satisfied once each calendar
year. The Calendar Year Deductible may not apply to all services. The Deductible applies to each
Member, subject to any family Deductible listed on the Schedule of Benefits. For purposes of the
Deductible, "family" means the Covered Employee and Covered Dependents.
2.13 Calendar Year Out -of -Pocket Maximum means the maximum amount you will pay during a
calendar year before AvMed begins to pay 100% of the Allowed Amount or Maximum Allowable
Payment for Covered Services during the same calendar year. This limit never includes your
Premiums, Prescription Drug Brand Additional Charges, third -party Copayment assistance toward
Member cost -sharing for Specialty Medications, charges in excess of the Maximum Allowable
Payment for Covered Services rendered by Out -of -Network Providers, or charges for health care
that AvMed does not cover.
2.14 Claim means a request for benefits under this Contract, made by or on behalf of a Member in
accordance with AvMed's procedures for filing benefit Claims.
a. Pre -Service Claim means any Claim for benefits under this Contract for which, in whole or in
part, a Claimant must obtain authorization from AvMed in advance of such services being
provided to or received by the Member.
b. Urgent Care Claim means any Claim for medical care or treatment for a Condition 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 Condition, would
subject the Member to severe pain that cannot be adequately managed without the care or
treatment requested.
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c. Concurrent Care Claim means any request by a Claimant that relates to an Urgent Care Claim
to extend a course of treatment beyond the initial period of time or number of treatments
previously approved.
d. Post -Service Claim means any Claim for benefits under this Contract that is not a Pre -Service
Claim.
2.15 Claimant means a Member or a Member's authorized representative acting on behalf of a
Member. AvMed may establish procedures for determining whether an individual is authorized to
act on behalf of a Member with respect to a Claim for benefits.
2.16 Coinsurance means the portion of the cost for a Covered Service that a Member must pay once
any applicable Deductible has been met, and is expressed as a percentage, established solely by
AvMed, of the Allowed Amount or Maximum Allowable Payment for the Covered Service, or the
percentage of an amount based on the Maximum Medicare Allowable or Average Wholesale
Price for the Covered Service. Members are responsible for the payment of any applicable
Coinsurance directly to a Health Care Provider at the time Covered Services are received.
2.17 Condition means a disease, illness, ailment, injury, or pregnancy.
2.18 Contract means this AvMed Choice Plan Large Group Medical and Hospital Service Contract with
Point of Service Rider, which may at times be referred to as "Group Contract" or "Subscribing Group
Contract" or "Point of Service Plan" and all Applications, Rate Letters (as described in Part XVII.
GENERAL PROVISIONS), schedules, amendments, and any other document approved by the
Florida Office of Insurance Regulation for incorporation into this Contract.
2.19 Copayment means the fixed dollar amount, established solely by AvMed, that a Member must pay
once any applicable Deductible has been met, for certain Covered Services rendered by a Health
Care Provider at the time the Covered Services are received. The Copayment is a portion of the
Allowed Amount or Maximum Allowable Payment for the Covered Service, or a portion of the
Maximum Medicare Allowable or Average Wholesale Price, for the Covered Service.
2.20 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. AvMed
reserves the right to make changes in Coverage Criteria for covered products and services.
2.21 Covered Benefits or Covered Services means those Health Care Services to which a Member is
entitled under the terms of this Contract. Member's cost -sharing responsibilities for Covered
Services, including any applicable Deductible, Copayments and Coinsurance amounts, are
outlined in the Schedule of Benefits.
2.22 Covered Dependent means any dependent of a Subscriber's family, who meets and continues to
meet all applicable eligibility requirements, and who is enrolled and actually covered under this
Contract other than as a Subscriber.
2.23 Custodial or Custodial Care means care that serves to assist an individual in the activities of daily
living, such as assistance in walking, getting in and out of bed, bathing, dressing, feeding, using the
toilet, preparation of special diets, and supervision of medication that usually can be self-
administered. Custodial Care essentially is personal care that does not require the continuing
attention of trained medical personnel. In determining whether a person is receiving Custodial
Care, consideration is given to the frequency, intensity and level of care, medical supervision
required and furnished, patient's diagnosis, type of Condition, degree of functional limitation, or
rehabilitation potential.
2.24 Dental Care means:
a. 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
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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).
2.25 Detoxification means a process whereby an alcohol or drug intoxicated, or alcohol or drug
dependent, individual is assisted through the period of time necessary to eliminate, by metabolic
or other means, the intoxicating alcohol or drug, alcohol or drug dependent factors, or alcohol in
combination with drugs, as determined by a licensed Health Professional, while keeping the
physiological risk to the individual at a minimum.
2.26 Durable Medical Equipment (DME) is any equipment that meets all of the following requirements:
a. can withstand repeated use; and
b. is primarily and customarily used to serve a medical purpose; and
c. generally is not useful to a person in the absence of an illness or injury; and
d. is appropriate for use in the Member's home.
2.27 Emergency Medical Condition means:
a. A 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:
i. serious jeopardy to the health of a patient, including a pregnant woman or fetus;
ii. serious impairment to bodily functions; or
iii. serious dysfunction of any bodily organ or part; and
iv. with respect to a pregnant woman:
1) that there is inadequate time to effect safe transfer to another Hospital prior to delivery;
2) that a transfer may pose a threat to the health and safety of the patient or fetus; or
3) that there is evidence of the onset and persistence of uterine contractions or rupture
of the membranes.
b. Examples of Emergency Medical Conditions include heart attack, stroke, massive internal or
external bleeding, fractured limbs, or severe trauma.
2.28 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.
a. In -area emergency does not include elective or routine care, care of minor illnesses or care that
can reasonably be sought and obtained from the Member's Physician. The determination as to
whether or not an illness or injury constitutes an Emergency Medical Condition will be made by
AvMed and may be made retrospectively based upon all information known at the time the
Member was present for treatment.
b. 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 Medical Condition will be made by
AvMed and may be made retrospectively based upon all information known at the time the
Member was present for treatment.
2.29 Essential Health Benefits has the meaning set forth under the Affordable Care Act, Section 1302(b),
and applicable regulations. The ten categories of Essential Health Benefits are:
a. ambulatory patient services;
b. emergency services;
c. hospitalization;
d. maternity and newborn care;
e. mental health and substance use disorder services (including behavioral health treatment);
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f. prescription drugs;
g. rehabilitative and habilitative services and devices;
h. laboratory services;
i. preventive and wellness services and chronic disease management;
j. pediatric services (including oral and vision care).
2.30 Exclusion means any provision of this Contract whereby coverage for a specific hazard, service or
Condition is entirely eliminated.
2.31 Experimental or Investigational means:
a. Any evaluation, treatment, therapy, or device which involves the application, administration or
use, of procedures, techniques, equipment, supplies, products, remedies, vaccines, biological
products, drugs, pharmaceuticals, or chemical compounds if, as determined by AvMed:
i. such evaluation, treatment, therapy, or device cannot be lawfully marketed without
approval of the U.S. Food and Drug Administration (FDA) or the Florida Department of
Health and approval for marketing has not, in fact, been given at the time such is furnished
to the Member;
ii. such evaluation, treatment, therapy, or device is provided pursuant to a written protocol
which describes as among its objectives the following: determinations of safety, efficacy,
or efficacy in comparison to the standard evaluation, treatment, therapy, or device;
iii. such evaluation, treatment, therapy, or device is delivered or should be delivered subject
to the approval and supervision of an institutional review board or other entity as required
and defined by federal regulations;
iv. credible scientific evidence shows that such evaluation, treatment, therapy, or device is
the subject of an ongoing Phase I or II clinical investigation, or the experimental or research
arm of a Phase I II 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;
v. credible scientific evidence shows that the consensus of opinion among experts is that
further studies, research, or clinical investigations are necessary 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;
vi. credible scientific evidence shows that such evaluation, treatment, therapy, or device has
not been proven safe and effective for treatment of the Condition in question, as
evidenced in the most recently published medical literature in the United States, Canada,
or Great Britain, using generally accepted scientific, medical, or public health
methodologies or statistical practices.
b. Credible scientific evidence is defined by AvMed as one of the following:
i. records maintained by Physicians or Hospitals rendering care or treatment to the Member
or other patients with the same or similar Condition;
ii. reports, articles, or written assessments in authoritative medical and scientific literature
published in the United States, Canada, or Great Britain;
iii. published reports, articles, or other literature of the United States Department of Health
and Human Services or the United States Public Health Service, including any of the
National Institutes of Health, or the United States Office of Technology Assessment;
iv. the written protocol or protocols relied upon by the Attending Physician or institution or the
protocols of another Physician or institution studying substantially the same evaluation,
treatment, therapy, or device;
v. the written informed consent used by the Attending Physician or institution or by another
Physician or institution studying substantially the same evaluation, treatment, therapy, or
device; or
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vi. the records (including any reports) of any institutional review board of any institution which
has reviewed the evaluation, treatment, therapy, or device for the Condition in question.
2.32 Full -lime Student or Part -Time Student means one who is attending a recognized and accredited
college, university, vocational or secondary school and is carrying sufficient credits to qualify as a
Full -Time or Part -Time Student in accordance with the requirements of the school.
2.33 Habilitation Services are services that help a person keep, learn or improve skills and functioning for
daily living. Such services may be provided in order for a person to attain and maintain a skill or
function never learned or acquired due to a disabling Condition. They are services that are
deemed necessary to meet the needs of individuals with developmental disabilities in programs
designed to achieve objectives of improved health, welfare and the realization of individuals'
maximum physical, social, psychological and vocational potential for useful and productive
activities.
2.34 Health Care Providers means Health Professionals and includes institutional providers, such as
Hospitals, Medical Offices or Other Health Care Facilities that are engaged in the delivery of Health
Care Services and are licensed and practice under an institutional license or other authority
consistent with state law.
2.35 Health Care Services (except as limited or excluded by this Contract) means the 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 Health Professionals acting within the scope of their
licenses; and
c. Medically Necessary (except for preventive services as stated herein) for the diagnosis and
treatment of injury or illness.
2.36 Health Professionals means allopathic and osteopathic Physicians, podiatrists, chiropractors,
physician assistants, nurses, licensed clinical social workers, pharmacists, optometrists, nutritionists,
occupational therapists, physical therapists, certified nurse midwives and midwives, and other
professionals engaged in the delivery of Health Care Services, who are appropriately licensed
under applicable state law.
2.37 Home Health Care Services (Skilled Home Health Care) means Physician -directed professional,
technical and related medical and personal care services provided on an intermittent or part-time
basis directly by (or indirectly through) a home health agency in your home or residence. Such
services include professional visiting nurses or other Health Professionals for services covered under
this Contract. For purposes of this definition, a Hospital, Skilled Nursing Facility, nursing home or other
facility will not be considered a home or residence.
2.38 Hospice means a public agency or private organization licensed pursuant to Chapter 400, Florida
Statutes (or if outside Florida, applicable state law), to provide Hospice services. Such licensed entity
must be principally engaged in providing pain relief, symptom management, and supportive
services to terminally ill Members and their families.
2.39 Hospital means a facility licensed pursuant to Chapter 395, Florida Statutes (or if outside Florida,
applicable state law), that offers services which are more intensive than those required for room,
board, personal services and general nursing care; offers facilities and beds for use beyond 24
hours; and regularly makes available at least clinical laboratory services, diagnostic x-ray services
and treatment facilities for surgery or obstetrical care or other definitive medical treatment of similar
extent.
a. The term Hospital does not include an Ambulatory Surgery Center; Skilled Nursing Facility; stand-
alone Birthing Center; convalescent, rest or nursing home; or facility which primarily provides
Custodial, educational or rehabilitative therapies.
b. If services specifically for the treatment of a physical disability are provided in a licensed Hospital
which is accredited by The Joint Commission, the American Osteopathic Association or the
Commission on the Accreditation of Rehabilitative Facilities, payment for these services will not
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be denied solely because such Hospital lacks major surgical facilities and is primarily of a
rehabilitative nature. Recognition of these facilities does not expand the scope of Covered
Services. It only expands the setting where Covered Services can be performed for coverage
purposes.
2.40 Hospital -owned or affiliated means under common ownership, licensure or control of a Hospital. As
may be noted in your Schedule of Benefits, the cost -sharing for some services can vary depending
on whether or not they are obtained at a Hospital -owned or Hospital -affiliated facility. Also see
Independent Facility below.
2.41 Identification Card means the cards AvMed issues to Members. The card is our property and is not
transferable to another person. Possession of such card in no way verifies that a particular individual
is eligible for, or covered under, this Contract.
2.42 Independent Facility means a facility not under common ownership, licensure or control of a
Hospital. The cost -sharing for some services may vary depending on whether or not they are
obtained at an Independent Facility.
2.43 In -Network Provider means any Health Care Provider with whom AvMed has contracted or made
arrangements to render the Covered Benefits and Covered Services described in this Contract to
AvMed Choice Plan Members. For a listing of In -Network Providers, please refer to your AvMed
Choice Plan Provider Directory or visit our online directory at www.avmed.org.
2.44 Injectable Medication means a medication that is approved by the U.S. Food and Drug
Administration (FDA) for administration by one or more of the following routes: intra-articular,
intracavernous, intramuscular, intraocular, intrathecal, intravenous or subcutaneous injection; or
intravenous infusion. Medications intended to be injected or infused by a Health Professional are
generally covered as a medical benefit. Prior Authorization may be required for Injectable
Medications.
2.45 Intensive Outpatient Treatment means treatment in which an individual receives at least three
clinical hours of institutional care per day (24 -hour period) for at least three days a week and returns
home or is not treated as an inpatient during the remainder of that 24 -hour period. A Hospital shall
not be considered a 'home' for purposes of this definition.
2.46 Limitation means any provision other than an Exclusion that restricts coverage under this Contract.
2.47 Master Application means the Subscribing Group application form entitled 'Group Master
Application' which becomes a part of the Contract when the Group Master Application has been
completed and executed by the Subscribing Group and AvMed.
2.48 Material Misrepresentation means the omission, concealment of facts or incorrect statements
made on any application or enrollment forms by an applicant, Subscriber or Covered Dependent
which, had they been known, would have affected our decision to issue this Contract, the issuance
of different benefits, or the issuance of this Contract only at a higher rate.
2.49 Maximum Allowable Payment means the maximum amount, as established by AvMed, which
AvMed will pay for any Covered Service rendered by an Out -of -Network Provider or supplier of
services, medications or supplies, except for Emergency Medical Services and Care as defined
herein. The Maximum Allowable Payment may be changed at any time by AvMed without notice
to you or your consent. You may obtain an estimate of the Maximum Allowable Payment for
particular services from Out -of -Network Providers, by contacting AvMed's Member Engagement
Center at the telephone number on the cover of this Contract or on your AvMed Identification
Card. The fact that we may provide you with such information does not mean, and will not be
construed to mean, that the particular service is a Covered Service. All terms and conditions
included in your Contract apply.
2.50 Medical Office means any outpatient facility or Physician's office utilized by a Health Professional.
2.51 Medical Supplies - outpatient disposable. Outpatient disposable Medical Supplies means
disposable medical supplies that are prescribed by a Physician for outpatient use; are usable only
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by the Member for whom they are prescribed; have no further use when the medical need ends;
and are not primarily for comfort or hygiene, environmental control, or exercise.
2.52 Medically Necessary or Medical Necessity 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, as determined by AvMed, for the diagnosis, care or treatment of
a Member's illness or injury and which is:
a. consistent with the symptoms, 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;
d. not primarily intended for the personal comfort or convenience of the Member, the Member's
family, the Physician or other Health Professionals;
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; and
f. not Experimental or Investigational.
2.53 Medicare means the federal health insurance provided pursuant to Title XVIII of the Social Security
Act and all amendments thereto.
2.54 Member means any person who meets all applicable requirements of Part III. ELIGIBILITY FOR
COVERAGE and enrolls in the Plan as a Subscriber or Covered Dependent, and for whom the
Premium prepayment required by Part VI. PREMIUMS, COPAYMENTS, COINSURANCE, DEDUCTIBLES,
AND OTHER EXPENSES has actually been received by AvMed.
2.55 Mental/Behavioral Health Disorder means any disorder listed in the diagnostic categories of the
most recent International Classification of Disease, or their equivalents in the most recently
published version of the American Psychiatric Association's Diagnostic and Statistical Manual of
Mental Disorders, regardless of the underlying cause, or effect, of the disorder.
2.56 Morbid Obesity (clinically severe obesity) means a body mass index (BMI), as determined by an in -
network Health Professional as of the date of service, of:
a. 40 kilograms or greater per meter squared (kg/m2); or
b. 35 kilograms or greater per meter squared (kg/m2) with an associated comorbid condition such
as uncontrolled hypertension, type II diabetes, life -threatening cardiopulmonary conditions, or
severe sleep apnea.
2.57 Out -of -Network Provider means any Health Care Provider with whom AvMed has neither
contracted nor made arrangements to render the Covered Benefits or Covered Services described
in this Contract as an In -Network Provider.
2.58 Orthotic Appliances or Orthotic Devices means any rigid or semi -rigid device needed to support a
weak or deformed body part or to restrict or eliminate body movement.
2.59 Other Health Care Facility(ies) means any facility licensed in accordance with the laws of the
appropriate legally authorized agency, other than acute care Hospitals and those facilities
providing services to ventilator dependent patients, which provides inpatient services at an
intermediate or lower level of care such as skilled nursing care, Residential Treatment and
Rehabilitation Services.
2.60 Outpatient Rehabilitation Facility means an entity that renders, through Health Professionals licensed
pursuant to Florida law (or if outside Florida, applicable state law), outpatient physical,
occupational, speech, pulmonary and cardiac rehabilitation therapies for the primary purpose of
restoring or improving a bodily function impaired or eliminated by a Condition. The term Outpatient
Rehabilitation Facility, as used herein, will not include any Hospital, including a general acute care
Hospital, or any separately organized unit of a Hospital that provides comprehensive medical
rehabilitation inpatient or rehabilitation outpatient services, including a Class I I I or Class IV "specialty
rehabilitation hospital" as described in Chapter 59A, Florida Administrative Code.
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2.61 Pain Management means pain assessment, medication, physical therapy, biofeedback, and
counseling. Pain rehabilitation programs are programs featuring multidisciplinary services directed
toward helping those with chronic pain to reduce or limit their pain.
2.62 Partial Hospitalization means outpatient treatment in which an individual receives at least six clinical
hours of institutional care per day (24 -hour period) for at least five days per week and returns home
or is not treated as an inpatient during the remainder of that 24 -hour period. A Hospital shall not be
considered a "home" for purposes of this definition.
2.63 Participating Provider means any Health Care Provider with whom AvMed has contracted or made
arrangements to render the Covered Benefits and Covered Services described in this Contract to
AvMed Choice Plan Members. For a listing of AvMed Choice Plan Participating (In -Network)
Providers, please refer to your Provider Directory or visit our online directory at www.avmed.ora.
2.64 Physician means any provider licensed under Chapter 458 (Physician), 459 (osteopath), 460
(chiropractor) or 461 (podiatrist), Florida Statutes (or if outside Florida, applicable state law).
2.65 Premium means the total amount of monthly prepayment subscription charges required to be paid
by the Subscribing Group to AvMed in order for there to be coverage under this Contract.
2.66 Prescription Medication or Prescription Drug means a medication that is approved by the FDA and
that can only be dispensed pursuant to a prescription in accordance with state and federal law.
For more information, please see Part XII. PRESCRIPTION MEDICATION BENEFITS, LIMITATIONS AND
EXCLUSIONS.
2.67 Primary Care Physician (PCP) means any Choice Plan in -network Physician engaged in general or
family practice, internal medicine, pediatrics, geriatrics, obstetrics/gynecology or any Specialty
Physician from time to time designated by AvMed as a 'Primary Care Physician' in AvMed's current
list of In -Network Providers. A PCP is one who directly provides or coordinates a range of Health
Care Services for a Member.
2.68 Prior Authorization means a decision by AvMed, prior to the time a Health Care Service or other
benefit is to be delivered, that the Health Care Services are Medically Necessary. Prior Authorization
is sometimes called pre -authorization, prior approval or pre -certification. AvMed requires you or
your Physician to obtain Prior Authorization for certain services and medications before you receive
them to ensure that you receive the most appropriate treatment. Prior Authorization is not a promise
that AvMed will cover the cost of such services or medications.
2.69 Private Healthcare Systems (PHCS) means a proprietary preferred provider organization with whom
AvMed has entered into an agreement to provide Covered Benefits and Covered Services to
AvMed Choice Plan Members outside AvMed's Service Area. The AvMed Choice Point of Service
Plan provides access to PHCS providers as described in this Contract.
2.70 Prosthetic Device means a device which replaces all or part of a body part or an internal body
organ or replaces all or part of the functions of a permanently inoperative or malfunctioning body
part or organ.
2.71 Rehabilitation Services are Health Care Services that help a person keep, get back, or improve skills
and functioning for daily living that have been lost or impaired because a person was sick, injured
or disabled. These services may include physical and occupational therapies, speech -language
pathology and psychiatric Rehabilitation Services in a variety of inpatient or outpatient settings.
2.72 Residential Treatment is a 24 -hour intensive, structured and supervised treatment program providing
inpatient care but in a non -Hospital environment, and is utilized for those mental health or substance
use disorders that cannot be effectively treated in an outpatient or Partial Hospitalization
environment.
2.73 Retail Clinics are a category of walk-in medical facilities located inside pharmacies, supermarkets
and other retail establishments that treat uncomplicated minor illnesses and provide preventive
Health Care Services, generally delivered by nurse practitioners, and often without a Physician on
the premises.
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2.74 Service Area means those counties in the State of Florida where AvMed has been approved to
conduct business by the Agency for Health Care Administration (AHCA), and where the majority of
the Covered Benefits and Covered Services are available from In -Network Providers to Members of
the AvMed Choice Plan.
2.75 Shared Savings Incentive means a voluntary and optional financial incentive that a health insurer
may provide to an insured for choosing certain Shoppable Health Care Services under a Shared
Savings Incentive Program.
2.76 Shoppable Health Care Service means a lower -cost, high -quality nonemergency Health Care
Service for which a Shared Savings Incentive is available for insureds under a health insurer's Shared
Savings Incentive Program.
2.77 Skilled Nursing Facility means an institution or part thereof that is licensed as a Skilled Nursing Facility
by the State of Florida (or if outside Florida, applicable state entity), and is accredited as a Skilled
Nursing Facility by The Joint Commission or recognized as a Skilled Nursing Facility by the Secretary
of Health and Human Services of the United States under Medicare.
2.78 Sound Natural Teeth (Tooth) means teeth that are whole or properly restored (restoration with
amalgams, resin or composite only); are without impairment, periodontal, or other Conditions; and
are not in need of services provided for any reason other than an Accidental Dental Injury. For
purposes of this Contract, a tooth previously restored with a crown inlay, onlay, or porcelain
restoration, or treated by endodontics, is not considered a Sound Natural Tooth.
2.79 Specialty Physician means any Physician licensed under Chapter 458 (Physician), 459 (osteopath),
460 (chiropractor) or 461 (podiatrist), Florida Statutes (or if outside Florida, applicable state law),
other than the Member's Primary Care Physician.
2.80 Subscriber means an employee of the Subscribing Group who meets all applicable requirements
of Part III. ELIGIBILITY FOR COVERAGE, enrolls in the Plan, and for whom the Premium prepayment
required by Part VI. PREMIUMS, COPAYMENTS, COINSURANCE, DEDUCTIBLES AND OTHER EXPENSES,
has actually been received by AvMed.
2.81 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 Care
Services and benefits provided herein for its eligible employees.
2.82 Substance Dependency means a Condition where a person's alcohol or drug use injures his health,
interferes with his social or economic functioning, or causes the individual to lose self-control.
2.83 Total Disability means a totally disabling Condition resulting from an illness or injury that prevents a
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.
2.84 Urgent Care Center means a facility licensed to provide care for minor injuries and illnesses that
require immediate attention, but are not severe enough for a trip to an emergency facility,
including cuts, sprains, eye injuries, colds, flu, fever, insect bites, and simple fractures. For purposes
of this Contract, an Urgent Care Center is not a Hospital, Skilled Nursing Facility, Outpatient
Rehabilitation Facility or Retail Clinic.
2.85 Urgent Medical Condition means a Condition manifesting itself by acute symptoms that are of lesser
severity than those recognized for an Emergency Medical Condition, such that a prudent layperson
who possesses an average knowledge of health and medicine could reasonably expect the illness
or injury to place the health or safety of the Member or another individual in serious jeopardy, in the
absence of medical treatment within 24 hours. Examples of Urgent Medical Conditions include high
fever, dizziness, animal bites, sprains, severe pain, respiratory ailments and infectious illnesses.
2.86 Urgent Medical Services and Care means medical screening, examination and evaluation in an
ambulatory setting outside of a Hospital emergency department, including an Urgent Care Center,
Retail Clinic or PCP office after-hours, on a walk-in basis and usually without a scheduled
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appointment; and the Covered Services for those Conditions which, although not life -threatening,
could result in serious injury or disability if left untreated.
2.87 Utilization Management Programs means those comprehensive initiatives that are designed to
validate medical appropriateness, including Medical Necessity, and to coordinate Covered
Services and supplies, including:
a. concurrent review of all patients hospitalized in acute care, psychiatric, rehabilitation, and
Skilled Nursing Facilities, including on -site review when appropriate;
b. 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
c. prospective reviews for select Health Care Services to ensure that services are Medically
Necessary Covered Benefits under this Contract.
2.88 Ventilator Dependent Care Unit means any facility, other than an acute care Hospital setting, that
provides services to ventilator dependent patients 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 an Independent Facility or maintained in a Hospital or
Skilled Nursing Facility setting.
2.89 Virtual Visits:
a. Telehealth Services are live, interactive audio and visual transmissions of a Physician -patient
encounter from one site to another, using telecommunications technologies and may include
transmissions of real-time telecommunications or those transmitted by store -and -forward
technology.
b. Telemedicine Services are Health Care Services provided via telephone, the Internet, or other
communications networks or devices that do not involve direct, in -person patient contact.
III. ELIGIBILITY FOR COVERAGE
Any employee and the dependents of an employee who meet and continue to meet the eligibility
requirements described in this Contract, will be entitled to enroll in coverage under this Contract. These
eligibility requirements are binding upon you and your eligible dependents. We may require acceptable
documentation that an individual meets and continues to meet the eligibility requirements (e.g. proof of
residency, copies of a court order naming the Subscriber as legal guardian, or appropriate adoption
documentation, as described in Part IV. ENROLLMENT AND EFFECTIVE DATE OF COVERAGE).
3.1 Subscriber Eligibility. To be eligible to enroll as a Subscriber, a person must be:
a. an employee of the Subscribing Group who works the required number of hours per week as
set forth in the Group Master Application for this Contract. The employee must either work or
reside in the Choice Plan Service Area; and
b. employed for the period of time required for eligibility as set forth in the Group Master
Application; and
c. entitled on his own behalf to participate in the medical and Hospital care benefits arranged by
the Subscribing Group under this Contract.
3.2 Dependent Eligibility. To be eligible to enroll as a Covered Dependent, a person must be:
a. the spouse of a Subscriber under a legally valid existing marriage; or
b. the child of a Subscriber or a Covered Dependent of the Subscriber, provided that the following
conditions apply:
i. the child is under the age of 26; and
ii. the natural child or stepchild of the Subscriber;
iii. a legally adopted child in the custody of the Subscriber;
iv. a child for whom the Subscriber or the Subscriber's covered spouse has been appointed
legal guardian pursuant to a valid court order; or
AV-LG-COC-21 12 Choice-LG-7638 (07/21)
v. the newborn child of a Covered Dependent child of the Subscriber (such coverage
terminates 18 months after the birth of the newborn child).
3.3 Qualified Medical Child Support Order (QMCSO). In the event an eligible dependent child does not
reside with the Subscriber, coverage will be extended when the Subscriber is obligated by QMCSO
to provide medical care. You (or your beneficiaries) may obtain, without charge, copies of the
Plan's procedures governing QMCSOs and a sample QMCSO by contacting the Plan Administrator.
3.4 Extended Coverage for Dependent Children
a. Dependent Children Aged 26 to 30. A dependent child who meets the following requirements
may be eligible for coverage until the end of the calendar year in which the child reaches age
30, if the child:
i. is unmarried and does not have a dependent of his own;
ii. resides within the Service Area, or is a Full -Time or Part -Time Student; and
iii. is not provided coverage under any other group, blanket or franchise health insurance
policy or individual health benefits plan, or is not entitled to benefits under Medicare.
b. Continuous Coverage Requirement. If an eligible dependent child is covered under this
Contract after reaching age 26, and the child's coverage is subsequently terminated before
the end of the calendar year in which the child reaches age 30, the child is ineligible to be
covered again under this Contract unless the child was continuously covered by other
creditable coverage without a coverage gap of more than 63 days.
c. Children with Disabilities - Attainment of Limiting Age. Attainment of the limiting age by an
eligible dependent child will not operate to exclude from or terminate the coverage of such
child while such child is, and continues to be, both:
i. incapable of self-sustaining employment by reason of intellectual or physical disability; and
ii. chiefly dependent upon the Subscriber for support and maintenance.
iii. Proof of such incapacity and dependency must be furnished to AvMed within 30 days
after the date the child attains 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.
d. Dependent Students on Medically Necessary Leave of Absence
i. If an eligible dependent child is covered because they are a Full -Time or Part -Time Student
at a post -secondary school, and they no longer meet the Plan's definition of Full -Time or
Part -Time Student due to a Medically Necessary leave of absence, coverage may be
extended until the earlier of the following:
1) one year after the Medically Necessary leave of absence begins; or
2) the date coverage would otherwise terminate under the Contract.
ii. The Medically Necessary leave of absence or change in enrollment status must begin
while the child is suffering from a serious illness or injury; or the leave of absence from the
school must be medically certified by the child's Attending Physician; and
iii. certification must state that the child is suffering from a serious illness or injury and that the
leave of absence (or other change of enrollment) is Medically Necessary.
3.5 Eligibility Requirements Control. The eligibility requirements set forth herein 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 this Part.
3.6 Enrollment Restriction. No person is otherwise eligible to enroll hereunder whose AvMed coverage
was previously terminated for non-payment of Premium or cause, except with AvMed's written
approval.
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IV. ENROLLMENT AND EFFECTIVE DATE OF COVERAGE
With respect to eligible employees and eligible dependents properly enrolled, coverage becomes
effective, at 12:00 a.m. on the date specified in your Plan materials. With respect to eligible individuals who
are subsequently enrolled, coverage will become effective at 12:00 a.m. on the date described in this Part.
Any individual who is not properly enrolled hereunder will not be covered under this Contract, and AvMed
has no obligation whatsoever to any individual who is not properly enrolled.
4.1 Open Enrollment. During the Subscribing Group's annual open enrollment period any eligible
employee, on behalf of himself and his eligible dependents, may elect to enroll in the Plan. Eligible
employees and eligible dependents who enroll during the open enrollment period will be covered
Members as of the effective date of this Contract or the subsequent anniversary thereof.
4.2 Initial Enrollment. New employees who are eligible for coverage must enroll by submitting any
application forms acceptable to or provided by AvMed, along with supporting documentation as
may be required, within 30 days after the date of becoming eligible. The effective date of coverage
for an eligible new employee will be (i) the date immediately following completion of any
applicable waiting period, or (ii) the first of the month following completion of any applicable
waiting period, as set forth in the Group Master Application. If the required information is not
received within 30 days after the date of eligibility the new employee may not enroll until the
Subscribing Group's next annual open enrollment period, or a special enrollment period if
applicable.
4.3 Special Enrollment. Under the circumstances described below, referred to as "qualifying events",
eligible employees and/or eligible dependents may request to enroll in the Plan outside of the initial
and annual open enrollment periods, during a special enrollment period.
a. If an eligible employee or eligible dependents declined coverage under the Plan when it was
first offered because of other group health plan or insurance coverage and that other
coverage is lost due to any of the following qualifying events, the eligible employee or eligible
dependents are entitled to a special enrollment period. Loss of other coverage due to an
individual's failure to pay Premiums (including COBRA Premiums) on a timely basis, or
termination of coverage for cause (fraud or intentional misrepresentation of material fact) will
not trigger a special enrollment period.
i. exhaustion of COBRA continuation coverage;
ii. termination of employment or reduction in hours of employment;
iii. termination of employer Premium contributions;
iv. change in dependent status due to: attainment of limiting age, change in legal custody
or legal guardianship, divorce or annulment, or the death of an employee whose
employment afforded the dependent coverage;
v. relocation out of an HMO service area;
vi. gaining eligibility for Premium assistance subsidy, or termination of coverage due to loss of
eligibility, under Medicaid or CHIP.
b. Upon gaining a new dependent (or dependents) as a result of any of the following qualifying
events, a covered employee's new dependents, or an eligible employee on behalf of himself
and his new dependents, may request to enroll during the special enrollment period, providing
such dependents are otherwise eligible for coverage:
i. marriage;
ii. birth;
iii. adoption or placement for adoption; or
iv. child support order or other court order (except for a court order to cover a former spouse).
4.4 Special Enrollment Procedures
a. A covered employee's eligible dependents, or an eligible employee on behalf of himself and
his eligible dependents, must enroll by submitting any application or enrollment forms
acceptable to or provided by AvMed, along with supporting documentation as we may
AV-LG-COC-21 14 Choice-LG-7638 (07/21)
require, within the following timeframes; otherwise, the eligible employee and/or eligible
dependents must wait until the Subscribing Group's next annual open enrollment period:
i. within 30 days after the date of the loss of other coverage (proof of continuous other
coverage is required);
ii. within 30 days after the date of marriage (certificate of marriage is required);
iii. within 30 days after the date of placement in the Subscriber's home for adoption, or
adoption, of a child other than a newborn (proof of such placement or adoption is
required);
iv. within 60 days after gaining eligibility for Premium assistance, or loss of eligibility, under
Medicaid or CHIP (proof of such change in eligibility is required);
v. within 60 days after the birth of a child, including an adopted newborn child, as described
below (for an adopted newborn, a copy of a written agreement to adopt, entered into
by the Subscriber prior to the birth of such child, is required).
1) If notice is given within 30 days after the date of birth, no additional Premium will be
charged for the newborn child's coverage during the 30 -day period immediately
following the newborn's birth.
2) If notice is received within 31 to 60 days after the date of birth, we will charge the
applicable Premium from the date of birth. You must pay the additional Premium for
coverage to be provided for the newborn child.
3) If notice is not received within 60 days after the date of birth, the child may not be
enrolled until the Subscribing Group's next open enrollment period.
4.5 Special Enrollment Effective Date of Coverage. The effective date of any coverage provided by
AvMed is dependent upon the timely receipt of any enrollment forms and supporting
documentation we may require. If received within the required timeframes, coverage will become
effective as described below; otherwise, a Subscriber's eligible dependents, or an eligible
employee on behalf of himself and his eligible dependents, may not enroll until the Subscribing
Group's next open enrollment period:
a. General Effective Date. Except as provided for newborns and adopted children (including
adopted newborns), the effective date of coverage for eligible individuals properly enrolled will
be the first day of the first month following receipt of the enrollment request.
b. Newborns and Adopted Newborns. The effective date of coverage for a natural newborn child
properly enrolled will be the moment of birth. For an adopted newborn properly enrolled,
coverage will be effective from the moment of birth provided a written agreement to adopt
such child was entered into by the Subscriber prior to the birth of the child. However, coverage
will not be required if the child is not ultimately placed in the Subscriber's home in compliance
with Chapter 63, Florida Statutes.
c. Adopted Children other than Newborns. The effective date of coverage for an adopted child
properly enrolled, other than a newborn, will be the moment of placement in the Subscriber's
home for adoption, or the date of adoption, whichever is earlier. However, coverage will not
be required if the child is not ultimately placed in the Subscriber's home in compliance with
Chapter 63, Florida Statutes.
d. Qualified Medical Child Support Order (QMCSO). If a court has ordered coverage to be
provided by you for a minor child who is an eligible dependent, you must submit to us any
required application or enrollment forms including a copy of the court order, along with any
additional Premium due. The effective date of coverage for the eligible dependent properly
enrolled will be the date of the order. You must pay the additional Premium for coverage to be
provided for the eligible dependent.
AV-LG-COC-21 15 Choice-LG-7638 (07/21)
V. TERMINATION
This Contract will 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 will cease at 12:00 a.m. (midnight) on the effective date of termination unless otherwise stated.
5.1 Termination of Group Contract by Subscribing Group
a. Termination on Anniversary Date. The Subscribing Group may terminate this Group Contract on
the anniversary date by giving written notice to AvMed 15 days prior to the Contract anniversary
date. In such event, benefits hereunder will terminate for all Members on the Group Contract
expiration date.
b. Early Termination. The Subscribing Group may terminate this Group Contract by giving at least
45 days prior written notice to AvMed. In such event, benefits hereunder will terminate for all
Members on the date specified by the Subscribing Group in their written notice to AvMed and
for which the Premium was paid.
5.2 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
will terminate for all Members on the Contract termination date as described.
a. Termination of Group Contract for Cause
i. Failure to Make Premium Payment. If the Subscribing Group fails to make payment of the
monthly Premium by the Premium due date and within the grace period as provided in
Part VI. PREMIUMS, COPAYMENTS, COINSURANCE, DEDUCTIBLES AND OTHER EXPENSES,
coverage hereunder will terminate for all Members for whom Premium payment has not
been received, on the last day for which the monthly Premium was received.
1) Coverage will remain in effect during the grace period. However, if Premium payments
are not received by the end of the grace period, and AvMed has provided the
Subscribing Group written notice of termination within 45 days after the Premium due
date, late payment fees may apply and AvMed may retroactively terminate the
Subscribing Group's coverage.
11. Breach of Material Contract Provision. If the Subscribing Group fails to comply with a
material provision of the Contract that relates to rules for employer Premium contributions
or group participation, termination will be effective upon 45 days written notice from
AvMed to the Subscribing Group.
iii. Fraud/Material Misrepresentation. If the Subscribing Group performs an act or practice
that constitutes fraud, or makes an intentional misrepresentation of material fact under the
terms of this Contract, the Subscribing Group's coverage will be immediately terminated.
b. Notification by Subscribing Group Required. In the event of termination for the reasons
described in paragraphs 5.2 a i. through 5.2 a iii. above, the Subscribing Group agrees to
provide written notification of such termination to all its employees who are Subscribers under
this Contract, and AvMed will be deemed to have complied with its notification requirements.
c. No Enrollees in Service Area. If there are no longer any enrollees in connection with the Plan
who work or reside in the Service Area, termination of coverage will be effective on the last day
of the month for which Premium payments were received by AvMed.
d. Discontinuation of Large Group Plans or Product
i. If we cease to offer AvMed Choice Plans for Large Groups in the Service Area, we will
provide written notice to the Subscribing Group at least 90 days prior to such
discontinuation.
ii. If we cease to offer any Large Group coverage in the Service Area, we will provide written
notice to the Subscribing Group at least 180 days prior to such discontinuation.
e. Failure to Meet Eligibility or Participation Requirements. The Subscribing Group must meet group
eligibility guidelines at each renewal period as specified in the Rate Letter (as defined in Part
XVII. GENERAL PROVISIONS) to the Subscribing Group. Prior to the Subscribing Group's Contract
anniversary date, AvMed will request written documentation to verify eligibility and
AV-LG-COC-21 16 Choice-LG-7638 (07/21)
participation requirements. Failure to timely meet such requirements, or return the appropriate
documentation, will result in the termination of this Group Contract on the Subscribing Group's
anniversary date.
5.3 Termination of a Member's Coverage
a. Loss of Eligibility. Subject to the continuation rights described herein:
i. Subscribers
1) Termination of Employment. Upon the loss of a Subscriber's eligibility for coverage due
to termination of employment, coverage for the Subscriber and the Subscriber's
Covered Dependents will terminate on the last day of the Subscriber's employment,
or the last day of the month for which the monthly Premium was paid and during which
the Subscriber was eligible for coverage, as set forth in the Group Master Application.
2) Other Loss of Eligibility. Upon the loss of a Subscriber's eligibility for coverage due to a
qualifying event other than termination of employment, coverage for the Subscriber
and the Subscriber's Covered Dependents will terminate on the date of the qualifying
event, or the last day of the month for which the monthly Premium was paid and during
which the Subscriber was eligible for coverage, as set forth in the Group Master
Application.
ii. Covered Dependents. Upon the loss of a Covered Dependent's eligibility except as
described in the following paragraphs 1) and 2), coverage will terminate on the date
eligibility is lost, or the last day of the month for which the monthly Premium was paid and
during which the Covered Dependent was eligible for coverage, as set forth in the Group
Master Application.
1) Covered Dependent children who reach age 26 and are not otherwise eligible for
coverage, will cease to be covered on the last day of the month during which the
child turns 26.
2) Covered Dependent children who reach age 30 and are not otherwise eligible for
coverage, will cease to be covered on the last day of the calendar year during which
the child turns 30.
iii. Notification Requirements - Responsibility of Subscribing Group and Subscriber
1) It is the sole responsibility of the Subscribing Group to notify AvMed in writing within 30
days after the effective date of termination regarding any Subscriber who becomes
ineligible to participate in the Plan.
2) It is the sole responsibility of Subscribers to notify AvMed in writing within 30 days after
the date of a Covered Dependent's loss of eligibility.
3) Failure of the Subscribing Group or Subscribers to provide timely written notice may
lead to retroactive termination of the Subscriber and/or Covered Dependents. The
effective date for any such retroactive termination will be the last day for which the
Premium was received by AvMed, and during which the Subscriber and/or Covered
Dependents were eligible for coverage.
b. Termination of Coverage for Cause
i. AvMed may terminate the coverage of any Member immediately upon written notice for
the following reasons which lead to a loss of Member eligibility:
1) fraud, intentional Material Misrepresentation of fact, or intentional omission in applying
for membership, coverage or benefits 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 Contract or deny any Claim
for a loss occurred or disability starting after the two-year period;
2) misuse of AvMed's Identification Card furnished to the Member;
3) furnishing to AvMed incorrect or incomplete information for the purpose of obtaining
membership, coverage or benefits under this Contract; or
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17 Choice-LG-7638 (07/21)
4) 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.
5.4 Retroactive Termination. Retroactive adjustments in coverage will only be made for up to a 60 -day
period from the date of notification. In the event of retroactive termination due to the Subscribing
Group's nonpayment of Premiums, or failure of the Subscribing Group or Members to timely notify
AvMed of Member ineligibility, AvMed will not be responsible for Claims we incur in arranging for
the provision of benefits to Members under the terms of this Contract after the effective date of
such retroactive termination.
5.5 AvMed's Obligations upon Termination. Upon termination of your coverage for any reason, AvMed
will have no further liability or responsibility to you under this Contract whatsoever, except as
specifically described herein.
5.6 Continuation Coverage Rights Under COBRA
a. Introduction.
i. This notice has important information about your right to COBRA continuation coverage,
which is a temporary extension of coverage under the Plan. This notice explains COBRA
continuation coverage, when it may become available to you and your family, and what
you need to do to protect your right to get it. When you become eligible for COBRA, you
may also become eligible for other coverage options that may cost less than COBRA
continuation coverage.
ii. The right to COBRA continuation coverage was created by a federal law, the
Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation
coverage can become available to you and other members of your family when group
health coverage would otherwise end. For more information about your rights and
obligations under the Plan and under federal law, you should review the Plan's Summary
Plan Description or contact the Plan Administrator.
iii. You may have other options available to you when you lose group health coverage. For
example, you may be eligible to buy an individual plan through the Health Insurance
Marketplace. By enrolling in coverage through the Marketplace, you may qualify for lower
costs on your monthly premiums and lower out-of-pocket costs. Additionally, you may
qualify for a 30 -day special enrollment period for another group health plan for which you
are eligible (such as a spouse's plan), even if that plan generally doesn't accept late
enrollees.
b. What is COBRA continuation coverage?
i. COBRA continuation coverage is a continuation of Plan coverage when it would otherwise
end because of a life event. This is also called a "qualifying event." Specific qualifying
events are listed later in this notice. After a qualifying event, COBRA continuation
coverage must be offered to each person who is a "qualified beneficiary." You, your
spouse, and your dependent children could become qualified beneficiaries if coverage
under the Plan is lost because of the qualifying event. Under the Plan, qualified
beneficiaries who elect COBRA continuation coverage must pay the entire cost for
COBRA continuation coverage, plus a 2% administrative fee for the duration of the COBRA
continuation coverage.
ii. If you're an employee, you'll become a qualified beneficiary if you lose your coverage
under the Plan because of the following qualifying events:
1) Your hours of employment are reduced, or
2) Your employment ends for any reason other than your gross misconduct.
iii. If you're the spouse of an employee, you'll become a qualified beneficiary if you lose your
coverage under the Plan because of the following qualifying events:
1) Your spouse dies;
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18 Choice-LG-7638 (07/21)
2) Your spouse's hours of employment are reduced;
3) Your spouse's employment ends for any reason other than his or her gross misconduct;
4) Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or
5) You become divorced or legally separated from your spouse.
iv. Your dependent children will become qualified beneficiaries if they lose coverage under
the Plan because of the following qualifying events:
1) The parent -employee dies;
2) The parent -employee's hours of employment are reduced;
3) The parent -employee's employment ends for any reason other than his or her gross
misconduct;
4) The parent -employee becomes entitled to Medicare benefits (Part A, Part B, or both);
5) The parents become divorced or legally separated; or
6) The child stops being eligible for coverage under the Plan as a "dependent child."
v. If your plan offers retiree coverage, filing a proceeding in bankruptcy under Title 11 of the
United States Code can be a qualifying event. If a proceeding in bankruptcy is filed with
respect to your employer, and that bankruptcy results in the loss of coverage of any retired
employee covered under the Plan, the retired employee will become a qualified
beneficiary. The retired employee's spouse, surviving spouse, and dependent children will
also become qualified beneficiaries if bankruptcy results in the loss of their coverage under
the Plan.
c. When is COBRA continuation coverage available?
i. The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the
Plan Administrator has been notified that a qualifying event has occurred. The employer
must notify the Plan Administrator of the following qualifying events:
1) The end of employment or reduction of hours of employment;
2) Death of the employee;
3) If your Plan provides retiree health coverage, the commencement of a proceeding in
bankruptcy with respect to the employer; or
4) The employee's becoming entitled to Medicare benefits (under Part A, Part B, or both).
ii. For all other qualifying events (divorce or legal separation of the employee and spouse or
a dependent child's losing eligibility for coverage as a dependent child), you must notify
the Plan Administrator within 60 days. You must provide this notice to: AvMed Enrollment
and Premium Services, using the contact information listed at the end of this Notice. You
must include the Member's name, ID number and address, the names of all qualified
beneficiaries, and the name of the Subscribing Group.
d. How is COBRA continuation coverage provided?
i. Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA
continuation coverage will be offered to each of the qualified beneficiaries. Each
qualified beneficiary will have an independent right to elect COBRA continuation
coverage. Covered Employees may elect COBRA continuation coverage on behalf of
their spouses, and parents may elect COBRA continuation coverage on behalf of their
children.
ii. COBRA continuation coverage is a temporary continuation of coverage that generally
lasts for 18 months due to employment termination or reduction of hours of work. Certain
qualifying events, or a second qualifying event during the initial period of coverage, may
permit a beneficiary to receive a maximum of 36 months of coverage.
iii. There are also ways in which this 18 -month period of COBRA continuation coverage can
be extended:
1) Disability extension of 18 -month period of COBRA continuation coverage. If you or
anyone in your family covered under the Plan is determined by Social Security to be
AV-LG-COC-21
19 Choice-LG-7638 (07/21)
disabled and you notify the Plan Administrator in a timely fashion, you and your entire
family may be entitled to get up to an additional 11 months of COBRA continuation
coverage, for a maximum of 29 months. The disability would have to have started at
some time before the 60th day of COBRA continuation coverage and must last at least
until the end of the 18 -month period of COBRA continuation coverage. The Plan
Administrator must be notified before the end of the initial 18 months of COBRA
coverage, and within 60 days after the date of the disability determination.
2) Second qualifying event extension of 18 -month period of continuation coverage. If
your family experiences another qualifying event during the 18 months of COBRA
continuation coverage, the spouse and dependent children in your family can get up
to 18 additional months of COBRA continuation coverage, for a maximum of 36
months, if the Plan is properly notified about the second qualifying event. This extension
may be available to the spouse and any dependent children getting COBRA
continuation coverage if the employee or former employee dies; becomes entitled to
Medicare benefits (under Part A, Part B, or both); gets divorced or legally separated;
or if the dependent child stops being eligible under the Plan as a dependent child. This
extension is only available if the second qualifying event would have caused the
spouse or dependent child to lose coverage under the Plan had the first qualifying
event not occurred.
e. Are there other coverage options besides COBRA Continuation Coverage? Yes. Instead of
enrolling in COBRA continuation coverage, there may be other coverage options for you and
your family through the Health Insurance Marketplace, Medicaid, or other group health plan
coverage options (such as a spouse's plan) through what is called a "special enrollment
period." Some of these options may cost less than COBRA continuation coverage. You can
learn more about many of these options at www.healthcare.gov.
f. If you have questions. Questions concerning your Plan or your COBRA continuation coverage
rights should be addressed to the contact or contacts identified below. For more information
about your rights under the Employee Retirement Income Security Act (ERISA), including
COBRA, the Patient Protection and Affordable Care Act, and other laws affecting group health
plans, contact the nearest Regional or District Office of the U.S. Department of Labor's
Employee Benefits Security Administration (EBSA) in your area or visit www.dol.gov/ebsa.
(Addresses and phone numbers of Regional and District EBSA Offices are available through
EBSA's website.) For more information about the Marketplace, visit www.healthcare.gov.
Keep your Plan informed of address changes. To protect your family's rights, let the Plan
Administrator know about any changes in the addresses of family members. You should also
keep a copy, for your records, of any notices you send to the Plan Administrator.
h. Plan contact information: AvMed Enrollment and Premium Services, 9400 South Dadeland Blvd.,
Suite 510, Miami, FL 33156. You may also contact AvMed by fax at 305-671-0087 or by email at
enrollment@avmed.org. For further information, contact AvMed's COBRA Coordinator at:
AvMed Enrollment and Premium Services, Attention: COBRA Coordinator, 9400 South Dadeland
Blvd., Suite 510, Miami, FL 33156, or by telephone at 305-671-5437 extension 26109.
5.7 Continuation Coverage during Leaves of Absence
a. Family and Medical Leaves of Absence (FMLA). Under FMLA, a Subscriber may be entitled to
up to a total of 12 weeks of unpaid, job -protected leave during each calendar year for the
following:
i. the birth of the Subscriber's child, to care for the newborn child, or for placement of a child
in the Subscriber's home for adoption or foster care;
ii. to care for a spouse, child or parent with a serious health condition; or
iii. for the Subscriber's own serious health condition.
iv. If the FMLA leave is paid, such pay will be reduced by the Subscriber's before -tax Premium
contributions as usual for the coverage level in effect on the date FMLA leave begins. If
FMLA leave is unpaid, the Subscriber will be required to pay Premium contributions directly
to the employer until returning to active pay status.
g.
AV-LG-COC-21 20 Choice-LG-7638 (07/21)
v. If a Subscriber notifies the employer that he is terminating employment during FMLA leave,
coverage will end on the date of notification. If the Subscriber does not return to work on
the expected FMLA return date, and the employer is not notified of the intent to either
terminate employment or extend the period of leave, coverage will end on the date the
Subscriber was expected to return.
vi. Plan elections may not be changed during FMLA leave unless an open enrollment occurs
or the Subscriber has a change in status event or a special enrollment event under The
Health Insurance Portability and Accountability Act of 1996 (HIPAA).
b. Military Caregiver Leave Entitlements. Subscribers who need to provide care for injured service
members may also be eligible for FMLA as follows. FMLA leave for this purpose is called "military
caregiver leave."hjh Military caregiver leave allows an eligible Subscriber who is the spouse, son,
daughter, parent or next of kin of a covered service member with a serious injury or illness to
take up to a total of 26 workweeks of unpaid leave during a single 12 -month period to provide
care for the service member. A covered service member is a current member of the Armed
Forces, including a member of the National Guard or Reserves, who is receiving medical
treatment, recuperation, or therapy, or is in outpatient status, or is on the temporary disability
retired list for a serious injury or illness.
c. Military Leaves of Absence. If a Subscriber is absent from work due to military service,
continuation coverage under the Plan (including coverage for enrolled dependents) may be
elected for up to 24 months from the first day of absence (or if earlier, until the day after the
date the Subscriber is required to apply for or return to active employment with the employer
under the Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA)).
The Subscriber's Premium contributions for continued coverage will be the same as for similarly
situated active Members in the Plan. Whether or not coverage is continued during military
service, a Subscriber may reinstate coverage under the Plan option elected on return to
employment under USERRA. The reinstatement will be without any waiting period otherwise
required under the Plan, except to the extent that any required waiting period was not
completed prior to the start of the military service.
5.8 Extension of Benefits. In the event this Contract is terminated for any reason, except nonpayment
of Premium or as set forth in this Section, such termination will be without prejudice to any continuous
losses to a Member which commenced while this Contract was in force, but any extension of
benefits beyond the date of termination will be predicated upon the Member's continuous Total
Disability, as defined in Part II. DEFINITIONS, and will be limited to payment for the treatment of a
specific accident or illness incurred while coverage under this Contract was effective.
a. The extension of benefits covered under this Contract will be limited to the occurrence of the
earliest of the following events:
i. the expiration of 12 months;
ii. such time as the Member is no longer totally disabled;
iii. a succeeding carrier elects to provide replacement coverage without limitation as to the
disability condition; or
iv. the maximum benefits payable under this Contract have been paid.
b. 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 will be for the period
of that pregnancy only and will not be based upon Total Disability.
c. Except as provided above, no Subscriber is entitled to an extension of benefits if the termination
of this Contract by AvMed, is based upon one or more of the following reasons:
i. fraud or intentional misrepresentation in applying for any benefits under this Contract;
ii. disenrollment for cause; or
iii. the Subscriber has left the Service Area with the intent to work and reside outside the
Service Area.
AV-LG-COC-21 21 Choice-LG-7638 (07/21)
VI. PREMIUMS, COPAYMENTS, COINSURANCE, DEDUCTIBLES AND OTHER EXPENSES
This Part explains the Premium payment responsibilities of the Subscribing Group under this Contract, and
Members' monetary responsibility for expenses for Covered Services received. Members are responsible
and will be liable for applicable Deductibles, Copayments or Coinsurance amounts which must be paid to
Health Care Providers for certain services at the time services are rendered, as shown in the Schedule of
Benefits and for charges in excess of the Maximum Allowable Payment for Covered Services rendered by
Out -of -Network Providers. In addition to the information explained in this Part, it is important that you refer
to your Schedule of Benefits to determine your share of the costs for Covered Services.
6.1 Subscribing Group's Obligations
a. Monthly Premium Payment. On or before the first day of each month for which coverage is
sought, Subscribing Group or its designated agent will remit to AvMed, on behalf of each
Subscriber and his Covered Dependents, the monthly Premium based on the Rate Letter (as
defined in Part XVII. GENERAL PROVISIONS), and the Group Master Application. Only Members
for whom the stipulated payment is actually received by AvMed will be entitled to the Health
Care Services covered under this Contract and then only for the period for which such payment
is applicable.
b. 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 grace
period. Acceptance of payment received after the grace period will be solely at AvMed's
discretion, and may be subject to late payment fees.
i. Coverage will remain in force during the grace period. However, if payment is not
received by the last day of the grace period, and AvMed has provided the Subscribing
Group written notice of termination within 45 days after the Premium due date, termination
of this Contract for nonpayment of the Premium will be retroactive to 12:00 a.m. (midnight)
on the last day for which the Premium was received by AvMed, unless Premium payment
has otherwise been contractually adjusted and specified by the parties in a fully executed
addendum to this Contract.
ii. In the event of retroactive termination for any reason, AvMed reserves the right to recover
an amount equal to the Allowed Amount or Maximum Allowable Payment for any Health
Care Services provided after the effective date of such retroactive termination, less any
Premiums received by us for such Member's coverage after such date. 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 will be refunded on a pro rata basis, and
limited to the total excess Premium amounts paid, less any Claims incurred after the
effective date of termination.
6.2 Member's Obligations
a. Calendar Year Deductible. This amount, when applicable, must be satisfied each calendar year
before AvMed's payment toward Covered Services will begin. Subject to Section 12.9, only
those expenses for Covered Services submitted on Claims to AvMed will be credited toward the
Calendar Year Deductible, and only up to the applicable Allowed Amount or Maximum
Allowable Payment. Certain Covered Services may not be subject to the Calendar Year
Deductible, as shown in your Schedule of Benefits.
i. Self -only or Individual Calendar Year Deductible. The Self -only or Individual Calendar Year
Deductible, when applicable, must be satisfied by each Member each calendar year
before AvMed's payment toward Covered Services will begin during that calendar year.
ii. Family Calendar Year Deductible. The Family Calendar Year Deductible, when applicable,
may be satisfied by any combination of two or more family Members meeting the Family
Deductible amount. The maximum amount that any one Member in a family can
contribute toward the Family Calendar Year Deductible is the Individual Calendar Year
Deductible. Once the Family Calendar Year Deductible has been satisfied, no other
Member in the family will have any additional Calendar Year Deductible responsibility for
the remainder of that calendar year.
AV-LG-COC-21 22 Choice-LG-7638 (07/21)
b. Same Calendar Year Look -Back Credit. This provision means that eligible expenses incurred by
a Member while covered under the Subscribing Group's prior carrier will be credited toward
satisfaction of the Calendar Year Deductible and Out -of -Pocket Maximum under this Plan if:
i. the expenses were incurred before the effective date of this Plan but within the same
calendar year; and
ii. the expenses were applied toward satisfaction of the Deductible or Out -of -Pocket
Maximum under the prior coverage before the effective date of this Plan but within the
same calendar year; and
iii. the expenses were for items or services that are Covered Benefits under this Contract.
However, in order to receive credit, you may be required to provide AvMed written proof
of what was paid from the prior carrier.
c. Copayment and Coinsurance Requirements. Covered Services rendered by certain Health
Care Providers will be subject to a Copayment or Coinsurance requirement. This is the fixed
dollar amount (Copayment) or percentage (Coinsurance) of the Allowed Amount or Maximum
Allowable Payment you have to pay when you receive these services. Please refer to your
Schedule of Benefits for particular Covered Services that are subject to a Copayment or
Coinsurance. All applicable Calendar Year Deductible, Copayment or Coinsurance amounts
must be satisfied before we will pay any portion of the cost for Covered Services.
d. Calendar Year Out -of -Pocket Maximum. Subject to Section 12.9, Deductible, Copayment and
Coinsurance amounts paid for Covered Benefits received during the calendar year will
accumulate toward the Calendar Year Out -of -Pocket Maximum. Expenses for items and
services that are not, as determined by AvMed, Medically Necessary Covered Benefits or
Covered Services under this Contract will not accumulate toward the Calendar Year Out -of -
Pocket Maximums.
i. Individual Calendar Year Out -of -Pocket Maximum. Once a Member reaches the
Individual Calendar Year Out -of -Pocket Maximum amount shown in the Schedule of
Benefits, we will pay for Covered Services received by that Member during the remainder
of that calendar year at 100% of the Allowed Amount or Maximum Allowable Payment.
ii. Family Calendar Year Out -of -Pocket Maximum. If your Plan includes a Family Calendar
Year Out -of -Pocket Maximum, once your family has reached the Family Calendar Year
Out -of -Pocket Maximum amount shown in your Schedule of Benefits, we will pay for
Covered Services received by you and your Covered Dependents during the remainder
of that calendar year at 100% of the Allowed Amount or Maximum Allowable Payment.
The maximum amount any one Member in a family can contribute toward the Family
Calendar Year Out -of -Pocket Maximum is the Individual Calendar Year Out -of -Pocket
Maximum.
6.3 Additional Expenses You Must Pay. In addition to your share of expenses as described above, you
are responsible for payment of charges for:
a. non -covered services;
b. Prescription Drug Brand Additional Charges;
c. expenses for Claims denied because we did not receive information requested from you
regarding any other coverage and the details of such coverage; and
d. charges in excess of the Maximum Allowable Payment for Covered Services rendered by Out -
of -Network Providers who have not agreed to accept our Maximum Allowable Payment as
payment in full. Except in the case of emergencies, a Member who chooses an Out -of -Network
Provider may be responsible to pay an amount that exceeds the Maximum Allowable Payment
for the particular Health Care Services involved, in addition to the applicable Deductible and
Coinsurance amounts. Also, fees that are in excess of allowable charges are not a Covered
Benefit and therefore do not apply to your Deductible or annual out-of-pocket expense. In
addition, if you receive services from an Out -of -Network Provider you are responsible for filing
the Claim, and payment will be made directly to you. If the provider files the Claim for you,
payment will be made directly to the provider. WE RECOMMEND THAT, PRIOR TO CHOOSING
AN OUT -OF -NETWORK PROVIDER FOR PARTICULAR COVERED SERVICES, YOU CONTACT MEMBER
AV-LG-COC-21 23 Choice-LG-7638 (07/21)
ENGAGEMENT AT THE TELEPHONE NUMBER ON PAGE ii OF THIS CONTRACT OR ON YOUR AVMED
IDENTIFICATION CARD TO OBTAIN AN ESTIMATE OF THE MAXIMUM ALLOWABLE PAYMENT SO THAT
YOU ARE AWARE OF YOUR FINANCIAL RESPONSIBILITIES WITH REGARD TO THOSE SERVICES.
6.4 Estimate of Cost for Services. You may obtain an estimate of the cost for particular services from In -
Network Providers by contacting AvMed's Member Engagement Center at the telephone number
on page ii of this Contract or on your AvMed Identification Card. The fact that we may provide you
with such information does not mean, and will not be construed to mean, that the particular service
is a Covered Service. All terms and conditions of this Contract apply.
VII. PHYSICIANS, HOSPITALS AND OTHER PROVIDERS
7.1 Provider and Service Arrangement. AvMed is committed to arranging for comprehensive prepaid
Health Care Services rendered to Members through the Choice Plan's network of contracted
Physicians, Hospitals and other Health Professionals, and Out -of -Network Providers, as described in
this Contract, under reasonable standards of quality health care. The professional judgment of a
Physician licensed under Chapter 458 (Physician), 459 (osteopath), 460 (chiropractor) or 461
(podiatrist), Florida Statutes (or if outside Florida, applicable state law), concerning the proper
course of treatment for a Member, will not be subject to modification by AvMed or its Board of
Directors, Officers, or Administrators. However, this Section is not intended to, and will not, restrict
any Utilization Management Program established by AvMed.
7.2 Physician and Provider Options
a. Within the Plan Service Area, Members are entitled to receive Covered Benefits and Services
from In -Network Providers, or from Out -of -Network Providers, as described in this Contract.
b. Outside the Service Area, Members are entitled to receive Covered Benefits and Services from
PHCS providers or Out -of -Network Providers, as described in this Contract.
c. Your choice of Health Professional or facility may result in lower or higher out-of-pocket expenses
and you may be required to follow certain procedures to avoid additional costs. Please
remember that using In -Network Providers will result in lower out-of-pocket expenses for you. You
should always determine whether a provider is an In -Network or Out -of -Network Provider prior
to receiving services. Doing so will help inform you of the amount you are responsible for paying
out-of-pocket. For more information, see Part VIII. ACCESSING COVERED BENEFITS AND
SERVICES.
7.3 Primary Care Physicians. With the AvMed Choice Plan, each Member may select a PCP upon
enrollment, but is not required to do so. Although you have the option to select any provider, we
encourage you to select and develop a relationship with a PCP. You can choose any PCP who is
available and accepting new patients, from the list of PCPs who are AvMed Choice In -Network
Providers.
a. Advantages of utilizing a PCP
i. PCPs are trained to provide a broad range of medical care. Developing and continuing
a relationship with a PCP allows the Physician to become knowledgeable about you and
your family's health history and act as a valuable resource to coordinate your overall
healthcare needs.
ii. A PCP can help you determine when you need to visit a Specialty Physician and help you
find one based on your PCP's knowledge of you and your specific healthcare needs.
iii. Care rendered by PCPs usually results in lower out-of-pocket expenses for you.
b. Selecting a PCP
i. Types of PCPs include family, general, and internal medicine practitioners, OB/GYNs who
may be selected as PCPs for women, and pediatricians who may be selected as PCPs for
children.
ii. You must notify AvMed of your PCP selection. Members must also notify and receive
approval from AvMed prior to changing PCPs. PCP changes will become effective on the
first day of the month after AvMed is notified.
AV-LG-COC-21 24 Choice-LG-7638 (07/21)
7.4 Specialty Physicians. You are entitled to see in -network Specialty Physicians under this Choice Plan
without the requirement of a referral from your PCP.
7.5 Provider Directory. The names and addresses of AvMed Choice Plan In -Network Providers are set
forth in a separate booklet which, by reference, is made a part hereof. The list of In -Network
Providers, which may change from time to time, will be provided to all Subscribing Groups. The list
of In -Network Providers may also be accessed from AvMed's website at www.avmed.org. In -
network Health Care Providers may from time to time cease their affiliation with AvMed. In such
cases, Members may be required to receive services from another in -network Health Care Provider.
Notwithstanding the printed booklet, the names and addresses of In -Network Providers on file with
AvMed at any given time will constitute the official and controlling list of In -Network Providers.
7.6 Resident Referral to Skilled Nursing Unit or Assisted Living Facility. If you currently reside in a
continuing care facility or a retirement facility consisting of a nursing home or assisted living facility
and residential apartments, this notice applies to you. You may request to be referred to that
facility's skilled nursing unit or assisted living facility. If the request for referral is denied, you may use
the appeal process described in Part XIII. REVIEW PROCEDURES AND HOW TO APPEAL A CLAIM
(BENEFIT) DENIAL.
7.7 WARNING: LIMITED BENEFITS WILL BE PAID WHEN OUT -OF -NETWORK PROVIDERS ARE USED. You should
be aware that when you elect to utilize the services of an Out -of -Network Provider for a covered
non -emergency service, benefit payments to the provider are not based upon the amount the
provider charges. The basis of the payment will be determined according to the out -of -network
reimbursement benefit as described in this Contract. Out -of -Network Providers may bill Members for
any difference in the amount. YOU MAY BE REQUIRED TO PAY MORE THAN THE COINSURANCE OR
COPAYMENT AMOUNT. In -Network Providers have agreed to accept discounted payments for
Covered Services with no additional billing to you other than Coinsurance, Copayment, and
Deductible amounts. You may obtain further information about the providers who have contracted
with AvMed by consulting AvMed's website or contacting AvMed directly. As described in this
Contract, the payment for out -of -network benefits will be the Maximum Allowable Payment.
VIII. ACCESSING COVERED BENEFITS AND SERVICES
8.1 Covered Benefits and Services. Members are entitled to receive Covered Benefits and Services only
as specified herein, appropriately prescribed or directed by In -Network Providers or Out-of-Nework
Providers, in conformity with Part II. DEFINITIONS, Part IX. COVERED MEDICAL SERVICES, Part X.
LIMITATIONS OF COVERED MEDICAL SERVICES, Part XI. EXCLUSIONS FROM COVERED MEDICAL
SERVICES, Part XII. PRESCRIPTION MEDICATION BENEFITS, LIMITATIONS AND EXCLUSIONS, and the
Schedule of Benefits, which by reference is made a part of this Contract.
a. If a Member does not follow the access rules described herein, he risks having the services and
supplies received not covered under this Contract. In such a circumstance, any payment that
AvMed may make will not exceed the Maximum Allowable Payment and the Member will be
responsible for reimbursing AvMed for the services and supplies received.
b. The AvMed Choice Plan creates two benefit payment levels: one for services provided by
AvMed In -Network providers within the Service Area, or provided by PHCS providers located
outside the Service Area; and a second for services provided by Out -of -Network Providers. Your
choice of Health Professional or facility, and wise use of these benefits, can save you money.
i. If the Health Professional or facility is an In -Network Provider inside the Service Area, or the
Health Professional or facility is a PHCS provider and is outside the Service Area, benefits
for Covered Services are payable at the high Benefit Level shown in your Schedule of
Benefits. NOTE: Covered Services from PHCS providers are only payable at the high Benefit
Level when the PHCS provider is located outside the Service Area.
ii. If the Health Professional or facility is an Out -of -Network Provider, or is a PHCS provider
located inside the Service Area, benefits for Covered Services are payable at the low
Benefit Level shown in your Schedule of Benefits.
AV-LG-COC-21 25 Choice-LG-7638 (07/21)
c. Members choosing In -Network Providers while inside the Service Area, or PHCS providers when
outside the Service Area, will be responsible for paying lower Deductibles, Copayment and
Coinsurance amounts. Members choosing Out -of -Network Providers, or PHCS providers while
inside the Service Area, will have to pay higher Deductibles and Coinsurance, and will also be
at risk for provider fees that are in excess of allowable charges.
8.2 Member's Responsibility in Seeking Covered Benefits and Services. Members are solely responsible
for selecting a provider when obtaining Health Care Services and for verifying whether that provider
is an In -Network Provider at the time Health Care Services are rendered. Members are also
responsible for determining any corresponding payment options at the time the Health Care
Services are rendered. It is the Member's responsibility when seeking benefits under this Contract to
identify himself as a Member of AvMed.
8.3 Decision -Making for Health Care Services. Any and all decisions pertaining to the medical need
for, or desirability of, the provision or non -provision of Health Care Services, including without
limitation the most appropriate level of such services, 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.
a. AvMed does not have the right of control over the medical decisions made by a Member's
Physician. A Member and his Health Professionals are responsible for deciding what medical
care should be rendered or received and when that care should be provided. AvMed is solely
responsible for determining whether expenses incurred for Health Care Services are Covered
Benefits or Covered Services under this Contract. In making coverage decisions, we will not be
deemed to participate in or override your decisions concerning your health or the medical
decisions of your Attending Physicians and other Health Professionals.
b. The ordering of a service by a Health Care Provider does not in itself make such service
Medically Necessary or a Covered Service. The Subscribing Group and Members acknowledge
it is possible that a Member and his Physicians may determine that such services are appropriate
even though such services are not covered and will not be arranged or paid for by AvMed.
8.4 Pre-existing condition exclusions are not applicable under this Contract.
8.5 Medicare Secondary Payer Provision. If you become eligible for Medicare while covered under this
Plan, please visit www.medicare.gov or contact your local Social Security office to learn about your
eligibility, coverage options, enrollment periods and necessary steps to follow to ensure that you
have adequate coverage. Members are urged to carefully review Part XIV. COORDINATION OF
BENEFITS for more information about how this Plan works with Medicare.
8.6 Care Management Programs
a. We have established (and from time to time establish) various Member -focused health
education and information programs as well as benefit Utilization Management Programs and
utilization review programs. These voluntary programs, collectively called the Care
Management Programs, are designed to:
i. provide you with information that will help you make more informed decisions about your
health;
ii. help us facilitate the management and review of the coverage and benefits provided
under our policies; and
iii. present opportunities as explained below, to mutually agree upon alternative benefits for
cost-effective medically appropriate Health Care Services.
b. Please note that we reserve the right to discontinue or modify our Prior Authorization
requirements and any Care Management Programs at any time without your consent.
8.7 Concurrent Review and Discharge Planning. We may review Hospital stays, Skilled Nursing Facility
services, and other Health Care Services rendered during the course of an inpatient stay or
treatment program. We may conduct this review while you are an inpatient or after your discharge.
The review is conducted solely to determine whether we should provide coverage or payment for
a particular admission or Health Care Services rendered during that admission. Using our established
AV-LG-COC-21 26 Choice-LG-7638 (07/21)
criteria then in effect, a concurrent review of the inpatient stay may occur at regular intervals. We
will provide notification to your Physician when inpatient Coverage Criteria is no longer met. In
anticipation of your needs following an inpatient stay, we may provide you and your Physician with
information about other Care Management Programs which may be beneficial to you, and we
may help you and your Physician identify health care resources which may be available in your
community. Upon request, we will answer questions your Physician has regarding your coverage or
benefits following discharge from the Hospital or Other Health Care Facility.
8.8 Medical Necessity. In order for Health Care Services to be covered under this Contract, such
services must meet all of the requirements to be a Covered Benefit or Covered Service, including
being Medically Necessary, as defined by AvMed.
a. Review of Medical Necessity. It is important to remember that any review of Medical Necessity
by us is solely for the purposes of determining coverage, benefits, or payment under the terms
of this Contract and not for the purpose of recommending or providing medical care. In this
respect, we may review specific medical facts or information pertaining to you. Any such
review, however, is strictly for the purpose of determining whether a Health Care Service
provided or proposed meets the definition of Medical Necessity in this Contract, as determined
by us. In applying the definition of Medical Necessity in this Contract to a specific Health Care
Service, we will apply our coverage and payment guidelines then in effect. You are free to
obtain a service even if we deny coverage because the service is not Medically Necessary;
however, you will be solely responsible for paying for the service.
i. Examples of hospitalization and other Health Care Services that are not Medically
Necessary include:
1) staying in the Hospital because arrangements for discharge have not been
completed;
2) staying in the Hospital because supervision in the home, or care in the home, is not
available or is inconvenient; or being hospitalized for any service which could have
been provided adequately in an alternate setting (e.g., Hospital outpatient
department);
3) inpatient admissions to a Hospital, Skilled Nursing Facility, or any other facility for the
purpose of Custodial Care, convalescent care, or any other service primarily for the
convenience of a Member, his family members or a provider; and
4) use of laboratory, x-ray, or other diagnostic testing that has no clear indication, or is
not expected to alter your treatment.
b. Whether or not a Health Care Service is specifically listed as an Exclusion, the fact that a provider
may prescribe, recommend, approve, or furnish a Health Care Service does not mean that the
service is Medically Necessary (as defined by us) or a Covered Service. Please refer to Part II.
DEFINITIONS for the definition of "Medically Necessary or Medical Necessity".
8.9 Prior Authorization of Services
a. If your Health Care Provider is an In -Network Provider, he or she will handle all authorizations,
notifications and utilization reviews with AvMed. If your Health Care Provider is an Out -of -
Network Provider, you are responsible for making sure he or she contacts AvMed to obtain Prior
Authorization for a Covered Service when it is required. Please refer to your AvMed Identification
Card for the telephone number where authorization may be obtained, or have your Health
Professional call 1-800-452-8633.
b. Members must remember that services provided or received without Prior Authorization from
AvMed when authorization is required, are not covered except when required to treat an
Emergency Medical Condition. Furthermore, if an inpatient admission is extended beyond the
number of days initially approved, without Prior Authorization for the continued stay, it may result
in services not being covered. Before a service is performed, you should verify with your Health
Professional that the service has received Prior Authorization. If you are unable to secure
verification from your Health Professional, you may also call AvMed at 1-800-452-8633.
c. Services that require Prior Authorization from AvMed include:
AV-LG-COC-21 27 Choice-LG-7638 (07/21)
i. inpatient admissions (including Hospital and observation stays, Skilled Nursing Facilities,
ventilator dependent care, acute rehabilitation and inpatient mental health or substance
abuse services including Residential Treatment);
ii. surgical procedures or services performed in an outpatient Hospital or Ambulatory Surgery
Center;
iii. complex diagnostic and therapeutic, and sub -specialty procedures (including CT, CTA,
MRI, MRA, PET, and nuclear medicine) and psychological and neuropsychological testing;
iv. Partial Hospitalization and Intensive Outpatient Treatment;
v. Pain Management and outpatient Detoxification;
vi. radiation oncology;
vii. certain medications including Injectable Medications, and select medications
administered in a Physician's office, an outpatient Hospital or infusion therapy setting;
viii. Home Health Care Services;
ix. cardiac rehabilitation;
x. dialysis services;
xi. transplant services;
xii. non -emergency transport services.
d. Services requiring Prior Authorization may change from time to time. For more information about
which services require Prior Authorization, contact AvMed's Member Engagement Center at 1-
800-882-8633. You should always make sure your Physician contacts us to obtain Prior
Authorization.
IX. COVERED MEDICAL SERVICES
The Covered Benefits or Covered Services described below may be subject to Limitations, as described in
Part X. LIMITATIONS OF COVERED MEDICAL SERVICES and Exclusions as described in Part XI. EXCLUSIONS
FROM COVERED MEDICAL SERVICES. Please refer to Parts X. LIMITATIONS OF COVERED MEDICAL SERVICES
and XI. EXCLUSIONS FROM COVERED MEDICAL SERVICES for applicable benefit maximums, and services
that are excluded under this Contract.
9.1 Allergy Injections, Allergy Skin Testing and Treatments
9.2 Ambulance Services
a. Ambulance services provided by a local professional ground ambulance transport may be
covered provided it is necessary, as determined by us, to transport you from:
i. the place a medical emergency occurs to the nearest emergency facility appropriately
staffed and equipped to provide proper care;
ii. a Hospital which is unable to provide proper care to the nearest emergency facility
appropriately staffed and equipped to provide proper care;
iii. a Hospital to your nearest home or Skilled Nursing Facility when associated with an
approved hospitalization or other confinement and your Condition requires the skill of
medically trained personnel during the transport; or
iv. a Skilled Nursing Facility to your nearest home or a Hospital when associated with an
approved hospitalization or other confinement and your Condition requires the skill of
medically trained personnel during transport.
b. Expenses for ambulance services by boat, airplane, or helicopter are covered under the
following circumstances:
i. the pick-up point is inaccessible by ground vehicle;
ii. speed in excess of ground vehicle speed is critical; or
AV-LG-COC-21 28 Choice-LG-7638 (07/21)
iii. the travel distance involved in getting you to the nearest emergency facility appropriately
staffed and equipped to provide proper care is too far for medical safety by ground
vehicle, as determined by us.
c. Member cost -sharing for air and water ambulance services is higher than for ground
transportation.
9.3 Ambulatory Surgery Centers. Health Care Services rendered at Ambulatory Surgery Centers are
covered and include:
a. use of operating and recovery rooms;
b. respiratory, or inhalation therapy (e.g., oxygen);
c. medications administered (except for take-home medications) at the Ambulatory Surgery
Center;
d. intravenous solutions;
e. dressings, including ordinary casts;
f. anesthetics and their administration;
g. administration of, including the cost of, whole blood or blood products;
h. transfusion supplies and equipment;
i. diagnostic services, including radiology, ultrasound, laboratory, pathology and approved
machine testing (e.g., EKG); and
chemotherapy treatment for proven malignant disease.
1•
9.4 Anesthesia Administration Services. Administration of anesthesia by a Physician or certified
registered nurse anesthetist (CRNA) may be covered. In those instances where the CRNA is actively
directed by a Physician other than the Physician who performed the surgical procedure, our
payment for Covered Services, if any, will be made for both the CRNA and the Physician Health
Care Services at the lower directed -services amount.
9.5 Cardiac rehabilitation means Health Care Services provided under the supervision of a Physician,
or another appropriate Health Care Provider trained for cardiac therapy, for the purpose of aiding
in the restoration of normal heart function in connection with a myocardial infarction, coronary
occlusion or coronary bypass surgery. Cardiac rehabilitation is covered for acute myocardial
infarction, percutaneous transluminal coronary angioplasty (PTCA), coronary artery bypass graft
(CABG), and repair or replacement of heart valves or heart transplant. Please refer to Part X.
LIMITATIONS OF COVERED MEDICAL SERVICES for applicable benefit maximums.
9.6 Child Cleft Lip and Cleft Palate Treatment. For treatment of a child under the age of 18 who has a
cleft lip or cleft palate, Health Care Services for child cleft lip and cleft palate, including medical,
dental, speech therapy, audiology, and nutrition services are covered. See also Physical,
Occupational and Speech Therapies in Part IX. The speech therapy coverage provided herein is
subject to the Limitations described in Part X. LIMITATIONS OF COVERED MEDICAL SERVICES. In order
to be covered, the Member's Attending Physician must specifically prescribe such services and
such services must be consequent to treatment of the cleft lip or cleft palate.
9.7 Child Health Supervision Services
a. Periodic Physician -delivered or Physician -supervised services from the moment of birth through
the end of the month in which a Covered Dependent child turns 19, are covered as follows:
i. periodic examinations, which include a history, a physical examination, and a
developmental assessment and anticipatory guidance necessary to monitor the normal
growth and development of a child;
ii. immunizations; and
iii. laboratory tests normally performed for a well -child.
b. Services must be provided in accordance with prevailing medical standards consistent with the
Recommendations for Preventive Pediatric Health Care of the American Academy of
Pediatrics.
AV-LG-COC-21 29 Choice-LG-7638 (07/21)
9.8 Chiropractic Services. Office visits for the purpose of evaluation and diagnosis, diagnostic x-rays,
manual manipulation of the spine to correct subluxation, and certain rehabilitative therapies when
performed within the scope of the practitioner's license are covered when determined by us to be
Medically Necessary. Please refer to Part X. LIMITATIONS OF COVERED MEDICAL SERVICES for
applicable benefit maximums.
9.9 Clinical Trials
a. Routine patient care costs may be covered for Members enrolled in a qualifying clinical trial
that is a Phase I, II, III, or IV clinical trial conducted for the prevention, detection, or treatment
of:
i. cancer or other life -threatening disease or Condition that is, as determined by us, likely to
lead to death unless the course of the disease or Condition is interrupted;
ii. a Phase I, II, or III clinical trial conducted for the detection or treatment of cardiovascular
disease (cardiac/stroke) which is not life threatening; and
iii. surgical musculoskeletal disorders of the spine, hip and knees, which are not life -
threatening.
b. Routine patient care costs for qualifying clinical trials include:
i. Covered Services for which benefits are typically provided absent a clinical trial;
ii. Covered Services required solely for the provision of the investigational item or service, the
clinically appropriate monitoring of the effects of the item or service, or the prevention of
complications; and
iii. Covered Services needed for reasonable and necessary care arising from the provision of
an Investigational item or service.
c. To be eligible for participation in a clinical trial, the Member's Physician must provide
documentation establishing that the Member meets all inclusion criteria for the clinical trial as
defined by the researcher.
d. Members are required to use an In -Network Provider for any clinical trials covered under this
Contract.
e. The clinical trial must meet the following criteria:
i. Federally funded or approved by one or more of the following:
1) the National Institutes of Health (NIH);
2) the Centers for Disease Control and Prevention;
3) the Agency for Healthcare Research and Quality;
4) the Centers for Medicare and Medicaid Services;
5) a cooperative group or center of any of the entities listed above or the Department of
Defense (DOD) or the Department of Veteran's Affairs (VA);
6) a qualified non -governmental research entity identified in the NIH guidelines for center
support grants; or
7) the VA, DOD, or Department of Energy as long as the study or investigation has been
reviewed and approved through a system of peer review that is determined by the
Secretary of Health and Human Services to be both:
a) comparable to the system of peer review of studies and investigations used by the
NIH; and
b) ensures unbiased review of the highest scientific standard by qualified individuals
who have no interest in the outcome of the review.
ii. Conducted under an investigational new drug application reviewed by the United States
Food and Drug Administration; or
iii. A drug trial that is exempt from having such an investigational new drug application.
f. In addition, the clinical trial must have a written protocol that describes a scientifically sound
study and have been approved by all relevant institutional review boards before Members are
enrolled in the trial. AvMed may, at any time, request documentation about the trial.
AV-LG-COC-21 30 Choice-LG-7638 (07/21)
g. The subject or purpose of the trial must be the evaluation of an item or service that meets the
definition of a Covered Service and is not otherwise excluded under this Contract.
9.10 Complications of Pregnancy. Health Care Services provided to you for the treatment of
complications of pregnancy are Covered Services and will be treated the same as any other
medical Condition. Complications of pregnancy include:
a. acute nephritis;
b. nephrosis;
c. cardiac decompensation;
d. eclampsia (toxemia with convulsions);
e. ectopic pregnancy;
f. uncontrolled vomiting requiring fluid replacement;
g. missed abortion (i.e., fetal death without spontaneous abortion);
h. therapeutic and missed abortion (i.e., termination of pregnancy before the time of fetal viability
due to medical danger to the pregnant woman or when the pregnancy would result in the birth
of an infant with grave malformation);
i. Conditions that may require other than a vaginal delivery, such as: uterine wound separation,
premature labor, unresponsive to tocolytic therapy, failed trial labor, dystocia (i.e.,
cephalopelvic disproportion, failure to progress, dysfunctional labor), fetal distress requiring
neonatal support/intervention, breech presentation where external version is unsuccessful,
active clinical herpes at delivery, placenta previa, transverse lie where external version is
unsuccessful, presence of fetal anomaly;
j. miscarriages;
k. medical and surgical Conditions of similar severity; and
I. Medically Necessary non -elective cesarean section.
9.11 Dental Care
a. Dental Care is limited to the following:
i. care and stabilization treatment rendered within 90 days of an Accidental Dental Injury
provided such services are for the treatment of damage to Sound Natural Teeth;
ii. extraction of teeth required prior to radiation therapy when you have a diagnosis of
cancer of the head or neck.
b. General anesthesia and hospitalization services are covered when required to assure the safe
delivery of necessary dental treatment or surgery for a dental Condition which, if left untreated,
is likely to result in a medical Condition if:
i. a 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 Surgery Center; or
ii. a Covered Dependent child is under eight years of age and it is determined by a licensed
dentist and the Covered Dependent's Attending Physician that dental treatment or
surgery in a Hospital or Ambulatory Surgery Center is necessary due to a significantly
complex dental Condition, or a developmental disability in which patient management in
the dental office has proven to be ineffective.
9.12 Dermatological Services. AvMed will cover office visits to a dermatologist for Medically Necessary
Covered Services, subject to the Limitations described in Part X. LIMITATIONS OF COVERED MEDICAL
SERVICES. No prior referral or authorization is required for the first five visits to a dermatologist in a 12 -
month period for a dermatological problem.
9.13 Diabetes Outpatient Self -Management. All Medically Necessary equipment, supplies, and services
to treat diabetes are covered. 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 that the equipment, supplies or services are
Medically Necessary. Diabetes outpatient self -management training and educational services
AV-LG-COC-21 31 Choice-LG-7638 (07/21)
must be provided under the direct supervision of a certified diabetes educator or a board certified
endocrinologist.
9.14 Diabetic Supplies. Insulin and other covered anti -diabetic drugs and diabetic supplies, including
needles, syringes, lancets, lancet devices and test strips, are covered under the Subscribing Group's
supplemental Prescription Medication benefits. Insulin pumps, when Medically Necessary and
accompanied by a prescription from your Physician, are covered under your medical benefits,
subject to the cost -sharing for Durable Medical Equipment shown on your Schedule of Benefits.
9.15 Diagnosis and treatment of Autism Spectrum Disorders and Down syndrome through speech,
occupational and physical therapy, and Applied Behavior Analysis services, for a Member who is
(i) under 18 years of age, or (ii) 18 years of age or older and in high school, and was diagnosed at
8 years of age or younger as having a developmental disability. Services must be prescribed by the
Member's Attending Physician in accordance with a treatment plan. The treatment plan required
will include a diagnosis, the proposed treatment by type, the frequency and duration of treatment,
the anticipated outcomes stated as goals, the frequency with which the treatment plan will be
updated, and the signature of the Attending Physician.
9.16 Diagnostic Services. All prescribed diagnostic imaging, laboratory tests and services are covered
when Medically Necessary and ordered by a Physician as part of the diagnosis or treatment of a
covered illness or injury, or as a preventive Health Care Service. Specialized tests such as those to
diagnose Conditions that cannot be diagnosed by traditional blood tests (e.g. allergy,
endocrinology, genetics, and virology testing), are subject to higher Member out-of-pocket
expenses.
9.17 Diagnostic testing and treatment related to Attention Deficit Hyperactivity Disorder (ADHD) are
covered subject to Medical Necessity and utilization management guidelines. Covered Services
do not include those that are primarily educational or training in nature.
9.18 Dialysis services including equipment, training and medical supplies are covered when provided
at an AvMed Network location, by an AvMed Network Health Professional who is licensed to
perform dialysis, including an AvMed Network Dialysis Center. A Dialysis Center is an outpatient
facility certified by the Centers for Medicare and Medicaid Services and the Florida Agency for
Health Care Administration to provide hemodialysis and peritoneal dialysis services and support.
Dialysis services require Prior Authorization.
9.19 Drug Infusion Therapy. Infusion therapy medications are covered as a medical benefit if
administered by a Health Professional by way of intra-articular, intracavernous, intramuscular,
intraocular, intrathecal, intravenous or subcutaneous injection; or intravenous infusion. Beginning
with the second treatment in a course of treatment, outpatient infusion therapy must be received
in a non -Hospital setting, including a Physician's office, infusion clinic or the home. Prior Authorization
may be required.
9.20 Durable Medical Equipment (DME)
a. Coverage includes purchase or rental, when Medically Necessary, of such DME that:
i. can withstand repeated use (i.e. could normally be rented and used by successive
patients);
ii. is primarily and customarily used to serve a medical purpose;
iii. generally is not useful to a person in the absence of illness or injury; and
iv. is appropriate for use in a Member's home.
b. Some examples of DME are: standard hospital beds, crutches, canes, walkers, wheelchairs,
oxygen, respiratory equipment, apnea monitors and insulin pumps. DME does not include
hearing aids or corrective lenses, dental devices, or the professional fees 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 of
Member owned DME, and replacement of DME solely because it is old or used, is not covered.
AV-LG-COC-21 32 Choice-LG-7638 (07/21)
c. 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.
9.21 Emergency Services. AvMed will cover all Medically Necessary Physician and Hospital services for
an Emergency Medical Condition. In the event Hospital inpatient services are provided following
Emergency Medical Services and Care, AvMed should be notified by the Hospital, Member or a
designee, within 24 hours of the inpatient admission if reasonably possible. AvMed may recommend
and elect to transfer the Member to a Hospital that is an In -Network Provider or a PHCS provider
after the Member's Condition has been stabilized, and as soon as it is medically appropriate to do
so. If the Member chooses to stay in an out -of -network Hospital after the date AvMed decides a
transfer is medically appropriate, services will be paid as out -of -network benefits if the continued
stay is determined to be a Covered Service.
a. Any Member requiring medical, Hospital or ambulance services for an Emergency Medical
Condition while temporarily outside the Service Area, or within the Service Area but before they
can reach an In -Network Provider, may receive the emergency benefits specified herein. When
emergency services are rendered by an Out -of -Network Provider to treat an Emergency
Medical Condition, any Copayment or Coinsurance amount applicable to In -Network Providers
for emergency services will also apply to such Out -of -Network Provider.
b. For out -of -network emergency services, AvMed will pay an amount equal to the greater of the
three amounts specified below:
i. The median of the amount negotiated with In -Network Providers for the emergency
services furnished;
ii. The amount for the emergency services calculated using AvMed's Maximum Allowable
Payment, which is the same method the Plan generally uses to determine payments for
out -of -network services, and applying in -network cost -sharing; or
iii. The amount that would be paid under Medicare for the Emergency Medical Services and
Care.
c. Any request for reimbursement of payment made by a Member for services received must be
filed within 90 days after the emergency or as soon as reasonably possible but not later than
one year unless the Member was legally incapacitated; otherwise such a Claim will be
considered to have been waived. If Emergency Medical Services and Care are required while
outside the continental United States, Alaska or Hawaii, it is the Member's responsibility to pay
for such services at the time they are received. For information on filing a Claim for such services
see Part XIII. REVIEW PROCEDURES AND HOW TO APPEAL A CLAIM (BENEFIT) DENIAL.
9.22 Habilitation Services
a. Covered Services consist of physical, occupational and speech therapies that are provided for
developmental delay, developmental speech or language disorder, developmental
coordination disorder and mixed developmental disorder. Therapy services must be performed
by an appropriate registered physical, occupational or speech -language therapist licensed by
the appropriate state licensing board, and must be furnished under the direction and
supervision of a Physician or an advanced practice nurse in accordance with a written
treatment plan established or certified by the Attending Physician or advanced practice nurse.
b. Covered Services must take place in a non-residential setting separate from the home or facility
in which the Member lives.
c. Services are covered up to the point where no further progress can be documented. Services
are not considered a Covered Benefit when measurable functional improvement is not
expected or progress has plateaued.
d. Covered Habilitation Services do not include activities or training to which the Member may be
entitled under federal or state programs of public elementary or secondary education or
federally aided vocational rehabilitation.
9.23 Home Health Care Services (Skilled Home Health Care). All Home Health Care Services require Prior
Authorization.
AV-LG-COC-21 33 Choice-LG-7638 (07/21)
a. The Home Health Care Services listed below are covered when the following criteria are met:
i. A Member is unable to leave home without considerable effort and the assistance of
another person because the Member is:
1) bedridden or chair bound, or restricted in ambulation whether or not assistive devices
are used; or
2) significantly limited in physical activities due to a Condition; and
ii. the Home Health Care Services rendered have been prescribed by a Physician by way of
a formal written treatment plan. The written treatment plan must be reviewed and
renewed by the prescribing Physician at least every 30 days until benefits are exhausted.
AvMed reserves the right to request a copy of any written treatment plan in order to
determine whether such services are covered under this Contract; and
iii. the Home Health Care Services are provided directly by (or indirectly through) a home
health agency; and
iv. the Member is meeting or achieving the desired treatment goals set forth in the treatment
plan as documented in the clinical progress notes.
b. Home Health Care Services are limited to:
i. intermittent visits (i.e., up to, but not exceeding, two hours per day) for:
1) nursing care by a registered nurse or licensed practical nurse, and home health aide
services;
2) medical social services;
3) nutritional guidance;
4) respiratory or inhalation therapy (e.g., oxygen); and
5) short-term physical therapy by a physical therapist, occupational therapy by an
occupational therapist, and speech therapy by a speech therapist. Such therapies
provided in the home are subject to any rehabilitative outpatient physical,
occupational and speech therapy visit limits.
c. Services must be consistent with a plan of treatment ordered by the Member's Physician.
Nursing and home health aide services must be rendered under the supervision of a registered
nurse. See Part X. LIMITATIONS OF COVERED MEDICAL SERVICES for applicable Limitations.
9.24 Hospice Services. Services are available for a Member whose Attending Physician has determined
the Member's illness will result in a remaining life span of six months or less.
9.25 Hospital Inpatient Care and Services. Inpatient services received at Hospitals are covered when
prescribed by 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, medications, biologicals,
anesthesia and oxygen supplies, physical therapy, radiation therapy, respiratory therapy, and
administration of blood or blood plasma. See Part IX., Emergency Services, with regard to inpatient
admission following Emergency Medical Services and Care.
9.26 Inpatient Rehabilitation Services are covered when the following criteria are met:
a. Services must be provided under the direction of a Physician and must be provided by a
Medicare -certified facility in accordance with a comprehensive rehabilitation program;
b. A plan of care must be developed and managed by a coordinated multi -disciplinary team;
c. Coverage is limited to the specific acute, catastrophic target diagnoses of severe stroke,
multiple trauma, brain/spinal injury, severe neurological motor disorders and severe burns;
d. For Members in inpatient non -psychiatric or substance abuse rehabilitation facilities, the
Member must be able to actively participate in at least two rehabilitative therapies and be able
to tolerate at least three hours per day of skilled Rehabilitation Services for at least five days a
week and their Condition must be likely to result in significant improvement; and
AV-LG-COC-21 34 Choice-LG-7638 (07/21)
e. The Rehabilitation Services must be required at such intensity, frequency and duration as to
make it impractical for the Member to receive services in a less intensive setting. See Part X.
LIMITATIONS OF COVERED MEDICAL SERVICES for applicable benefit maximums.
9.27 Mammograms are covered in accordance with Florida Statutes and the U.S. Preventive Services
Task Force (USPSTF) preventive services 'A' and 'B' recommendations. 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.
9.28 Mastectomy Surgery when Performed for Breast Cancer. Mastectomy means the removal of all or
part of the breast, when Medically Necessary for the treatment of breast cancer, as determined by
a Physician.
a. Coverage for post -mastectomy reconstructive surgery will include:
i. all stages of reconstruction of the breast on which the mastectomy has been performed;
ii. surgery and reconstruction on the other breast to produce a symmetrical appearance;
and
iii. prostheses and treatment of physical complications during all stages of mastectomy,
including lymphedemas.
b. 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 Member. The Attending Physician, after consultation with the Member, may choose
that outpatient care be provided at the most medically appropriate setting, which may include
the Hospital, Attending Physician's office, outpatient facility, or the Member's home.
9.29 Mental Health Services. Inpatient, intermediate and outpatient mental health services are covered
when Medically Necessary and may be covered when a Member is admitted to a Hospital or Other
Health Care Facility.
a. For those disorders that cannot be effectively treated in an outpatient (including Partial
Hospitalization) environment, intermediate mental health services in a Residential Treatment
facility may be covered under a 24 -hour intensive and structured supervised treatment program
providing an inpatient level of care but in a non -Hospital environment. Treatment must be
received in a facility specifically licensed as a Residential Treatment facility or Residential
Treatment center by the State of Florida (or if outside Florida, applicable state law), to provide
Residential Treatment programs for mental health disorders. The facility must require admission
by a Physician; must have a behavioral health provider actively on duty 24 hours per day, 7
days per week; the Member must receive treatment by a psychiatrist at least once per week;
and the facility's medical director must be a psychiatrist. Prior Authorization is required.
b. As an alternative to inpatient hospitalization, Partial Hospitalization may be covered under a
structured program of active psychiatric treatment, provided in a Hospital outpatient setting or
by a community mental health center, that is more intense than the care received in a
Physician's or therapist's office. Prior Authorization is required.
c. Outpatient and Intensive Outpatient Treatment for mental health disorders may be covered
when provided by a state -licensed psychiatrist or other Physician, clinical psychologist, clinical
social worker, clinical nurse specialist, nurse practitioner, Physician assistant, or other qualified
mental health professional as allowed under applicable state law. Prior Authorization is required
for Intensive Outpatient Treatment.
9.30 Newborn Care. A newborn child will be covered from the moment of birth provided that the
newborn child is eligible for coverage and properly enrolled. Covered Services will consist of
coverage for injury or illness, including the necessary care or treatment of medically diagnosed
congenital defects, birth abnormalities, premature birth and transportation costs to the nearest
AV-LG-COC-21 35 Choice-LG-7638 (07/21)
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 the date
of birth.
9.31 Nutrition Therapy. Prescription -required nutritional supplements and low protein modified foods for
use at home by a Member through age 24, may be covered when prescribed or ordered by a
Physician, only for the treatment of an inborn error of metabolism genetic disease, e.g., Disorder of
Amino Acid metabolism such as phenylketonuria (PKU). Prior Authorization is required for coverage
of enteral, parenteral, or oral nutrition and any related supplies. See Part X. LIMITATIONS OF
COVERED MEDICAL SERVICES for applicable benefit maximums.
9.32 Obstetrical and Gynecological Care. An annual gynecological examination and Medically
Necessary follow-up care detected at that visit are available without the need for a referral from
your Primary Care Physician. You do not need Prior Authorization from AvMed or from any other
person (including a PCP) in order to obtain access to obstetrical or gynecological care from a
Health Professional who specializes in obstetrics or gynecology. The Health Professional may be
required to comply with certain procedures, including obtaining Prior Authorization for certain
services, following a pre -approved treatment plan, or procedures for making referrals. For a list of
in -network Health Professionals who specialize in obstetrics or gynecology contact AvMed's
Member Engagement Center, or visit us online at www.avmed.org. Obstetrical care benefits as
specified herein are covered and include Birthing Center care, Hospital care, anesthesia,
diagnostic imaging and laboratory services for Conditions related to pregnancy.
a. The length of a 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:
i. Hospital stays of at least 48 hours following a normal vaginal delivery, or at least 96 hours
following a cesarean section;
ii. The Attending Physician does not need to obtain Prior Authorization from AvMed to
prescribe a Hospital stay of this length;
iii. AvMed will cover an extended stay if Medically Necessary; however, the Physician or
Hospital must pre -certify the extended stay.
iv. Shorter Hospital stays are permitted if the Attending Physician, in consultation with the
mother, determines that to be the best course of action.
b. All covered preventive care and obstetrical services related to a pregnancy will be covered
without regard to the circumstances or purpose of the pregnancy.
9.33 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 is 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. 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.
9.34 Osteoporosis diagnosis and treatment when Medically Necessary for high -risk individuals, including
estrogen -deficient individuals who are at clinical risk for osteoporosis, individuals with vertebral
abnormalities, individuals on long-term glucocorticoid (steroid) therapy, individuals with primary
hyperparathyroidism and individuals with a family history of osteoporosis.
9.35 Other Health Care Facility(ies). All Medically Necessary Covered Services of Other Health Care
Facilities including Skilled Nursing Facilities, such as Physician visits, physiotherapy, diagnostic
imaging and laboratory work, are covered for Conditions that cannot be adequately treated with
Home Health Care Services, or on an ambulatory basis, when a Member is admitted to such a
facility following discharge from a Hospital. Residential Treatment facility services may be covered
for mental health or substance use disorders that cannot be adequately treated on an outpatient
AV-LG-COC-21 36 Choice-LG-7638 (07/21)
(including Partial Hospitalization) basis, and no prior Hospital stay is required. Services are subject to
Limitations as described in Part X. LIMITATIONS OF COVERED MEDICAL SERVICES.
9.36 Out -of -Network Provider Services. When, in the professional judgment of AvMed's Medical Director,
a Member needs Covered Services which require skills or facilities not available from In -Network
Providers, and it is in the best interest of the Member to obtain the needed care from an Out -of -
Network Provider, upon authorization by the Medical Director, payment not to exceed the
Maximum Allowable Payment, will be made for such Covered Services rendered by an Out -of -
Network Provider.
9.37 Outpatient Therapeutic Services. Covered Services for therapeutic treatments received on an
outpatient basis in the home, Physician's office, Other Health Care Facility, or Hospital, including
intravenous chemotherapy or other intravenous infusion therapy and Injectable Medications.
9.38 Pain Management. Outpatient Pain Management including pain assessment, medication, physical
therapy, biofeedback and counseling may be covered when Medically Necessary in order to
reduce or limit chronic pain.
9.39 Physical, Occupational and Speech Therapies
a. Short term rehabilitative physical, occupational and speech therapies provided in an
outpatient or home care setting are covered to improve or restore physical functioning
following disease, injury or loss of a body part.
b. Habilitative physical, occupational and speech therapies provided in an outpatient setting are
covered when provided to help a person keep, learn or improve skills and functioning for daily
living.
c. Clinical documentation or a treatment plan to support the need for therapy services or
continuing therapy must be submitted for review.
d. Continued therapy is only Medically Necessary when prescribed by a Physician in order to
significantly improve, develop or restore physical functions that have been lost or impaired.
Using additional diagnoses to obtain additional therapy for the same Condition is not
considered Medically Necessary. Once maximum therapeutic benefit has been achieved, and
there is no longer any progression, or a home exercise program could be used for any further
gains, continuing supervised therapy is not considered Medically Necessary. Therapy for persons
whose Condition is neither regressing nor improving is considered not Medically Necessary.
Therapy for asymptomatic persons or in persons without an identifiable clinical Condition is
considered not Medically Necessary.
e. Additional therapy can be considered for a new or separate Condition in a person who
previously received therapy for another indication. An exacerbation or flare-up of a chronic
illness is not considered a new incident of illness.
f. Home -based physical therapy is Medically Necessary in selected cases based upon the
Member's needs, i.e., the Member must be homebound. This may be considered Medically
Necessary in the transition of the Member from Hospital to home, and may be an extension of
case management services.
g. Services are subject to Limitations as described in Part X. LIMITATIONS OF COVERED MEDICAL
SERVICES.
9.40 Physician Care: Inpatient. All Health Care Services rendered by Physicians and other Health
Professionals when requested or directed by the Attending Physician, including surgical procedures,
anesthesia, consultation and treatment by Specialty Physicians, laboratory and diagnostic imaging
services, and physical therapy are covered while the Member is admitted to a Hospital as a
registered bed patient. When available and requested by the Member, the services of a CRNA
licensed under Chapter 464, Florida Statutes (or if outside Florida, applicable state law), will be
covered.
9.41 Physician Care: Outpatient
a. Diagnosis and Treatment. All Health Care Services rendered by Physicians and other Health
Professionals are covered when Medically Necessary and when provided at Medical Offices,
AV-LG-COC-21 37 Choice-LG-7638 (07/21)
including surgical procedures, routine hearing examinations, and vision examinations for glasses
for children through the end of the month in which they turn 19 (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) (or if outside Florida,
applicable state law), and consultation and treatment by Specialty Physicians. Also included
are non -reusable materials and surgical supplies.
b. Preventive and Health Maintenance Services. Services of Health Professionals for illness
prevention and health maintenance, including items or services that have an 'A' or 'B' rating
in the current recommendations of the USPSTF with respect to the Member involved;
immunizations recommended by the Advisory Committee on Immunization Practices of the
Centers for Disease Control and Prevention; evidence -informed preventive care and screenings
for infants, children, and adolescents as provided for in comprehensive guidelines supported by
the Health Resources and Services Administration (HRSA); and evidence -informed preventive
care and screening for women as provided for in comprehensive guidelines supported by the
HRSA. A listing of preventive health services with current 'A' or 'B' ratings is available on the
USPSTF website. Important note about gender -specific preventive care benefits: Covered
expenses include any recommended preventive care benefits described above that are
determined by your Health Professional to be Medically Necessary, regardless of the sex you
were assigned at birth, your gender identity, or your recorded gender.
9.42 Prescription Medications. Retail Prescription Medications may be covered when accompanied by
a prescription from your Attending Physician, subject to the cost -sharing shown in the Prescription
Medication Amendment to this Contract. Certain preventive medications that have an 'A' or 'B'
rating in current recommendations of the USPSTF, may be covered at no cost to you when deemed
Medically Necessary and accompanied by a prescription from your Attending Physician. Coverage
for insulin and other diabetic supplies is described in Part IX., under Diabetic Supplies. Allergy serums
and chemotherapy for cancer patients are covered under your medical benefits. See Part XII.
PRESCRIPTION MEDICATION BENEFITS, LIMITATIONS AND EXCLUSIONS for additional information
about Prescription Medications.
9.43 Prosthetic Devices. This Contract provides benefits, when Medically Necessary, for Prosthetic
Devices designed to restore bodily function or replace a physical portion of the body. Coverage
for Prosthetic Devices is limited to artificial limbs, artificial joints, ocular prostheses, and cochlear
implants. 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, including Prosthetic Devices for Deluxe, Myo-electric and
electronic Prosthetic Devices. 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.
9.44 Second Medical Opinions. Members are entitled to a second medical opinion when disputing the
appropriateness or necessity of a surgical procedure, or when subject to a serious injury or illness.
a. A Member may choose to obtain a second medical opinion from any in -network or out -of -
network Physician.
b. Once a second medical opinion has been rendered, AvMed will review and determine
AvMed's obligations under this Contract, and that judgment by AvMed is controlling. Any
treatment the Member obtains that is not authorized by AvMed will be at the Member's
expense.
c. AvMed may limit second medical opinions in connection with a particular diagnosis or
treatment to three per calendar year, if AvMed deems additional opinions to be an
unreasonable over -utilization by the Member.
9.45 Skilled Nursing Facilities
a. The following Health Care Services may be Covered Services when you are a patient in a Skilled
Nursing Facility:
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i. room and board;
ii. respiratory or inhalation therapy (e.g., oxygen);
iii. medications and medicines administered while an inpatient (except take-home
medications);
iv. intravenous solutions;
v. administration of, including the cost of, whole blood or blood products;
vi. dressings, including ordinary casts;
vii. transfusion supplies and equipment;
viii. diagnostic services, including radiology, ultrasound, laboratory, pathology and approved
machine testing (e.g., EKG);
ix. chemotherapy treatment for proven malignant disease; and
x. physical, occupational and speech therapies.
b. We reserve the right to request a treatment plan for determining coverage and payment.
Services are subject to Limitations as described in Part X. LIMITATIONS OF COVERED MEDICAL
SERVICES.
9.46 Speech Therapy. See Part IX., Physical, Occupational and Speech Therapies.
9.47 Spinal Manipulation. See Part IX., Chiropractic Services.
9.48 Substance Abuse Services. Inpatient, intermediate and outpatient substance abuse services are
covered when Medically Necessary and may be covered when a Member is admitted to a Hospital
or Other Health Care Facility.
a. For those disorders that cannot be effectively treated in an outpatient (including Partial
Hospitalization) environment, intermediate substance abuse services in a Residential Treatment
facility may be covered under a 24 -hour intensive and structured supervised treatment program
providing an inpatient level of care but in a non -Hospital environment. Treatment must be
received in a facility specifically licensed as a Residential Treatment facility or Residential
Treatment center by the State of Florida (or if outside Florida, applicable state law), to provide
Residential Treatment programs for substance use disorders. The facility must require admission
by a Physician, must have a behavioral health provider or an appropriately state certified
professional actively on duty during the day and evening therapeutic programming, and the
facility's medical director must be a Physician. For Detoxification programs in a Residential
Treatment setting there must be a registered nurse onsite 24 hours per day, 7 days per week,
and care must be provided under direct supervision of a Physician. Prior Authorization is
required.
b. As an alternative to inpatient hospitalization, Partial Hospitalization may be covered under a
structured program of active psychiatric treatment, provided in a Hospital outpatient setting or
by a community mental health center, that is more intense than the care received in a
Physician's or therapist's office. Prior Authorization is required.
c. Outpatient and Intensive Outpatient Treatment for substance use disorders may be covered
when provided by a state -licensed psychiatrist or other Physician, clinical psychologist, clinical
social worker, clinical nurse specialist, nurse practitioner, Physician assistant, or other qualified
mental health professional as allowed under applicable state law. Prior Authorization is required
for Intensive Outpatient Treatment.
9.49 Supplies. Ostomy and urostomy supplies are covered when Medically Necessary. Items that are not
medical supplies or that could be used by the Member or a family member for purposes other than
ostomy care are not covered. Wound care supplies are covered when Medically Necessary as part
of an approved treatment plan for treatment of a wound caused by or treated by a surgical
procedure; or treatment of a wound that requires debridement. Services are subject to Limitations
as described in Part X. LIMITATIONS OF COVERED MEDICAL SERVICES.
9.50 Transplant services, limited to the procedures listed below, are covered through AvMed's in -
network Center of Excellence facilities located within the State of Florida, subject to the conditions
AV-LG-COC-21 39 Choice-LG-7638 (07/21)
and Limitations described herein. Transplant services are subject to Prior Authorization before
benefits are paid. Transplant includes pre -transplant, transplant and post -discharge services, and
treatment of complications after transplantation.
a. AvMed will pay benefits for services, care and treatment received or provided, only in
connection with a:
i. Bone Marrow Transplant, which is specifically listed in Rule 59B-12.001, Florida
Administrative Code, or any successor or similar rule or covered by Medicare as described
in the most recently published Medicare National Coverage Determinations Manual issued
by the Centers for Medicare and Medicaid Services. Coverage includes expenses
associated with the donation or acquisition of an organ or tissue for the Member once the
donor has been identified and has agreed to the donation. Coverage for the reasonable
expenses of searching for a donor will be limited to a search among immediate family
members and donors identified through the National Bone Marrow Donor Program.
1) Bone Marrow Transplant means human blood precursor cells administered to a patient
to restore normal hematological and immunological functions following ablative
therapy. Human blood precursor cells may be obtained from the patient in an
autologous transplant, or an allogeneic transplant from a medically acceptable
related or unrelated donor, and may be derived from bone marrow, the circulating
blood, or a combination of bone marrow and circulating blood. If chemotherapy is an
integral part of the treatment involving bone marrow transplantation, the term 'Bone
Marrow Transplant' includes the transplantation as well as the administration of
chemotherapy and the chemotherapy medications. The term 'Bone Marrow
Transplant' also includes any services or supplies relating to any treatment or therapy
involving the use of high dose or intensive dose chemotherapy and human blood
precursor cells and includes any and all Hospital, Physician or other Health Care
Provider services which are rendered in order to treat the effects of, or complications
arising from, the use of high dose or intensive dose chemotherapy or human blood
precursor cells (e.g., Hospital room and board and ancillary services);
ii. corneal transplant;
iii. heart transplant (including a ventricular assist device, if indicated, when used as a bridge
to heart transplantation);
iv. heart-lung combination transplant;
v. liver transplant;
vi. kidney transplant;
vii. pancreas only transplant;
viii. pancreas transplant performed simultaneously with a kidney transplant; or
ix. lung (whole single or whole bilateral transplant).
b. We will cover donor costs and organ acquisition for transplants, other than Bone Marrow
Transplants, provided such costs are not covered in whole or in part by any other carrier,
organization or person other than the donor's family or estate.
9.51 Urgent Care Services. All Medically Necessary Covered Services received in Urgent Care Centers,
Retail Clinics or your Primary Care Physician's office after-hours to treat an Urgent Medical Condition
will be covered by AvMed. Any request for reimbursement of payment made by a Member for
services received must be filed within 90 days or as soon as reasonably possible but not later than
one year unless the Member was legally incapacitated. If Urgent Medical Services and Care are
required while outside the continental United States, Alaska or Hawaii, it is the Member's
responsibility to pay for such services at the time they are received. For information on filing a Claim
for such services, see Part XIII. REVIEW PROCEDURES AND HOW TO APPEAL A CLAIM (BENEFIT) DENIAL.
9.52 Virtual Visits (Telehealth and Telemedicine Services) using interactive audio, video, or other
electronic media for the purpose of Physician -patient encounters for non -emergency diagnoses,
consultations and treatment. Services are available from AvMed designated Telehealth providers
only.
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X. LIMITATIONS OF COVERED MEDICAL SERVICES
The rights of Members and obligations of In -Network Providers hereunder are subject to the following
Limitations:
10.1 Cardiac Rehabilitation. Outpatient cardiac rehabilitation, combined with chiropractic services,
outpatient pulmonary rehabilitation, and outpatient rehabilitative physical, occupational and
speech therapies, is limited to 35 visits per calendar year. Cardiac rehabilitation requires Prior
Authorization.
10.2 Chiropractic services, combined with outpatient cardiac rehabilitation, outpatient pulmonary
rehabilitation, outpatient rehabilitative physical, occupational and speech therapies are limited to
35 visits per calendar year.
10.3 Dermatological Services. Prior Authorization is required after a maximum of five visits to a
dermatologist in a 12 -month period for a dermatologic problem.
10.4 Dialysis Services. The provision of dialysis services is limited to AvMed in -network locations by in -
network Health Professionals when a Member is inside the Service Area, and PHCS providers when
a Member is outside the Service Area.
10.5 Drug Infusion Therapy.
a. Provision of outpatient infusion therapy services beginning with the second treatment in a
course of treatment, is limited to non -hospital settings. Services must be received in a Physician's
office, infusion clinic or the Member's home.
b. Any third -party Copayment assistance (sometimes also referred to as a "copay card" or "copay
coupon") provided by a drug manufacturer or any other entity to pay any applicable Calendar
Year Deductible, Copayment or Coinsurance amounts for any therapy medications
administered by a Health Professional will not be credited toward your Calendar Year
Deductible or Calendar Year Out -of -Pocket Maximum.
10.6 Habilitative Physical, Occupational and Speech Therapies. Outpatient habilitative physical,
occupational and speech therapies are covered up to a combined maximum of 100 visits per
calendar year for the treatment of Autism Spectrum Disorders and Down syndrome, for a Member
who is (i) under 18 years of age, or (ii) 18 years of age or older and in high school, and was
diagnosed at 8 years of age or younger as having a developmental disability.
10.7 Home Health Care Services (Skilled Home Health Care). Services are limited to 20 visits per calendar
year, including:
a. intermittent visits (i.e., up to, but not exceeding, two hours per day) for:
i. nursing care by a registered nurse or licensed practical nurse, and home health aide
services;
ii. medical social services;
iii. nutritional guidance;
iv. respiratory or inhalation therapy (e.g., oxygen) and;
v. short-term physical therapy by a physical therapist, occupational therapy by an
occupational therapist, and speech therapy by a speech therapist. Such therapies are
subject to any rehabilitative outpatient physical, occupational and speech therapy visit
limits.
b. Services must be consistent with a plan of treatment ordered by the Member's Physician.
Nursing and home health aide services must be rendered under the supervision of a registered
nurse.
10.8 Hyperbaric oxygen treatments are limited to 40 treatments per Condition as appropriate pursuant
to the Centers for Medicare and Medicaid Services (CMS) guidelines, and are subject to the cost -
sharing shown in your Schedule of Benefits for rehabilitative physical, occupational, and speech
therapies.
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41 Choice-LG-7638 (07/21)
10.9 Inpatient acute Rehabilitation Services received in a Hospital are limited to 30 days per calendar
year.
10.10 Licensed Dietitians/Nutritionists. Visits to licensed dietitians/nutritionists for treatment of diabetes,
renal disease or obesity control are limited to three outpatient visits per calendar year.
10.11 Nutrition Therapy. Coverage for enteral, parenteral or oral nutrition, and any related supplies, is
limited to treatment of inborn error of metabolism genetic diseases for Members through age 24.
Prior Authorization is required, and benefits are subject to additional authorization when Member
cost -sharing reaches $2,500 in a calendar year.
10.12 Orthotic Devices. Coverage for Orthotic Devices or 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. Replacements are covered only when Medically Necessary due to a change in bodily
configuration.
10.13 Other Health Care Facility(ies). Medically Necessary inpatient services of Other Health Care
Facilities, including Skilled Nursing Facilities, are covered up to a combined maximum of 60 post -
hospitalization days per calendar year, for conditions that cannot be adequately treated with
Home Health Care Services or on an ambulatory basis. Does not apply to treatment of mental
health and substance use disorders.
10.14 Prosthetic Devices. Coverage for Prosthetic Devices is limited to artificial limbs, artificial joints, ocular
prostheses and cochlear implants.
10.15 Pulmonary Rehabilitation. Outpatient pulmonary rehabilitation, combined with outpatient cardiac
rehabilitation, chiropractic services, and outpatient rehabilitative physical, occupational and
speech therapies is limited to 35 visits per calendar year. Prior Authorization is required.
10.16 Rehabilitative Physical, Occupational and Speech Therapies. Outpatient rehabilitative physical,
occupational and speech therapies, combined with outpatient cardiac rehabilitation, chiropractic
services and outpatient pulmonary rehabilitation are limited to 35 visits per calendar year, including
evaluations.
10.17 Second Medical Opinions. AvMed may limit second medical opinions in connection with a
particular diagnosis or treatment to three per calendar year, if AvMed deems additional opinions
to be an unreasonable over -utilization by the Member.
10.18 Skilled Nursing Facilities and Rehabilitation Centers. See Other Health Care Facility(ies) above.
10.19 Spinal Manipulation. See Chiropractic services above.
10.20 Supplies. Provision of ostomy and urostomy supplies is limited to a one -month supply every 30 days.
Coverage is limited to $2,500 per calendar year, subject to applicable Copayments and
Coinsurance. 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.
10.21 Transplant Services. Transplant services are limited to AvMed's in -network Center of Excellence
facilities located within the State of Florida. Transportation costs for a companion to accompany
the Member (or two companions when the patient is a minor) are covered only if the Member has
to travel greater than a 50 -mile radius to receive the transplant, and are limited to $200 per day up
to a $10,000 lifetime maximum.
10.22 Ventilator dependent care is limited to a lifetime maximum of 100 calendar days.
10.23 Virtual Visits (Telehealth and Telemedicine Services) are available from AvMed designated
Telehealth providers only and are subject to Medical Necessity and utilization management
guidelines.
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XI. EXCLUSIONS FROM COVERED MEDICAL SERVICES
This Contract expressly excludes coverage and expenses for the following services. These Exclusions are in
addition to any Exclusions specified in Part IX. COVERED MEDICAL SERVICES and any Limitations specified
in Part X. LIMITATIONS OF COVERED MEDICAL SERVICES.
11.1 General Exclusions include expenses for:
a. services received prior to your effective date or after the date your coverage terminates;
b. services not within the categories described in Part IX. COVERED MEDICAL SERVICES and any
amendments attached hereto, unless such services are specifically required to be covered by
applicable law;
c. services which are not Medically Necessary, as defined in this Contract, and as determined by
AvMed;
d. services provided by a Physician or other Health Care Provider related to you by blood or
marriage;
e. services beyond the scope of practice authorized for a Health Professional under applicable
state law;
f. services rendered at no charge;
g. services to diagnose or treat any Condition which initially occurred while you were (or which
directly or indirectly resulted from, or is connection with you being) under the influence of any
chemical substance set forth in Section 877.111, Florida Statutes, or any substance controlled
under Chapter 893, Florida Statutes or, with respect to such statutory provisions, any successor
statutory provisions (or if outside Florida, applicable state law). Notwithstanding, this Exclusion
will not apply to the use of any Prescription Medication by you if such medication is taken on
the specific advice of a Physician in a manner consistent with such advice;
h. services rendered by or through a medical or dental department maintained by or on behalf
of an employer, mutual association, labor union, trust, or similar person or group;
i. services to diagnose or treat a Condition which, directly or indirectly, resulted from or is in
connection with your participation in, or commission of, any act punishable by law as a
misdemeanor or felony whether or not you are charged or convicted; or which constitutes riot
or rebellion; or your engaging in an illegal occupation. Coverage will be available if a Member
demonstrates that an injury resulted from an act of domestic violence or a Condition, whether
or not the Condition was diagnosed before the occurrence of the injury.
j. any expenses for Claims denied because we did not receive information requested from you
about whether or not you have other coverage (including personal injury protection motor
vehicle insurance (PIP) or supplemental insurance plans) and the details of such coverage.
Additional Exclusions
11.2 Aids or devices that assist with oral, verbal, or nonverbal communications, including
communication boards, pre-recorded speech devices, laptop computers, desktop computers,
personal digital assistants, Braille typewriters, visual alert systems for the deaf, memory books,
software programs and associated devices.
11.3 Anesthesia administration services when performed by an operating Physician or the Physician's
partner or associate.
11.4 Armed forces service -connected medical care for both sickness and injury, including services
received at military or government facilities and services received to treat an injury arising out of
your service in the Armed Forces, Reserves or National Guard.
11.5 Autopsy or postmortem examinations and associated services, unless specifically requested by
AvMed.
11.6 Bariatric Surgery/Treatment of Morbid Obesity. Gastric stapling, gastric bypass, gastric banding,
gastric bubbles, and other procedures for the treatment of obesity or Morbid Obesity, as well as
AV-LG-COC-21 43 Choice-LG-7638 (07/21)
any related evaluations or diagnostic tests. Ongoing visits for the treatment of obesity, other than
establishing a program of obesity control, are also excluded.
11.7 Breast reduction or augmentation surgery except as required for the comprehensive treatment of
breast cancer.
11.8 Complementary or alternative medicine including: acupuncture, aromatherapy, Ayurvedic
medicine such as lifestyle modifications, purification and massage therapies, biofield therapies,
bioelectromagnetic applications and medicine, biofeedback, chelation therapy, cognitive
therapy, environmental medicine including the field of clinical ecology, herbal therapies,
homeopathic medicine and counseling, hypnotherapy, mind -body interactions such as
meditation, imagery, yoga, dance and art therapy, manual healing methods such as the
Alexander technique, massage therapy, craniosacral balancing, Feldenkrais method, Hellerwork,
reflexology, Rolfing, shiatsu, traditional Chinese massage, Trager therapy, trigger -point myotherapy,
and polarity therapy, naturopathic medicine, prayer and mental healing, Reichian therapy, Reiki,
self -care and self-help training, sex therapy, SHEN therapy, sleep therapy, therapeutic touch,
thermography, traditional Chinese medicine and vocational rehabilitation.
11.9 Complications of any non -covered service, including the evaluation, diagnosis or treatment of any
Condition that arises as a complication of a non -covered service (e.g., services to treat a
complication of cosmetic surgery are not covered).
11.10 Cosmetic services including any procedures which are undertaken primarily to improve or
otherwise modify the Member's external appearance, except for reconstructive surgery to correct
and repair a functional disorder as a result of a disease, injury, or congenital defect; and initial
implanted prosthesis and reconstructive surgery incident to a mastectomy for cancer of the breast.
Also excluded are surgical excision or reformation of any sagging skin of any part of the body,
including: 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 the face, lips, jaw, chin, nose, ears, breasts, or genitals (including
circumcision, except newborns for up to one year from the date of birth); hair transplantation;
chemical face peels or abrasion of the skin, electrolysis depilation, removal of tattooing, or any
other surgical or non -surgical procedures which are primarily for cosmetic purposes or to create
body symmetry. Additionally, all medical complications resulting from cosmetic surgical or non-
surgical procedures are excluded.
1 1.11 Counseling, including marriage or pre -marital counseling, religious, family, career, social
adjustment, pastoral or financial counseling.
11.12 Court -ordered services and supplies including court -ordered care or testing, or services required as
a condition of parole, probation, release or because of any legal proceeding.
11.13 Costs related to telephone consultations, failure to keep a scheduled appointment, or completion
and preparation of any form or medical information, including requests for medical records.
11.14 Custodial Care and any service of a Custodial nature, including without limitation: services primarily
to assist in the activities of daily living, rest homes, home companions or sitters, home parents,
domestic maid services, food or home delivered meals, housing, respite care, and provision of
services which are for the sole purpose of allowing a family member or caregiver of a Member to
return to work.
11.15 Dental Care or treatment of the teeth or their supporting structures or gums, or dental procedures,
including: extraction of teeth; restoration of teeth with or without fillings, crowns or other materials;
bridges; cleaning of teeth; dental implants; dentures; periodontal or endodontic procedures;
orthodontic treatment (e.g., braces); intraoral Prosthetic Devices; palatal expansion devices;
bruxism appliances; dental x-rays and dental services provided more than 90 days after the date
of an Accidental Dental Injury regardless of whether or not such services could have been rendered
within 90 days. This Exclusion also applies to services related to the diagnosis and treatment of
temporomandibular joint (TMJ) dysfunction except when Medically Necessary, and all dental
treatment for TMJ.
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11.16 Dialysis services received from providers who are not part of the AvMed Provider Network or who
are not PHCS providers when the Member is outside the Service Area.
11.17 Durable Medical Equipment (DME)
a. Items that are not covered include:
i. bed related items: bed trays, over -the -bed tables, bed wedges, pillows, custom bedroom
equipment, mattresses, including non -power mattresses, custom mattresses and
posturepedic mattresses;
ii. bath related items: bath lifts, non -portable whirlpools, bathtub rails, toilet rails, raised toilet
seats, bath benches, bath stools, hand held showers, paraffin baths, bath mats, and spas;
iii. chairs, lifts and standing devices: computerized or gyroscopic mobility systems, roll about
chairs, geriatric chairs, hip chairs, seat lifts (mechanical or motorized), patient lifts
(mechanical or motorized - manual hydraulic lifts are covered if patient is 2 -person
transfer), and auto tilt chairs;
iv. electric or powered scooters; non-standard customized wheelchairs, motorized or manual;
v. fixtures to real property, including ceiling lifts and wheelchair ramps;
vi. car/van modifications;
vii. air quality items: air conditioners, room humidifiers, vaporizers, air purifiers and electrostatic
machines;
viii. blood/injection related items: blood pressure cuffs, centrifuges, nova pens and needleless
injectors; and
ix. other equipment: heat lamps, heating pads, cryounits, cryotherapy machines, electronic -
controlled therapy units, ultraviolet cabinets, sheepskin pads and boots, postural drainage
board, AC/DC adaptors, enuresis alarms, magnetic equipment, scales (baby and adult),
stair gliders, elevators, saunas, any exercise equipment, emergency alert equipment, and
diathermy machines.
b. Repair of Member -owned DME, and replacement of DME solely because it is old or used, is
excluded.
11.18 Educational Services. Any service or supply for education, training or retraining services or testing
including: special education, remedial education; cognitive remediation; wilderness/outdoor
treatment, therapy or adventure programs (whether or not the program is part of a Residential
Treatment facility or otherwise licensed institution); job training or job hardening programs;
educational services and schooling or any such related or similar program including therapeutic
programs within a school setting.
11.19 Examinations. Any health examinations needed because a third party requires the exam, including
examinations to get or keep a job, examinations required under a labor agreement or other
contract, to buy insurance or to get or keep a license, to travel, to go to a school, camp, sporting
event, or to join in a sport or other recreational activity.
11.20 Exercise programs, gym memberships or exercise equipment of any kind, including 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.
11.21 Experimental or Investigational services and supplies except as otherwise covered for Bone Marrow
Transplants, pursuant to Section 59B-12.001, Florida Administrative Code.
11.22 Eye care, including:
a. eye examinations for Members over age 19 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.
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45 Choice-LG-7638 (07/21)
d. This Exclusion does not include pediatric vision services that are covered as an Essential Health
Benefit, as set forth under PPACA, Section 1302(b) of the Federal Act, for children through the
end of the month in which they turn 19.
11.23 Foot care (routine), including any service involving the feet or parts of the feet, in the absence of
diabetes, peripheral circulatory or neurovascular disease including: non -surgical treatment of
bunions; flat feet; fallen arches; chronic foot strain; trimming of toenails, corns or calluses. This
Exclusion does not apply to services otherwise covered under Diabetes Outpatient Self -
Management, as described in Part IX. COVERED MEDICAL SERVICES.
11.24 Foot supports including orthopedic or specialty shoes, shoe build-ups, shoe orthotics, shoe braces,
and shoe supports.
11.25 Gender Transition Services. Gender reassignment surgery and any treatment, service, supply or
medication associated with or as a result of gender reassignment or gender dysphoria are
excluded; except for Members aged 18 or over who are diagnosed with gender dysphoria by an
AvMed Network provider, and when the recommended services are deemed Medically Necessary
and all criteria under AvMed's current coverage guidelines are met. All services must be rendered
by AvMed Network providers in order to be covered. Coverage guidelines are available at
www.avmed.org.
11.26 Gene or Cellular Therapy Products. Cellular therapy products include cellular immunotherapies,
cancer vaccines, and other types of both autologous and allogeneic cells for certain therapeutic
indications, including hematopoetic stem cells and adult and embryonic stem cells. Human gene
therapy is the administration of genetic material to modify or manipulate the expression of a gene
product or to alter the biological properties of living cells for therapeutic use.
11.27 Habilitation Services. Except as required by law for treatment of Autism Spectrum Disorders and
Down syndrome, non -covered Habilitation Services include residential, institutional and home -
based Habilitation Services, personal assistance/ attendant care services; errand services;
transportation to and from training facilities unless provided by the training facility; family education
and training; family support services; pre -vocational services designed to assist a Member in
acquiring basic work skills; supportive employment habilitation; respite care camps; hotel respite,
room and board; services that are purely educational in nature, and personal training or life
coaching.
11.28 Hearing aids (external or implantable) and services related to the fitting or provision of hearing aids,
including tinnitus maskers, batteries, and the cost of repairs.
11.29 Hearing examinations for Members over age 19 for the purpose of determining the need for hearing
correction.
11.30 Homemaker or domestic maid services; sitter or companion services; services rendered by an
employee or operator of an adult congregate living facility, an adult foster home, an adult day
care center, or a nursing home facility.
11.31 Home monitoring devices and measuring devices (other than apnea monitors and Holter monitors),
and any other equipment or devices for use outside the Hospital that are not covered elsewhere in
this Contract.
11.32 Hospital Services that are associated with excluded surgery or excluded Dental Care.
11.33 Immunizations and medications for the purpose of foreign travel or employment.
11.34 Infertility Diagnosis, Treatment and Supplies (Assisted Reproductive Therapy), including infertility
evaluation, testing, diagnosis and treatment, medication and supplies, to determine or correct the
reason for infertility or inability to achieve conception. This includes artificial insemination (Al), in -
vitro fertilization (IVF), ovum or embryo placement or transfer, gamete intra-fallopian transfer (GIFT),
or cryogenic or other preservation techniques used in such or similar procedures.
11.35 Mandibular and maxillary osteotomies except when Medically Necessary to treat Conditions
caused by congenital or developmental deformity, disease or injury.
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11.36 Medical supplies including pre -fabricated splints, Thromboemboletic/support hose and all other
bandages, except as described under Supplies in Part IX.
11.37 Mental Health and Substance Abuse Services rendered in connection with a Condition not
classified in the most recent edition of the American Psychiatric Association's Diagnostic and
Statistical Manual of Mental Disorders (DSM) are excluded from coverage; and services for the
following categories (or equivalent terms) as listed in the most recent edition of the DSM: inpatient
treatment for dementia and amnesia without a behavioral disturbance that necessitates mental
health treatment; sexual deviations and disorders except for gender identity disorders; tobacco use
disorders, except as required under USPSTF preventive care guidelines; pathological gambling,
kleptomania, pyromania; inpatient stays primarily intended as a change of environment; school
and/or education services, including special education, remedial education, wilderness/outdoor
treatment, therapy or adventure programs (whether or not the program is part of a Residential
Treatment facility or otherwise licensed institution); services provided in conjunction with school,
vocation, work or recreational activities.
11.38 Nutritional therapy except as described under Nutrition Therapy in Part IX.
11.39 Oral surgery for Members over age 19, except as described under Dental Care in Part IX.
11.40 Organ Donor Treatment and Services. The Health Care 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. The reasonable costs of searching for a bone marrow donor are limited to a
Member's family members and the National Bone Marrow Donor Program. Post -transplant donor
complications will not be covered.
11.41 Orthotic Devices except as described in Part IX. COVERED MEDICAL SERVICES. Expenses for arch
supports, shoe inserts designed to effect conformational changes in the foot or foot alignment,
orthopedic shoes, over-the-counter, custom-made or built-up shoes, cast shoes, sneakers, ready-
made compression hose or support hose, or similar type devices/appliances regardless of intended
use (except for therapeutic shoes, including inserts and modifications for the treatment of severe
diabetic foot disease); expenses for Orthotic Appliances or Orthotic Devices, which straighten or
re -shape the conformation of the head or bones of the skull or cranium through cranial banding or
molding (e.g. dynamic orthotic cranioplasty or molding helmets); and expenses for devices
necessary to exercise, train, or participate in sports, e.g. custom-made knee braces.
11.42 Over-the-counter medications and Prescription Medications not otherwise covered including
hypodermic needles and syringes and self-administered Injectable Medications except insulin and
insulin syringes for the treatment of diabetes as described under Diabetic Supplies in Part IX.
11.43 Pain Management. Inpatient rehabilitation for Pain Management is excluded.
11.44 Personal comfort, hygiene or convenience items and services deemed not Medically Necessary
and not directly related to a Member's treatment, including beauty and barber services; clothing
(including support hose); radio and television; guest meals and accommodations; telephone
charges; take-home supplies; travel expenses (other than Medically Necessary ambulance
services); motel/hotel accommodations; air conditioners, furnaces, air filters, air or water purification
systems, water softening systems, humidifiers, dehumidifiers, vacuum cleaners or any other similar
equipment and devices used for environmental control or to enhance an environmental setting;
hot tubs, jacuzzis, heated spas, pools, or memberships to health clubs; heating pads; hot water
bottles or ice packs; physical fitness equipment; and hand rails and grab bars.
11.45 Private Duty Nursing care or services rendered at any location.
11.46 Professional Services. Non -patient -specific professional services associated with machine or other
testing including oversight of a medical laboratory to assure timeliness, reliability, and usefulness of
test results and overseeing calibration of laboratory testing equipment.
11.47 Prosthetic Devices except as described in Part IX. COVERED MEDICAL SERVICES. Expenses for
microprocessor controlled or myoelectric artificial limbs (e.g. C -legs); and expenses for cosmetic
enhancements to artificial limbs are also not covered.
AV-LG-COC-21 47 Choice-LG-7638 (07/21)
11.48 Rehabilitation Programs. Vocational rehabilitation, long term rehabilitation, or any other
rehabilitation program.
11.49 Rehabilitative Therapies. Rehabilitative therapies for chronic Conditions are not covered. Therapies
provided on either an inpatient or outpatient basis for the purpose of maintaining rather than
improving your Condition are excluded. Maintenance therapy begins when the therapeutic goals
of a treatment plan have been met or no further functional progress is expected. Services that
involve non -diagnostic, non -therapeutic, routine, or repetitive procedures to maintain general
welfare and do not require the skilled assistance of a licensed therapist are excluded. Therapy for
abnormal speech pathology, including lisping and stuttering; rehabilitative therapy modalities that
are considered investigational including cognitive therapy, Interactive Metronome Program,
Augmented Soft Tissue Mobilization, Kinesio Taping/Taping, MEDEK Therapy, Hands -Free Ultrasound
and Low -Frequency Sound (Infrasound), and Hivamat Therapy (Deep Oscillation Therapy) are
excluded.
11.50 Removal of benign skin lesions, including warts, moles, skin tags, lipomas, keloids and scars is not
covered, even with a recommendation or prescription from a Physician.
11.51 Reversal of voluntary surgically -induced sterility including the reversal of tubal ligations and
vasectomies.
11.52 Sexual Dysfunction. All medications, devices and other forms of treatment related to a diagnosis of
sexual dysfunction, regardless of etiology.
11.53 Skilled Nursing Facilities. Expenses for an inpatient admission to a Skilled Nursing Facility for purposes
of Custodial Care, convalescent care, or any other service primarily for the convenience of you or
your family members or the provider.
11.54 Sports -related devices, services and medications used to affect performance primarily in sports -
related activities; all expenses related to physical conditioning programs such as athletic training,
bodybuilding, exercise, fitness, flexibility, and diversion or general motivation.
11.55 Supplies. 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.
11.56 Surgically implanted devices and any associated external devices, except for cardiac
pacemakers, intraocular lenses, cochlear implants, artificial joints, orthopedic hardware and
vascular grafts. Dental appliances, other corrective lenses and hearing aids, including the
professional fee for fitting them, are not covered.
11.57 Temporomandibular Joint (TMJ) Dysfunction. Services related to the diagnosis and treatment of TMJ
except when Medically Necessary; and all dental treatment for TMJ.
11.58 Termination of pregnancy unless deemed Medically Necessary, subject to applicable state and
federal laws.
11.59 Training and educational programs or materials, except as described under Diabetes Outpatient
Self -Management in Part IX. COVERED MEDICAL SERVICES, including programs or materials for Pain
Management and vocational rehabilitation.
11.60 Transplant Services. Expenses for the following are excluded:
a. transplant procedures excluded under this Contract (e.g., Experimental or Investigational
transplant procedures);
b. transplant procedures involving the transplantation or implantation of any non -human organ or
tissue;
c. transplant procedures related to the donation or acquisition of an organ or tissue for a recipient
who is not covered by AvMed;
d. transplant procedures involving the implant of an artificial organ, including the implant of the
artificial organ;
e. any organ, tissue, marrow, or stem cells which is/are sold rather than donated;
AV-LG-COC-21 48 Choice-LG-7638 (07/21)
f. any Bone Marrow Transplant, as defined herein, which is not specifically listed in Rule 59B-12.001,
Florida Administrative Code, or any successor or similar rule or covered by Medicare pursuant
to a national coverage decision made by CMS as evidenced in the most recently published
Medicare National Coverage Determinations Manual;
any service in connection with the identification of a donor from a local, state or national listing,
except in the case of a Bone Marrow Transplant;
h. any non -medical costs, including temporary lodging or transportation costs for you or your
family to and from the approved facility, except as described in Part X. LIMITATIONS OF
COVERED MEDICAL SERVICES;
i. any artificial heart, mechanical device, or ventricular assist device (VAD) that replaces either
the atrium or the ventricle;
j. collection and storage costs associated with the banking of umbilical cord blood;
k. transplant services and procedures provided by or at facilities that are not AvMed in -network
Center of Excellence facilities located within the State of Florida.
11.61 Transportation including expenses for ambulance services to and from a Physician or Hospital
except as described in Part IX. COVERED MEDICAL SERVICES and Part X. LIMITATIONS OF COVERED
MEDICAL SERVICES.
11.62 Travel or vacation expenses even if prescribed or ordered by a Health Professional.
11.63 Treatment in a federal, state, or governmental entity including any care in a Hospital or Other Health
Care Facility owned or operated by any federal, state or other governmental entity unless
coverage is required by applicable laws.
11.64 Treatment, services or supplies received outside the United States. However, benefits will be
payable for Covered Services required to treat an Emergency Medical Condition or Urgent Medical
Condition arising during travel outside of the continental United States, Alaska and Hawaii.
Members are responsible for payment of such services at the time they are received and should
submit the Claim to AvMed as described in Part XIII. REVIEW PROCEDURES/ AND HOW TO APPEAL A
CLAIM (BENEFIT) DENIAL.
11.65 Ventilator dependent care, except as described in Part II. DEFINITIONS for 100 calendar days lifetime
maximum benefit.
11.66 Volunteer services, or services which would normally be provided free of charge and any charges
associated with Deductible, Coinsurance, or Copayment (if applicable) requirements which are
waived by a Health Care Provider.
11.67 Weight Control Services. Except those services deemed preventive and given an 'A' or 'B' rating in
current recommendations by the USPSTF, any service, treatment or program to lose, gain, or
maintain weight, including and without limitation, appetite suppressants, dietary regimens, food or
food supplements (except as described under Nutrition Therapy in Part IX. COVERED MEDICAL
SERVICES), and exercise programs or equipment, whether or not a part of a treatment plan for a
Condition.
g.
11.68 Wigs or cranial prostheses.
11.69 Workers' Compensation Benefits. Any sickness or injury for which the Member is paid benefits, or
may be paid benefits if claimed, if the Member is covered or could be covered by Workers'
Compensation. In addition, if the Member enters into a settlement giving up rights to recover past
or future medical benefits under a Workers' Compensation law, AvMed will not cover past or future
Health Care Services that are the subject of or related to that settlement. Furthermore, if the
Member is covered by a Worker's Compensation program that limits benefits if other than specified
Health Care Providers are used and the Member receives care or services from a Health Care
Provider not specified by the program, AvMed will not cover the balance of any costs remaining
after the program has paid.
AV-LG-COC-21 49 Choice-LG-7638 (07/21)
XII. PRESCRIPTION MEDICATION BENEFITS, LIMITATIONS AND EXCLUSIONS
See the Prescription Medication Amendment to your Contract for important information including Member
cost -sharing, Limitations and Exclusions. See also Part II. DEFINITIONS.
12.1 Prescription Medication Definitions. For the purposes of this Contract, the following terms have the
meanings set forth below. See also Part II. Definitions.
a. Brand Medication means a Prescription Drug that is usually manufactured and sold under a
name or trademark by a pharmaceutical manufacturer or a medication that is identified as a
Brand Medication by AvMed. AvMed delegates determination of Generic/Brand status to our
Pharmacy Benefits Manager.
b. Brand Additional Charge means the additional charge that must be paid if you or your Physician
choose a Brand Medication when a Generic equivalent is available. The charge is the
difference between the cost of the Brand Medication and the Generic Medication. This charge
must be paid in addition to the non -preferred brand cost -sharing amount. The Brand Additional
Charge does not apply toward the Calendar Year Deductible or Out -of -Pocket Maximum.
c. Dental -specific Medication is medication used for dental -specific purposes including fluoride
medications and medications packaged and labeled for dental -specific purposes.
d. Formulary List means the listing of preferred and non -preferred medications as determined by
AvMed's Pharmacy and Therapeutics Committee based on the clinical efficacy, relative safety
and cost in comparison to similar medications within a therapeutic class. This multi -tiered list
establishes different levels of cost -sharing 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. Specific medications on the
Formulary List and their placement in a given therapeutic class are subject to change at any
time without prior notice to you or your approval. It is your responsibility to consult with your
Attending Physician to determine whether a medication is on the Formulary List at the time the
prescription is rendered.
e. Generic Medication means a medication that has the same active ingredient as a Brand
Medication or is identified as a Generic Medication by AvMed's Pharmacy Benefits Manager.
f. In -Network Pharmacy means a pharmacy (retail, mail order or specialty pharmacy) that has
entered into an agreement to provide Prescription Medications to AvMed Members and has
been designated as an In -Network Pharmacy. Except for emergencies, covered Prescription
Medications must be obtained at In -Network Pharmacies.
Maintenance Medication is a medication that is approved by the U.S. Food and Drug
Administration (FDA), for which the duration of therapy can reasonably be expected to exceed
one year, as determined by the Pharmacy Benefits Manager.
h. Specialty Medications are high cost medications that are self-administered by Members. These
medications may be limited in distribution to in -network specialty pharmacies. Many of these
medications require Prior Authorization and are limited to a maximum 30 -day supply per
dispensing.
12.2 Pharmacy Coverage Criteria. Your Prescription Medication coverage includes outpatient
medications (including certain contraceptives) that require a prescription, are prescribed by a
Physician in accordance with AvMed's Coverage Criteria, and are filled at an AvMed In -Network
Pharmacy. AvMed reserves the right to make changes in Coverage Criteria for covered products
and services.
g.
12.3 Prior Authorization and Progressive Medication Program. Your Prescription Medication coverage
may require Prior Authorization, and such Prior Authorization may include the Progressive
Medication Program for certain covered medications. The prescribing Physician or the In -Network
Pharmacy must obtain approval (prior to dispensing) from AvMed. The list of Prescription
Medications requiring Prior Authorization is subject to periodic review and modification by AvMed
and may be amended without notice. A copy of the list of covered Prescription Medications, drugs
requiring Prior Authorization and drugs that are a part of the Progressive Medication Program are
AV-LG-COC-21 50 Choice-LG-7638 (07/21)
available from AvMed's Member Engagement Center or from the AvMed website. The Progressive
Medication Program encourages the use of therapeutically -equivalent lower -cost medications by
requiring certain medications to be utilized to treat a Condition prior to approving another
medication for that Condition. The Progressive Medication Program includes the first -line use of
preferred medications that are proven to be safe and effective for a given Condition and can
provide the same health benefit as more expensive non -preferred medications at a lower cost.
12.4 Cost -Sharing and Refilling Prescriptions. Your retail Prescription Drug coverage includes up to a 30 -
day supply of a medication for the cost -sharing amounts shown in your Prescription Medication
Amendment. Your prescription may be refilled via retail or mail order after 75% of your previous fill
has been used and subject to a maximum of 13 refills per year. You also have the opportunity to
obtain a 90 -day supply of Prescription Medications used for chronic Conditions including asthma,
cardiovascular disease, and diabetes, from a retail In -Network Pharmacy or via mail order for the
applicable cost -sharing per 30 -day supply.
12.5 Quantity Limits for Prescriptions. Quantity limits are set in accordance with FDA approved
prescribing limitations, general practice guidelines supported by medical specialty organizations,
or evidence -based, statistically valid clinical studies without published conflicting data. This means
that a medication -specific quantity limit may apply to Prescription Medications that have an
increased potential for over -utilization or an increased potential for a Member to experience an
adverse effect at higher doses.
12.6 Obtaining Prescribed Medications. To obtain your Prescription Medication, take your prescription
to, or have your Physician call, an AvMed In -Network Pharmacy. Present your prescription along
with your AvMed Identification Card. Pay any applicable Calendar Year Deductible and
Copayment or Coinsurance (as well as any additional charge that may apply if a Brand Medication
is chosen when a Generic equivalent is available) as described in the Prescription Medication
Amendment to this Contract. Your Physician should submit prescriptions for Specialty Medications
to AvMed's in -network specialty pharmacy.
12.7 Mail Services for Prescriptions. Mail-order Prescription Drug coverage, If available under your Plan,
includes up to a 90 -day supply of a routine Maintenance Medication for the cost -sharing amount
shown in your Prescription Medication Amendment. If the amount of medication is less than a 90 -
day supply, you will still be charged the mail order cost -sharing amount. Mail service is a benefit
option for Maintenance Medications needed for chronic or long-term health Conditions. It is often
best to get an initial prescription filled at your retail In -Network Pharmacy. Ask your Physician for an
additional prescription for a 60 -90 -day supply of your medication to be ordered through mail
service. Please refer to your Prescription Medication Amendment for cost -sharing amounts for
Prescription Medications ordered through mail services.
12.8 Prescription Medication Benefits Disclaimer. Filling a prescription at a pharmacy is not a Claim for
benefits and is not subject to the Claims and Appeals procedures under the Employee Retirement
Income Security Act of 1974 (ERISA). However, any Prescription Medications that require Prior
Authorization will be treated as a Claim for benefits subject to the Claims and Appeals Procedures,
as outlined in this Contract.
12.9 Third -Party Assistance for Specialty Medications. If you use any third -party Copayment assistance
(sometimes also referred to as a "copay card" or "copay coupon") provided by a drug
manufacturer or any other entity to pay any applicable Calendar Year Deductible, Copayment,
or Coinsurance amounts for any Specialty Medications, you will not receive credit toward your
Calendar Year Out -of -Pocket Maximum or Calendar Year Deductible for any such assistance you
use.
XIII. REVIEW PROCEDURES AND HOW TO APPEAL A CLAIM (BENEFIT) DENIAL
13.1 Member's Rights of Review. Members have the right to a review of any complaint regarding the
services or benefits covered under this Contract. AvMed encourages the informal resolution of
complaints. If you have a complaint, you or someone you name to act on your behalf (an
AV-LG-COC-21 51 Choice-LG-7638 (07/21)
authorized representative) may call AvMed's Member Engagement Center, and a Representative
will try to resolve the complaint for you over the telephone. If you ask for a written response, or if the
complaint is related to quality of care, we will respond in writing. The Member Engagement Center
can also advise you how to name your authorized representative.
13.2 Filing a Grievance. If a Member's complaint cannot be resolved informally, it may be submitted to
AvMed in writing. We call this 'filing a Grievance'. A Grievance is any complaint relating to Plan
services, other than one that involves a request (Claim) for benefits or an appeal of an Adverse
Benefit Determination. Grievances must be filed within 1 year of the occurrence of the event or
action that led to the Grievance. Grievances will be deemed to have been filed on the date
received by AvMed, and will be processed through AvMed's formal Member Grievance
Procedures. AvMed will acknowledge and investigate the Grievance and provide a written
response advising of the disposition within 60 days after receipt of the Grievance.
a. Grievances relating to Plan services may be submitted in writing to:
AvMed Member Engagement Center
P.O. Box 569008
Miami, Florida 33256-9908
Telephone: 1-800-882-8633
Fax: (305) 671-4736
b. If you are not satisfied with AvMed's final decision, you may file a written Grievance with the
Department of Financial Services (DFS) within 1 year of receipt of AvMed's final decision letter.
You also have the right to contact DFS at any time to inform them of an unresolved Grievance.
DFS may be contacted at the address below:
Florida Department of Financial Services
200 East Gaines Street
Tallahassee, Florida 32399
Telephone: 1-877-693-5236
13.3 Claims for Benefits. All Claims for benefits will be deemed to have been filed on the date received
by AvMed. If a Claim is a Pre -Service or Urgent Care Claim, a Health Professional with knowledge
of the Member's Condition will be permitted to act as the Member's authorized representative, and
will be notified of all approvals on the Member's behalf.
a. Pre -Service Claims
i. Initial Claim. AvMed will notify the Claimant of the benefit determination with respect to a
Pre -Service Claim no later than 15 days after receipt of the Claim. AvMed may extend this
period one time for up to 15 additional days, if we determine that such an extension is
necessary due to matters beyond our control, and we notify the Claimant before the
expiration of the initial 15 -day period, of the circumstances requiring the extension of time
and the date by which we expect to render a decision.
1) If such an extension is necessary because the Claimant failed to provide sufficient
information to decide the Claim, the notice of extension will specifically describe the
required information, and the Claimant will be afforded at least 45 days from receipt
of the notice to provide the specified information.
2) In the case of a failure by a Claimant to follow AvMed's procedures for filing a Pre -
Service Claim, the Claimant will be notified of the failure and the proper procedures
to be followed, no later than five days following such failure.
3) AvMed's period for making the benefit determination will be tolled from the date the
notification of the extension is sent to the Claimant, until the date 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 will be denied.
ii. Appeal of a Pre -Service Claim. A Claimant may appeal an Adverse Benefit Determination
with respect to a Pre -Service Claim within 1 year of receiving the Adverse Benefit
Determination. AvMed will review the Claim and notify the Claimant of its determination
on review, no later than 30 days after AvMed receives the Claimant's request; except in
AV-LG-COC-21 52 Choice-LG-7638 (07/21)
limited cases when AvMed provides new information to the Claimant that AvMed is
considering in the appeal, and gives the Claimant an opportunity to respond. An appeal
of an Adverse Benefit Determination with respect to a Pre -Service Claim may be submitted
to:
AvMed Member Engagement Center
P.O. Box 569008
Miami, Florida 33256-9908
Telephone: 1-800-882-8633
Fax: (305) 671-4736
b. Urgent Care Claims
i. Initial Claim. Generally, the determination of whether a Claim is an Urgent Care Claim will
be made by an individual acting on behalf of AvMed, applying the judgment of a prudent
layperson possessing an average knowledge of health and medicine. However, if a
Physician with knowledge of the Member's Condition determines that the Claim is an
Urgent Care Claim, it will be deemed urgent. Urgent Care Claims may be made orally or
in writing. AvMed will notify the Claimant of the benefit determination as soon as possible,
taking into account the medical exigencies, but no later than 72 hours after receipt of the
Urgent Care Claim.
1) If the Claimant fails to provide sufficient information to determine whether or to what
extent benefits are covered or payable under this Contract, AvMed will notify the
Claimant, no later than 24 hours after receipt of the Claim, of the specific information
necessary to complete the Claim. The Claimant will be afforded no less than 48 hours,
to provide the specified information.
2) AvMed will notify the Claimant of the benefit determination no later than 48 hours after
the earlier of: AvMed's receipt of the specified information, or the end of the period
afforded the Claimant to provide the specified information. If the Claimant fails to
supply the specified information within the 48 -hour period, the Claim will be denied.
3) AvMed may notify the Claimant of the benefit determination orally or in writing. If the
notification is provided orally, a written or electronic notification will also be provided
to the Claimant no later than three days after the oral notification.
ii. Appeal of an Urgent Care Claim. A Claimant may appeal an Adverse Benefit
Determination with respect to an Urgent Care Claim within 1 year of receiving the Adverse
Benefit Determination. AvMed will review the Claim and notify the Claimant of its benefit
determination on review as soon as possible, taking into account the medical exigencies,
but no later than 72 hours after receipt of the Claimant's request; except in limited cases
when AvMed provides new information to the Claimant that AvMed is considering in the
appeal, and gives the Claimant an opportunity to respond. An appeal of an Adverse
Benefit Determination with respect to an Urgent Care Claim may be submitted to AvMed's
Member Engagement Center at the address listed under Appeal of a Pre -Service Claim,
above.
c. Concurrent Care Claims
i. Any reduction or termination by AvMed of Concurrent Care (other than by an
amendment to this Contract or termination), before the end of an approved period of
time or number of treatments, will constitute an Adverse Benefit Determination. In the
event a Concurrent Care Claim results in an Adverse Benefit Determination, AvMed will
notify the Claimant at a time sufficiently in advance of the reduction or termination to
allow the Claimant to appeal and obtain a determination on review before the benefit is
reduced or terminated.
1) Any request by a Claimant that relates to an Urgent Care Claim to extend the course
of treatment beyond the period of time or number of treatments previously authorized,
will be decided as soon as possible, taking into account the medical exigencies.
AvMed will notify the Claimant of the benefit determination within 24 hours after
AV-LG-COC-21 53 Choice-LG-7638 (07/21)
receipt of the Claim, provided the Claim is made to AvMed at least 24 hours before
the expiration of the prescribed period of time or number of treatments.
2) Notification and appeal of any Adverse Benefit Determination concerning a request
to extend a course of treatment, whether involving an Urgent Care Claim or not, will
be made in accordance with AvMed's review and notification procedures described
herein.
d. Post -Service Claims
i. Initial Claim. Post -Service Claims must be submitted to AvMed within 90 days from the date
of service or within one year unless the Member was legally incapacitated; otherwise the
Claim will be considered to have been waived.
1) Post -Service Claims must include all of the information listed below. If a Claim is for
services received to treat an Emergency Medical Condition or an Urgent Medical
Condition while outside the continental United States, Alaska or Hawaii, the information
must be translated into English.
a) The name of the individual who received the services;
b) The Member's name and Member ID number as they appear on the Member
Identification Card;
c) The place of service and the date of service;
d) A description of the services including any applicable procedure codes;
e) The diagnosis including any applicable diagnosis codes;
f) The provider's name and address; and
g) The amount actually charged by the provider and a copy of the paid receipts;
2) AvMed will notify the Claimant of the benefit determination no later than 30 days after
receipt of a Post -Service Claim. AvMed may extend this period one time for up to 15
additional days if we determine such an extension is necessary due to matters beyond
our control and we notify the Claimant, before the expiration of the initial 30 -day
period, of the circumstances requiring the extension of time and the date by which we
expect to render a decision.
a) If such an extension is necessary because the Claimant failed to provide sufficient
information to decide the Claim, the notice of extension will specifically describe
the required information, and the Claimant will be afforded at least 45 days from
receipt of the notice to provide the specified information.
b) AvMed's period for making the benefit determination will be tolled from the date
the notification of the extension is sent to the Claimant, until the date 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 will be denied.
ii. Appeal of a Post -Service Claim. A Claimant may appeal an Adverse Benefit Determination
with respect to a Post -Service Claim within 1 year of receiving the Adverse Benefit
Determination. AvMed will review the Claim and notify the Claimant of its determination
on review, no later than 60 days after receipt of the Claimant's request; except in limited
cases when AvMed provides new information to the Claimant that AvMed is considering
in the appeal, and gives the Claimant an opportunity to respond. An appeal of an Adverse
Benefit Determination with respect to a Post -Service Claim may be submitted to AvMed's
Member Engagement Center, at the address listed in Appeal of a Pre -Service Claim,
above.
13.4 Manner and Content of Initial Claims Determination Notification. AvMed will provide a Claimant
with written or electronic notification of any Adverse Benefit Determination. The notification will set
forth the following, in a manner calculated to be understood by the Claimant:
a. sufficient information to identify the Claim, including (as applicable) the date of service,
Health Care Provider, and Claim amount, as well as notice that the diagnosis and treatment
codes, along with the corresponding meaning, are available free of charge upon request;
AV-LG-COC-21 54 Choice-LG-7638 (07/21)
b. the specific reason for the Adverse Benefit Determination including the denial code and its
corresponding meaning;
c. reference to the specific Contract provisions on which the determination is based;
d. 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;
e. a description of AvMed's review procedures and the applicable time limits;
f. in the case of an Adverse Benefit Determination involving an Urgent Care Claim, a description
of the expedited review process applicable to such Claim;
any internal rule, guideline, protocol or other similar criterion relied upon in making the Adverse
Benefit Determination; or a statement that a copy of such rule, guideline, protocol or other
similar criterion will be provided free of charge to the Claimant upon request;
h. if the Adverse Benefit Determination is based on whether the treatment or service is
Experimental or Investigational, or not Medically Necessary, either an explanation of the
scientific or clinical judgment for the determination, applying the terms of this Contract to the
Member's medical circumstances; or a statement that such explanation will be provided free
of charge upon request.
13.5 Review Procedure upon Appeal. In order to assure Claimants a full and fair review, AvMed's review
procedures will include the following procedures and safeguards:
a. Claimants may present evidence and submit written comments, documents, records and other
information relating to a Claim.
b. upon request and free of charge, Claimants will have reasonable access to and copies of any
Relevant Documents. Relevant Document means, any documentation that (i) was relied upon
in making a benefit determination; (ii) was submitted, considered or generated in the course of
making a benefit determination, without regard to whether it was relied upon in making the
determination; (iii) demonstrates compliance with the Plan's administrative process; and (iv)
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.
c. the review will 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 review will 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 will 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,
medication, or other item is Experimental or Investigational, or not Medically Necessary, the
appropriate named fiduciary will consult with a Health Professional who has appropriate training
and experience in the field of medicine relevant to the medical judgment.
f. the review will 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.
the review will provide that the Health Professional engaged for purposes of a consultation will
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 will be an expedited review process available,
pursuant to which:
i. a request for an expedited appeal of an Adverse Benefit Determination may be submitted
orally or in writing by the Claimant; and
g.
g.
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ii. all necessary information, including AvMed's benefit determination on review, will be
transmitted between AvMed and the Claimant by telephone, facsimile or other available
similarly expeditious methods.
13.6 Manner and Content of Appeal Notification. AvMed will provide a Claimant with written or
electronic notification of its benefit determination upon review. In the case of an Adverse Benefit
Determination, AvMed will notify both the Member and the Health Professional, and the notification
will set forth all of the following as appropriate, in a manner calculated to be understood by the
Claimant:
a. the specific reasons for the Adverse Benefit Determination;
b. reference to the specific Contract provisions on which the Adverse Benefit Determination is
based;
c. a statement that the Claimant is entitled to receive reasonable access to, and copies of, any
Relevant Documents, upon request and free of charge;
d. a statement describing any voluntary appeal procedures offered by AvMed and the
Claimant's right to obtain information about such procedures, and a statement of the
Claimant's right to bring an action under ERISA Section 502(a) when applicable;
e. any internal rule, guideline, protocol, or other similar criterion relied upon in making the Adverse
Benefit Determination; or a statement that a copy of such rule, guideline, protocol or other
similar criterion will be provided free of charge to the Claimant upon request;
f. if the Adverse Benefit Determination is based on whether a treatment or service is Experimental
or Investigational, or not Medically Necessary, either an explanation of the scientific or clinical
judgment for the determination, applying the terms of the Contract to the Member's medical
circumstances; or a statement that such explanation will be provided free of charge upon
request.
13.7 External Review. In the event of a final internal Adverse Benefit Determination, a Claimant may be
entitled to an external review of the Claim. This request must be submitted in writing on an External
Review Request form within 120 days of receipt of the Adverse Benefit Determination. The external
reviewer will render a recommendation within 45 calendar days unless the request meets expedited
criteria, in which case it will be resolved in no later than 72 hours. The external reviewer's
recommendation will be binding. The external reviewer will notify the Claimant of its decision in
writing, and the Plan will take action as appropriate to comply with such recommendation. For
detailed information about the external review process, please contact AvMed's Member
Engagement Center.
13.8 Remedies if Process "Deemed Exhausted"
a. If we continue to deny the payment, coverage, or service requested or you do not receive a
timely decision, you may be able to request an external review of your Claim by an
independent third -party, who will review the denial and issue a final decision. You may contact
AvMed's Member Engagement Center at 1-800-882-8633 with any questions on your rights to
external review. Please understand that if you want to be informed about the legal remedies
that may be available to you and whether they are a better option for you than seeking
independent external review, you should consult a lawyer of your choice. AvMed cannot
provide you with legal advice. We can only explain the procedures for obtaining independent
external review.
b. If this Plan is subject to ERISA, please see the Addendum to this Group Medical and Hospital
Service Contract. You also have the right to seek such legal remedies as may be available to
you under ERISA Section 502 or state law.
XIV. COORDINATION OF BENEFITS
14.1 How Coordination of Benefits (COB) Works. 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
health plan, program or policy which may be subject to COB. The amount of our payment, if any,
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when we coordinate benefits under this Part, is based on whether or not AvMed is the primary
payer. When AvMed is not primary, our payment for Covered Services may be reduced so that
total benefits under all your plans will not exceed 100% of the total reasonable expenses actually
incurred for Covered Services. For purposes of this Part, in the event you receive Covered Services
from an In -Network Provider, 'total reasonable expenses' will mean the amount we are obligated
to pay to the provider pursuant to the applicable provider agreement we have with such provider,
or if there is no such provider agreement, the amount we are obligated to pay the provider pursuant
to state or federal law. When AvMed is not the primary payer, and the primary payer's payment
exceeds AvMed's contracted amount, no payment will be made for such services.
14.2 Plans Subject to COB
a. Health plans, programs or policies which may be subject to COB include the following, which
will be referred to as "plans" for purposes of this Part:
i. any group or non -group health insurance contract, HMO contract, or other forms of group
or group -type coverage whether insured or uninsured;
ii. medical care components of long-term care contracts such as skilled nursing care,
medical benefits under group or individual automobile contracts; and
iii. Medicare or any other governmental plan as permitted by law.
14.3 Member's Responsibilities to Avoid Duplication of Coverage. You are responsible for providing us
with written information concerning any other coverage you or your Covered Dependents may
have. This information may be requested at the time of enrollment, by written correspondence
annually thereafter or in connection with a specific Health Care Service you receive. Information
should be provided within 30 days of a request. Information received after one year from the date
of service will not be considered. If we do not receive the information we request from you, we may
deny your Claims and you will be responsible for payment of any expenses related to such denied
Claims.
14.4 Order of Benefit Determination. If any covered person is eligible for services or benefits under two or
more plans, any plan without a COB provision is automatically designated as the primary plan.
When all applicable plans have COB provisions, the order of benefit determination will be as follows:
a. Non -Dependent or Dependent. The plan that covers the person other than as a dependent (for
example, as an employee, policyholder, Subscriber or retiree) is primary to the plan which
covers the person as a dependent.
i. 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, a plan covering a person as an
employee or subscriber is primary; a plan of an active worker covering a person as a
dependent is secondary; and Medicare is last.
b. Dependent Children Covered Under More Than One Plan
i. Dependent children whose parents are not separated or divorced
1) the plan of the parent whose birthday, excluding year of birth, falls earlier in the year
will be primary; or
2) if both parents have the same birthday, excluding year of birth, the plan that has
covered the parent the longest will be primary.
ii. Dependent children whose parents are separated or divorced
1) if a parent with sole parental responsibility is not remarried, the plan of the parent with
custody is primary;
2) if a parent with sole parental responsibility has remarried, the plan of the parent with
sole parental responsibility is primary; the step -parent's plan is secondary; and the plan
of the parent without parental responsibility pays last; and
3) regardless of which parent has sole parental responsibility, whenever a court order
specifies that one parent is financially responsible for the child's health care expenses,
the plan of that parent is primary.
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c. However, if a plan subject to the birthday rule as stated above coordinates with an out-of-state
plan under which the plan covering a person as a dependent of a male is primary, and those
covering the person as a dependent of a female are secondary and if, as a result, the plans do
not agree on the order of benefits, the provisions of the other plan will determine the order of
benefits.
d. A plan covering a person as an employee who is neither laid off nor retired, or as that
employee's dependent, is primary to a plan covering 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 paragraph will
not apply.
e. If none of the rules in paragraphs a. through d. above determine the order of benefits, the
benefits of the plan which covered an employee or subscriber the longest will be primary.
f. If the other plan does not have rules that establish the same order of benefits as under this
Contract, the benefits under the other plan will be determined primary to the benefits under
this Contract.
If an individual is covered under a COBRA continuation plan and also under another Group
Health Insurance plan, the plan covering the person as an employee or as the employee's
dependent will be primary to the plan covering the person as a former employee or as the
former employee's dependent.
h. We will not coordinate benefits against an indemnity -type policy, an excess insurance policy, a
policy with coverage limited to specified illnesses or accidents, or a Medicare supplement
policy.
14.5 Medicare Secondary Payer Provisions. Individuals are eligible for Medicare and can be covered
under it because of age, disability or end stage renal disease (ESRD). Individuals are also eligible for
Medicare even when not covered under it if they refused it, dropped it or did not make a proper
request for it. When you are eligible for Medicare, AvMed coordinates your benefits under this plan
with the benefits Medicare pays. If you are eligible but not covered under Medicare, we may
coordinate your benefits under this Plan with the benefits Medicare would pay had you enrolled. If
you become Medicare eligible while covered under the Plan, you should visit www.medicare.gov
or contact your local Social Security office to learn about your eligibility, coverage options,
enrollment periods and necessary steps to follow to ensure that you have adequate coverage.
a. If you are eligible for Medicare due to age, have group health coverage based on you or your
spouse's current employment and the employer has 20 or more employees, the group health
plan is primary and Medicare is secondary.
b. If you are eligible for Medicare due to ESRD and have group health coverage based on you or
your spouse's current employment, the group health plan is primary for the first 30 months
beginning with the earlier of:
i. the month in which you became covered under Medicare Part A ESRD benefits; or
ii. the first month in which you would have been covered under Medicare Part A ESRD
benefits if a timely application had been made.
iii. After 30 months, Medicare is primary and the group health plan is secondary.
c. If you are eligible for Medicare due to a disability other than ESRD, have group health coverage
based on you or a family member's current employment and the employer has:
i. 100 or more employees: the group health plan is primary and Medicare is secondary;
ii. less than 100 employees: Medicare is primary and the group health plan is secondary.
d. If you are eligible for Medicare due to age and have retiree coverage, Medicare is primary and
the group health plan (retiree coverage) is secondary.
e. If you become covered under Medicare and are still eligible and covered under a group health
plan, the employer may not offer, subsidize, procure or provide a Medicare supplement policy
to you; nor may an employer persuade you to decline or terminate your coverage under the
plan and elect Medicare as the primary payer.
g.
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14.6 Right to Receive and Release Necessary Information. 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, plan or organization release to or
obtain from any person, plan or organization any information, with respect to any Member or
applicant for subscription, which AvMed deems to be necessary for such purposes.
14.7 Facility of Payment. Whenever payments which should have been made under this Plan have been
made under any other plans, AvMed will have the right, exercisable alone and in its sole discretion,
to pay over to any organizations making such other payments any amounts AvMed determines to
be warranted in order to satisfy the intent of this provision, and amounts so paid will be deemed to
be benefits paid under this Plan.
14.8 Right of Recovery. If the amount of the payments made by AvMed is more than it should have paid
under the provisions of this Part, it may recover the excess from one or more of the persons it has
paid, or for whom it has paid, or any other person or organization that may be responsible for the
benefits or services provided for the Member. The 'amount of the payments made' includes the
reasonable cash value of any benefits provided in the form of services.
XV. SUBROGATION AND RIGHT OF RECOVERY
15.1 AvMed's Right of Subrogation and Recovery. If AvMed provides health care benefits under this
Contract for a Member for injuries or illness for which another party is or may be responsible, then
AvMed retains the right to repayment of the full cost of all such benefits. AvMed's rights of recovery
apply to any recoveries made by or on behalf of the Member from the following third -party sources,
as allowed by law, including payments made by a third -party tortfeasor or any insurance company
on behalf of the third -party tortfeasor; any payments or awards under an uninsured or underinsured
motorist coverage policy; any worker's compensation or disability award or settlement; medical
payments coverage under any automobile policy, premises or homeowners medical payments
coverage or premises or homeowners insurance coverage; any other payments from a source
intended to compensate a Member for injuries resulting from an accident or alleged negligence.
For purposes of this Contract, a tortfeasor is any party who has committed injury, or wrongful act
done willingly, negligently or in circumstances involving strict liability, but not including breach of
contract for which a civil suit can be brought.
15.2 Members Specifically Acknowledge AvMed's Right of Subrogation. When AvMed provides health
care benefits for injuries or illnesses for which a third -party is or may be responsible, AvMed will be
subrogated to the Member's rights of recovery against any party to the extent of the full cost of all
benefits provided by AvMed, to the fullest extent permitted by law. AvMed may proceed against
any party with or without the Member's consent.
15.3 Members Specifically Acknowledge AvMed's Right of Reimbursement. This right of reimbursement
attaches, to the fullest extent permitted by law, when AvMed has provided health care benefits for
injuries or illness for which another party is or may be responsible and the Member or the Member's
representative has recovered any amounts from the third party or any party making payments on
the third party's behalf. By providing any benefit under this Contract, AvMed is granted an
assignment of the proceeds of any settlement, judgment or other payment received by the
Member to the extent of the full cost of all benefits provided by AvMed. AvMed's right of
reimbursement is cumulative with and not exclusive of AvMed's subrogation right and AvMed may
choose to exercise either or both rights of recovery.
15.4 Assent for Member Notification. Member and the Member's representatives further agree to:
a. notify AvMed promptly and in writing when notice is given to any third -party of the intention to
investigate or pursue a claim to recover damages or obtain compensation due to injuries or
illness sustained by the Member that may be the legal responsibility of a third -party; and
b. cooperate with AvMed and do whatever is necessary to secure AvMed's rights of subrogation
and reimbursement under this Contract; and
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c. give AvMed a first -priority lien on any recovery, settlement or judgment or other source of
compensation which may be had from a third -party to the extent of the full cost of all benefits
provided by AvMed that are associated with injuries or illness for which a third -party is or may
be responsible (regardless of whether specifically set forth in the recovery, settlement, judgment
or compensation agreement); and
d. pay, as the first priority, from any recovery, settlement or judgment or other source of
compensation, any and all amounts due AvMed as reimbursement for the full cost of all benefits
provided by AvMed that are associated with injuries or illness for which a third -party is or may
be responsible (regardless of whether specifically set forth in the recovery, settlement, judgment
or compensation agreement), unless otherwise agreed to by AvMed in writing; and
e. do nothing to prejudice AvMed's rights as set forth above. This includes refraining from making
any settlement or recovery which specifically attempts to reduce or exclude the full cost of all
benefits, provided by AvMed.
15.5 Recovery of Full Cost. AvMed may recover the full cost of all benefits provided by AvMed under this
Contract without regard to any claim of fault on the part of the Member, whether by comparative
negligence or otherwise. No court costs or attorney fees may be deducted from AvMed's recovery
without the prior express written consent of AvMed. In the event the Member or the Member's
representative fails to cooperate with AvMed, the Member will be responsible for all benefits paid
by AvMed in addition to costs and attorney's fees incurred by AvMed in obtaining repayment.
XVI. DISCLAIMER OF LIABILITY AND RELATIONSHIPS BETWEEN THE PARTIES
16.1 Indemnity of Parties
a. Subscribing Group. Neither Subscribing Group nor its agents, servants or employees, nor any
Member is the agent or representative of AvMed, and none of them will be liable for any acts
or omissions of AvMed, its agents or employees, or of an in -network Hospital or Physician, or any
other person or organization with which AvMed has made or hereafter will make arrangements
for the performance of services under this Contract.
b. Members. Members will not be liable to AvMed or In -Network Providers except as specifically
set forth herein, provided all procedures set forth herein are followed.
c. AvMed. Neither AvMed nor its agents, servants or employees is the agent or representative of
the Subscribing Group, and none of them will be liable for any acts or omissions of Subscribing
Group, its agents or employees, or any other person representing or acting on behalf of the
Subscribing Group.
16.2 Relationship of AvMed and In -Network Providers. 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 will be deemed not to be a
Health Care Provider with respect to any services performed or rendered by any such independent
contractors. In -Network Providers maintain the Physician/patient relationship with Members and are
solely responsible for all Health Care Services which In -Network Providers render to Members.
Therefore, AvMed will 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 Professionals or any of their employees or agents who may, from
time to time, provide Health Care Services to a Member of AvMed. Furthermore, AvMed will not be
vicariously liable for any negligent act or omission of any of these independent Health Professionals
who treat a Member of AvMed.
16.3 Member's Refusal of Procedures or Treatment. Certain Members may, for personal reasons, refuse
to accept procedures or treatment recommended by in -network Physicians. 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, and the
Physician may terminate his provider relationship with the Member. If a Member refuses to accept
the medical treatment or procedure recommended by the in -network Physician and if, in the
judgment of the in -network Physician, no professionally acceptable alternative exists or if an
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alternative treatment does exist but is not recommended by the in -network Physician, the in -
network Physician will advise the Member accordingly.
XVII. GENERAL PROVISIONS
17.1 Amendment. The terms of coverage and benefits to be provided by us may be amended annually
on this Contract's anniversary date, without your consent or the consent of any other person, upon
60 days prior written notice to the Subscribing Group. In the event the amendment is unacceptable
to the Subscribing Group, the Subscribing Group may terminate this Contract upon at least ten days
prior written notice to us. Any such amendment will be without prejudice to Claims filed with us and
related to Covered Services prior to the date of such amendment. No agent or other person,
except a duly authorized officer of AvMed, has the authority to modify the terms of this Contract,
or to bind us in any manner not expressly described herein, including the making of any promise or
representation, or by giving or receiving any information. The terms of coverage and benefits to be
provided by us may not be amended by the Subscribing Group unless such amendment is
evidenced in writing and signed by a duly authorized officer of AvMed.
17.2 Assignment and Delegation. Your rights and obligations arising hereunder may not be assigned,
delegated or otherwise transferred by you without our written consent. We may assign our rights
and coverage, or benefit obligations to our successor in interest or an affiliated entity without your
consent at any time. Any assignment, delegation, or transfer made in violation of this provision will
be void.
17.3 Circumstances Not Reasonably Within the Control of AvMed. In the event of circumstances not
reasonably within the control of AvMed, including major disasters and under such circumstances
as complete or partial destruction of facilities, an act of God, war, riot, civil insurrection, disability of
a significant part of a Hospital or in -network medical personnel or similar causes, if the rendition of
Health Care Services and Hospital services provided under this Contract is delayed or rendered
impractical, neither AvMed, In -Network Providers, nor any Physician will have any liability or
obligation on account of such delay or failure to provide services; however, AvMed will make a
good faith effort to arrange for the timely provision of Covered Services during such event.
17.4 Clerical Errors. Clerical errors will neither deprive any individual Member of any benefits or coverage
provided under this Group Contract nor will such errors act as authorization of benefits or coverage
for the Member that is not otherwise validly in force.
17.5 Compliance with Law. The terms of coverage and benefits to be provided by us under this Contract
will be deemed to have been modified by the parties, and will be interpreted so as to comply with
applicable State of Florida and United States laws and regulations dealing with rates, benefits,
eligibility, enrollment, termination, conversion, or other rights and duties of you, or AvMed.
17.6 Confidentiality
a. Except as otherwise specifically provided herein, and except as may be required in order for us
to administer coverage and benefits, specific medical information concerning you, received
by providers, will be kept confidential by us in conformity with applicable law. Such information
may be disclosed to third parties for use in connection with bona fide medical research and
education, or as reasonably necessary in connection with the administration of coverage and
benefits, specifically including our quality assurance and Care Management Programs.
Additionally, we may disclose such information to entities affiliated with us or other persons or
entities we utilize to assist in providing coverage, benefits or services under this Contract. Further,
any documents or information properly subpoenaed in a judicial proceeding, or by order of a
regulatory agency, will not be subject to this provision.
b. Our arrangements with a provider may require that we release certain Claims and medical
information about persons covered under this Contract to that provider even if treatment has
not been sought by or through that provider. By accepting coverage, you hereby authorize us
to release to providers Claims information, including related medical information, pertaining to
you in order for any such provider to evaluate your financial responsibility under this Contract.
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17.7 Contracting Parties. By executing this Contract, Subscribing Group and AvMed agree to make the
Health Care Services and Hospital services specified herein available to persons who are eligible
under the provisions of Part III. ELIGIBILITY FOR COVERAGE. Subscribing Group hereby represents that
it has met the non-discrimination testing requirements under U.S. Code Section 105(h). The delivery
of benefits and services covered in this Contract will 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 Health Care 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.
17.8 Contract Review by Subscribing Group. The 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 will be deemed to
have been accepted.
17.9 Cooperation Required of You and Your Covered Dependents. You must cooperate with us, and
must execute and submit to us any consents, releases, assignments, and other documents we may
request in order to administer and exercise our rights hereunder. Failure to do so may result in the
denial of Claims and will constitute grounds for termination of coverage for cause, by us, as set forth
in Part V. TERMINATION.
17.10 Eligibility Requirements Control. The eligibility requirements set forth herein will at all times control
and no coverage contrary thereto will be effective. Coverage will not be implied due to clerical or
administrative errors if such coverage would be contrary to Part III.
17.11 Entire Agreement. This Contract, including the Group Master Application and any enrollment forms,
schedules and amendments, sets forth the exclusive and entire understanding and agreement
between you and AvMed and will be binding upon Subscribing Group, all Members, AvMed, and
any of their subsidiaries, affiliates, successors, heirs, and permitted assignees. All prior negotiations,
agreements, and understandings are superseded hereby.
17.12 Evidence of Coverage. You have been provided with this Contract as evidence of coverage.
17.13 ERISA. When this Contract is purchased by the Subscribing Group to provide benefits under a
welfare plan governed by ERISA, AvMed will 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.
17.14 Florida Agency for Health Care Administration (AHCA) Performance Outcome and Financial Data.
The performance outcome and financial data published by AHCA, pursuant to Section 408.05,
Florida Statutes, or any successor statute, located at the website address may be accessed through
the link provided on AvMed's website at www.avmed.org.
17.15 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 Care
Services or other benefits under this Contract. To be entitled to such services or benefits the holder
of the card must be, in fact, a Member on whose behalf all applicable Premiums under this Contract
have actually been paid and accepted by AvMed. Please carry your Identification Card with you
at all times, and present it before Covered Services are rendered. If your Identification Card is
missing, lost, or stolen, contact AvMed's Member Engagement Center at 1-800-882-8633, or visit
AvMed's website at www.avmed.org. Member Identification Cards are AvMed's property and,
upon request, will be returned to AvMed within 30 days of the termination of your coverage.
17.16 Membership Application. Members or applicants for membership will complete and submit to
AvMed such applications or other forms or statements as AvMed may reasonably request. If a
Member or applicant fails to provide accurate information which AvMed deems material then,
upon ten days written notice, AvMed may deny membership to such individual. Any person who
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knowingly and with intent to injure, defraud or deceive any insurer files a statement of Claim or an
application containing any false, incomplete or misleading information is guilty of a felony,
punishable as provided by Florida Statutes.
17.17 Minimum Enrollment Requirement. This Contract, at the sole option of AvMed, will not be accepted
if at the time of the renewal offering to the Subscribing Group the total enrollment does not result
in a predetermined minimum enrollment as established by AvMed, pursuant to Florida law. The
required minimum group enrollment is included in the Rate Letter (as defined in this Part) furnished
to the Subscribing Group.
17.18 Misrepresentation of Material Fact by Party Applying for Coverage. Time limit on certain defenses:
Fraudulent or intentional misrepresentation of material facts made by the applicant, Subscriber, or
Covered Dependents which are discovered by AvMed within two years of the issue date of the
Contract may prevent payment of benefits under this Contract and may void this Contract for the
individual making the misrepresentation or fraudulent statement. Fraudulent misstatements
discovered by AvMed at any time, may result in this Contract being voided or Claims being denied
for the individual about whom the fraudulent misstatement is made.
17.19 Misstatement of Age, Residence or Tobacco Use. If any written information has been misstated by
you, upon 30 days' notice from AvMed, the Premium amount owed under this Contract will be what
the Premium would have been had the correct information been provided to AvMed. If such
misstatement causes us to accept Premiums for a time period during which we would not have
accepted Premiums if the correct information had been stated, our only liability will be the return
of any unearned Premium. We will not provide any coverage for that time period. This right is in
addition to any other rights we may have under this Contract and applicable laws.
17.20 Modification of AvMed Provider Network and Participation Status. The AvMed Choice Plan provider
network and the participation status of individual providers available under this Contract are
subject to change at any time without prior notice to you or your approval. Additionally, we may
at any time terminate or modify the terms of any provider contract, and may enter into additional
provider contracts, without prior notice to or approval by you. It is your responsibility to determine
whether a Health Care Provider is an In -Network Provider at the time the Health Care Service is
rendered.
17.21 Non -Waiver. Any failure by us at any time, or from time to time, to enforce or to require the strict
adherence to any of the terms or conditions described herein, will in no event constitute a waiver
of any such terms or conditions. Further, it will not affect our right at any time to enforce or avail
ourselves of any such remedies as we may be entitled to under applicable law or this Contract.
17.22 Notices. Any notice required or permitted hereunder will be deemed given if hand delivered or if
mailed by the United States Postal Service, postage prepaid, and addressed as listed below. Such
notice will be deemed effective as of the date delivered or so deposited in the mail.
a. If to us:
To the address printed on the AvMed Identification Card.
b. If to you:
To the latest address provided by you according to our records or to the Member's latest
address on enrollment forms actually delivered to us.
c. If to Subscribing Group:
To the address provided in the Group Master Application.
17.23 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.
17.24 Premium Tax/Surcharge. If any government entity will impose a Premium tax or surcharge, then
upon 30 days' notice from AvMed, the sums due from the Subscribing Group under the terms of this
Contract will be increased by the amount of such Premium tax or surcharge.
17.25 Promissory Estoppel. No oral statements, representations, or understanding by any person can
change, alter, delete, add, or otherwise modify the express written terms of this Contract.
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17.26 Rate Letter. The term 'Rate Letter' refers to a compilation of documents which constitute AvMed's
formal notice to the Subscribing Group of: (i) the Premium rates applicable to the Subscribing
Group, (ii) the conditions under which the rates are valid, (iii) the Premium payment terms and due
dates, and (iv) the additional charge which will apply to all late Premium payments. AvMed
reserves the right to adjust (re -rate) the Premium rates to account for material changes in group
size or in the data supplied by the Subscribing Group to AvMed.
17.27 Right to Receive Necessary Information. We have the right to receive, from you and any Health
Care Provider rendering services to you, information that is reasonably necessary, as determined
by us, in order to administer the coverage and benefits we provide, subject to all applicable
confidentiality requirements listed above. By accepting coverage, you authorize every Health Care
Provider who renders services to you, to disclose to us or to entities affiliated with us, upon request,
all facts, records, and reports pertaining to your care, treatment, and physical or mental Condition,
and to permit us to copy any such records and reports so obtained.
17.28 Third -Party Beneficiary. This Contract was issued by AvMed to the Subscriber, and was entered into
solely and specifically for the benefit of AvMed and the Subscriber. The terms and provisions of the
Contract will be binding solely upon, and inure solely to the benefit of, AvMed and the Subscriber,
and no other person will have any rights, interest or claims hereunder, or be entitled to sue for a
breach hereof as a third -party beneficiary or otherwise. AvMed and the Subscriber hereby
specifically express their intent that Health Care Providers that have not entered into contracts with
AvMed to render the professional Health Care Services set forth herein will not be third -party
beneficiaries under this Contract.
AV-LG-COC-21
64 Choice-LG-7638 (07/21)
Addendum to the AvMed Group Medical
and Hospital Service Contract
This addendum together with the benefits provisions of the AvMed Group Medical and Hospital Service
Contract (the "Contract") and the other attached documents constitute the summary plan description for this
portion of your Subscribing Group's Welfare and/or Benefit Plan (the "Plan"). To the extent there are any
inconsistencies between the provisions of this Addendum and the provisions of the Contract, the terms and
provisions of this Addendum will govern. The official Plan document contains the full Plan details. This
document does not create a contract of employment between the Subscribing Group and any employee. The
Subscribing Group reserves the right to discontinue, amend or replace this Plan at its discretion at any time
for any reason. If you have further questions about the Plan or would like a complete copy of the Plan
document, contact your human resources representative.
Statement of ERISA Rights
As a participant in the Plan, you are entitled to certain rights and protections under the Employee Retirement
Income Security Act of 1974 ("ERISA"). ERISA provides that all Plan participants shall be entitled to:
Receive Information About Your Plan and Benefits
Examine, without charge, at the Plan Administrator's office and at other specified locations, such as
worksites and union halls, all documents governing the Plan, including insurance contracts and collective
bargaining agreements, and a copy of the latest annual report (Form 5500 series), if any, filed by the Plan
with the U.S. Department of Labor and available at the Public Disclosure Room of the Employee Benefits
Security Administration.
Obtain, upon written request to the Plan Administrator, copies of documents governing the operation of the
Plan, including insurance contracts and collective bargaining agreements, and copies of the latest annual
report (Form 5500 series), if any, and updated summary plan description (SPD). The Plan Administrator may
make a reasonable charge for the copies.
Receive a summary of the Plan's annual Form 5599, if any is required by ERISA to be prepared, in which
case, the Plan Administrator is required by law to furnish each Participant with a copy of this summary
annual report.
Prudent Actions by Plan Fiduciaries
In addition to creating rights for Plan Participants, ERISA imposes duties upon the people who are
responsible for the operation of the employee benefit plan. The people who operate your Plan, called
"fiduciaries" of the Plan, have a duty to do so prudently and in the interest of you and other Plan Participants
and beneficiaries. No one, including your employer, your union, or any other person, may fire you or
otherwise discriminate against you in any way to prevent you from obtaining a Plan (pension/welfare) benefit
or exercising your rights under ERISA.
Enforce Your Rights
If your claim for a (pension/welfare) benefit is denied or ignored, in whole or in part, you have a right to
know why this was done, to obtain copies of documents relating to the decision without charge, and to appeal
any denial, all within certain time schedules. Under ERISA there are steps you can take to enforce the above
rights. For instance, if you request a copy of Plan documents or the latest annual report (Form 5500) from the
Plan and do not receive them within 30 days, you may file suit in a Federal court. In such a case, the court
may require the Plan Administrator to provide the materials and pay you up to $110 a day until you receive
the materials, unless the materials were not sent because of reasons beyond the control of the administrator.
If you have a claim for benefits which is denied or ignored in whole or in part, you may file suit in a state or
federal court. In addition, if you disagree with the Plan's decision or lack thereof concerning the qualified
status of a domestic relations order or a medical child support order, you may file suit in federal court.
If it should happen that Plan fiduciaries misuse the Plan's money, or if you are discriminated against for
asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in a
1 of 2 MP -6046 (01/18)
federal court. The court will decide who should pay court costs and legal fees. If you are successful the court
may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay
these costs and fees, for example if it fords your claim is frivolous.
Assistance with Your Questions
If you have any questions about your Plan, you should contact the Plan Administrator. If you have any
questions about this statement or about your rights under ERISA, or if you need assistance in obtaining
documents from the Plan Administrator, you should contact the nearest office of the Employee Benefits
Security Administration, U.S. Department of Labor (listed in your telephone directory), or contact the
Division of Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department
of Labor, 200 Constitution Avenue N.W., Washington, D.C. 20210. You may also obtain certain publications
about your rights and responsibilities under ERISA by calling the publications hotline of the Employee
Benefits Security Administration.
2 of 2 MP -6046 (01/18)
ERISA SUMMARY PLAN DESCRIPTION INFORMATION
Official Plan Name:
Plan Sponsor:
Plan Administrator:
Claims Administrator:
City of Opa Locka
City of Opa Locka
3400 NW 135th St Bldg B
Opa Locka, FL 33054-4708
City of Opa Locka
3400 NW 135th St Bldg B
Opa Locka, FL 33054-4708
AvMed Inc.
9400 S Dadeland Blvd.
Miami, FL 33156
Plan Year: 2021
Effective Date of Plan: 10/1/2021
Employer Identification Number: 59-6000394
Plan Type: Fully -insured welfare benefit plan: POS
Sources of Funding for the Plan:
Sources of Contribution:
ERISA Plan No:
Agent for Service of Legal Process:
Organization that Provides the Benefit:
Benefits under the plan are provided
through a fully -insured contract with
AvMed Inc.
Employer and Employee contributions.
The amount of the contributions are
determined by Plan Administrator.
501
Steven M. Ziegler
4300 NW 89th Blvd.
Gainsville, FL 32606
AvMed Inc.
9400 S Dadeland Blvd.
Miami, FL 33156
Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 10/01/2021 - 09/30/2022
AvMed bane health Large Group Choice CM250-LG21
Coverage for: Individual or Individual + Family' Plan Type: POS
AThe Summary of Benefits and Coverage (SBC) document will help you choose a health plan . The SBC shows you how you and the plan would share the
cost for covered health care services . NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a
summary. For more information about your coverage, or to get a copy of the complete terms of coverage, call 1-800-88-AVMED (1-800-882-8633) or visit
www.avmed.org. For general definitions of common terms, such as allowed a mount, balance billing, coinsurance, copayment, deductible, provider, or other
underlined terms see the Glossary . You can view the Glossary at www .cciio.cms.gov or call 1-800-88-AVMED (1-800-882-8633) to request a copy .
Important Questions
Answers
Why This Matters:
What is the overall
deductible?
In -Network: $2,500 individual / $5,000 family
Generally, you must pay all of the costs from providers up to the deductible
PHCS Network (outside AvMed service area):
amount before this plan begins to pay . If you have other family members on the
$2,500 individual / $5,000 family
Out -of -Network: $7,500 individual / $15,000 family
plan, each family member must meet their own individual deductible until the
total amount of deductible expenses paid by all family members meets the overall
Accumulates across all benefit levels .
family deductible.
Are there services covered
before you meet your
deductible?
Yes. Preventive care, office visits, certain lab tests,
This plan covers some items and services even if you haven, t yet met the
diagnostic tests and imaging at independent
facilities, certain prescription drugs, urgent and
deductible amount . But a copayment or coinsurance may apply . For example,
this plan covers certain preventive services without cost -sharing and before you
emer ant care, and certain recove services, e.
meet your deductible . See a list of covered preventive services at
habilitation and rehabilitation services are covered
https://www .healthcare.gov/coverage/preventive-care-benefits/ .
before you meet your deductible.
Are there other deductibles
Yes. $500 individual / $1,000 family for prescription
You must pay all of the costs for these services up to the specific deductible
drugs.
for specific services?
amount before this plan begins to pay for these services .
There are no other specific deductibles.
What is the out-of-pocket
In -Network: $6,500 individual / $13,000 family
The out-of-pocket limit is the most you could pay in a year for covered services .
PHCS Network (outside AvMed service area):
$6,500 individual / $13,000 family
Out -of -Network: $19,500 individual / $39,000 family
If you have other family members in this plan, they have to meet their own out -of -
limit for this plan?
pocket limits until the overall family out-of-pocket limit has been met.
Accumulates across all benefit levels.
What is not included in the
out-of-pocket limit?
Premiums, prescription drug brand additional
Even though you pay these expenses, they don't count toward the out-of-pocket
charges and manufacturer assistance, balance
billing charges, and health care this plan doesn't
limit.
cover.
Will you pay less if you use
a network provider?
Yes. See www.avmed. org or call 1-800-88-AVMED
(1-800-882-8633) for a list of network providers.
This plan uses a provider network. You will pay less if you use a provider in the
plan's network. You will pay the most if you use an out -of -network provider, and
you might receive a bill from a provider for the difference between the provider's
charge and what your plan pays (balance billing) . Be aware your network
provider might use an out -of -network provider for some services (such as lab
work). Check with your provider before you get services .
(DT - OMB control num ber: 1545-0047/Expiration DATE: 12/31/2019)(DOL - OMB control number: 1210-0147/Expiration DATE: 5/31/2022)
AVLG_C_7628_R7479_0721 (HHS - OMB control number: 0938-1146/Expiration DATE: 10/31/2022)
Page 1 of 8
Important Questions Answers
Why This Matters:
Do you need a referral to
see a specialist?
No.
i You can see the specialist you choose without a referral.
All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.
Common
Medical Event
Services You May Need
an In -Network
Provider (You will
pay the least)
What You Will Pay
a PHCS Network
Provider (outside
AvMed service area)
(You will pay more
an Out of Net work
Provider (You will
pay the most)
Limitations, Exceptions, & Other Important
Information
If you visit a health
care provider's office or
clinic
If you have a test
Prim ary care visit to treat an
injury or illness
$25 copay/ visit
$25 copay/ visit
40% coinsurance
after deductible
Additional charges may apply for non -
preventive services performed in the
Physician's office .
Specialist visit
$50 copay/ visit
$50 copay/ visit
40% coinsurance
after deductible
Additional charges may apply for non -
preventive services performed in the
Physician's office .
Preventive care/screening/
immunization
No Charge
No Charge
40% coinsurance
after deductible
You may have to pay for services that
aren't preventive. Ask your provider if the
services you need are preventive . Then
check what your plan will pay for.
Diagnostic test (x-ray, blood
work)
$50 copay/ visit at
independent
facilities; $100
copay/ visit at
hospital -owned or
affiliated facilities;
no charge for lab
work at participating
labs
$50 copay/ visit at
independent
facilities; $100
copay/ visit at
hospital -owned or
affiliated facilities;
no charge for lab
work at participating
labs
40% coinsurance
after deductible
Charges for office visits may apply if
services are performed in a Physician's
office. Charges for certain other labs and
Specialty labs will be higher.
Imaging (CT/PET scans,
MRIs)
$200 copay/ visit at
independent
facilities; $400
copay/ visit after
deductible at
hospital -owned or
affiliated facilities
$200 copay/ visit at
independent
facilities; $400
copay/ visit after
deductible at
hospital -owned or
affiliated facilities
40% coinsurance
after deductible
Charges for office visits or
Physician/professional services may also
apply depending where services are
received.
AVLG_C_7628_R7479_0721
Page 2 of 8
Common
Medical Event
Services You May Need
an In -Network
Provider (You will
pay the least)
What You Will Pay
a PHCS Net work
Provider (outside
AvMed service area)
(You will pay more
an Out of Network
Provider (You will
pay the most)
Limitations, Exceptions, & Other Important
Information
If you need drugs to
treat your illness or
condition
More information about
prescription drug
coverage is available
at www.avmed.org
If you have outpatient
surgery
Value generic drugs (Tier 1)
$10 copay/
prescription (retail);
$25 copay/
prescription (mail
order)
Not Covered
Not Covered
Generic drugs (Tier 2)
$25 copay/
prescription (retail);
$62.50 copay/
prescription (mail
order)
Not Covered
Not Covered
Preferred brand drugs (Tier 3)
$50 copay/ 1
prescription (retail);
$125 copay/ 1 Not Covered
prescription (mail
order)
Not Covered
Non -Preferred brand drugs
(Tier 4)
$100 copay/
prescription (retail);
$250 copay/
prescription (mail
order)
Not Covered
Not Covered
Specialty drugs (Tier 5)
30% coinsurance
after RX deductible Not Covered
(retail only)
Not Covered
Retail charge applies per 30 -day supply.
Generic & brand drugs: covers up to a 90 -
day supply at retail pharmacies and a 60-
90 day supply via mail order.
Certain drugs in all tiers require prior
authorization.
Brand additional charges may apply .
Specialty drugs available in 30 -day supply
only; not available via mail order .
Facility fee (e.g., ambulatory
surgery center)
10% coinsurance
after deductible
10% coinsurance
after deductible
40% coinsurance Prior authorization required .
after deductible
Physician/surgeon fees
10% coinsurance
after deductible
10% coinsurance
after deductible
40% coinsurance
after deductible
Prior authorization required .
AVLG_C_7628_R7479_0721
Page 3 of 8
Common
Medical Event
Services You May Need
What You Will Pay
an In -Network a PHCS Network
Provider (You will Provider (outside
pay the least) AvMed service area)
(You will pay more
an Out of Network
Provider (You will
pay the most)
Li mitations, Exceptions, & Other Important
Information
If you need immediate
medical attention
Emergency room care
$350 copay/ visit $350 copay/ visit
$350 copay/ visit
AvMed must be notified within 24 -hours of
inpatient admission following emergency
services, or as soon as reasonably
possible . Charges are waived if admitted .
Emergency medical
transportation
$150 copay/ one
way ground
transport
$150 copay/ one
way ground
transport
$150 copay/ one
way ground
transport
50% coinsurance after In -Network
deductible for air and water transportation.
Urgent care
$75 copay/ visit at
urgent care
facilities; $25
copay/ visit at retail
clinics
$75 copay/ visit at
urgent care
facilities; $25
copay/ visit at retail
clinics
40% coinsurance
after deductible at
urgent care facilities
or retail clinics
None
If you have a hospital
stay
Facility fee (e.g., hospital
room)
10% coinsurance
after deductible
10% coinsurance
after deductible
40% coinsurance
after deductible
Prior authorization required.
Physician/surgeon fees
10% coinsurance
after deductible
10% coinsurance
after deductible
If you need mental
health, behavioral
health, or substance
abuse services
Outpatient services
$25 copay/ visit
$25 copay/ visit
40% coinsurance
after deductible
40% coinsurance
after deductible
Prior authorization required.
Prior authorization may be required.
Inpatient services
10% coinsurance
after deductible
10% coinsurance
after deductible
40% coinsurance
after deductible
Prior authorization may be required .
AVLG_C_7628_R7479_0721
Page 4 of 8
Common
Medical Event
Services You May Need
What You Will Pay
an In -Network a PHCS Network an Out of Network
Provider (You will Provider (outside Provider (You will Li mitations, Exceptions, & Other Important
pay the least) AvMed service area) pay the most) Information
(You will pay more
1 .1
If you are pregnant
Office visits
!Routine OB &
midwife: $25 copay/
1st visit only;
subsequent visits at
no charge
Routine OB &
midwife: $25 copayl
1st visit only;
subsequent visits at
no charge
40% coinsurance
after deductible
None
Childbirth/delivery
professional services
10% coinsurance
after deductible
10% coinsurance
after deductible
40% coinsurance
after deductible
Maternity care may include tests and
services described elsewhere in the SBC
(e.g., ultrasound) .
Childbirth/delivery facility
services
Hospital stay: 10%
coinsurance after
deductible;
Birthing center:
same as routine OB
I Hospital stay: 10%
coinsurance after
deductible;
Birthing center:
same as routine OB
40% coinsurance
after deductible
Prior authorization required .
AVLG_C_7628_R7479_0721
Page 5of8
Common
Medical Event
If you need help
recovering or have
other special health
needs
If your child needs
dental or eye care
Services You May Need
Home health care
Rehabilitation services
Habilitation services
Skilled nursing care
Durable medical equipment
Hospice services
Children's eye exam
Children's glasses
Children's dental check-up
an In -Network
Provider (You will
pay the least)
$50 copay/ visit
after deductible
$50 copay/ visit at
independent
facilities;
$50 copay/ visit
after deductible at
hospital -owned or
affiliated facilities;
$25 copay/ visit for
chiropractic
services
$50 copay/ visit
$250 copay/ day for
the first 5 days per
admission after
deductible
$250 copay/
episode of illness
No charge after
deductible
$35 copay/ exam
Not Covered
What You Will Pay
a PHCS Net work
Provider (outside
AvMed service area)
(You will pay more
than Tier A
Not Covered
$50 copay/ visit
after deductible
$50 copay/ visit at
independent
facilities;
$50 copay/ visit
after deductible at
hospital -owned or
affiliated facilities;
$25 copay/ visit for
chiropractic
services
$50 copay/ visit
$250 copay/ day for
the first 5 days per
admission after
deductible
$250 copay/
episode of illness
No charge after
deductible
$35 copay/ exam
Not Covered
Not Covered
an Out of Network
Provider (You will
pay the most)
40% coinsurance
after deductible
40% coinsurance
after deductible
40% coinsurance
after deductible
40% coinsurance
after deductible
40% coinsurance
after deductible
40% coinsurance
after deductible
40% coinsurance
after deductible
Not Covered
Not Covered
Limitations, Exceptions, & Other Important
Information
Limited to 20 skilled visits per calendar
year. Approved treatment plan required .
Limited to 35 visits per calendar year for
rehabilitative outpatient PT, OT, ST,
cardiac rehab, pulmonary rehab, and
chiropractic services combined. Cardiac
and pulmonary rehab require prior
authorization.
Habilitative PT, OT, and ST, when
provided for the treatment of autism
spectrum disorder and Down syndrome,
are limited to a combined maximum of 100
visits per calendar year .
Limited to 60 days post -hospitalization care
per calendar year. Prior authorization
required.
Excludes vehicle modifications, home
modifications, exercise equipment, and
bathroom equipment .
Physician certification required.
Limited to one eye exam per calendar year
to deter mine the need for sight correction .
None
None
AVLG_C_7628_R7479_0721
Page 6 of 8
Excluded Services & Other Covered Services:
Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)
I
• Acupuncture
• Bariatric Surgery
• Child Dental Check Up
• Child Glasses
• Cosmetic Surgery
• Dental Care (Adult)
• Hearing Aids
• Infertility Treatment
• Long -Term Care
• Non -Emergency Care When Traveling Outside
the U.S.
• Private -Duty Nursing
• Routine Eye Care (Adult)
• Routine Foot Care
• Weight Loss Programs
Other Covered Services (Limitations may apply to these services. This isn't a complete list . Please see your plan document .)
• Chiropractic Care
Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends . The contact information for those agencies
is: the Florida Office of Insurance Regulation at 1-877-693-5236 or w ww.floir .com/consumers, the U.S. Department of Labor, Employee Benefits Security
Adm inistration, at 1-866-444-3272 or www.dol.gov/ebsa/contactEBSA/consumerassistance.html, or the U.S. Department of Health and Human Ser vices at 1-877-267-
2323 x61565 or www. cciio. cms. gov. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance
Marketplace. For more information about the Marketplace, visit www .HealthCare.gov or call 1-800-318-2596 .
Your Grievance and Appeals Rights:There are agencies that can help if you have a complaint against your plan for a denial of a claim . This complaint is called a
grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also
provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance,
contact AvMed's Member Engagement Center at 1-800-882-8633. For plans subject to ERISA, you may also contact the U .S . Department of Labor's Employee
Benefits Security Administration at 1-866-444-3272 or www.dol. gov/ebsa/healthreform . Additionally, a consumer assistance program can help you file your appeal.
Contact the Florida Department of Financial Services, Division of Consumer Services, at 1-877-693-5236 or www .floir.com/consumers.
Does this plan provide Minimum Essential Coverage? Yes.
Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid,
CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit .
Does this plan m eet Minimum Value Standards? Yes.
If your plan doesn't meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.
Language Access Services:
Para obtener asistencia en Espanol, Ilame al 1-800-882-8633.
To see examples of how this plan might cover costs for a sample medical situation, see the next section.
a
AVLG_C_7628_R7479_0721
Page 7 of 8
About these Coverage Examples:
This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different
//1\\\ depending on the actual care you receive, the prices your providers charge, and many other factors . Focus on the cost sharing amounts
(deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might
pay under different health plans. Please note these coverage exa mples are based on self -only coverage.
Peg is Having a Baby
(9 months of in -network pre -natal care and a
hospital delivery)
The plan's overall deductible
Specialist copayment
Hospital (facility) coinsurance
Other coinsurance
This EXAMPLE event includes services like:
Specialist office visits (prenatal care)
Childbirth/delivery professional services
Childbirth/delivery facility services
Diagnostic tests (ultrasounds and blood work)
Specialist visit (anesthesia)
$2,500
$50
10%
10%
Total Example Cost
$12,700
In this example, Peg would pay:
Cost Sharing
Deductibles*
Managing Joe's type 2 Diabetes
(a year of routine in -network care of a well -
controlled condition)
The plan's overall deductible
Specialist copayment
Hospital (facility) coinsurance
Other coinsurance
This EXAMPLE event includes services like:
Primary care physician office visits (including
disease education)
Diagnostic tests (blood work)
Prescription drugs
Durable medical equipment (glucose meter)
$2,500
$50
10%
10%
Total Example Cost
$5,600
In this example, Joe would pay:
Mia's Simple Fracture
(in -network emergency room visit and follow up
care)
The plan's overall deductible
Specialist copayment
Hospital (facility) coinsurance
Other coinsurance
This EXAMPLE event includes services like:
Emergency room care (including medical
supplies)
Diagnostic test (x-ray)
Durable medical equipment (crutches)
Rehabilitation services (physical therapy
$2,500
$50
10%
10%
Total Example Cost
$2,800
In this example, Mia would pay:
Cost Sharing
Cost Sharing
$2,500 Deductibles*
Copayments
Coinsurance
$100
$600
What isn't covered
Limits or exclusions
$0 Deductibles*
$40
Copayments
Coinsurance
$2,000
$0
Copayments
Coinsurance
$1,400
$0
What isn't covered
What isn't covered
$60 Limits or exclusions
The total Peg would pay is $3,260
$20 Limits or exclusions
The total Joe would pay is
$2,020
$0
The total Mia would pay is
$1,440
This plan has other deductibles for specific services included in this coverage example. See "Are there other deductibles for specific services?" row above. "
The plan would be responsible for the other costs of these EXAMPLE covered services .
AVLG_C_7628_R7479_0721
Page 8 of 8
Prescription Medication Benefits
$10 / $25 / $50 / $100 / 30% AD
AvMed
DEFINITIONS
Brand Medication means a Prescription Medication that is usually manufactured and sold under a name or trademark by a
pharmaceutical manufacturer or a medication that is identified as a Brand Medication by AvMed. AvMed delegates
determination of Generic/Brand status to AvMed's Pharmacy Benefits Manager.
Brand Additional Charge means the additional charge that must be paid if you choose a Brand Medication when a Generic
equivalent is available. The charge is the difference between the cost of the Brand Medication and the Generic Medication.
This charge must be paid in addition to the Non -preferred Brand cost -sharing. However, if the prescribing Physician or other
Participating Provider authorized to prescribe medications within the scope of his or her license indicates on the prescription
"Brand Medically Necessary" or "dispense as written" for a medication for which there is a Generic equivalent, the Brand
Medication shall be dispensed for the applicable Non -preferred Brand cost -sharing only. The Brand Additional Charge does
not apply toward the Deductible or the Out -of -Pocket Maximum.
Dental -specific Medication is medication used for dental -specific purposes, including but not limited to fluoride medications
and medications packaged and labeled for dental -specific purposes.
Formulary List means the listing of Preferred and Non -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 cost -sharing 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. Specific medications on the Formulary List and their placement in a given
therapeutic class are subject to change at any time without prior notice to you or your approval. It is your responsibility to
consult with your Attending Physician to determine whether a medication is on the Formulary List at the time the prescription
is rendered.
Generic Medication means a medication that has the same active ingredient as a Brand Medication or is identified as a
Generic Medication by AvMed's Pharmacy Benefits Manager.
Maintenance Medication is a medication that has been approved by the FDA, for which the duration of therapy can
reasonably be expected to exceed one year, as determined by AvMed's Pharmacy Benefits Manager.
Participating Pharmacy means a pharmacy (retail, mail order or specialty pharmacy) that has entered into an agreement
with AvMed to provide Prescription Medications to AvMed Members and has been designated by AvMed as a Participating
Pharmacy.
Specialty Medications are high cost medications that are self-administered by Members. These medications may be limited
in distribution to participating specialty pharmacies and Prior Authorization is often required.
HOW DOES YOUR RETAIL PRESCRIPTION COVERAGE WORK?
Cost -sharing for covered Prescription Medications (retail, mail order and specialty pharmacy), and any applicable
Prescription Medication Calendar Year Deductible, applies toward your Calendar Year Out -of -Pocket Maximum. To obtain
your Prescription Medication, take your prescription to, or have your Physician call, an AvMed Participating Pharmacy. Your
Physician should submit prescriptions for Specialty Medications to AvMed's specialty pharmacy. Present your prescription
along with your AvMed Identification Card. Once you meet your Prescription Medication Deductible (as shown below), you
will pay the following cost -sharing (as well as the Brand Additional Charge if you choose a Brand Medication when a Generic
equivalent is available).
Prescription Medication Benefit Deductible:
Individual $ 500.00 per Calendar Year
Family $ 1,000.00 per Calendar Year
Prescription Medication Retail Cost -sharing:
Tier 1 Value Generic Medications:
Tier 2
Tier 3
Tier 4
Tier 5
Generic Medications:
Preferred Brand Medications:
Non -preferred Brand or Non -preferred Generic Medications:
Specialty Medications:
$ 10.00
$ 25.00
$ 50.00
$ 100.00
30%
Copay per prescription
Copay per prescription
Copay per prescription
Copay per prescription
Coinsurance after Deductible
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 a 60 -90 -day supply
of your medication to be ordered through mail service. If the amount of medication is less than a 90 -day supply, you will still
be charged the listed mail order cost -sharing. Up to 2-3 refits are allowed per prescription. Pay the following cost -sharing (as
well as the Brand Additional Charge if you choose a Brand Medication when a Generic equivalent is available).
AV-LG-RX-19
Page 1 of 3 MP -7479 (07/20)
Prescription Medication Benefits, continued
Prescription Medication Mail Order Cost -sharing:
Tier 1
Tier 2
Tier 3
Tier 4
Tier 5
Value Generic Medications:
Generic Medications:
Preferred Brand Medications:
Non -preferred Brand or Non -preferred Generic Medications:
Specialty Medications are not available through mail service.
$ 25.00
$ 62.50
$ 125.00
$ 250.00
Copay per prescription
Copay per prescription
Copay per prescription
Copay per prescription
WHAT IS COVERED?
• Your Prescription Medication coverage includes outpatient medications that require a prescription and are prescribed by
your Attending Physician in accordance with AvMed's Coverage Criteria. AvMed reserves the right to make changes in
Coverage Criteria for covered products and services.
• Your Prescription Medication coverage may require Prior Authorization, and such Prior Authorization may include the
Progressive Medication Program for certain covered medications. A copy of the list of covered Prescription Medications,
drugs requiring Prior Authorization and drugs that are a part of the Progressive Medication Program are available from
AvMed's Member Engagement Center or from AvMed's website. The Progressive Medication Program encourages the use
of therapeutically -equivalent lower -cost medications by requiring certain medications to be utilized to treat a medical
condition prior to approving another medication for that condition. This includes the first -line use of Preferred Medications
that are proven to be safe and effective for a given condition and can provide the same health benefit as more expensive
Non -preferred Medications at a lower cost.
• Your retail Prescription Medications coverage includes up to a 30 -day supply of a medication for the listed cost -sharing.
Your prescription may be refilled via retail or mail order after 75% of your previous fill has been used and is subject to a
maximum of 12-13 refills per year. You also have the opportunity to obtain a 90 -day supply of medications used for chronic
conditions including asthma, cardiovascular disease, and diabetes from a retail pharmacy for the applicable cost -sharing
per 30 -day supply.
• Your mail-order Prescription Medication coverage includes up to a 60 -90 -day supply of a routine Maintenance Medication
for the listed cost -sharing. If the amount of medication is less than a 60 -90 -day supply, you will still be charged the listed mail
order cost -sharing.
• Your Specialty Medication coverage extends to many injectable and high cost oral medications approved by the FDA.
These medications must be prescribed by a Physician and dispensed by a participating specialty pharmacy. Specialty
Medications are limited to a 30 -day supply.
• Quantity limits are set in accordance with FDA approved prescribing limitations, general practice guidelines supported by
medical specialty organizations, and/or evidence -based, statistically valid clinical studies without published conflicting
data. This means that a medication -specific quantity limit may apply for medications that have an increased potential for
over -utilization or an increased potential for a Member to experience an adverse effect at higher doses.
• When ordered by your Physician, and accompanied by a prescription, certain contraceptives are covered under your
Prescription Medication benefits at no cost. Please refer to the Formulary List on AvMed's website or call Member
Engagement for more details.
NOTE: Your Group Medical and Hospital Service Contract contains important information about your coverage, including your
prescription medication coverage. Please review your Contract for a full description of services, supplies and conditions of
coverage.
QUESTIONS? Call AvMed Member Engagement at: 1-800-88-AvMed (1-800-882-8633)
EXCLUSIONS AND LIMITATIONS
• Allergy serums; however, 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
subject to cost -sharing as shown on the Schedule of Benefits.
• Compounded prescriptions, except pediatric preparations.
• Cosmetic products, including hair growth, skin bleaching, sun damage and anti -wrinkle medications.
• Dental -specific Medications for dental purposes, including fluoride medications (except for children less than 5 years of
age with a non -fluorinated water supply);
• Experimental or Investigational drugs (except as required by law);
• Fertility drugs;
• Immunizations (except for those preventive immunizations for routine use in children, adolescents, and adults that have in
effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and
Prevention);
• Medical supplies, including therapeutic devices, dressings, appliances and support garments;
• Medications and immunizations for non -business related travel, including Transdermal Scopolamine;
• Medications which do not require a prescription (i.e. over-the-counter medications) or when a non-prescription alternative
is available, unless otherwise indicated on AvMed's Formulary List, or unless considered preventive and given an 'A' or 'B'
AV-LG-RX-19
Page 2 of 3 MP -7479 (07/20)
Prescription Medication Benefits, continued
rating in current recommendations of the United States Preventive Services Task Force (USPSTF), and accompanied by a
prescription from your Attending Physician;
• Medications not included on AvMed's Formulary List;
• Medications or devices for the diagnosis or treatment of sexual dysfunction;
• Nutritional supplements except as described under Nutrition Therapy in Part IX. COVERED MEDICAL SERVICES;
• Prescription and non-prescription vitamins and minerals except prenatal vitamins;
• Prescription and non-prescription appetite suppressants and products for the purpose of weight loss;
• Replacement Prescription Drug products resulting from a lost, stolen, expired, broken or destroyed prescription order or refill.
• Third-Parly Assistance for Specialty Medications. If you use any third -party copayment assistance (sometimes also referred to
as a "copay card" or "copay coupon") provided by a drug manufacturer or any other entity to pay any applicable Calendar
Year Deductible, Copayment, or Coinsurance amounts for any Specialty Medications, you will not receive credit toward your
Calendar Year Out -of -Pocket Maximum or Calendar Year Deductible for any such assistance you use.
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 medications that require Prior 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.
James M. Repp
President & COO
AV-LG-RX-19
Page 3 of 3 MP -7479 (07/20)
Amendment
DOMESTIC PARTNER - TWELVE MONTH
AvMed
As of the Effective Date, the AvMed Large Group Medical and Hospital Service Contract, Part III. ELIGIBILITY
FOR COVERAGE, is amended by the addition of the following provisions:
Dependent Eligibility will be added for a Domestic Partner and his or her children. Declaration of a Domestic
Partner relationship by the Subscriber and the Subscriber's Domestic Partner, by sworn Affidavit, will be
considered a qualifying event that triggers a special enrollment period.
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 dependent eligibility requirements of the Employer's health benefits plan.
For further information, contact AvMed Member Engagement at 1-800-882-8633.
James M. Repp
President & COO
AV-LG-DP-19 MP -3147 (01/19)
Amendment
ELECTIVE TERMINATION OF PREGNANCY
AvMed
As of the Effective Date, the AvMed Large Group Medical and Hospital Service Contract with Point of
Service rider is amended as follows:
• Elective termination of pregnancy will be a Covered Benefit subject to any applicable Deductible, and
facility and physician charges.
• Member cost -sharing will apply toward the Calendar Year Out -of -Pocket Maximum.
• Prior Authorization is required.
For further information, contact AvMed Member Engagement at 1-800-882-8633.
James M. Repp
President & COO
AV-LG-ETOP-19 MP -6444 (01/19)
AvMed
Embrace
better health:!
Large Group Achieve Plan
Medical and Hospital Service Contract
James M. Repp
President & COO
AV-LG-COC-21 Achieve-LG-7636 (07/21)
TABLE OF CONTENTS
Service Area ii
I. INTRODUCTION 1
II. DEFINITIONS 2
III. ELIGIBILITY FOR COVERAGE 11
IV. ENROLLMENT AND EFFECTIVE DATE OF COVERAGE 13
V. TERMINATION 15
VI. PREMIUMS, COPAYMENTS, COINSURANCE, DEDUCTIBLES AND OTHER EXPENSES 21
VII. PHYSICIANS, HOSPITALS AND OTHER PROVIDERS 23
VIII. ACCESSING COVERED BENEFITS AND SERVICES 24
IX. COVERED MEDICAL SERVICES 26
X. LIMITATIONS OF COVERED MEDICAL SERVICES 39
XI. EXCLUSIONS FROM COVERED MEDICAL SERVICES 41
XII. PRESCRIPTION MEDICATION BENEFITS, LIMITATIONS AND EXCLUSIONS 48
XIII. REVIEW PROCEDURES AND HOW TO APPEAL A CLAIM (BENEFIT) DENIAL 50
XIV. COORDINATION OF BENEFITS 55
XV. SUBROGATION AND RIGHT OF RECOVERY 57
XVI. DISCLAIMER OF LIABILITY AND RELATIONSHIPS BETWEEN THE PARTIES 58
XVII. GENERAL PROVISIONS 59
AV-LG-COC-21 i Achieve-LG-7636 (07/21)
AVMED CORPORATE OFFICE
9400 S. DADELAND BOULEVARD
MIAMI, FL 33156-9004
AVMED MEMBER ENGAGEMENT CENTER - ALL AREAS
1-800-88 AVMED
(1-800-882-8633)
Alachua
Baker
Bradford
Broward
Citrus
Clay
Columbia
Dixie
Duval
Gilchrist
SERVICE AREA
Hamilton
Hernando
Hillsborough
Lake
Lee
Levy
Manatee
Marion
Miami -Dade
Nassau
Orange
SERVICE AREA OFFICES
MIAMI
9400 South Dadeland Boulevard
Miami, Florida 33156-9004
(305) 671-5437
(800) 432-6676
Osceola
Palm Beach
Pasco
Pinellas
Polk
St. Johns
Sarasota
Seminole
Suwannee
Union
GAINESVILLE
4300 Northwest 89th Boulevard
Post Office Box 749
Gainesville, Florida 32627-0749
(352) 372-8400
(800) 346-0231
AV-LG-COC-21 ii Achieve-LG-7636 (07/21)
AVMED, INC.
LARGE GROUP ACHIEVE PLAN
MEDICAL AND HOSPITAL SERVICE CONTRACT
IN CONSIDERATION of the payment of pre -paid monthly Premiums as provided herein, AvMed, Inc., a
private Florida not -for-profit corporation, state licensed as a health maintenance organization under
Chapter 641, Florida Statutes (hereinafter, "AvMed"), and the Subscribing Group as named on the Group
Master Application (hereinafter "Subscribing Group"), agree as follows:
I. INTRODUCTION
1.1 Provision of Health Care Services and Benefits. The Subscribing Group engages AvMed, on behalf
of the group health plan described in this Contract, to arrange for the provision of Covered Benefits
or Covered Services which are Medically Necessary for the diagnosis and treatment of Members of
the Subscribing Group. AvMed arranges for the delivery of Covered Services in accordance with
the covenants and conditions contained in this Contract, and does not directly provide these
Covered Services. AvMed will rely upon the statements of the Subscriber in his application in
arranging for the provision of Covered Services under this Contract.
1.2 Interpretation. In order to provide the advantages of Hospital and medical facilities and of In -
Network Providers, AvMed operates on a direct service rather than indemnity basis. The
interpretation of this Contract will be guided by the direct service nature of AvMed's program and
the definitions and other provisions contained herein.
1.3 Important Considerations. When reading your Contract, please remember:
a. You should read this Contract in its entirety in order to determine if a particular Health Care
Service is covered.
b. Many of the provisions of this Contract are interrelated. Therefore, reading just one or two
provisions may give you a misleading impression. Many words used in this Contract have special
meanings (see Part I I . DEFINITIONS).
c. The headings of Parts and Sections contained in this Contract are for reference purposes only
and will not affect in any way the meaning or interpretation of particular provisions.
1.4 References in this Contract
a. References to "you" or "your" throughout refer to you as the Subscriber and to your Covered
Dependents, unless expressly stated otherwise or unless, in the context in which the term is used,
it is clearly intended otherwise. Any references which refer solely to you as the Subscriber or
solely to your Covered Dependents will be noted as such.
b. References to "we", "us" and "our" throughout refer to AvMed.
c. Whenever used, the singular will include the plural and the plural the singular, and the use of
any gender will include all genders.
d. References to the "Plan" refer to this AvMed Large Group Achieve Plan.
e. If a word or phrase starts with a capital letter, it is either the first word in a sentence, a proper
name, a title, or a defined term. If a word or phrase has a defined meaning, it will either be in
Part II. DEFINITIONS or defined within the particular section where it is used.
1.5 Shared Savings Incentive Program. This Contract is eligible for the Shared Savings Incentive Program
per Section 641.31076, F.S. This voluntary program allows Members to participate in the savings
generated from Shoppable Health Care Services located at providers on the AvMed's shared
savings list.
a. AvMed's shared savings list is available at www.avmed.org/smartshopper. This list includes all
available Shoppable Health Care Services and their Shared Savings Incentive amount. Be
aware, this list may change. Please check frequently to ensure you have accurate information.
b. When you qualify for a reward, your Shared Saving Incentive will be sent to you by check
approximately 30 days after we confirm that you received care at an incentive eligible location.
AV-LG-COC-21 1 Achieve-LG-7636 (07/21)
c. AvMed must notify you, and the Office of Insurance Regulation, at least 30 days before
termination of this program.
1.6 Contract Renewal. This Contract is guaranteed renewable and will stay in effect as long as the
Subscribing Group meets and continues to meet the eligibility guidelines set forth in the Group
Master Application and Premiums are paid on time. Subscribing Group and Members are subject
to all terms, conditions, Limitations, and Exclusions in this Contract and to all of the rules and
regulations of the Plan. By paying Premiums or having Premiums paid on your behalf, you accept
the provisions of this Contract.
1.7 You must notify us immediately of any address change (or email us if you have opted for electronic
communications).
II. DEFINITIONS
As used in this Contract, each of the following terms will have the meaning indicated. For further definitions,
go to www.healthcare.gov/glossary to review the Uniform Glossary provided as a result of the Affordable
Care Act.
2.1 Accidental Dental Injury means an injury to Sound Natural Teeth (not previously compromised by
decay) caused by a sudden, unintentional, and unexpected event or force. This term does not
include injuries to the mouth, structures within the oral cavity, or injuries to Sound Natural Teeth
caused by biting or chewing, surgery or treatment for a disease or illness.
2.2 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; and including:
a. a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in
part) for, 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 or Investigational, or not Medically Necessary; and
b. a cancellation or discontinuance of coverage that has retroactive effect, unless attributable to
a failure to timely pay required Premiums or contributions toward the cost of coverage.
2.3 Allowed Amount means the maximum amount established by AvMed upon which payment will
be based for Covered Services rendered by In -Network Providers. The Allowed Amount may be
changed at any time without notice to you or your consent.
2.4 Ambulatory Surgery Center means a facility licensed pursuant to Chapter 395, Florida Statutes, the
primary purpose of which is to provide surgical care to a patient admitted to, and discharged
from, such facility within 24 hours.
2.5 Applied Behavior Analysis means the design, implementation, and evaluation of environmental
modifications, using behavioral stimuli and consequences, to produce socially significant
improvement in human behavior, including the use of direct observation, measurement, and
functional analysis of the relations between environment and behavior. Applied Behavior Analysis
services will be provided by an individual certified pursuant to Section 393.17, Florida Statutes, or an
individual licensed under Chapter 490 or Chapter 491, Florida Statutes.
2.6 Attending Physician means the Physician primarily responsible for the care of a Member with
respect to any particular Condition.
2.7 Autism Spectrum Disorders means any of the following disorders as defined in the most recent
edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric
Association:
a. Autistic disorder;
b. Asperger's syndrome;
c. Pervasive developmental disorder not otherwise specified.
AV-LG-COC-21 2 Achieve-LG-7636 (07/21)
2.8 AvMed Provider Network or AvMed Network means the Health Care Providers with whom AvMed
has contracted or made arrangements to provide Covered Benefits and Covered Services to
Achieve Plan Members.
2.9 Birthing Center means a facility licensed pursuant to Chapter 383, Florida Statutes, which is
freestanding, and is not a Hospital or in a Hospital, in which births are planned to occur away from
the mother's usual residence following a normal, uncomplicated, low -risk pregnancy. Birthing
Centers must provide facilities for obstetrical delivery and short-term recovery after delivery, care
under the full-time supervision of a Physician and either a registered nurse (R.N.) or a licensed nurse
midwife, and have a written agreement with a Hospital in the same locality for immediate
acceptance of patients who develop complications or require pre- or post- delivery confinement.
2.10 Breast Reconstructive Surgery means surgery to reestablish symmetry between the two breasts
following breast cancer treatment.
2.11 Calendar Year Deductible means the first payments up to a specified dollar amount that a Member
must make in the applicable calendar year for Covered Benefits. It is the amount you owe for
certain Covered Services before AvMed begins to pay, and must be satisfied once each calendar
year. The Calendar Year Deductible may not apply to all services. The Deductible applies to each
Member, subject to any family Deductible listed on the Schedule of Benefits. For purposes of the
Deductible, "family" means the Covered Employee and Covered Dependents.
2.12 Calendar Year Out -of -Pocket Maximum means the maximum amount you will pay during a
calendar year before AvMed begins to pay 100% of the Allowed Amount for Covered Services
during the same calendar year. This limit never includes your Premiums, Prescription Drug Brand
Additional Charges, third -party Copayment assistance toward Member cost -sharing for Specialty
Medications or charges for health care that AvMed does not cover.
2.13 Claim means a request for benefits under this Contract, made by or on behalf of a Member in
accordance with AvMed's procedures for filing benefit Claims.
a. Pre -Service Claim means any Claim for benefits under this Contract for which, in whole or in
part, a Claimant must obtain authorization from AvMed in advance of such services being
provided to or received by the Member.
b. Urgent Care Claim means any Claim for medical care or treatment for a Condition 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 Condition, would
subject the Member to severe pain that cannot be adequately managed without the care or
treatment requested.
c. Concurrent Care Claim means any request by a Claimant that relates to an Urgent Care Claim
to extend a course of treatment beyond the initial period of time or number of treatments
previously approved.
d. Post -Service Claim means any Claim for benefits under this Contract that is not a Pre -Service
Claim.
2.14 Claimant means a Member or a Member's authorized representative acting on behalf of a
Member. AvMed may establish procedures for determining whether an individual is authorized to
act on behalf of a Member with respect to a Claim for benefits.
2.15 Coinsurance means the portion of the cost for a Covered Service that a Member must pay once
any applicable Deductible has been met, and is expressed as a percentage, established solely by
AvMed, of the Allowed Amount for the Covered Service, or the percentage of an amount based
on the Maximum Medicare Allowable or Average Wholesale Price for the Covered Service.
Members are responsible for the payment of any applicable Coinsurance directly to a Health Care
Provider at the time Covered Services are received.
2.16 Condition means a disease, illness, ailment, injury, or pregnancy.
2.17 Contract means this AvMed Achieve Plan Large Group Medical and Hospital Service Contract,
which may at times be referred to as "Group Contract" or "Subscribing Group Contract" and all
AV-LG-COC-21 3 Achieve-LG-7636 (07/21)
Applications, Rate Letters (as described in Part XVII. GENERAL PROVISIONS), schedules,
amendments, and any other document approved by the Florida Office of Insurance Regulation for
incorporation into this Contract.
2.18 Copayment means the fixed dollar amount, established solely by AvMed, that a Member must pay
once any applicable Deductible has been met, for certain Covered Services rendered by a Health
Care Provider at the time the Covered Services are received. The Copayment is a portion of the
Allowed Amount for the Covered Service, or a portion of the Maximum Medicare Allowable or
Average Wholesale Price, for the Covered Service.
2.19 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. AvMed
reserves the right to make changes in Coverage Criteria for covered products and services.
2.20 Covered Benefits or Covered Services means those Health Care Services to which a Member is
entitled under the terms of this Contract. Member's cost -sharing responsibilities for Covered
Services, including any applicable Deductible, Copayments and Coinsurance amounts, are
outlined in the Schedule of Benefits.
2.21 Covered Dependent means any dependent of a Subscriber's family, who meets and continues to
meet all applicable eligibility requirements, and who is enrolled and actually covered under this
Contract other than as a Subscriber.
2.22 Custodial or Custodial Care means care that serves to assist an individual in the activities of daily
living, such as assistance in walking, getting in and out of bed, bathing, dressing, feeding, using the
toilet, preparation of special diets, and supervision of medication that usually can be self-
administered. Custodial Care essentially is personal care that does not require the continuing
attention of trained medical personnel. In determining whether a person is receiving Custodial
Care, consideration is given to the frequency, intensity and level of care, medical supervision
required and furnished, patient's diagnosis, type of Condition, degree of functional limitation, or
rehabilitation potential.
2.23 Dental Care means:
a. 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).
2.24 Detoxification means a process whereby an alcohol or drug intoxicated, or alcohol or drug
dependent, individual is assisted through the period of time necessary to eliminate, by metabolic
or other means, the intoxicating alcohol or drug, alcohol or drug dependent factors, or alcohol in
combination with drugs, as determined by a licensed Health Professional, while keeping the
physiological risk to the individual at a minimum.
2.25 Durable Medical Equipment (DME) is any equipment that meets all of the following requirements:
a. can withstand repeated use; and
b. is primarily and customarily used to serve a medical purpose; and
c. generally is not useful to a person in the absence of an illness or injury; and
d. is appropriate for use in the Member's home.
2.26 Emergency Medical Condition means:
a. A 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:
i. serious jeopardy to the health of a patient, including a pregnant woman or fetus;
ii. serious impairment to bodily functions; or
AV-LG-COC-21 4 Achieve-LG-7636 (07/21)
iii. serious dysfunction of any bodily organ or part; and
iv. with respect to a pregnant woman:
1) that there is inadequate time to effect safe transfer to another Hospital prior to delivery;
2) that a transfer may pose a threat to the health and safety of the patient or fetus; or
3) that there is evidence of the onset and persistence of uterine contractions or rupture
of the membranes.
b. Examples of Emergency Medical Conditions include heart attack, stroke, massive internal or
external bleeding, fractured limbs, or severe trauma.
2.27 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.
a. In -area emergency does not include elective or routine care, care of minor illnesses or care that
can reasonably be sought and obtained from the Member's in -network Physician. The
determination as to whether or not an illness or injury constitutes an Emergency Medical
Condition will be made by AvMed and may be made retrospectively based upon all
information known at the time the Member was present for treatment.
b. 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 Medical Condition will be made by
AvMed and may be made retrospectively based upon all information known at the time the
Member was present for treatment.
2.28 Essential Health Benefits has the meaning set forth under the Affordable Care Act, Section 1302(b),
and applicable regulations. The ten categories of Essential Health Benefits are:
a. ambulatory patient services;
b. emergency services;
c. hospitalization;
d. maternity and newborn care;
e. mental health and substance use disorder services (including behavioral health treatment);
f. prescription drugs;
g. rehabilitative and habilitative services and devices;
h. laboratory services;
i. preventive and wellness services and chronic disease management;
j. pediatric services (including oral and vision care).
2.29 Exclusion means any provision of this Contract whereby coverage for a specific hazard, service or
Condition is entirely eliminated.
2.30 Experimental or Investigational means:
a. Any evaluation, treatment, therapy, or device which involves the application, administration or
use, of procedures, techniques, equipment, supplies, products, remedies, vaccines, biological
products, drugs, pharmaceuticals, or chemical compounds if, as determined by AvMed:
i. such evaluation, treatment, therapy, or device cannot be lawfully marketed without
approval of the U.S. Food and Drug Administration (FDA) or the Florida Department of
Health and approval for marketing has not, in fact, been given at the time such is furnished
to the Member;
ii. such evaluation, treatment, therapy, or device is provided pursuant to a written protocol
which describes as among its objectives the following: determinations of safety, efficacy,
or efficacy in comparison to the standard evaluation, treatment, therapy, or device;
AV-LG-COC-21 5 Achieve-LG-7636 (07/21)
iii. such evaluation, treatment, therapy, or device is delivered or should be delivered subject
to the approval and supervision of an institutional review board or other entity as required
and defined by federal regulations;
iv. credible scientific evidence shows that such evaluation, treatment, therapy, or device is
the subject of an ongoing Phase I or II clinical investigation, or the experimental or research
arm of a Phase I II 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;
v. credible scientific evidence shows that the consensus of opinion among experts is that
further studies, research, or clinical investigations are necessary 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;
vi. credible scientific evidence shows that such evaluation, treatment, therapy, or device has
not been proven safe and effective for treatment of the Condition in question, as
evidenced in the most recently published medical literature in the United States, Canada,
or Great Britain, using generally accepted scientific, medical, or public health
methodologies or statistical practices.
b. Credible scientific evidence is defined by AvMed as one of the following:
i. records maintained by Physicians or Hospitals rendering care or treatment to the Member
or other patients with the same or similar Condition;
ii. reports, articles, or written assessments in authoritative medical and scientific literature
published in the United States, Canada, or Great Britain;
iii. published reports, articles, or other literature of the United States Department of Health
and Human Services or the United States Public Health Service, including any of the
National Institutes of Health, or the United States Office of Technology Assessment;
iv. the written protocol or protocols relied upon by the Attending Physician or institution or the
protocols of another Physician or institution studying substantially the same evaluation,
treatment, therapy, or device;
v. the written informed consent used by the Attending Physician or institution or by another
Physician or institution studying substantially the same evaluation, treatment, therapy, or
device; or
vi. the records (including any reports) of any institutional review board of any institution which
has reviewed the evaluation, treatment, therapy, or device for the Condition in question.
2.31 Full -Time Student or Part -Time Student means one who is attending a recognized and accredited
college, university, vocational or secondary school and is carrying sufficient credits to qualify as a
Full -Time or Part -Time Student in accordance with the requirements of the school.
2.32 Habilitation Services are services that help a person keep, learn or improve skills and functioning for
daily living. Such services may be provided in order for a person to attain and maintain a skill or
function never learned or acquired due to a disabling Condition. They are services that are
deemed necessary to meet the needs of individuals with developmental disabilities in programs
designed to achieve objectives of improved health, welfare and the realization of individuals'
maximum physical, social, psychological and vocational potential for useful and productive
activities.
2.33 Health Care Providers means Health Professionals and includes institutional providers, such as
Hospitals, Medical Offices or Other Health Care Facilities that are engaged in the delivery of Health
Care Services and are licensed and practice under an institutional license or other authority
consistent with state law.
2.34 Health Care Services (except as limited or excluded by this Contract) means the 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;
AV-LG-COC-21 6 Achieve-LG-7636 (07/21)
b. performed, prescribed or directed by Health Professionals acting within the scope of their
licenses; and
c. Medically Necessary (except for preventive services as stated herein) for the diagnosis and
treatment of injury or illness.
2.35 Health Professionals means allopathic and osteopathic Physicians, podiatrists, chiropractors,
physician assistants, nurses, licensed clinical social workers, pharmacists, optometrists, nutritionists,
occupational therapists, physical therapists, certified nurse midwives and midwives, and other
professionals engaged in the delivery of Health Care Services, who are appropriately licensed
under applicable state law.
2.36 Home Health Care Services (Skilled Home Health Care) means Physician -directed professional,
technical and related medical and personal care services provided on an intermittent or part-time
basis directly by (or indirectly through) a home health agency in your home or residence. Such
services include professional visiting nurses or other Health Professionals for services covered under
this Contract. For purposes of this definition, a Hospital, Skilled Nursing Facility, nursing home or other
facility will not be considered a home or residence.
2.37 Hospice means a public agency or private organization licensed pursuant to Chapter 400, Florida
Statutes, to provide Hospice services. Such licensed entity must be principally engaged in providing
pain relief, symptom management, and supportive services to terminally ill Members and their
families.
2.38 Hospital means a facility licensed pursuant to Chapter 395, Florida Statutes, that offers services
which are more intensive than those required for room, board, personal services and general
nursing care; offers facilities and beds for use beyond 24 hours; and regularly makes available at
least clinical laboratory services, diagnostic x-ray services and treatment facilities for surgery or
obstetrical care or other definitive medical treatment of similar extent.
a. The term Hospital does not include an Ambulatory Surgery Center; Skilled Nursing Facility; stand-
alone Birthing Center; convalescent, rest or nursing home; or facility which primarily provides
Custodial, educational or rehabilitative therapies.
b. If services specifically for the treatment of a physical disability are provided in a licensed Hospital
which is accredited by The Joint Commission, the American Osteopathic Association or the
Commission on the Accreditation of Rehabilitative Facilities, payment for these services will not
be denied solely because such Hospital lacks major surgical facilities and is primarily of a
rehabilitative nature. Recognition of these facilities does not expand the scope of Covered
Services. It only expands the setting where Covered Services can be performed for coverage
purposes.
2.39 Hospital -owned or affiliated means under common ownership, licensure or control of a Hospital. As
may be noted in your Schedule of Benefits, the cost -sharing for some services can vary depending
on whether or not they are obtained at a Hospital -owned or Hospital -affiliated facility. Also see
Independent Facility below.
2.40 Identification Card means the cards AvMed issues to Members. The card is our property and is not
transferable to another person. Possession of such card in no way verifies that a particular individual
is eligible for, or covered under, this Contract.
2.41 Independent Facility means a facility not under common ownership, licensure or control of a
Hospital. The cost -sharing for some services may vary depending on whether or not they are
obtained at an Independent Facility.
2.42 In -Network Provider means any Health Care Provider with whom AvMed has contracted or made
arrangements to render the Covered Benefits and Covered Services described in this Contract to
AvMed Achieve Plan Members. For a listing of In -Network Providers, please refer to your AvMed
Achieve Plan Provider Directory or visit our online directory at www.avmed.org.
2.43 Injectable Medication means a medication that is approved by the U.S. Food and Drug
Administration (FDA) for administration by one or more of the following routes: intra-articular,
intracavernous, intramuscular, intraocular, intrathecal, intravenous or subcutaneous injection; or
AV-LG-COC-21 7 Achieve-LG-7636 (07/21)
intravenous infusion. Medications intended to be injected or infused by a Health Professional are
generally covered as a medical benefit. Prior Authorization may be required for Injectable
Medications.
2.44 Intensive Outpatient Treatment means treatment in which an individual receives at least three
clinical hours of institutional care per day (24 -hour period) for at least three days a week and returns
home or is not treated as an inpatient during the remainder of that 24 -hour period. A Hospital shall
not be considered a 'home' for purposes of this definition.
2.45 Limitation means any provision other than an Exclusion that restricts coverage under this Contract.
2.46 Master Application means the Subscribing Group application form entitled 'Group Master
Application' which becomes a part of the Contract when the Group Master Application has been
completed and executed by the Subscribing Group and AvMed.
2.47 Material Misrepresentation means the omission, concealment of facts or incorrect statements
made on any application or enrollment forms by an applicant, Subscriber or Covered Dependent
which, had they been known, would have affected our decision to issue this Contract, the issuance
of different benefits, or the issuance of this Contract only at a higher rate.
2.48 Maximum Allowable Payment means the maximum amount, as established by AvMed, which
AvMed will pay for any Covered Service rendered by an Out -of -Network Provider or supplier of
services, medications or supplies, except for Emergency Medical Services and Care as defined
herein. The Maximum Allowable Payment may be changed at any time by AvMed without notice
to you or your consent.
2.49 Medical Office means any outpatient facility or Physician's office within the AvMed Achieve Plan
Service Area utilized by an in -network Health Professional.
2.50 Medical Supplies - outpatient disposable. Outpatient disposable Medical Supplies means
disposable medical supplies that are prescribed by a Physician for outpatient use; are usable only
by the Member for whom they are prescribed; have no further use when the medical need ends;
and are not primarily for comfort or hygiene, environmental control, or exercise.
2.51 Medically Necessary or Medical Necessity 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, as determined by AvMed, for the diagnosis, care or treatment of
a Member's illness or injury and which is:
a. consistent with the symptoms, 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;
d. not primarily intended for the personal comfort or convenience of the Member, the Member's
family, the Physician or other Health Professionals;
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; and
f. not Experimental or Investigational.
2.52 Medicare means the federal health insurance provided pursuant to Title XVIII of the Social Security
Act and all amendments thereto.
2.53 Member means any person who meets all applicable requirements of Part III. ELIGIBILITY FOR
COVERAGE and enrolls in the Plan as a Subscriber or Covered Dependent, and for whom the
Premium prepayment required by Part VI. PREMIUMS, COPAYMENTS, COINSURANCE, DEDUCTIBLES,
AND OTHER EXPENSES has actually been received by AvMed.
2.54 Mental/Behavioral Health Disorder means any disorder listed in the diagnostic categories of the
most recent International Classification of Disease, or their equivalents in the most recently
published version of the American Psychiatric Association's Diagnostic and Statistical Manual of
Mental Disorders, regardless of the underlying cause, or effect, of the disorder.
AV-LG-COC-21 8 Achieve-LG-7636 (07/21)
2.55 Morbid Obesity (clinically severe obesity) means a body mass index (BMI), as determined by an in -
network Health Professional as of the date of service, of:
a. 40 kilograms or greater per meter squared (kg/m2); or
b. 35 kilograms or greater per meter squared (kg/m2) with an associated comorbid condition such
as uncontrolled hypertension, type II diabetes, life -threatening cardiopulmonary conditions, or
severe sleep apnea.
2.56 Out -of -Network Provider means any Health Care Provider with whom AvMed has neither
contracted nor made arrangements to render the Covered Benefits or Covered Services described
in this Contract as an In -Network Provider.
2.57 Orthotic Appliances or Orthotic Devices means any rigid or semi -rigid device needed to support a
weak or deformed body part or to restrict or eliminate body movement.
2.58 Other Health Care Facility(ies) means any facility licensed in accordance with the laws of the
appropriate legally authorized agency, other than acute care Hospitals and those facilities
providing services to ventilator dependent patients, which provides inpatient services at an
intermediate or lower level of care such as skilled nursing care, Residential Treatment and
Rehabilitation Services.
2.59 Outpatient Rehabilitation Facility means an entity that renders, through Health Professionals licensed
pursuant to Florida law, outpatient physical, occupational, speech, pulmonary and cardiac
rehabilitation therapies for the primary purpose of restoring or improving a bodily function impaired
or eliminated by a Condition. The term Outpatient Rehabilitation Facility, as used herein, will not
include any Hospital, including a general acute care Hospital, or any separately organized unit of
a Hospital that provides comprehensive medical rehabilitation inpatient or rehabilitation outpatient
services, including a Class III or Class IV "specialty rehabilitation hospital" as described in Chapter
59A, Florida Administrative Code.
2.60 Pain Management means pain assessment, medication, physical therapy, biofeedback, and
counseling. Pain rehabilitation programs are programs featuring multidisciplinary services directed
toward helping those with chronic pain to reduce or limit their pain.
2.61 Partial Hospitalization means outpatient treatment in which an individual receives at least six clinical
hours of institutional care per day (24 -hour period) for at least five days per week and returns home
or is not treated as an inpatient during the remainder of that 24 -hour period. A Hospital shall not be
considered a "home" for purposes of this definition.
2.62 Participating Provider means any Health Care Provider with whom AvMed has contracted or made
arrangements to render the Covered Benefits and Covered Services described in this Contract to
AvMed Achieve Plan Members. For a listing of AvMed Achieve Plan Participating (In -Network)
Providers, please refer to your Provider Directory or visit our online directory at www.avmed.org.
2.63 Physician means any provider licensed under Chapter 458 (Physician), 459 (osteopath), 460
(chiropractor) or 461 (podiatrist), Florida Statutes.
2.64 Premium means the total amount of monthly prepayment subscription charges required to be paid
by the Subscribing Group to AvMed in order for there to be coverage under this Contract.
2.65 Prescription Medication or Prescription Drug means a medication that is approved by the FDA and
that can only be dispensed pursuant to a prescription in accordance with state and federal law.
For more information, please see Part XII. PRESCRIPTION MEDICATION BENEFITS, LIMITATIONS AND
EXCLUSIONS.
2.66 Primary Care Physician (PCP) means any Achieve Plan in -network Physician engaged in general or
family practice, internal medicine, pediatrics, geriatrics, obstetrics/gynecology or any Specialty
Physician from time to time designated by AvMed as a 'Primary Care Physician' in AvMed's current
list of In -Network Providers. A PCP is one who directly provides or coordinates a range of Health
Care Services for a Member.
2.67 Prior Authorization means a decision by AvMed, prior to the time a Health Care Service or other
benefit is to be delivered, that the Health Care Services are Medically Necessary. Prior Authorization
AV-LG-COC-21 9 Achieve-LG-7636 (07/21)
is sometimes called pre -authorization, prior approval or pre -certification. AvMed requires you or
your Physician to obtain Prior Authorization for certain services and medications before you receive
them to ensure that you receive the most appropriate treatment. Prior Authorization is not a promise
that AvMed will cover the cost of such services or medications.
2.68 Prosthetic Device means a device which replaces all or part of a body part or an internal body
organ or replaces all or part of the functions of a permanently inoperative or malfunctioning body
part or organ.
2.69 Rehabilitation Services are Health Care Services that help a person keep, get back, or improve skills
and functioning for daily living that have been lost or impaired because a person was sick, injured
or disabled. These services may include physical and occupational therapies, speech -language
pathology and psychiatric Rehabilitation Services in a variety of inpatient or outpatient settings.
2.70 Residential Treatment is a 24 -hour intensive, structured and supervised treatment program providing
inpatient care but in a non -Hospital environment, and is utilized for those mental health or substance
use disorders that cannot be effectively treated in an outpatient or Partial Hospitalization
environment.
2.71 Retail Clinics are a category of walk-in medical facilities located inside pharmacies, supermarkets
and other retail establishments that treat uncomplicated minor illnesses and provide preventive
Health Care Services, generally delivered by nurse practitioners, and often without a Physician on
the premises.
2.72 Service Area means those counties in the State of Florida where AvMed has been approved to
conduct business by the Agency for Health Care Administration (AHCA), and where Covered
Benefits and Covered Services are available from In -Network Providers to Members of the AvMed
Achieve Plan.
2.73 Shared Savings Incentive means a voluntary and optional financial incentive that a health insurer
may provide to an insured for choosing certain Shoppable Health Care Services under a Shared
Savings Incentive Program.
2.74 Shoppable Health Care Service means a lower -cost, high -quality nonemergency Health Care
Service for which a Shared Savings Incentive is available for insureds under a health insurer's Shared
Savings Incentive Program.
2.75 Skilled Nursing Facility means an institution or part thereof that is licensed as a Skilled Nursing Facility
by the State of Florida, and is accredited as a Skilled Nursing Facility by The Joint Commission or
recognized as a Skilled Nursing Facility by the Secretary of Health and Human Services of the United
States under Medicare.
2.76 Sound Natural Teeth (Tooth) means teeth that are whole or properly restored (restoration with
amalgams, resin or composite only); are without impairment, periodontal, or other Conditions; and
are not in need of services provided for any reason other than an Accidental Dental Injury. For
purposes of this Contract, a tooth previously restored with a crown inlay, onlay, or porcelain
restoration, or treated by endodontics, is not considered a Sound Natural Tooth.
2.77 Specialty Physician means any in -network Physician licensed under Chapter 458 (Physician), 459
(osteopath), 460 (chiropractor) or 461 (podiatrist), Florida Statutes, other than the Member's Primary
Care Physician.
2.78 Subscriber means an employee of the Subscribing Group who meets all applicable requirements
of Part III . ELIGIBILITY FOR COVERAGE, enrolls in the Plan, and for whom the Premium prepayment
required by Part VI. PREMIUMS, COPAYMENTS, COINSURANCE, DEDUCTIBLES AND OTHER EXPENSES,
has actually been received by AvMed.
2.79 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 Care
Services and benefits provided herein for its eligible employees.
2.80 Substance Dependency means a Condition where a person's alcohol or drug use injures his health,
interferes with his social or economic functioning, or causes the individual to lose self-control.
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2.81 Total Disability means a totally disabling Condition resulting from an illness or injury that prevents a
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.
2.82 Urgent Care Center means a facility licensed to provide care for minor injuries and illnesses that
require immediate attention, but are not severe enough for a trip to an emergency facility,
including cuts, sprains, eye injuries, colds, flu, fever, insect bites, and simple fractures. For purposes
of this Contract, an Urgent Care Center is not a Hospital, Skilled Nursing Facility, Outpatient
Rehabilitation Facility or Retail Clinic.
2.83 Urgent Medical Condition means a Condition manifesting itself by acute symptoms that are of lesser
severity than those recognized for an Emergency Medical Condition, such that a prudent layperson
who possesses an average knowledge of health and medicine could reasonably expect the illness
or injury to place the health or safety of the Member or another individual in serious jeopardy, in the
absence of medical treatment within 24 hours. Examples of Urgent Medical Conditions include high
fever, dizziness, animal bites, sprains, severe pain, respiratory ailments and infectious illnesses.
2.84 Urgent Medical Services and Care means medical screening, examination and evaluation in an
ambulatory setting outside of a Hospital emergency department, including an Urgent Care Center,
Retail Clinic or PCP office after-hours, on a walk-in basis and usually without a scheduled
appointment; and the Covered Services for those Conditions which, although not life -threatening,
could result in serious injury or disability if left untreated.
2.85 Utilization Management Programs means those comprehensive initiatives that are designed to
validate medical appropriateness, including Medical Necessity, and to coordinate Covered
Services and supplies, including:
a. concurrent review of all patients hospitalized in acute care, psychiatric, rehabilitation, and
Skilled Nursing Facilities, including on -site review when appropriate;
b. 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
c. prospective reviews for select Health Care Services to ensure that services are Medically
Necessary Covered Benefits under this Contract.
2.86 Ventilator Dependent Care Unit means any facility, other than an acute care Hospital setting, that
provides services to ventilator dependent patients 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 an Independent Facility or maintained in a Hospital or
Skilled Nursing Facility setting.
2.87 Virtual Visits:
a. Telehealth Services are live, interactive audio and visual transmissions of a Physician -patient
encounter from one site to another, using telecommunications technologies and may include
transmissions of real-time telecommunications or those transmitted by store -and -forward
technology.
b. Telemedicine Services are Health Care Services provided via telephone, the Internet, or other
communications networks or devices that do not involve direct, in -person patient contact.
III. ELIGIBILITY FOR COVERAGE
Any employee and the dependents of an employee who meet and continue to meet the eligibility
requirements described in this Contract, will be entitled to enroll in coverage under this Contract. These
eligibility requirements are binding upon you and your eligible dependents. We may require acceptable
documentation that an individual meets and continues to meet the eligibility requirements (e.g. proof of
residency, copies of a court order naming the Subscriber as legal guardian, or appropriate adoption
documentation, as described in Part IV. ENROLLMENT AND EFFECTIVE DATE OF COVERAGE).
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11 Achieve-LG-7636 (07/21)
3.1 Subscriber Eligibility. To be eligible to enroll as a Subscriber, a person must be:
a. an employee of the Subscribing Group who works the required number of hours per week as
set forth in the Group Master Application for this Contract. The employee must either work or
reside in the Achieve Plan Service Area; and
b. employed for the period of time required for eligibility as set forth in the Group Master
Application; and
c. entitled on his own behalf to participate in the medical and Hospital care benefits arranged by
the Subscribing Group under this Contract.
3.2 Dependent Eligibility. To be eligible to enroll as a Covered Dependent, a person must be:
a. the spouse of a Subscriber under a legally valid existing marriage; or
b. the child of a Subscriber or a Covered Dependent of the Subscriber, provided that the following
conditions apply:
i. the child is under the age of 26; and
ii. the natural child or stepchild of the Subscriber;
iii. a legally adopted child in the custody of the Subscriber;
iv. a child for whom the Subscriber or the Subscriber's covered spouse has been appointed
legal guardian pursuant to a valid court order; or
v. the newborn child of a Covered Dependent child of the Subscriber (such coverage
terminates 18 months after the birth of the newborn child).
3.3 Qualified Medical Child Support Order (QMCSO). In the event an eligible dependent child does not
reside with the Subscriber, coverage will be extended when the Subscriber is obligated by QMCSO
to provide medical care. You (or your beneficiaries) may obtain, without charge, copies of the
Plan's procedures governing QMCSOs and a sample QMCSO by contacting the Plan Administrator.
3.4 Extended Coverage for Dependent Children
a. Dependent Children Aged 26 to 30. A dependent child who meets the following requirements
may be eligible for coverage until the end of the calendar year in which the child reaches age
30, if the child:
i. is unmarried and does not have a dependent of his own;
ii. resides within the Service Area, or is a Full -Time or Part -Time Student; and
iii. is not provided coverage under any other group, blanket or franchise health insurance
policy or individual health benefits plan, or is not entitled to benefits under Medicare.
b. Continuous Coverage Requirement. If an eligible dependent child is covered under this
Contract after reaching age 26, and the child's coverage is subsequently terminated before
the end of the calendar year in which the child reaches age 30, the child is ineligible to be
covered again under this Contract unless the child was continuously covered by other
creditable coverage without a coverage gap of more than 63 days.
c. Children with Disabilities - Attainment of Limiting Age. Attainment of the limiting age by an
eligible dependent child will not operate to exclude from or terminate the coverage of such
child while such child is, and continues to be, both:
i. incapable of self-sustaining employment by reason of intellectual or physical disability; and
ii. chiefly dependent upon the Subscriber for support and maintenance.
iii. Proof of such incapacity and dependency must be furnished to AvMed within 30 days
after the date the child attains 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.
d. Dependent Students on Medically Necessary Leave of Absence
i. If an eligible dependent child is covered because they are a Full -Time or Part -Time Student
at a post -secondary school, and they no longer meet the Plan's definition of Full -Time or
AV-LG-COC-21
12 Achieve-LG-7636 (07/21)
Part -Time Student due to a Medically Necessary leave of absence, coverage may be
extended until the earlier of the following:
1) one year after the Medically Necessary leave of absence begins; or
2) the date coverage would otherwise terminate under the Contract.
ii. The Medically Necessary leave of absence or change in enrollment status must begin
while the child is suffering from a serious illness or injury; or the leave of absence from the
school must be medically certified by the child's Attending Physician; and
iii. certification must state that the child is suffering from a serious illness or injury and that the
leave of absence (or other change of enrollment) is Medically Necessary.
3.5 Eligibility Requirements Control. The eligibility requirements set forth herein 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 this Part.
3.6 Enrollment Restriction. No person is otherwise eligible to enroll hereunder whose AvMed coverage
was previously terminated for non-payment of Premium or cause, except with AvMed's written
approval.
IV. ENROLLMENT AND EFFECTIVE DATE OF COVERAGE
With respect to eligible employees and eligible dependents properly enrolled, coverage becomes
effective, at 12:00 a.m. on the date specified in your Plan materials. With respect to eligible individuals who
are subsequently enrolled, coverage will become effective at 12:00 a.m. on the date described in this Part.
Any individual who is not properly enrolled hereunder will not be covered under this Contract, and AvMed
has no obligation whatsoever to any individual who is not properly enrolled.
4.1 Open Enrollment. During the Subscribing Group's annual open enrollment period any eligible
employee, on behalf of himself and his eligible dependents, may elect to enroll in the Plan. Eligible
employees and eligible dependents who enroll during the open enrollment period will be covered
Members as of the effective date of this Contract or the subsequent anniversary thereof.
4.2 Initial Enrollment. New employees who are eligible for coverage must enroll by submitting any
application forms acceptable to or provided by AvMed, along with supporting documentation as
may be required, within 30 days after the date of becoming eligible. The effective date of coverage
for an eligible new employee will be (i) the date immediately following completion of any
applicable waiting period, or (ii) the first of the month following completion of any applicable
waiting period, as set forth in the Group Master Application. If the required information is not
received within 30 days after the date of eligibility the new employee may not enroll until the
Subscribing Group's next annual open enrollment period, or a special enrollment period if
applicable.
4.3 Special Enrollment. Under the circumstances described below, referred to as "qualifying events",
eligible employees and/or eligible dependents may request to enroll in the Plan outside of the initial
and annual open enrollment periods, during a special enrollment period.
a. If an eligible employee or eligible dependents declined coverage under the Plan when it was
first offered because of other group health plan or insurance coverage and that other
coverage is lost due to any of the following qualifying events, the eligible employee or eligible
dependents are entitled to a special enrollment period. Loss of other coverage due to an
individual's failure to pay Premiums (including COBRA Premiums) on a timely basis, or
termination of coverage for cause (fraud or intentional misrepresentation of material fact) will
not trigger a special enrollment period.
i. exhaustion of COBRA continuation coverage;
ii. termination of employment or reduction in hours of employment;
iii. termination of employer Premium contributions;
AV-LG-COC-21 13 Achieve-LG-7636 (07/21)
iv. change in dependent status due to: attainment of limiting age, change in legal custody
or legal guardianship, divorce or annulment, or the death of an employee whose
employment afforded the dependent coverage;
v. relocation out of an HMO service area;
vi. gaining eligibility for Premium assistance subsidy, or termination of coverage due to loss of
eligibility, under Medicaid or CHIP.
b. Upon gaining a new dependent (or dependents) as a result of any of the following qualifying
events, a covered employee's new dependents, or an eligible employee on behalf of himself
and his new dependents, may request to enroll during the special enrollment period, providing
such dependents are otherwise eligible for coverage:
i. marriage;
ii. birth;
iii. adoption or placement for adoption; or
iv. child support order or other court order (except for a court order to cover a former spouse) .
4.4 Special Enrollment Procedures
a. A covered employee's eligible dependents, or an eligible employee on behalf of himself and
his eligible dependents, must enroll by submitting any application or enrollment forms
acceptable to or provided by AvMed, along with supporting documentation as we may
require, within the following timeframes; otherwise, the eligible employee and/or eligible
dependents must wait until the Subscribing Group's next annual open enrollment period:
i. within 30 days after the date of the loss of other coverage (proof of continuous other
coverage is required);
ii. within 30 days after the date of marriage (certificate of marriage is required);
iii. within 30 days after the date of placement in the Subscriber's home for adoption, or
adoption, of a child other than a newborn (proof of such placement or adoption is
required);
iv. within 60 days after gaining eligibility for Premium assistance, or loss of eligibility, under
Medicaid or CHIP (proof of such change in eligibility is required);
v. within 60 days after the birth of a child, including an adopted newborn child, as described
below (for an adopted newborn, a copy of a written agreement to adopt, entered into
by the Subscriber prior to the birth of such child, is required).
1) If notice is given within 30 days after the date of birth, no additional Premium will be
charged for the newborn child's coverage during the 30 -day period immediately
following the newborn's birth.
2) If notice is received within 31 to 60 days after the date of birth, we will charge the
applicable Premium from the date of birth. You must pay the additional Premium for
coverage to be provided for the newborn child.
3) If notice is not received within 60 days after the date of birth, the child may not be
enrolled until the Subscribing Group's next open enrollment period.
4.5 Special Enrollment Effective Date of Coverage. The effective date of any coverage provided by
AvMed is dependent upon the timely receipt of any enrollment forms and supporting
documentation we may require. If received within the required timeframes, coverage will become
effective as described below; otherwise, a Subscriber's eligible dependents, or an eligible
employee on behalf of himself and his eligible dependents, may not enroll until the Subscribing
Group's next open enrollment period:
a. General Effective Date. Except as provided for newborns and adopted children (including
adopted newborns), the effective date of coverage for eligible individuals properly enrolled will
be the first day of the first month following receipt of the enrollment request.
b. Newborns and Adopted Newborns. The effective date of coverage for a natural newborn child
properly enrolled will be the moment of birth. For an adopted newborn properly enrolled,
AV-LG-COC-21 14 Achieve-LG-7636 (07/21)
coverage will be effective from the moment of birth provided a written agreement to adopt
such child was entered into by the Subscriber prior to the birth of the child. However, coverage
will not be required if the child is not ultimately placed in the Subscriber's home in compliance
with Chapter 63, Florida Statutes.
c. Adopted Children other than Newborns. The effective date of coverage for an adopted child
properly enrolled, other than a newborn, will be the moment of placement in the Subscriber's
home for adoption, or the date of adoption, whichever is earlier. However, coverage will not
be required if the child is not ultimately placed in the Subscriber's home in compliance with
Chapter 63, Florida Statutes.
d. Qualified Medical Child Support Order (QMCSO). If a court has ordered coverage to be
provided by you for a minor child who is an eligible dependent, you must submit to us any
required application or enrollment forms including a copy of the court order, along with any
additional Premium due. The effective date of coverage for the eligible dependent properly
enrolled will be the date of the order. You must pay the additional Premium for coverage to be
provided for the eligible dependent.
V. TERMINATION
This Contract will 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 will cease at 12:00 a.m. (midnight) on the effective date of termination unless otherwise stated.
5.1 Termination of Group Contract by Subscribing Group
a. Termination on Anniversary Date. The Subscribing Group may terminate this Group Contract on
the anniversary date by giving written notice to AvMed 15 days prior to the Contract anniversary
date. In such event, benefits hereunder will terminate for all Members on the Group Contract
expiration date.
b. Early Termination. The Subscribing Group may terminate this Group Contract by giving at least
45 days prior written notice to AvMed. In such event, benefits hereunder will terminate for all
Members on the date specified by the Subscribing Group in their written notice to AvMed and
for which the Premium was paid.
5.2 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
will terminate for all Members on the Contract termination date as described.
a. Termination of Group Contract for Cause
i. Failure to Make Premium Payment. If the Subscribing Group fails to make payment of the
monthly Premium by the Premium due date and within the grace period as provided in
Part VI. PREMIUMS, COPAYMENTS, COINSURANCE, DEDUCTIBLES AND OTHER EXPENSES,
coverage hereunder will terminate for all Members for whom Premium payment has not
been received, on the last day for which the monthly Premium was received.
1) Coverage will remain in effect during the grace period. However, if Premium payments
are not received by the end of the grace period, and AvMed has provided the
Subscribing Group written notice of termination within 45 days after the Premium due
date, late payment fees may apply and AvMed may retroactively terminate the
Subscribing Group's coverage.
ii. Breach of Material Contract Provision. If the Subscribing Group fails to comply with a
material provision of the Contract that relates to rules for employer Premium contributions
or group participation, termination will be effective upon 45 days written notice from
AvMed to the Subscribing Group.
iii. Fraud/Material Misrepresentation. If the Subscribing Group performs an act or practice
that constitutes fraud, or makes an intentional misrepresentation of material fact under the
terms of this Contract, the Subscribing Group's coverage will be immediately terminated.
AV-LG-COC-21 15 Achieve-LG-7636 (07/21)
b. Notification by Subscribing Group Required. In the event of termination for the reasons
described in paragraphs 5.2 a i. through 5.2 a iii. above, the Subscribing Group agrees to
provide written notification of such termination to all its employees who are Subscribers under
this Contract, and AvMed will be deemed to have complied with its notification requirements.
c. No Enrollees in Service Area. If there are no longer any enrollees in connection with the Plan
who work or reside in the Service Area, termination of coverage will be effective on the last day
of the month for which Premium payments were received by AvMed.
d. Discontinuation of Large Group Plans or Product
i. If we cease to offer AvMed Achieve Plans for Large Groups in the Service Area, we will
provide written notice to the Subscribing Group at least 90 days prior to such
discontinuation.
ii. If we cease to offer any Large Group coverage in the Service Area, we will provide written
notice to the Subscribing Group at least 180 days prior to such discontinuation.
e. Failure to Meet Eligibility or Participation Requirements. The Subscribing Group must meet group
eligibility guidelines at each renewal period as specified in the Rate Letter (as defined in Part
XVII. GENERAL PROVISIONS) to the Subscribing Group. Prior to the Subscribing Group's Contract
anniversary date, AvMed will request written documentation to verify eligibility and
participation requirements. Failure to timely meet such requirements, or return the appropriate
documentation, will result in the termination of this Group Contract on the Subscribing Group's
anniversary date.
5.3 Termination of a Member's Coverage
a. Loss of Eligibility. Subject to the continuation rights described herein:
i. Subscribers
1) Termination of Employment. Upon the loss of a Subscriber's eligibility for coverage due
to termination of employment, coverage for the Subscriber and the Subscriber's
Covered Dependents will terminate on the last day of the Subscriber's employment,
or the last day of the month for which the monthly Premium was paid and during which
the Subscriber was eligible for coverage, as set forth in the Group Master Application.
2) Other Loss of Eligibility. Upon the loss of a Subscriber's eligibility for coverage due to a
qualifying event other than termination of employment, coverage for the Subscriber
and the Subscriber's Covered Dependents will terminate on the date of the qualifying
event, or the last day of the month for which the monthly Premium was paid and during
which the Subscriber was eligible for coverage, as set forth in the Group Master
Application.
ii. Covered Dependents. Upon the loss of a Covered Dependent's eligibility except as
described in the following paragraphs 1) and 2), coverage will terminate on the date
eligibility is lost, or the last day of the month for which the monthly Premium was paid and
during which the Covered Dependent was eligible for coverage, as set forth in the Group
Master Application.
1) Covered Dependent children who reach age 26 and are not otherwise eligible for
coverage, will cease to be covered on the last day of the month during which the
child turns 26.
2) Covered Dependent children who reach age 30 and are not otherwise eligible for
coverage, will cease to be covered on the last day of the calendar year during which
the child turns 30.
iii. Notification Requirements - Responsibility of Subscribing Group and Subscriber
1) It is the sole responsibility of the Subscribing Group to notify AvMed in writing within 30
days after the effective date of termination regarding any Subscriber who becomes
ineligible to participate in the Plan.
2) It is the sole responsibility of Subscribers to notify AvMed in writing within 30 days after
the date of a Covered Dependent's loss of eligibility.
AV-LG-COC-21 16 Achieve-LG-7636 (07/21)
3) Failure of the Subscribing Group or Subscribers to provide timely written notice may
lead to retroactive termination of the Subscriber and/or Covered Dependents. The
effective date for any such retroactive termination will be the last day for which the
Premium was received by AvMed, and during which the Subscriber and/or Covered
Dependents were eligible for coverage.
b. Termination of Coverage for Cause
i. AvMed may terminate the coverage of any Member immediately upon written notice for
the following reasons which lead to a loss of Member eligibility:
1) fraud, intentional Material Misrepresentation of fact, or intentional omission in applying
for membership, coverage or benefits 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 Contract or deny any Claim
for a loss occurred or disability starting after the two-year period;
2) misuse of AvMed's Identification Card furnished to the Member;
3) furnishing to AvMed incorrect or incomplete information for the purpose of obtaining
membership, coverage or benefits under this Contract; or
4) 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.
5.4 Retroactive Termination. Retroactive adjustments in coverage will only be made for up to a 60 -day
period from the date of notification. In the event of retroactive termination due to the Subscribing
Group's nonpayment of Premiums, or failure of the Subscribing Group or Members to timely notify
AvMed of Member ineligibility, AvMed will not be responsible for Claims we incur in arranging for
the provision of benefits to Members under the terms of this Contract after the effective date of
such retroactive termination.
5.5 AvMed's Obligations upon Termination. Upon termination of your coverage for any reason, AvMed
will have no further liability or responsibility to you under this Contract whatsoever, except as
specifically described herein.
5.6 Continuation Coverage Rights Under COBRA
a. Introduction.
i. This notice has important information about your right to COBRA continuation coverage,
which is a temporary extension of coverage under the Plan. This notice explains COBRA
continuation coverage, when it may become available to you and your family, and what
you need to do to protect your right to get it. When you become eligible for COBRA, you
may also become eligible for other coverage options that may cost less than COBRA
continuation coverage.
ii. The right to COBRA continuation coverage was created by a federal law, the
Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation
coverage can become available to you and other members of your family when group
health coverage would otherwise end. For more information about your rights and
obligations under the Plan and under federal law, you should review the Plan's Summary
Plan Description or contact the Plan Administrator.
iii. You may have other options available to you when you lose group health coverage. For
example, you may be eligible to buy an individual plan through the Health Insurance
Marketplace. By enrolling in coverage through the Marketplace, you may qualify for lower
costs on your monthly premiums and lower out-of-pocket costs. Additionally, you may
qualify for a 30 -day special enrollment period for another group health plan for which you
are eligible (such as a spouse's plan), even if that plan generally doesn't accept late
enrollees.
AV-LG-COC-21 17 Achieve-LG-7636 (07/21)
b. What is COBRA continuation coverage?
i. COBRA continuation coverage is a continuation of Plan coverage when it would otherwise
end because of a life event. This is also called a "qualifying event." Specific qualifying
events are listed later in this notice. After a qualifying event, COBRA continuation
coverage must be offered to each person who is a "qualified beneficiary." You, your
spouse, and your dependent children could become qualified beneficiaries if coverage
under the Plan is lost because of the qualifying event. Under the Plan, qualified
beneficiaries who elect COBRA continuation coverage must pay the entire cost for
COBRA continuation coverage, plus a 2% administrative fee for the duration of the COBRA
continuation coverage.
ii. If you're an employee, you'll become a qualified beneficiary if you lose your coverage
under the Plan because of the following qualifying events:
1) Your hours of employment are reduced, or
2) Your employment ends for any reason other than your gross misconduct.
iii. If you're the spouse of an employee, you'll become a qualified beneficiary if you lose your
coverage under the Plan because of the following qualifying events:
1) Your spouse dies;
2) Your spouse's hours of employment are reduced;
3) Your spouse's employment ends for any reason other than his or her gross misconduct;
4) Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or
5) You become divorced or legally separated from your spouse.
iv. Your dependent children will become qualified beneficiaries if they lose coverage under
the Plan because of the following qualifying events:
1) The parent -employee dies;
2) The parent -employee's hours of employment are reduced;
3) The parent -employee's employment ends for any reason other than his or her gross
misconduct;
4) The parent -employee becomes entitled to Medicare benefits (Part A, Part B, or both);
5) The parents become divorced or legally separated; or
6) The child stops being eligible for coverage under the Plan as a "dependent child."
v. If your plan offers retiree coverage, filing a proceeding in bankruptcy under Title 11 of the
United States Code can be a qualifying event. If a proceeding in bankruptcy is filed with
respect to your employer, and that bankruptcy results in the loss of coverage of any retired
employee covered under the Plan, the retired employee will become a qualified
beneficiary. The retired employee's spouse, surviving spouse, and dependent children will
also become qualified beneficiaries if bankruptcy results in the loss of their coverage under
the Plan.
c. When is COBRA continuation coverage available?
i. The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the
Plan Administrator has been notified that a qualifying event has occurred. The employer
must notify the Plan Administrator of the following qualifying events:
1) The end of employment or reduction of hours of employment;
2) Death of the employee;
3) If your Plan provides retiree health coverage, the commencement of a proceeding in
bankruptcy with respect to the employer; or
4) The employee's becoming entitled to Medicare benefits (under Part A, Part 8, or both).
ii. For all other qualifying events (divorce or legal separation of the employee and spouse or
a dependent child's losing eligibility for coverage as a dependent child), you must notify
the Plan Administrator within 60 days. You must provide this notice to: AvMed Enrollment
and Premium Services, using the contact information listed at the end of this Notice. You
AV-LG-COC-21 18 Achieve-LG-7636 (07/21)
must include the Member's name, ID number and address, the names of all qualified
beneficiaries, and the name of the Subscribing Group.
d. How is COBRA continuation coverage provided?
i. Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA
continuation coverage will be offered to each of the qualified beneficiaries. Each
qualified beneficiary will have an independent right to elect COBRA continuation
coverage. Covered Employees may elect COBRA continuation coverage on behalf of
their spouses, and parents may elect COBRA continuation coverage on behalf of their
children.
ii. COBRA continuation coverage is a temporary continuation of coverage that generally
lasts for 18 months due to employment termination or reduction of hours of work. Certain
qualifying events, or a second qualifying event during the initial period of coverage, may
permit a beneficiary to receive a maximum of 36 months of coverage.
iii. There are also ways in which this 18 -month period of COBRA continuation coverage can
be extended:
1) Disability extension of 18 -month period of COBRA continuation coverage. If you or
anyone in your family covered under the Plan is determined by Social Security to be
disabled and you notify the Plan Administrator in a timely fashion, you and your entire
family may be entitled to get up to an additional 11 months of COBRA continuation
coverage, for a maximum of 29 months. The disability would have to have started at
some time before the 60th day of COBRA continuation coverage and must last at least
until the end of the 18 -month period of COBRA continuation coverage. The Plan
Administrator must be notified before the end of the initial 18 months of COBRA
coverage, and within 60 days after the date of the disability determination.
2) Second qualifying event extension of 18 -month period of continuation coverage. If
your family experiences another qualifying event during the 18 months of COBRA
continuation coverage, the spouse and dependent children in your family can get up
to 18 additional months of COBRA continuation coverage, for a maximum of 36
months, if the Plan is properly notified about the second qualifying event. This extension
may be available to the spouse and any dependent children getting COBRA
continuation coverage if the employee or former employee dies; becomes entitled to
Medicare benefits (under Part A, Part B, or both); gets divorced or legally separated;
or if the dependent child stops being eligible under the Plan as a dependent child. This
extension is only available if the second qualifying event would have caused the
spouse or dependent child to lose coverage under the Plan had the first qualifying
event not occurred.
e. Are there other coverage options besides COBRA Continuation Coverage? Yes. Instead of
enrolling in COBRA continuation coverage, there may be other coverage options for you and
your family through the Health Insurance Marketplace, Medicaid, or other group health plan
coverage options (such as a spouse's plan) through what is called a "special enrollment
period." Some of these options may cost less than COBRA continuation coverage. You can
learn more about many of these options at www.healthcare.gov.
f. If you have questions. Questions concerning your Plan or your COBRA continuation coverage
rights should be addressed to the contact or contacts identified below. For more information
about your rights under the Employee Retirement Income Security Act (ERISA), including
COBRA, the Patient Protection and Affordable Care Act, and other laws affecting group health
plans, contact the nearest Regional or District Office of the U.S. Department of Labor's
Employee Benefits Security Administration (EBSA) in your area or visit www.dol.gov/ebsa.
(Addresses and phone numbers of Regional and District EBSA Offices are available through
EBSA's website.) For more information about the Marketplace, visit www.healthcare.gov.
Keep your Plan informed of address changes. To protect your family's rights, let the Plan
Administrator know about any changes in the addresses of family members. You should also
keep a copy, for your records, of any notices you send to the Plan Administrator.
g.
AV-LG-COC-21
19 Achieve-LG-7636 (07/21)
h. Plan contact information: AvMed Enrollment and Premium Services, 9400 South Dadeland Blvd.,
Suite 510, Miami, FL 33156. You may also contact AvMed by fax at 305-671-0087 or by email at
enrollment@avmed.org. For further information, contact AvMed's COBRA Coordinator at:
AvMed Enrollment and Premium Services, Attention: COBRA Coordinator, 9400 South Dadeland
Blvd., Suite 510, Miami, FL 33156, or by telephone at 305-671-5437 extension 26109.
5.7 Continuation Coverage during Leaves of Absence
a. Family and Medical Leaves of Absence (FMLA1. Under FMLA, a Subscriber may be entitled to
up to a total of 12 weeks of unpaid, job -protected leave during each calendar year for the
following:
i. the birth of the Subscriber's child, to care for the newborn child, or for placement of a child
in the Subscriber's home for adoption or foster care;
ii. to care for a spouse, child or parent with a serious health condition; or
iii. for the Subscriber's own serious health condition.
iv. If the FMLA leave is paid, such pay will be reduced by the Subscriber's before -tax Premium
contributions as usual for the coverage level in effect on the date FMLA leave begins. If
FMLA leave is unpaid, the Subscriber will be required to pay Premium contributions directly
to the employer until returning to active pay status.
v. If a Subscriber notifies the employer that he is terminating employment during FMLA leave,
coverage will end on the date of notification. If the Subscriber does not return to work on
the expected FMLA return date, and the employer is not notified of the intent to either
terminate employment or extend the period of leave, coverage will end on the date the
Subscriber was expected to return.
vi. Plan elections may not be changed during FMLA leave unless an open enrollment occurs
or the Subscriber has a change in status event or a special enrollment event under The
Health Insurance Portability and Accountability Act of 1996 (HIPAA).
b. Military Caregiver Leave Entitlements. Subscribers who need to provide care for injured service
members may also be eligible for FMLA as follows. FMLA leave for this purpose is called "military
caregiver leave." Military caregiver leave allows an eligible Subscriber who is the spouse, son,
daughter, parent or next of kin of a covered service member with a serious injury or illness to
take up to a total of 26 workweeks of unpaid leave during a single 12 -month period to provide
care for the service member. A covered service member is a current member of the Armed
Forces, including a member of the National Guard or Reserves, who is receiving medical
treatment, recuperation, or therapy, or is in outpatient status, or is on the temporary disability
retired list for a serious injury or illness.
c. Military Leaves of Absence. If a Subscriber is absent from work due to military service,
continuation coverage under the Plan (including coverage for enrolled dependents) may be
elected for up to 24 months from the first day of absence (or if earlier, until the day after the
date the Subscriber is required to apply for or return to active employment with the employer
under the Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA)).
The Subscriber's Premium contributions for continued coverage will be the same as for similarly
situated active Members in the Plan. Whether or not coverage is continued during military
service, a Subscriber may reinstate coverage under the Plan option elected on return to
employment under USERRA. The reinstatement will be without any waiting period otherwise
required under the Plan, except to the extent that any required waiting period was not
completed prior to the start of the military service.
5.8 Extension of Benefits. In the event this Contract is terminated for any reason, except nonpayment
of Premium or as set forth in this Section, such termination will be without prejudice to any continuous
losses to a Member which commenced while this Contract was in force, but any extension of
benefits beyond the date of termination will be predicated upon the Member's continuous Total
Disability, as defined in Part II. DEFINITIONS, and will be limited to payment for the treatment of a
specific accident or illness incurred while coverage under this Contract was effective.
AV-LG-COC-21 20 Achieve-LG-7636 (07/21)
a. The extension of benefits covered under this Contract will be limited to the occurrence of the
earliest of the following events:
i. the expiration of 12 months;
ii. such time as the Member is no longer totally disabled;
iii. a succeeding carrier elects to provide replacement coverage without limitation as to the
disability condition; or
iv. the maximum benefits payable under this Contract have been paid.
b. 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 will be for the period
of that pregnancy only and will not be based upon Total Disability.
c. Except as provided above, no Subscriber is entitled to an extension of benefits if the termination
of this Contract by AvMed, is based upon one or more of the following reasons:
i. fraud or intentional misrepresentation in applying for any benefits under this Contract;
ii. disenrollment for cause; or
iii. the Subscriber has left the Service Area with the intent to work and reside outside the
Service Area.
VI. PREMIUMS, COPAYMENTS, COINSURANCE, DEDUCTIBLES AND OTHER EXPENSES
This Part explains the Premium payment responsibilities of the Subscribing Group under this Contract, and
Members' monetary responsibility for expenses for Covered Services received. Members are responsible
and will be liable for applicable Deductibles, Copayments or Coinsurance amounts which must be paid to
Health Care Providers for certain services at the time services are rendered, as shown in the Schedule of
Benefits. In addition to the information explained in this Part, it is important that you refer to your Schedule
of Benefits to determine your share of the costs for Covered Services.
6.1 Subscribing Group's Obligations
a. Monthly Premium Payment. On or before the first day of each month for which coverage is
sought, Subscribing Group or its designated agent will remit to AvMed, on behalf of each
Subscriber and his Covered Dependents, the monthly Premium based on the Rate Letter (as
defined in Part XVII. GENERAL PROVISIONS), and the Group Master Application. Only Members
for whom the stipulated payment is actually received by AvMed will be entitled to the Health
Care Services covered under this Contract and then only for the period for which such payment
is applicable.
b. 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 grace
period. Acceptance of payment received after the grace period will be solely at AvMed's
discretion, and may be subject to late payment fees.
i. Coverage will remain in force during the grace period. However, if payment is not
received by the last day of the grace period, and AvMed has provided the Subscribing
Group written notice of termination within 45 days after the Premium due date, termination
of this Contract for nonpayment of the Premium will be retroactive to 12:00 a.m. (midnight)
on the last day for which the Premium was received by AvMed, unless Premium payment
has otherwise been contractually adjusted and specified by the parties in a fully executed
addendum to this Contract.
ii. In the event of retroactive termination for any reason, AvMed reserves the right to recover
an amount equal to the Allowed Amount or Maximum Allowable Payment for any Health
Care Services provided after the effective date of such retroactive termination, less any
Premiums received by us for such Member's coverage after such date. 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 will be refunded on a pro rata basis, and
AV-LG-COC-21 21 Achieve-LG-7636 (07/21)
limited to the total excess Premium amounts paid, less any Claims incurred after the
effective date of termination.
6.2 Member's Obligations
a. Calendar Year Deductible. This amount, when applicable, must be satisfied each calendar year
before AvMed's payment toward Covered Services will begin. Subject to Section 12.9, only
those expenses for Covered Services submitted on Claims to AvMed will be credited toward the
Calendar Year Deductible, and only up to the applicable Allowed Amount or Maximum
Allowable Payment. Certain Covered Services may not be subject to the Calendar Year
Deductible, as shown in your Schedule of Benefits.
i. Self -only or Individual Calendar Year Deductible. The Self -only or Individual Calendar Year
Deductible, when applicable, must be satisfied by each Member each calendar year
before AvMed's payment toward Covered Services will begin during that calendar year.
ii. Family Calendar Year Deductible. The Family Calendar Year Deductible, when applicable,
may be satisfied by any combination of two or more family Members meeting the Family
Deductible amount. The maximum amount that any one Member in a family can
contribute toward the Family Calendar Year Deductible is the Individual Calendar Year
Deductible. Once the Family Calendar Year Deductible has been satisfied, no other
Member in the family will have any additional Calendar Year Deductible responsibility for
the remainder of that calendar year.
b. Same Calendar Year Look -Back Credit. This provision means that eligible expenses incurred by
a Member while covered under the Subscribing Group's prior carrier will be credited toward
satisfaction of the Calendar Year Deductible and Out -of -Pocket Maximum under this Plan if:
i. the expenses were incurred before the effective date of this Plan but within the same
calendar year; and
ii. the expenses were applied toward satisfaction of the Deductible or Out -of -Pocket
Maximum under the prior coverage before the effective date of this Plan but within the
same calendar year; and
iii. the expenses were for items or services that are Covered Benefits under this Contract.
However, in order to receive credit, you may be required to provide AvMed written proof
of what was paid from the prior carrier.
c. Copayment and Coinsurance Requirements. Covered Services rendered by certain Health
Care Providers will be subject to a Copayment or Coinsurance requirement. This is the fixed
dollar amount (Copayment) or percentage (Coinsurance) of the Allowed Amount or Maximum
Allowable Payment you have to pay when you receive these services. Please refer to your
Schedule of Benefits for particular Covered Services that are subject to a Copayment or
Coinsurance. All applicable Calendar Year Deductible, Copayment or Coinsurance amounts
must be satisfied before we will pay any portion of the cost for Covered Services.
d. Calendar Year Out -of -Pocket Maximum. Subject to Section 12.9, Deductible, Copayment and
Coinsurance amounts paid for Covered Benefits received during the calendar year will
accumulate toward the Calendar Year Out -of -Pocket Maximum. Expenses for items and
services that are not, as determined by AvMed, Medically Necessary Covered Benefits or
Covered Services under this Contract will not accumulate toward the Calendar Year Out -of -
Pocket Maximums.
i. Individual Calendar Year Out -of -Pocket Maximum. Once a Member reaches the
Individual Calendar Year Out -of -Pocket Maximum amount shown in the Schedule of
Benefits, we will pay for Covered Services received by that Member during the remainder
of that calendar year at 100% of the Allowed Amount or Maximum Allowable Payment.
ii. Family Calendar Year Out -of -Pocket Maximum. If your Plan includes a Family Calendar
Year Out -of -Pocket Maximum, once your family has reached the Family Calendar Year
Out -of -Pocket Maximum amount shown in your Schedule of Benefits, we will pay for
Covered Services received by you and your Covered Dependents during the remainder
of that calendar year at 100% of the Allowed Amount or Maximum Allowable Payment.
The maximum amount any one Member in a family can contribute toward the Family
AV-LG-COC-21 22 Achieve-LG-7636 (07/21)
Calendar Year Out -of -Pocket Maximum is the Individual Calendar Year Out -of -Pocket
Maximum.
6.3 Additional Expenses You Must Pay. In addition to your share of expenses as described above, you
are responsible for payment of charges for:
a. non -covered services;
b. Prescription Drug Brand Additional Charges; and
c. expenses for Claims denied because we did not receive information requested from you
regarding any other coverage and the details of such coverage.
6.4 Estimate of Cost for Services. You may obtain an estimate of the cost for particular services from In -
Network Providers by contacting AvMed's Member Engagement Center at the telephone number
on page ii of this Contract or on your AvMed Identification Card. The fact that we may provide you
with such information does not mean, and will not be construed to mean, that the particular service
is a Covered Service. All terms and conditions of this Contract apply.
VII. PHYSICIANS, HOSPITALS AND OTHER PROVIDERS
7.1 Provider and Service Arrangement. AvMed is committed to arranging for comprehensive prepaid
Health Care Services rendered to Members through the Achieve Plan's network of contracted
Physicians, Hospitals and other Health Professionals as described in this Contract, under reasonable
standards of quality health care. The professional judgment of a Physician licensed under Chapter
458 (Physician), 459 (osteopath), 460 (chiropractor) or 461 (podiatrist), Florida Statutes, concerning
the proper course of treatment for a Member, will not be subject to modification by AvMed or its
Board of Directors, Officers, or Administrators. However, this Section is not intended to, and will not,
restrict any Utilization Management Program established by AvMed.
7.2 Primary Care Physicians. With the AvMed Achieve Plan, each Member may select a PCP upon
enrollment, but is not required to do so. Although you have the option to select any provider, we
encourage you to select and develop a relationship with a PCP. You can choose any PCP who is
available and accepting new patients, from the list of PCPs who are AvMed Achieve In -Network
Providers.
a. Advantages of utilizing a PCP
i. PCPs are trained to provide a broad range of medical care. Developing and continuing
a relationship with a PCP allows the Physician to become knowledgeable about you and
your family's health history and act as a valuable resource to coordinate your overall
healthcare needs.
ii. A PCP can help you determine when you need to visit a Specialty Physician and help you
find one based on your PCP's knowledge of you and your specific healthcare needs.
iii. Care rendered by PCPs usually results in lower out-of-pocket expenses for you.
b. Selecting a PCP
i. Types of PCPs include family, general, and internal medicine practitioners, OB/GYNs who
may be selected as PCPs for women, and pediatricians who may be selected as PCPs for
children.
ii. You must notify AvMed of your PCP selection. Members must also notify and receive
approval from AvMed prior to changing PCPs. PCP changes will become effective on the
first day of the month after AvMed is notified.
7.3 Specialty Physicians. You are entitled to see in -network Specialty Physicians under this Achieve Plan
without the requirement of a referral from your PCP.
7.4 Provider Directory. The names and addresses of AvMed Achieve Plan In -Network Providers are set
forth in a separate booklet which, by reference, is made a part hereof. The list of In -Network
Providers, which may change from time to time, will be provided to all Subscribing Groups. The list
of In -Network Providers may also be accessed from AvMed's website at www.avmed.org. In -
network Health Care Providers may from time to time cease their affiliation with AvMed. In such
AV-LG-COC-21 23 Achieve-LG-7636 (07/21)
cases, Members may be required to receive services from another in -network Health Care Provider.
Notwithstanding the printed booklet, the names and addresses of In -Network Providers on file with
AvMed at any given time will constitute the official and controlling list of In -Network Providers.
7.5 Resident Referral to Skilled Nursing Unit or Assisted Living Facility. If you currently reside in a
continuing care facility or a retirement facility consisting of a nursing home or assisted living facility
and residential apartments, this notice applies to you. You may request to be referred to that
facility's skilled nursing unit or assisted living facility. If the request for referral is denied, you may use
the appeal process described in Part XIII. REVIEW PROCEDURES AND HOW TO APPEAL A CLAIM
(BENEFIT) DENIAL.
VIII.
ACCESSING COVERED BENEFITS AND SERVICES
8.1 Covered Benefits and Services. Members are entitled to receive Covered Benefits and Services only
as specified herein, appropriately prescribed or directed by In -Network Providers in conformity with
Part II. DEFINITIONS, Part IX. COVERED MEDICAL SERVICES, Part X. LIMITATIONS OF COVERED MEDICAL
SERVICES, Part XI. EXCLUSIONS FROM COVERED MEDICAL SERVICES, Part XII. PRESCRIPTION
MEDICATION BENEFITS, LIMITATIONS AND EXCLUSIONS, and the Schedule of Benefits, which by
reference is made a part of this Contract.
a. Except for Emergency Medical Services and Care as provided in Part IX. COVERED MEDICAL
SERVICES, all services must be received from In -Network Physicians and Providers within the
Service Area, and AvMed will have no liability or obligation whatsoever on account of services
or benefits sought or received by any Member from any Out -of -Network Provider, or other
person, institution or organization, unless prior arrangements have been made for the Member
and confirmed by written referral or Prior Authorization from AvMed.
b. If a Member does not follow the access rules described herein, he risks having the services and
supplies received not covered under this Contract.
8.2 Member's Responsibility in Seeking Covered Benefits and Services. Members are solely responsible
for selecting a provider when obtaining Health Care Services and for verifying whether that provider
is an In -Network Provider at the time Health Care Services are rendered. Members are also
responsible for determining any corresponding payment options at the time the Health Care
Services are rendered. It is the Member's responsibility when seeking benefits under this Contract to
identify himself as a Member of AvMed and to assure that services received by the Member are
rendered by in -network Health Professionals.
8.3 Decision -Making for Health Care Services. Any and all decisions pertaining to the medical need
for, or desirability of, the provision or non -provision of Health Care Services, including without
limitation the most appropriate level of such services, 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.
a. AvMed does not have the right of control over the medical decisions made by a Member's
Physician. A Member and his Health Professionals are responsible for deciding what medical
care should be rendered or received and when that care should be provided. AvMed is solely
responsible for determining whether expenses incurred for Health Care Services are Covered
Benefits or Covered Services under this Contract. In making coverage decisions, we will not be
deemed to participate in or override your decisions concerning your health or the medical
decisions of your Attending Physicians and other Health Professionals.
b. The ordering of a service by a Health Care Provider does not in itself make such service
Medically Necessary or a Covered Service. The Subscribing Group and Members acknowledge
it is possible that a Member and his Physicians may determine that such services are appropriate
even though such services are not covered and will not be arranged or paid for by AvMed.
8.4 Pre-existing condition exclusions are not applicable under this Contract.
8.5 Medicare Secondary Payer Provision. If you become eligible for Medicare while covered under this
Plan, please visit www.medicare.gov or contact your local Social Security office to learn about your
AV-LG-COC-21 24 Achieve-LG-7636 (07/21)
eligibility, coverage options, enrollment periods and necessary steps to follow to ensure that you
have adequate coverage. Members are urged to carefully review Part XIV. COORDINATION OF
BENEFITS for more information about how this Plan works with Medicare.
8.6 Care Management Programs
a. We have established (and from time to time establish) various Member -focused health
education and information programs as well as benefit Utilization Management Programs and
utilization review programs. These voluntary programs, collectively called the Care
Management Programs, are designed to:
i. provide you with information that will help you make more informed decisions about your
health;
ii. help us facilitate the management and review of the coverage and benefits provided
under our policies; and
iii. present opportunities as explained below, to mutually agree upon alternative benefits for
cost-effective medically appropriate Health Care Services.
b. Please note that we reserve the right to discontinue or modify our Prior Authorization
requirements and any Care Management Programs at any time without your consent.
8.7 Concurrent Review and Discharge Planning. We may review Hospital stays, Skilled Nursing Facility
services, and other Health Care Services rendered during the course of an inpatient stay or
treatment program. We may conduct this review while you are an inpatient or after your discharge.
The review is conducted solely to determine whether we should provide coverage or payment for
a particular admission or Health Care Services rendered during that admission. Using our established
criteria then in effect, a concurrent review of the inpatient stay may occur at regular intervals. We
will provide notification to your Physician when inpatient Coverage Criteria is no longer met. In
anticipation of your needs following an inpatient stay, we may provide you and your Physician with
information about other Care Management Programs which may be beneficial to you, and we
may help you and your Physician identify health care resources which may be available in your
community. Upon request, we will answer questions your Physician has regarding your coverage or
benefits following discharge from the Hospital or Other Health Care Facility.
8.8 Medical Necessity. In order for Health Care Services to be covered under this Contract, such
services must meet all of the requirements to be a Covered Benefit or Covered Service, including
being Medically Necessary, as defined by AvMed.
a. Review of Medical Necessity. It is important to remember that any review of Medical Necessity
by us is solely for the purposes of determining coverage, benefits, or payment under the terms
of this Contract and not for the purpose of recommending or providing medical care. In this
respect, we may review specific medical facts or information pertaining to you. Any such
review, however, is strictly for the purpose of determining whether a Health Care Service
provided or proposed meets the definition of Medical Necessity in this Contract, as determined
by us. In applying the definition of Medical Necessity in this Contract to a specific Health Care
Service, we will apply our coverage and payment guidelines then in effect. You are free to
obtain a service even if we deny coverage because the service is not Medically Necessary;
however, you will be solely responsible for paying for the service.
i. Examples of hospitalization and other Health Care Services that are not Medically
Necessary include:
1) staying in the Hospital because arrangements for discharge have not been
completed;
2) staying in the Hospital because supervision in the home, or care in the home, is not
available or is inconvenient; or being hospitalized for any service which could have
been provided adequately in an alternate setting (e.g., Hospital outpatient
department);
3) inpatient admissions to a Hospital, Skilled Nursing Facility, or any other facility for the
purpose of Custodial Care, convalescent care, or any other service primarily for the
convenience of a Member, his family members or a provider; and
AV-LG-COC-21 25 Achieve-LG-7636 (07/21)
4) use of laboratory, x-ray, or other diagnostic testing that has no clear indication, or is
not expected to alter your treatment.
b. Whether or not a Health Care Service is specifically listed as an Exclusion, the fact that a provider
may prescribe, recommend, approve, or furnish a Health Care Service does not mean that the
service is Medically Necessary (as defined by us) or a Covered Service. Please refer to Part 11.
DEFINITIONS for the definition of "Medically Necessary or Medical Necessity".
8.9 Prior Authorization of Services
a. Members must remember that services provided or received without Prior Authorization from
AvMed when authorization is required, are not covered except when required to treat an
Emergency Medical Condition. Furthermore, if an inpatient admission is extended beyond the
number of days initially approved, without Prior Authorization for the continued stay, it may result
in services not being covered. Before a service is performed, you should verify with your Health
Professional that the service has received Prior Authorization. If you are unable to secure
verification from your Health Professional, you may also call AvMed at 1-800-452-8633.
b. Services that require Prior Authorization from AvMed include:
i. inpatient admissions (including Hospital and observation stays, Skilled Nursing Facilities,
ventilator dependent care, acute rehabilitation and inpatient mental health or substance
abuse services including Residential Treatment);
ii. surgical procedures or services performed in an outpatient Hospital or Ambulatory Surgery
Center;
iii. complex diagnostic and therapeutic, and sub -specialty procedures (including CT, CTA,
MRI, MRA, PET, and nuclear medicine) and psychological and neuropsychological testing;
iv. Partial Hospitalization and Intensive Outpatient Treatment;
v. Pain Management and outpatient Detoxification;
vi. radiation oncology;
vii. certain medications including Injectable Medications, and select medications
administered in a Physician's office, an outpatient Hospital or infusion therapy setting;
viii. Home Health Care Services;
ix. cardiac rehabilitation;
x. dialysis services;
xi. transplant services;
xii. non -emergency transport services;
xiii. care rendered by Out -of -Network Providers (except for Emergency Medical Services and
Care).
c. Services requiring Prior Authorization may change from time to time. For more information about
which services require Prior Authorization, contact AvMed's Member Engagement Center at 1-
800-882-8633. You should always make sure your Physician contacts us to obtain Prior
Authorization.
IX. COVERED MEDICAL SERVICES
The Covered Benefits or Covered Services described below may be subject to Limitations, as described in
Part X. LIMITATIONS OF COVERED MEDICAL SERVICES and Exclusions as described in Part XI. EXCLUSIONS
FROM COVERED MEDICAL SERVICES. Please refer to Parts X. LIMITATIONS OF COVERED MEDICAL SERVICES
and XI. EXCLUSIONS FROM COVERED MEDICAL SERVICES for applicable benefit maximums, and services
that are excluded under this Contract.
9.1 Allergy Injections, Allergy Skin Testing and Treatments
9.2 Ambulance Services
a. Ambulance services provided by a local professional ground ambulance transport may be
covered provided it is necessary, as determined by us, to transport you from:
AV-LG-COC-21 26 Achieve-LG-7636 (07/21)
i. the place a medical emergency occurs to the nearest emergency facility appropriately
staffed and equipped to provide proper care;
ii. a Hospital which is unable to provide proper care to the nearest emergency facility
appropriately staffed and equipped to provide proper care;
iii. a Hospital to your nearest home or Skilled Nursing Facility when associated with an
approved hospitalization or other confinement and your Condition requires the skill of
medically trained personnel during the transport; or
iv. a Skilled Nursing Facility to your nearest home or a Hospital when associated with an
approved hospitalization or other confinement and your Condition requires the skill of
medically trained personnel during transport.
b. Expenses for ambulance services by boat, airplane, or helicopter are covered under the
following circumstances:
i. the pick-up point is inaccessible by ground vehicle;
ii. speed in excess of ground vehicle speed is critical; or
iii. the travel distance involved in getting you to the nearest emergency facility appropriately
staffed and equipped to provide proper care is too far for medical safety by ground
vehicle, as determined by us.
c. Member cost -sharing for air and water ambulance services is higher than for ground
transportation.
9.3 Ambulatory Surgery Centers. Health Care Services rendered at in -network Ambulatory Surgery
Centers are covered and include:
a. use of operating and recovery rooms;
b. respiratory, or inhalation therapy (e.g., oxygen);
c. medications administered (except for take-home medications) at the Ambulatory Surgery
Center;
d. intravenous solutions;
e. dressings, including ordinary casts;
f. anesthetics and their administration;
g. administration of, including the cost of, whole blood or blood products;
h. transfusion supplies and equipment;
i. diagnostic services, including radiology, ultrasound, laboratory, pathology and approved
machine testing (e.g., EKG); and
chemotherapy treatment for proven malignant disease.
9.4 Anesthesia Administration Services. Administration of anesthesia by a Physician or certified
registered nurse anesthetist (CRNA) may be covered. In those instances where the CRNA is actively
directed by a Physician other than the Physician who performed the surgical procedure, our
payment for Covered Services, if any, will be made for both the CRNA and the Physician Health
Care Services at the lower directed -services amount.
9.5 Cardiac rehabilitation means Health Care Services provided under the supervision of a Physician,
or another appropriate Health Care Provider trained for cardiac therapy, for the purpose of aiding
in the restoration of normal heart function in connection with a myocardial infarction, coronary
occlusion or coronary bypass surgery. Cardiac rehabilitation is covered for acute myocardial
infarction, percutaneous transluminal coronary angioplasty (PTCA), coronary artery bypass graft
(CABG), and repair or replacement of heart valves or heart transplant. Please refer to Part X.
LIMITATIONS OF COVERED MEDICAL SERVICES for applicable benefit maximums.
9.6 Child Cleft Lip and Cleft Palate Treatment. For treatment of a child under the age of 18 who has a
cleft lip or cleft palate, Health Care Services for child cleft lip and cleft palate, including medical,
dental, speech therapy, audiology, and nutrition services are covered. See also Physical,
Occupational and Speech Therapies in Part IX. The speech therapy coverage provided herein is
subject to the Limitations described in Part X. LIMITATIONS OF COVERED MEDICAL SERVICES. In order
AV-LG-COC-21 27 Achieve-LG-7636 (07/21)
to be covered, the Member's Attending Physician must specifically prescribe such services and
such services must be consequent to treatment of the cleft lip or cleft palate.
9.7 Child Health Supervision Services
a. Periodic Physician -delivered or Physician -supervised services from the moment of birth through
the end of the month in which a Covered Dependent child turns 19, are covered as follows:
i. periodic examinations, which include a history, a physical examination, and a
developmental assessment and anticipatory guidance necessary to monitor the normal
growth and development of a child;
ii. immunizations; and
iii. laboratory tests normally performed for a well -child.
b. Services must be provided in accordance with prevailing medical standards consistent with the
Recommendations for Preventive Pediatric Health Care of the American Academy of
Pediatrics.
9.8 Chiropractic Services. Office visits for the purpose of evaluation and diagnosis, diagnostic x-rays,
manual manipulation of the spine to correct subluxation, and certain rehabilitative therapies when
performed within the scope of the practitioner's license are covered when determined by us to be
Medically Necessary. Please refer to Part X. LIMITATIONS OF COVERED MEDICAL SERVICES for
applicable benefit maximums.
9.9 Clinical Trials
a. Routine patient care costs may be covered for Members enrolled in a qualifying clinical trial
that is a Phase I, II, III, or IV clinical trial conducted for the prevention, detection, or treatment
of:
i. cancer or other life -threatening disease or Condition that is, as determined by us, likely to
lead to death unless the course of the disease or Condition is interrupted;
ii. a Phase 1, II, or III clinical trial conducted for the detection or treatment of cardiovascular
disease (cardiac/stroke) which is not life threatening; and
iii. surgical musculoskeletal disorders of the spine, hip and knees, which are not life -
threatening.
b. Routine patient care costs for qualifying clinical trials include:
i. Covered Services for which benefits are typically provided absent a clinical trial;
ii. Covered Services required solely for the provision of the investigational item or service, the
clinically appropriate monitoring of the effects of the item or service, or the prevention of
complications; and
iii. Covered Services needed for reasonable and necessary care arising from the provision of
an Investigational item or service.
c. To be eligible for participation in a clinical trial, the Member's Physician must provide
documentation establishing that the Member meets all inclusion criteria for the clinical trial as
defined by the researcher.
d. Members are required to use an In -Network Provider for any clinical trials covered under this
Contract.
e. The clinical trial must meet the following criteria:
i. Federally funded or approved by one or more of the following:
1) the National Institutes of Health (NIH);
2) the Centers for Disease Control and Prevention;
3) the Agency for Healthcare Research and Quality;
4) the Centers for Medicare and Medicaid Services;
5) a cooperative group or center of any of the entities listed above or the Department of
Defense (DOD) or the Department of Veteran's Affairs (VA);
AV-LG-COC-21 28 Achieve-LG-7636 (07/21)
6) a qualified non -governmental research entity identified in the NIH guidelines for center
support grants; or
7) the VA, DOD, or Department of Energy as long as the study or investigation has been
reviewed and approved through a system of peer review that is determined by the
Secretary of Health and Human Services to be both:
a) comparable to the system of peer review of studies and investigations used by the
NIH; and
b) ensures unbiased review of the highest scientific standard by qualified individuals
who have no interest in the outcome of the review.
ii. Conducted under an investigational new drug application reviewed by the United States
Food and Drug Administration; or
iii. A drug trial that is exempt from having such an investigational new drug application.
f. In addition, the clinical trial must have a written protocol that describes a scientifically sound
study and have been approved by all relevant institutional review boards before Members are
enrolled in the trial. AvMed may, at any time, request documentation about the trial.
The subject or purpose of the trial must be the evaluation of an item or service that meets the
definition of a Covered Service and is not otherwise excluded under this Contract.
9.10 Complications of Pregnancy. Health Care Services provided to you for the treatment of
complications of pregnancy are Covered Services and will be treated the same as any other
medical Condition. Complications of pregnancy include:
a. acute nephritis;
b. nephrosis;
c. cardiac decompensation;
d. eclampsia (toxemia with convulsions);
e. ectopic pregnancy;
f. uncontrolled vomiting requiring fluid replacement;
g. missed abortion (i.e., fetal death without spontaneous abortion);
h. therapeutic and missed abortion (i.e., termination of pregnancy before the time of fetal viability
due to medical danger to the pregnant woman or when the pregnancy would result in the birth
of an infant with grave malformation);
i. Conditions that may require other than a vaginal delivery, such as: uterine wound separation,
premature labor, unresponsive to tocolytic therapy, failed trial labor, dystocia (i.e.,
cephalopelvic disproportion, failure to progress, dysfunctional labor), fetal distress requiring
neonatal support/intervention, breech presentation where external version is unsuccessful,
active clinical herpes at delivery, placenta previa, transverse lie where external version is
unsuccessful, presence of fetal anomaly;
j. miscarriages;
k. medical and surgical Conditions of similar severity; and
I. Medically Necessary non -elective cesarean section.
9.11 Dental Care
a. Dental Care is limited to the following:
i. care and stabilization treatment rendered within 90 days of an Accidental Dental Injury
provided such services are for the treatment of damage to Sound Natural Teeth;
ii. extraction of teeth required prior to radiation therapy when you have a diagnosis of
cancer of the head or neck.
b. General anesthesia and hospitalization services are covered when required to assure the safe
delivery of necessary dental treatment or surgery for a dental Condition which, if left untreated,
is likely to result in a medical Condition if:
g.
AV-LG-COC-21 29 Achieve-LG-7636 (07/21)
i. a 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 Surgery Center; or
ii. a Covered Dependent child is under eight years of age and it is determined by a licensed
dentist and the Covered Dependent's Attending Physician that dental treatment or
surgery in a Hospital or Ambulatory Surgery Center is necessary due to a significantly
complex dental Condition, or a developmental disability in which patient management in
the dental office has proven to be ineffective.
9.12 Dermatological Services. AvMed will cover office visits to a dermatologist for Medically Necessary
Covered Services, subject to the Limitations described in Part X. LIMITATIONS OF COVERED MEDICAL
SERVICES. No prior referral or authorization is required for the first five visits to a dermatologist in a 12 -
month period for a dermatological problem.
9.13 Diabetes Outpatient Self -Management. All Medically Necessary equipment, supplies, and services
to treat diabetes are covered. 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 that the equipment, supplies or services are
Medically Necessary. Diabetes outpatient self -management training and educational services
must be provided under the direct supervision of a certified diabetes educator or a board certified
endocrinologist under contract with AvMed.
9.14 Diabetic Supplies. Insulin and other covered anti -diabetic drugs and diabetic supplies, including
needles, syringes, lancets, lancet devices and test strips, are covered under the Subscribing Group's
supplemental Prescription Medication benefits. Insulin pumps, when Medically Necessary and
accompanied by a prescription from your Physician, are covered under your medical benefits,
subject to the cost -sharing for Durable Medical Equipment shown on your Schedule of Benefits.
9.15 Diagnosis and treatment of Autism Spectrum Disorders and Down syndrome through speech,
occupational and physical therapy, and Applied Behavior Analysis services, for a Member who is
(i) under 18 years of age, or (ii) 18 years of age or older and in high school, and was diagnosed at
8 years of age or younger as having a developmental disability. Services must be prescribed by the
Member's Attending Physician in accordance with a treatment plan. The treatment plan required
will include a diagnosis, the proposed treatment by type, the frequency and duration of treatment,
the anticipated outcomes stated as goals, the frequency with which the treatment plan will be
updated, and the signature of the Attending Physician.
9.16 Diagnostic Services. All prescribed diagnostic imaging, laboratory tests and services are covered
when Medically Necessary and ordered by an in -network Physician as part of the diagnosis or
treatment of a covered illness or injury, or as a preventive Health Care Service. Specialized tests
such as those to diagnose Conditions that cannot be diagnosed by traditional blood tests (e.g.
allergy, endocrinology, genetics, and virology testing), are subject to higher Member out-of-pocket
expenses.
9.17 Diagnostic testing and treatment related to Attention Deficit Hyperactivity Disorder (ADHD) are
covered subject to Medical Necessity and utilization management guidelines. Covered Services
do not include those that are primarily educational or training in nature.
9.18 Dialysis services including equipment, training and medical supplies are covered when provided
at an AvMed Network location, by an AvMed Network Health Professional who is licensed to
perform dialysis, including an AvMed Network Dialysis Center. A Dialysis Center is an outpatient
facility certified by the Centers for Medicare and Medicaid Services and the Florida Agency for
Health Care Administration to provide hemodialysis and peritoneal dialysis services and support.
Dialysis services require Prior Authorization.
9.19 Drug Infusion Therapy. Infusion therapy medications are covered as a medical benefit if
administered by a Health Professional by way of intra-articular, intracavernous, intramuscular,
intraocular, intrathecal, intravenous or subcutaneous injection; or intravenous infusion. Beginning
with the second treatment in a course of treatment, outpatient infusion therapy must be received
AV-LG-COC-21 30 Achieve-LG-7636 (07/21)
in a non -Hospital setting, including a Physician's office, infusion clinic or the home. Prior Authorization
may be required.
9.20 Durable Medical Equipment (DME)
a. Coverage includes purchase or rental, when Medically Necessary, of such DME that:
i. can withstand repeated use (i.e. could normally be rented and used by successive
patients);
ii. is primarily and customarily used to serve a medical purpose;
iii. generally is not useful to a person in the absence of illness or injury; and
iv. is appropriate for use in a Member's home.
b. Some examples of DME are: standard hospital beds, crutches, canes, walkers, wheelchairs,
oxygen, respiratory equipment, apnea monitors and insulin pumps. DME does not include
hearing aids or corrective lenses, dental devices, or the professional fees 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 of
Member owned DME, and replacement of DME solely because it is old or used, is not covered.
c. 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.
9.21 Emergency Services. AvMed will cover all Medically Necessary Physician and Hospital services for
an Emergency Medical Condition. In the event Hospital inpatient services are provided following
Emergency Medical Services and Care, AvMed should be notified by the Hospital, Member or a
designee, within 24 hours of the inpatient admission if reasonably possible. AvMed may recommend
and elect to transfer the Member to an In -Network Hospital after the Member's Condition has been
stabilized, and as soon as it is medically appropriate to do so.
a. Any Member requiring medical, Hospital or ambulance services for an Emergency Medical
Condition while temporarily outside the Service Area, or within the Service Area but before they
can reach an In -Network Provider, may receive the emergency benefits specified herein. When
emergency services are rendered by an Out -of -Network Provider to treat an Emergency
Medical Condition, any Copayment or Coinsurance amount applicable to In -Network Providers
for emergency services will also apply to such Out -of -Network Provider.
b. For out -of -network emergency services, AvMed will pay an amount equal to the greater of the
three amounts specified below:
i. The median of the amount negotiated with In -Network Providers for the emergency
services furnished;
ii. The amount for the emergency services calculated using AvMed's Maximum Allowable
Payment, which is the same method the Plan generally uses to determine payments for
out -of -network services, and applying in -network cost -sharing; or
iii. The amount that would be paid under Medicare for the Emergency Medical Services and
Care.
c. Any request for reimbursement of payment made by a Member for services received must be
filed within 90 days after the emergency or as soon as reasonably possible but not later than
one year unless the Member was legally incapacitated; otherwise such a Claim will be
considered to have been waived. If Emergency Medical Services and Care are required while
outside the continental United States, Alaska or Hawaii, it is the Member's responsibility to pay
for such services at the time they are received. For information on filing a Claim for such services
see Part XIII. REVIEW PROCEDURES AND HOW TO APPEAL A CLAIM (BENEFIT) DENIAL.
9.22 Habilitation Services
a. Covered Services consist of physical, occupational and speech therapies that are provided for
developmental delay, developmental speech or language disorder, developmental
coordination disorder and mixed developmental disorder. Therapy services must be performed
by an appropriate registered physical, occupational or speech -language therapist licensed by
AV-LG-COC-21 31 Achieve-LG-7636 (07/21)
the appropriate state licensing board, and must be furnished under the direction and
supervision of an in -network Physician or an advanced practice nurse in accordance with a
written treatment plan established or certified by the Attending Physician or advanced practice
nurse.
b. Covered Services must take place in a non-residential setting separate from the home or facility
in which the Member lives.
c. Services are covered up to the point where no further progress can be documented. Services
are not considered a Covered Benefit when measurable functional improvement is not
expected or progress has plateaued.
d. Covered Habilitation Services do not include activities or training to which the Member may be
entitled under federal or state programs of public elementary or secondary education or
federally aided vocational rehabilitation.
9.23 Home Health Care Services (Skilled Home Health Care). All Home Health Care Services require Prior
Authorization.
a. The Home Health Care Services listed below are covered when the following criteria are met:
i. A Member is unable to leave home without considerable effort and the assistance of
another person because the Member is:
1) bedridden or chair bound, or restricted in ambulation whether or not assistive devices
are used; or
2) significantly limited in physical activities due to a Condition; and
ii. the Home Health Care Services rendered have been prescribed by an in -network
Physician by way of a formal written treatment plan. The written treatment plan must be
reviewed and renewed by the prescribing Physician at least every 30 days until benefits
are exhausted. AvMed reserves the right to request a copy of any written treatment plan
in order to determine whether such services are covered under this Contract; and
iii. the Home Health Care Services are provided directly by (or indirectly through) a home
health agency; and
iv. the Member is meeting or achieving the desired treatment goals set forth in the treatment
plan as documented in the clinical progress notes.
b. Home Health Care Services are limited to:
i. intermittent visits (i.e., up to, but not exceeding, two hours per day) for:
1) nursing care by a registered nurse or licensed practical nurse, and home health aide
services;
2) medical social services;
3) nutritional guidance;
4) respiratory or inhalation therapy (e.g., oxygen); and
5) short-term physical therapy by a physical therapist, occupational therapy by an
occupational therapist, and speech therapy by a speech therapist. Such therapies
provided in the home are subject to any rehabilitative outpatient physical,
occupational and speech therapy visit limits.
c. Services must be consistent with a plan of treatment ordered by the Member's Physician.
Nursing and home health aide services must be rendered under the supervision of a registered
nurse. See Part X. LIMITATIONS OF COVERED MEDICAL SERVICES for applicable Limitations.
9.24 Hospice Services. Services are available for a Member whose Attending Physician has determined
the Member's illness will result in a remaining life span of six months or less.
9.25 Hospital Inpatient Care and Services. Inpatient services received at in -network Hospitals are
covered when prescribed by in -network 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,
AV-LG-COC-21 32 Achieve-LG-7636 (07/21)
medications, biologicals, anesthesia and oxygen supplies, physical therapy, radiation therapy,
respiratory therapy, and administration of blood or blood plasma. See Part IX., Emergency Services,
with regard to inpatient admission following Emergency Medical Services and Care.
9.26 Inpatient Rehabilitation Services are covered when the following criteria are met:
a. Services must be provided under the direction of an in -network Physician and must be provided
by a Medicare -certified facility in accordance with a comprehensive rehabilitation program;
b. A plan of care must be developed and managed by a coordinated multi -disciplinary team;
c. Coverage is limited to the specific acute, catastrophic target diagnoses of severe stroke,
multiple trauma, brain/spinal injury, severe neurological motor disorders and severe burns;
d. For Members in inpatient non -psychiatric or substance abuse rehabilitation facilities, the
Member must be able to actively participate in at least two rehabilitative therapies and be able
to tolerate at least three hours per day of skilled Rehabilitation Services for at least five days a
week and their Condition must be likely to result in significant improvement; and
e. The Rehabilitation Services must be required at such intensity, frequency and duration as to
make it impractical for the Member to receive services in a less intensive setting. See Part X.
LIMITATIONS OF COVERED MEDICAL SERVICES for applicable benefit maximums.
9.27 Mammograms are covered in accordance with Florida Statutes and the U.S. Preventive Services
Task Force (USPSTF) preventive services 'A' and 'B' recommendations. 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.
9.28 Mastectomy Surgery when Performed for Breast Cancer. Mastectomy means the removal of all or
part of the breast, when Medically Necessary for the treatment of breast cancer, as determined by
a Physician.
a. Coverage for post -mastectomy reconstructive surgery will include:
i. all stages of reconstruction of the breast on which the mastectomy has been performed;
ii. surgery and reconstruction on the other breast to produce a symmetrical appearance;
and
iii. prostheses and treatment of physical complications during all stages of mastectomy,
including lymphedemas.
b. 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 Member. The Attending Physician, after consultation with the Member, may choose
that outpatient care be provided at the most medically appropriate setting, which may include
the Hospital, Attending Physician's office, outpatient facility, or the Member's home.
9.29 Mental Health Services. Inpatient, intermediate and outpatient mental health services are covered
when Medically Necessary and may be covered when a Member is admitted to an in -network
Hospital or Other Health Care Facility.
a. For those disorders that cannot be effectively treated in an outpatient (including Partial
Hospitalization) environment, intermediate mental health services in a Residential Treatment
facility may be covered under a 24 -hour intensive and structured supervised treatment program
providing an inpatient level of care but in a non -Hospital environment. Treatment must be
received in a facility specifically licensed as a Residential Treatment facility or Residential
Treatment center by the State of Florida to provide Residential Treatment programs for mental
health disorders. The facility must require admission by a Physician; must have a behavioral
health provider actively on duty 24 hours per day, 7 days per week; the Member must receive
AV-LG-COC-21 33 Achieve-LG-7636 (07/21)
treatment by a psychiatrist at least once per week; and the facility's medical director must be
a psychiatrist. Prior Authorization is required.
b. As an alternative to inpatient hospitalization, Partial Hospitalization may be covered under a
structured program of active psychiatric treatment, provided in a Hospital outpatient setting or
by a community mental health center, that is more intense than the care received in a
Physician's or therapist's office. Prior Authorization is required.
c. Outpatient and Intensive Outpatient Treatment for mental health disorders may be covered
when provided by a state -licensed psychiatrist or other Physician, clinical psychologist, clinical
social worker, clinical nurse specialist, nurse practitioner, Physician assistant, or other qualified
mental health professional as allowed under applicable state law. Prior Authorization is required
for Intensive Outpatient Treatment.
9.30 Newborn Care. A newborn child will be covered from the moment of birth provided that the
newborn child is eligible for coverage and properly enrolled. Covered Services will consist of
coverage for injury or illness, including the necessary care or treatment of medically diagnosed
congenital defects, birth abnormalities, premature birth 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 the date
of birth.
9.31 Nutrition Therapy. Prescription -required nutritional supplements and low protein modified foods for
use at home by a Member through age 24, may be covered when prescribed or ordered by an in -
network Physician, only for the treatment of an inborn error of metabolism genetic disease, e.g.,
Disorder of Amino Acid metabolism such as phenylketonuria (PKU). Prior Authorization is required for
coverage of enteral, parenteral, or oral nutrition and any related supplies. See Part X. LIMITATIONS
OF COVERED MEDICAL SERVICES for applicable benefit maximums.
9.32 Obstetrical and Gynecological Care. An annual gynecological examination and Medically
Necessary follow-up care detected at that visit are available without the need for a referral from
your Primary Care Physician. You do not need Prior Authorization from AvMed or from any other
person (including a PCP) in order to obtain access to obstetrical or gynecological care from an in -
network Health Professional who specializes in obstetrics or gynecology. The Health Professional may
be required to comply with certain procedures, including obtaining Prior Authorization for certain
services, following a pre -approved treatment plan, or procedures for making referrals. For a list of
in -network Health Professionals who specialize in obstetrics or gynecology contact AvMed's
Member Engagement Center, or visit us online at www.avmed.org. Obstetrical care benefits as
specified herein are covered and include Birthing Center care, Hospital care, anesthesia,
diagnostic imaging and laboratory services for Conditions related to pregnancy.
a. The length of a 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:
i. Hospital stays of at least 48 hours following a normal vaginal delivery, or at least 96 hours
following a cesarean section;
ii. The Attending Physician does not need to obtain Prior Authorization from AvMed to
prescribe a Hospital stay of this length;
iii. AvMed will cover an extended stay if Medically Necessary; however, the Physician or
Hospital must pre -certify the extended stay.
iv. Shorter Hospital stays are permitted if the Attending Physician, in consultation with the
mother, determines that to be the best course of action.
b. All covered preventive care and obstetrical services related to a pregnancy will be covered
without regard to the circumstances or purpose of the pregnancy.
9.33 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 is 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
AV-LG-COC-21 34 Achieve-LG-7636 (07/21)
Medically Necessary due to a change in bodily configuration. All other Orthotic Appliances are not
covered. 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.
9.34 Osteoporosis diagnosis and treatment when Medically Necessary for high -risk individuals, including
estrogen -deficient individuals who are at clinical risk for osteoporosis, individuals with vertebral
abnormalities, individuals on long-term glucocorticoid (steroid) therapy, individuals with primary
hyperparathyroidism and individuals with a family history of osteoporosis.
9.35 Other Health Care Facility(ies). All Medically Necessary Covered Services of Other Health Care
Facilities including Skilled Nursing Facilities, such as Physician visits, physiotherapy, diagnostic
imaging and laboratory work, are covered for Conditions that cannot be adequately treated with
Home Health Care Services, or on an ambulatory basis, when a Member is admitted to such a
facility following discharge from a Hospital. Residential Treatment facility services may be covered
for mental health or substance use disorders that cannot be adequately treated on an outpatient
(including Partial Hospitalization) basis, and no prior Hospital stay is required. Services are subject to
Limitations as described in Part X. LIMITATIONS OF COVERED MEDICAL SERVICES.
9.36 Out -of -Network Provider Services. When, in the professional judgment of AvMed's Medical Director,
a Member needs Covered Services which require skills or facilities not available from In -Network
Providers, and it is in the best interest of the Member to obtain the needed care from an Out -of -
Network Provider, upon authorization by the Medical Director, payment not to exceed the
Maximum Allowable Payment, will be made for such Covered Services rendered by an Out -of -
Network Provider.
9.37 Outpatient Therapeutic Services. Covered Services for therapeutic treatments received on an
outpatient basis in the home, Physician's office, Other Health Care Facility, or Hospital, including
intravenous chemotherapy or other intravenous infusion therapy and Injectable Medications.
9.38 Pain Management. Outpatient Pain Management including pain assessment, medication, physical
therapy, biofeedback and counseling may be covered when Medically Necessary in order to
reduce or limit chronic pain.
9.39 Physical, Occupational and Speech Therapies
a. Short term rehabilitative physical, occupational and speech therapies provided in an
outpatient or home care setting are covered to improve or restore physical functioning
following disease, injury or loss of a body part.
b. Habilitative physical, occupational and speech therapies provided in an outpatient setting are
covered when provided to help a person keep, learn or improve skills and functioning for daily
living.
c. Clinical documentation or a treatment plan to support the need for therapy services or
continuing therapy must be submitted for review.
d. Continued therapy is only Medically Necessary when prescribed by an in -network Physician in
order to significantly improve, develop or restore physical functions that have been lost or
impaired. Using additional diagnoses to obtain additional therapy for the same Condition is not
considered Medically Necessary. Once maximum therapeutic benefit has been achieved, and
there is no longer any progression, or a home exercise program could be used for any further
gains, continuing supervised therapy is not considered Medically Necessary. Therapy for persons
whose Condition is neither regressing nor improving is considered not Medically Necessary.
Therapy for asymptomatic persons or in persons without an identifiable clinical Condition is
considered not Medically Necessary.
e. Additional therapy can be considered for a new or separate Condition in a person who
previously received therapy for another indication. An exacerbation or flare-up of a chronic
illness is not considered a new incident of illness.
f. Home -based physical therapy is Medically Necessary in selected cases based upon the
Member's needs, i.e., the Member must be homebound. This may be considered Medically
AV-LG-COC-21 35 Achieve-LG-7636 (07/21)
Necessary in the transition of the Member from Hospital to home, and may be an extension of
case management services.
g. Services are subject to Limitations as described in Part X. LIMITATIONS OF COVERED MEDICAL
SERVICES.
9.40 Physician Care: Inpatient. All Health Care Services rendered by in -network Physicians and other in -
network Health Professionals when requested or directed by the Attending Physician, including
surgical procedures, anesthesia, consultation and treatment by in -network Specialty Physicians,
laboratory and diagnostic imaging services, and physical therapy are covered while the Member
is admitted to an in -network Hospital as a registered bed patient. When available and requested
by the Member, the services of a CRNA licensed under Chapter 464, Florida Statutes, will be
covered.
9.41 Physician Care: Outpatient
a. Diagnosis and Treatment. All Health Care Services rendered by in -network Physicians and other
in -network Health Professionals are covered when Medically Necessary and when provided at
Medical Offices, including surgical procedures, routine hearing examinations, and vision
examinations for glasses for children through the end of the month in which they turn 19 (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 in -network Specialty Physicians. Also included are non -reusable
materials and surgical supplies.
b. Preventive and Health Maintenance Services. Services of in -network Health Professionals for
illness prevention and health maintenance, including items or services that have an 'A' or 'B'
rating in the current recommendations of the USPSTF with respect to the Member involved;
immunizations recommended by the Advisory Committee on Immunization Practices of the
Centers for Disease Control and Prevention; evidence -informed preventive care and screenings
for infants, children, and adolescents as provided for in comprehensive guidelines supported by
the Health Resources and Services Administration (HRSA); and evidence -informed preventive
care and screening for women as provided for in comprehensive guidelines supported by the
HRSA. A listing of preventive health services with current 'A' or 'B' ratings is available on the
USPSTF website. Important note about gender -specific preventive care benefits: Covered
expenses include any recommended preventive care benefits described above that are
determined by your Health Professional to be Medically Necessary, regardless of the sex you
were assigned at birth, your gender identity, or your recorded gender.
9.42 Prescription Medications. Retail Prescription Medications may be covered when accompanied by
a prescription from your Attending Physician, subject to the cost -sharing shown in the Prescription
Medication Amendment to this Contract. Certain preventive medications that have an 'A' or 'B'
rating in current recommendations of the USPSTF, may be covered at no cost to you when deemed
Medically Necessary and accompanied by a prescription from your Attending Physician. Coverage
for insulin and other diabetic supplies is described in Part IX., under Diabetic Supplies. Allergy serums
and chemotherapy for cancer patients are covered under your medical benefits. See Part XII.
PRESCRIPTION MEDICATION BENEFITS, LIMITATIONS AND EXCLUSIONS for additional information
about Prescription Medications.
9.43 Prosthetic Devices. This Contract provides benefits, when Medically Necessary, for Prosthetic
Devices designed to restore bodily function or replace a physical portion of the body. Coverage
for Prosthetic Devices is limited to artificial limbs, artificial joints, ocular prostheses, and cochlear
implants. 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, including Prosthetic Devices for Deluxe, Myo-electric and
electronic Prosthetic Devices. 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.
AV-LG-COC-21 36 Achieve-LG-7636 (07/21)
9.44 Second Medical Opinions. Members are entitled to a second medical opinion when disputing the
appropriateness or necessity of a surgical procedure, or when subject to a serious injury or illness.
a. A Member may choose to obtain a second medical opinion from any in -network or out -of -
network Physician within the Service Area. If an in -network Physician is chosen, the applicable
office visit cost -sharing will apply. If an out -of -network Physician is chosen, Prior Authorization is
required, and the Member is responsible for 40% of the amount of the Maximum Allowable
Payment associated with consultation.
b. Once a second medical opinion has been rendered, AvMed will review and determine
AvMed's obligations under this Contract, and that judgment by AvMed is controlling. Any
treatment the Member obtains that is not authorized by AvMed will be at the Member's
expense.
c. AvMed may limit second medical opinions in connection with a particular diagnosis or
treatment to three per calendar year, if AvMed deems additional opinions to be an
unreasonable over -utilization by the Member.
9.45 Skilled Nursing Facilities
a. The following Health Care Services may be Covered Services when you are a patient in a Skilled
Nursing Facility:
i. room and board;
ii. respiratory or inhalation therapy (e.g., oxygen);
iii. medications and medicines administered while an inpatient (except take-home
medications);
iv. intravenous solutions;
v. administration of, including the cost of, whole blood or blood products;
vi. dressings, including ordinary casts;
vii. transfusion supplies and equipment;
viii. diagnostic services, including radiology, ultrasound, laboratory, pathology and approved
machine testing (e.g., EKG);
ix. chemotherapy treatment for proven malignant disease; and
x. physical, occupational and speech therapies.
b. We reserve the right to request a treatment plan for determining coverage and payment.
Services are subject to Limitations as described in Part X. LIMITATIONS OF COVERED MEDICAL
SERVICES.
9.46 Speech Therapy. See Part IX., Physical, Occupational and Speech Therapies.
9.47 Spinal Manipulation. See Part IX., Chiropractic Services.
9.48 Substance Abuse Services. Inpatient, intermediate and outpatient substance abuse services are
covered when Medically Necessary and may be covered when a Member is admitted to an in -
network Hospital or Other Health Care Facility.
a. For those disorders that cannot be effectively treated in an outpatient (including Partial
Hospitalization) environment, intermediate substance abuse services in a Residential Treatment
facility may be covered under a 24 -hour intensive and structured supervised treatment program
providing an inpatient level of care but in a non -Hospital environment. Treatment must be
received in a facility specifically licensed as a Residential Treatment facility or Residential
Treatment center by the State of Florida to provide Residential Treatment programs for
substance use disorders. The facility must require admission by a Physician, must have a
behavioral health provider or an appropriately state certified professional actively on duty
during the day and evening therapeutic programming, and the facility's medical director must
be a Physician. For Detoxification programs in a Residential Treatment setting there must be a
registered nurse onsite 24 hours per day, 7 days per week, and care must be provided under
direct supervision of a Physician. Prior Authorization is required.
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37 Achieve-LG-7636 (07/21)
b. As an alternative to inpatient hospitalization, Partial Hospitalization may be covered under a
structured program of active psychiatric treatment, provided in a Hospital outpatient setting or
by a community mental health center, that is more intense than the care received in a
Physician's or therapist's office. Prior Authorization is required.
c. Outpatient and Intensive Outpatient Treatment for substance use disorders may be covered
when provided by a state -licensed psychiatrist or other Physician, clinical psychologist, clinical
social worker, clinical nurse specialist, nurse practitioner, Physician assistant, or other qualified
mental health professional as allowed under applicable state law. Prior Authorization is required
for Intensive Outpatient Treatment.
9.49 Supplies. Ostomy and urostomy supplies are covered when Medically Necessary. Items that are not
medical supplies or that could be used by the Member or a family member for purposes other than
ostomy care are not covered. Wound care supplies are covered when Medically Necessary as part
of an approved treatment plan for treatment of a wound caused by or treated by a surgical
procedure; or treatment of a wound that requires debridement. Services are subject to Limitations
as described in Part X. LIMITATIONS OF COVERED MEDICAL SERVICES.
9.50 Transplant services, limited to the procedures listed below, are covered through AvMed's In -
Network Center of Excellence facilities located within the State of Florida, subject to the conditions
and Limitations described herein. Transplant services are subject to Prior Authorization before
benefits are paid. Transplant includes pre -transplant, transplant and post -discharge services, and
treatment of complications after transplantation.
a. AvMed will pay benefits for services, care and treatment received or provided, only in
connection with a:
i. Bone Marrow Transplant, which is specifically listed in Rule 59B-12.001, Florida
Administrative Code, or any successor or similar rule or covered by Medicare as described
in the most recently published Medicare National Coverage Determinations Manual issued
by the Centers for Medicare and Medicaid Services. Coverage includes expenses
associated with the donation or acquisition of an organ or tissue for the Member once the
donor has been identified and has agreed to the donation. Coverage for the reasonable
expenses of searching for a donor will be limited to a search among immediate family
members and donors identified through the National Bone Marrow Donor Program.
1) Bone Marrow Transplant means human blood precursor cells administered to a patient
to restore normal hematological and immunological functions following ablative
therapy. Human blood precursor cells may be obtained from the patient in an
autologous transplant, or an allogeneic transplant from a medically acceptable
related or unrelated donor, and may be derived from bone marrow, the circulating
blood, or a combination of bone marrow and circulating blood. If chemotherapy is an
integral part of the treatment involving bone marrow transplantation, the term 'Bone
Marrow Transplant' includes the transplantation as well as the administration of
chemotherapy and the chemotherapy medications. The term 'Bone Marrow
Transplant' also includes any services or supplies relating to any treatment or therapy
involving the use of high dose or intensive dose chemotherapy and human blood
precursor cells and includes any and all Hospital, Physician or other Health Care
Provider services which are rendered in order to treat the effects of, or complications
arising from, the use of high dose or intensive dose chemotherapy or human blood
precursor cells (e.g., Hospital room and board and ancillary services);
ii. corneal transplant;
iii. heart transplant (including a ventricular assist device, if indicated, when used as a bridge
to heart transplantation);
iv. heart-lung combination transplant;
v. liver transplant;
vi. kidney transplant;
vii. pancreas only transplant;
AV-LG-COC-21 38 Achieve-LG-7636 (07/21)
viii. pancreas transplant performed simultaneously with a kidney transplant; or
ix. lung (whole single or whole bilateral transplant).
b. We will cover donor costs and organ acquisition for transplants, other than Bone Marrow
Transplants, provided such costs are not covered in whole or in part by any other carrier,
organization or person other than the donor's family or estate.
9.51 Urgent Care Services. All Medically Necessary Covered Services received in Urgent Care Centers,
Retail Clinics or your Primary Care Physician's office after-hours to treat an Urgent Medical Condition
will be covered by AvMed. Any request for reimbursement of payment made by a Member for
services received must be filed within 90 days or as soon as reasonably possible but not later than
one year unless the Member was legally incapacitated. If Urgent Medical Services and Care are
required while outside the continental United States, Alaska or Hawaii, it is the Member's
responsibility to pay for such services at the time they are received. For information on filing a Claim
for such services, see Part XIII. REVIEW PROCEDURES AND HOW TO APPEAL A CLAIM (BENEFIT) DENIAL.
9.52 Virtual Visits (Telehealth and Telemedicine Services) using interactive audio, video, or other
electronic media for the purpose of Physician -patient encounters for non -emergency diagnoses,
consultations and treatment. Services are available from AvMed designated Telehealth providers
only.
X. LIMITATIONS OF COVERED MEDICAL SERVICES
The rights of Members and obligations of In -Network Providers hereunder are subject to the following
Limitations:
10.1 Cardiac Rehabilitation. Outpatient cardiac rehabilitation, combined with chiropractic services,
outpatient pulmonary rehabilitation, and outpatient rehabilitative physical, occupational and
speech therapies, is limited to 35 visits per calendar year. Cardiac rehabilitation requires Prior
Authorization.
10.2 Chiropractic services, combined with outpatient cardiac rehabilitation, outpatient pulmonary
rehabilitation, outpatient rehabilitative physical, occupational and speech therapies are limited to
35 visits per calendar year.
10.3 Dermatological Services. Prior Authorization is required after a maximum of five visits to a
dermatologist in a 12 -month period for a dermatologic problem.
10.4 Drug Infusion Therapy.
a. Provision of outpatient infusion therapy services beginning with the second treatment in a
course of treatment, is limited to non -hospital settings. Services must be received in a Physician's
office, infusion clinic or the Member's home.
b. Any third -party Copayment assistance (sometimes also referred to as a "copay card" or "copay
coupon") provided by a drug manufacturer or any other entity to pay any applicable Calendar
Year Deductible, Copayment or Coinsurance amounts for any therapy medications
administered by a Health Professional will not be credited toward your Calendar Year
Deductible or Calendar Year Out -of -Pocket Maximum.
10.5 Habilitative Physical, Occupational and Speech Therapies. Outpatient habilitative physical,
occupational and speech therapies are covered up to a combined maximum of 100 visits per
calendar year for the treatment of Autism Spectrum Disorders and Down syndrome, for a Member
who is (i) under 18 years of age, or (ii) 18 years of age or older and in high school, and was
diagnosed at 8 years of age or younger as having a developmental disability.
10.6 Home Health Care Services (Skilled Home Health Care). Services are limited to 20 visits per calendar
year, including:
a. intermittent visits (i.e., up to, but not exceeding, two hours per day) for:
i. nursing care by a registered nurse or licensed practical nurse, and home health aide
services;
AV-LG-COC-21 39 Achieve-LG-7636 (07/21)
ii. medical social services;
iii. nutritional guidance;
iv. respiratory or inhalation therapy (e.g., oxygen) and;
v. short-term physical therapy by a physical therapist, occupational therapy by an
occupational therapist, and speech therapy by a speech therapist. Such therapies are
subject to any rehabilitative outpatient physical, occupational and speech therapy visit
limits.
b. Services must be consistent with a plan of treatment ordered by the Member's Physician.
Nursing and home health aide services must be rendered under the supervision of a registered
nurse.
10.7 Hyperbaric oxygen treatments are limited to 40 treatments per Condition as appropriate pursuant
to the Centers for Medicare and Medicaid Services (CMS) guidelines, and are subject to the cost -
sharing shown in your Schedule of Benefits for rehabilitative physical, occupational, and speech
therapies.
10.8 Inpatient acute Rehabilitation Services received in a Hospital are limited to 30 days per calendar
year.
10.9 Licensed Dietitians/Nutritionists. Visits to licensed dietitians/nutritionists for treatment of diabetes,
renal disease or obesity control are limited to three outpatient visits per calendar year.
10.10 Nutrition Therapy. Coverage for enteral, parenteral or oral nutrition, and any related supplies, is
limited to treatment of inborn error of metabolism genetic diseases for Members through age 24.
Prior Authorization is required, and benefits are subject to additional authorization when Member
cost -sharing reaches $2,500 in a calendar year.
10.11 Orthotic Devices. Coverage for Orthotic Devices or 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. Replacements are covered only when Medically Necessary due to a change in bodily
configuration.
10.12 Other Health Care Facility(ies). Medically Necessary inpatient services of Other Health Care
Facilities, including Skilled Nursing Facilities, are covered up to a combined maximum of 60 post -
hospitalization days per calendar year, for conditions that cannot be adequately treated with
Home Health Care Services or on an ambulatory basis. Does not apply to treatment of mental
health and substance use disorders.
10.13 Prosthetic Devices. Coverage for Prosthetic Devices is limited to artificial limbs, artificial joints, ocular
prostheses and cochlear implants.
10.14 Pulmonary Rehabilitation. Outpatient pulmonary rehabilitation, combined with outpatient cardiac
rehabilitation, chiropractic services, and outpatient rehabilitative physical, occupational and
speech therapies is limited to 35 visits per calendar year. Prior Authorization is required.
10.15 Rehabilitative Physical, Occupational and Speech Therapies. Outpatient rehabilitative physical,
occupational and speech therapies, combined with outpatient cardiac rehabilitation, chiropractic
services and outpatient pulmonary rehabilitation are limited to 35 visits per calendar year, including
evaluations.
10.16 Second Medical Opinions. AvMed may limit second medical opinions in connection with a
particular diagnosis or treatment to three per calendar year, if AvMed deems additional opinions
to be an unreasonable over -utilization by the Member.
10.17 Skilled Nursing Facilities and Rehabilitation Centers. See Other Health Care Facility(ies) above.
10.18 Spinal Manipulation. See Chiropractic services above.
10.19 Supplies. Provision of ostomy and urostomy supplies is limited to a one -month supply every 30 days.
Coverage is limited to $2,500 per calendar year, subject to applicable Copayments and
AV-LG-COC-21 40 Achieve-LG-7636 (07/21)
Coinsurance. 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.
10.20 Transplant Services. Transplant services are limited to AvMed's In -Network Center of Excellence
facilities located within the State of Florida. Transportation costs for a companion to accompany
the Member (or two companions when the patient is a minor) are covered only if the Member has
to travel greater than a 50 -mile radius to receive the transplant, and are limited to $200 per day up
to a $10,000 lifetime maximum.
10.21 Ventilator dependent care is limited to a lifetime maximum of 100 calendar days.
10.22 Virtual Visits (Telehealth and Telemedicine Services) are available from AvMed designated
Telehealth providers only and are subject to Medical Necessity and utilization management
guidelines.
XI. EXCLUSIONS FROM COVERED MEDICAL SERVICES
This Contract expressly excludes coverage and expenses for the following services. These Exclusions are in
addition to any Exclusions specified in Part IX. COVERED MEDICAL SERVICES and any Limitations specified
in Part X. LIMITATIONS OF COVERED MEDICAL SERVICES.
1 1.1 General Exclusions include expenses for:
a. services received prior to your effective date or after the date your coverage terminates;
b. services not within the categories described in Part IX. COVERED MEDICAL SERVICES and any
amendments attached hereto, unless such services are specifically required to be covered by
applicable law;
c. services which are not Medically Necessary, as defined in this Contract, and as determined by
AvMed;
d. services provided by a Physician or other Health Care Provider related to you by blood or
marriage;
e. services beyond the scope of practice authorized for a Health Professional under applicable
state law;
f. services rendered at no charge;
g. services to diagnose or treat any Condition which initially occurred while you were (or which
directly or indirectly resulted from, or is connection with you being) under the influence of any
chemical substance set forth in Section 877.111, Florida Statutes, or any substance controlled
under Chapter 893, Florida Statutes or, with respect to such statutory provisions, any successor
statutory provisions. Notwithstanding, this Exclusion will not apply to the use of any Prescription
Medication by you if such medication is taken on the specific advice of a Physician in a manner
consistent with such advice;
h. services rendered by or through a medical or dental department maintained by or on behalf
of an employer, mutual association, labor union, trust, or similar person or group;
i. services to diagnose or treat a Condition which, directly or indirectly, resulted from or is in
connection with your participation in, or commission of, any act punishable by law as a
misdemeanor or felony whether or not you are charged or convicted; or which constitutes riot
or rebellion; or your engaging in an illegal occupation. Coverage will be available if a Member
demonstrates that an injury resulted from an act of domestic violence or a Condition, whether
or not the Condition was diagnosed before the occurrence of the injury.
any expenses for Claims denied because we did not receive information requested from you
about whether or not you have other coverage (including personal injury protection motor
vehicle insurance (PIP) or supplemental insurance plans) and the details of such coverage.
Additional Exclusions
11.2 Aids or devices that assist with oral, verbal, or nonverbal communications, including
communication boards, pre-recorded speech devices, laptop computers, desktop computers,
AV-LG-COC-21 41 Achieve-LG-7636 (07/21)
personal digital assistants, Braille typewriters, visual alert systems for the deaf, memory books,
software programs and associated devices.
11.3 Anesthesia administration services when performed by an operating Physician or the Physician's
partner or associate.
11.4 Armed forces service -connected medical care for both sickness and injury, including services
received at military or government facilities and services received to treat an injury arising out of
your service in the Armed Forces, Reserves or National Guard.
11.5 Autopsy or postmortem examinations and associated services, unless specifically requested by
AvMed.
11.6 Bariatric Surgery/Treatment of Morbid Obesity. 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 for the treatment of obesity, other than
establishing a program of obesity control, are also excluded.
11.7 Breast reduction or augmentation surgery except as required for the comprehensive treatment of
breast cancer.
11.8 Complementary or alternative medicine including: acupuncture, aromatherapy, Ayurvedic
medicine such as lifestyle modifications, purification and massage therapies, biofield therapies,
bioelectromagnetic applications and medicine, biofeedback, chelation therapy, cognitive
therapy, environmental medicine including the field of clinical ecology, herbal therapies,
homeopathic medicine and counseling, hypnotherapy, mind -body interactions such as
meditation, imagery, yoga, dance and art therapy, manual healing methods such as the
Alexander technique, massage therapy, craniosacral balancing, Feldenkrais method, Hellerwork,
reflexology, Rolfing, shiatsu, traditional Chinese massage, Trager therapy, trigger -point myotherapy,
and polarity therapy, naturopathic medicine, prayer and mental healing, Reichian therapy, Reiki,
self -care and self-help training, sex therapy, SHEN therapy, sleep therapy, therapeutic touch,
thermography, traditional Chinese medicine and vocational rehabilitation.
11.9 Complications of any non -covered service, including the evaluation, diagnosis or treatment of any
Condition that arises as a complication of a non -covered service (e.g., services to treat a
complication of cosmetic surgery are not covered).
11.10 Cosmetic services including any procedures which are undertaken primarily to improve or
otherwise modify the Member's external appearance, except for reconstructive surgery to correct
and repair a functional disorder as a result of a disease, injury, or congenital defect; and initial
implanted prosthesis and reconstructive surgery incident to a mastectomy for cancer of the breast.
Also excluded are surgical excision or reformation of any sagging skin of any part of the body,
including: 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 the face, lips, jaw, chin, nose, ears, breasts, or genitals (including
circumcision, except newborns for up to one year from the date of birth); hair transplantation;
chemical face peels or abrasion of the skin, electrolysis depilation, removal of tattooing, or any
other surgical or non -surgical procedures which are primarily for cosmetic purposes or to create
body symmetry. Additionally, all medical complications resulting from cosmetic surgical or non-
surgical procedures are excluded.
1 1.1 1 Counseling, including marriage or pre -marital counseling, religious, family, career, social
adjustment, pastoral or financial counseling.
11.12 Court -ordered services and supplies including court -ordered care or testing, or services required as
a condition of parole, probation, release or because of any legal proceeding.
11.13 Costs related to telephone consultations, failure to keep a scheduled appointment, or completion
and preparation of any form or medical information, including requests for medical records.
11.14 Custodial Care and any service of a Custodial nature, including without limitation: services primarily
to assist in the activities of daily living, rest homes, home companions or sitters, home parents,
AV-LG-COC-21 42 Achieve-LG-7636 (07/21)
domestic maid services, food or home delivered meals, housing, respite care, and provision of
services which are for the sole purpose of allowing a family member or caregiver of a Member to
return to work.
11.15 Dental Care or treatment of the teeth or their supporting structures or gums, or dental procedures,
including: extraction of teeth; restoration of teeth with or without fillings, crowns or other materials;
bridges; cleaning of teeth; dental implants; dentures; periodontal or endodontic procedures;
orthodontic treatment (e.g., braces); intraoral Prosthetic Devices; palatal expansion devices;
bruxism appliances; dental x-rays and dental services provided more than 90 days after the date
of an Accidental Dental Injury regardless of whether or not such services could have been rendered
within 90 days. This Exclusion also applies to services related to the diagnosis and treatment of
temporomandibular joint (TMJ) dysfunction except when Medically Necessary, and all dental
treatment for TMJ.
11.16 Durable Medical Equipment (DME)
a. Items that are not covered include:
i. bed related items: bed trays, over -the -bed tables, bed wedges, pillows, custom bedroom
equipment, mattresses, including non -power mattresses, custom mattresses and
posturepedic mattresses;
ii. bath related items: bath lifts, non -portable whirlpools, bathtub rails, toilet rails, raised toilet
seats, bath benches, bath stools, hand held showers, paraffin baths, bath mats, and spas;
iii. chairs, lifts and standing devices: computerized or gyroscopic mobility systems, roll about
chairs, geriatric chairs, hip chairs, seat lifts (mechanical or motorized), patient lifts
(mechanical or motorized - manual hydraulic lifts are covered if patient is 2 -person
transfer), and auto tilt chairs;
iv. electric or powered scooters; non-standard customized wheelchairs, motorized or manual;
v. fixtures to real property, including ceiling lifts and wheelchair ramps;
vi. car/van modifications;
vii. air quality items: air conditioners, room humidifiers, vaporizers, air purifiers and electrostatic
machines;
viii. blood/injection related items: blood pressure cuffs, centrifuges, nova pens and needleless
injectors; and
ix. other equipment: heat lamps, heating pads, cryounits, cryotherapy machines, electronic -
controlled therapy units, ultraviolet cabinets, sheepskin pads and boots, postural drainage
board, AC/DC adaptors, enuresis alarms, magnetic equipment, scales (baby and adult),
stair gliders, elevators, saunas, any exercise equipment, emergency alert equipment, and
diathermy machines.
b. Repair of Member -owned DME, and replacement of DME solely because it is old or used, is
excluded.
11.17 Educational Services. Any service or supply for education, training or retraining services or testing
including: special education, remedial education; cognitive remediation; wilderness/outdoor
treatment, therapy or adventure programs (whether or not the program is part of a Residential
Treatment facility or otherwise licensed institution); job training or job hardening programs;
educational services and schooling or any such related or similar program including therapeutic
programs within a school setting.
11.18 Examinations. Any health examinations needed because a third party requires the exam, including
examinations to get or keep a job, examinations required under a labor agreement or other
contract, to buy insurance or to get or keep a license, to travel, to go to a school, camp, sporting
event, or to join in a sport or other recreational activity.
11.19 Exercise programs, gym memberships or exercise equipment of any kind, including 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.
AV-LG-COC-21 43 Achieve-LG-7636 (07/21)
1 1.20 Experimental or Investigational services and supplies except as otherwise covered for Bone Marrow
Transplants, pursuant to Section 59B-12.001, Florida Administrative Code.
11.21 Eye care, including:
a. eye examinations for Members over age 19 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.
d. This Exclusion does not include pediatric vision services that are covered as an Essential Health
Benefit, as set forth under PPACA, Section 1302(b) of the Federal Act, for children through the
end of the month in which they turn 19.
11.22 Foot care (routine), including any service involving the feet or parts of the feet, in the absence of
diabetes, peripheral circulatory or neurovascular disease including: non -surgical treatment of
bunions; flat feet; fallen arches; chronic foot strain; trimming of toenails, corns or calluses. This
Exclusion does not apply to services otherwise covered under Diabetes Outpatient Self -
Management, as described in Part IX. COVERED MEDICAL SERVICES.
11.23 Foot supports including orthopedic or specialty shoes, shoe build-ups, shoe orthotics, shoe braces,
and shoe supports.
11.24 Gender Transition Services. Gender reassignment surgery and any treatment, service, supply or
medication associated with or as a result of gender reassignment or gender dysphoria are
excluded; except for Members aged 18 or over who are diagnosed with gender dysphoria by an
AvMed Network provider, and when the recommended services are deemed Medically Necessary
and all criteria under AvMed's current coverage guidelines are met. All services must be rendered
by AvMed Network providers in order to be covered. Coverage guidelines are available at
www.avmed.org.
1 1.25 Gene or Cellular Therapy Products. Cellular therapy products include cellular immunotherapies,
cancer vaccines, and other types of both autologous and allogeneic cells for certain therapeutic
indications, including hematopoetic stem cells and adult and embryonic stem cells. Human gene
therapy is the administration of genetic material to modify or manipulate the expression of a gene
product or to alter the biological properties of living cells for therapeutic use.
11.26 Habilitation Services. Except as required by law for treatment of Autism Spectrum Disorders and
Down syndrome, non -covered Habilitation Services include residential, institutional and home -
based Habilitation Services, personal assistance/ attendant care services; errand services;
transportation to and from training facilities unless provided by the training facility; family education
and training; family support services; pre -vocational services designed to assist a Member in
acquiring basic work skills; supportive employment habilitation; respite care camps; hotel respite,
room and board; services that are purely educational in nature, and personal training or life
coaching.
1 1.27 Hearing aids (external or implantable) and services related to the fitting or provision of hearing aids,
including tinnitus maskers, batteries, and the cost of repairs.
1 1.28 Hearing examinations for Members over age 19 for the purpose of determining the need for hearing
correction.
11.29 Homemaker or domestic maid services; sitter or companion services; services rendered by an
employee or operator of an adult congregate living facility, an adult foster home, an adult day
care center, or a nursing home facility.
11.30 Home monitoring devices and measuring devices (other than apnea monitors and Holter monitors),
and any other equipment or devices for use outside the Hospital that are not covered elsewhere in
this Contract.
11.31 Hospital Services that are associated with excluded surgery or excluded Dental Care.
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11.32 Immunizations and medications for the purpose of foreign travel or employment.
11.33 Infertility Diagnosis, Treatment and Supplies (Assisted Reproductive Therapy), including infertility
evaluation, testing, diagnosis and treatment, medication and supplies, to determine or correct the
reason for infertility or inability to achieve conception. This includes artificial insemination (Al), in -
vitro fertilization (IVF), ovum or embryo placement or transfer, gamete intra-fallopian transfer (GIFT),
or cryogenic or other preservation techniques used in such or similar procedures.
11.34 Mandibular and maxillary osteotomies except when Medically Necessary to treat Conditions
caused by congenital or developmental deformity, disease or injury.
11.35 Medical care or surgery not rendered by an In -Network Provider, except for Emergency Medical
Services and Care.
11.36 Medical supplies including pre -fabricated splints, Thromboemboletic/support hose and all other
bandages, except as described under Supplies in Part IX.
11.37 Mental Health and Substance Abuse Services rendered in connection with a Condition not
classified in the most recent edition of the American Psychiatric Association's Diagnostic and
Statistical Manual of Mental Disorders (DSM) are excluded from coverage; and services for the
following categories (or equivalent terms) as listed in the most recent edition of the DSM: inpatient
treatment for dementia and amnesia without a behavioral disturbance that necessitates mental
health treatment; sexual deviations and disorders except for gender identity disorders; tobacco use
disorders, except as required under USPSTF preventive care guidelines; pathological gambling,
kleptomania, pyromania; inpatient stays primarily intended as a change of environment; school
and/or education services, including special education, remedial education, wilderness/outdoor
treatment, therapy or adventure programs (whether or not the program is part of a Residential
Treatment facility or otherwise licensed institution); services provided in conjunction with school,
vocation, work or recreational activities.
11.38 Nutritional therapy except as described under Nutrition Therapy in Part IX.
11.39 Oral surgery for Members over age 19, except as described under Dental Care in Part IX.
11.40 Organ Donor Treatment and Services. The Health Care 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. The reasonable costs of searching for a bone marrow donor are limited to a
Member's family members and the National Bone Marrow Donor Program. Post -transplant donor
complications will not be covered.
11.41 Orthotic Devices except as described in Part IX. COVERED MEDICAL SERVICES. Expenses for arch
supports, shoe inserts designed to effect conformational changes in the foot or foot alignment,
orthopedic shoes, over-the-counter, custom-made or built-up shoes, cast shoes, sneakers, ready-
made compression hose or support hose, or similar type devices/appliances regardless of intended
use (except for therapeutic shoes, including inserts and modifications for the treatment of severe
diabetic foot disease); expenses for Orthotic Appliances or Orthotic Devices, which straighten or
re -shape the conformation of the head or bones of the skull or cranium through cranial banding or
molding (e.g. dynamic orthotic cranioplasty or molding helmets); and expenses for devices
necessary to exercise, train, or participate in sports, e.g. custom-made knee braces.
11.42 Out -of -Network Providers. Any treatment or service from an Out -of -Network Provider, except in the
case of an emergency or when specifically pre -authorized by AvMed, including Hospital care from
an out -of -network Physician or Hospital if elected by a Member. In such circumstances, 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.
11.43 Over-the-counter medications and Prescription Medications not otherwise covered including
hypodermic needles and syringes and self-administered Injectable Medications except insulin and
insulin syringes for the treatment of diabetes as described under Diabetic Supplies in Part IX.
11.44 Pain Management. Inpatient rehabilitation for Pain Management is excluded.
AV-LG-COC-21 45 Achieve-LG-7636 (07/21)
11.45 Personal comfort, hygiene or convenience items and services deemed not Medically Necessary
and not directly related to a Member's treatment, including beauty and barber services; clothing
(including support hose); radio and television; guest meals and accommodations; telephone
charges; take-home supplies; travel expenses (other than Medically Necessary ambulance
services); motel/hotel accommodations; air conditioners, furnaces, air filters, air or water purification
systems, water softening systems, humidifiers, dehumidifiers, vacuum cleaners or any other similar
equipment and devices used for environmental control or to enhance an environmental setting;
hot tubs, jacuzzis, heated spas, pools, or memberships to health clubs; heating pads; hot water
bottles or ice packs; physical fitness equipment; and hand rails and grab bars.
11.46 Private Duty Nursing care or services rendered at any location.
11.47 Professional Services. Non -patient -specific professional services associated with machine or other
testing including oversight of a medical laboratory to assure timeliness, reliability, and usefulness of
test results and overseeing calibration of laboratory testing equipment.
11.48 Prosthetic Devices except as described in Part IX. COVERED MEDICAL SERVICES. Expenses for
microprocessor controlled or myoelectric artificial limbs (e.g. C-Iegs); and expenses for cosmetic
enhancements to artificial limbs are also not covered.
11.49 Rehabilitation Programs. Vocational rehabilitation, long term rehabilitation, or any other
rehabilitation program.
11.50 Rehabilitative Therapies. Rehabilitative therapies for chronic Conditions are not covered. Therapies
provided on either an inpatient or outpatient basis for the purpose of maintaining rather than
improving your Condition are excluded. Maintenance therapy begins when the therapeutic goals
of a treatment plan have been met or no further functional progress is expected. Services that
involve non -diagnostic, non -therapeutic, routine, or repetitive procedures to maintain general
welfare and do not require the skilled assistance of a licensed therapist are excluded. Therapy for
abnormal speech pathology, including lisping and stuttering; rehabilitative therapy modalities that
are considered investigational including cognitive therapy, Interactive Metronome Program,
Augmented Soft Tissue Mobilization, Kinesio Taping/Taping, MEDEK Therapy, Hands -Free Ultrasound
and Low -Frequency Sound (Infrasound), and Hivamat Therapy (Deep Oscillation Therapy) are
excluded.
11.51 Removal of benign skin lesions, including warts, moles, skin tags, lipomas, keloids and scars is not
covered, even with a recommendation or prescription from a Physician.
11.52 Reversal of voluntary surgically -induced sterility including the reversal of tubal ligations and
vasectomies.
11.53 Sexual Dysfunction. All medications, devices and other forms of treatment related to a diagnosis of
sexual dysfunction, regardless of etiology.
11.54 Skilled Nursing Facilities. Expenses for an inpatient admission to a Skilled Nursing Facility for purposes
of Custodial Care, convalescent care, or any other service primarily for the convenience of you or
your family members or the provider.
11.55 Sports -related devices, services and medications used to affect performance primarily in sports -
related activities; all expenses related to physical conditioning programs such as athletic training,
bodybuilding, exercise, fitness, flexibility, and diversion or general motivation.
11.56 Supplies. 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.
11.57 Surgically implanted devices and any associated external devices, except for cardiac
pacemakers, intraocular lenses, cochlear implants, artificial joints, orthopedic hardware and
vascular grafts. Dental appliances, other corrective lenses and hearing aids, including the
professional fee for fitting them, are not covered.
11.58 Temporomandibular Joint (TMJ) Dysfunction. Services related to the diagnosis and treatment of TMJ
except when Medically Necessary; and all dental treatment for TMJ.
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11.59 Termination of pregnancy unless deemed Medically Necessary, subject to applicable state and
federal laws.
1 1.60 Training and educational programs or materials, except as described under Diabetes Outpatient
Self -Management in Part IX. COVERED MEDICAL SERVICES, including programs or materials for Pain
Management and vocational rehabilitation.
11.61 Transplant Services. Expenses for the following are excluded:
a. transplant procedures excluded under this Contract (e.g., Experimental or Investigational
transplant procedures);
b. transplant procedures involving the transplantation or implantation of any non -human organ or
tissue;
c. transplant procedures related to the donation or acquisition of an organ or tissue for a recipient
who is not covered by AvMed;
d. transplant procedures involving the implant of an artificial organ, including the implant of the
artificial organ;
e. any organ, tissue, marrow, or stem cells which is/are sold rather than donated;
f. any Bone Marrow Transplant, as defined herein, which is not specifically listed in Rule 59B-12.001,
Florida Administrative Code, or any successor or similar rule or covered by Medicare pursuant
to a national coverage decision made by CMS as evidenced in the most recently published
Medicare National Coverage Determinations Manual;
any service in connection with the identification of a donor from a local, state or national listing,
except in the case of a Bone Marrow Transplant;
h. any non -medical costs, including temporary lodging or transportation costs for you or your
family to and from the approved facility, except as described in Part X. LIMITATIONS OF
COVERED MEDICAL SERVICES;
i. any artificial heart, mechanical device, or ventricular assist device (VAD) that replaces either
the atrium or the ventricle;
j. collection and storage costs associated with the banking of umbilical cord blood;
k. transplant services and procedures provided by or at facilities that are not AvMed In -Network
Center of Excellence facilities located within the State of Florida.
11.62 Transportation including expenses for ambulance services to and from a Physician or Hospital
except as described in Part IX. COVERED MEDICAL SERVICES and Part X. LIMITATIONS OF COVERED
MEDICAL SERVICES.
11.63 Travel or vacation expenses even if prescribed or ordered by a Health Professional.
11.64 Treatment in a federal, state, or governmental entity including any care in a Hospital or Other Health
Care Facility owned or operated by any federal, state or other governmental entity unless
coverage is required by applicable laws.
11.65 Treatment, services or supplies received outside the United States. However, benefits will be
payable for Covered Services required to treat an Emergency Medical Condition or Urgent Medical
Condition arising during travel outside of the continental United States, Alaska and Hawaii.
Members are responsible for payment of such services at the time they are received and should
submit the Claim to AvMed as described in Part XIII. REVIEW PROCEDURES/ AND HOW TO APPEAL A
CLAIM (BENEFIT) DENIAL.
11.66 Ventilator dependent care, except as described in Part II . DEFINITIONS for 100 calendar days lifetime
maximum benefit.
11.67 Volunteer services, or services which would normally be provided free of charge and any charges
associated with Deductible, Coinsurance, or Copayment (if applicable) requirements which are
waived by a Health Care Provider.
11.68 Weight Control Services. Except those services deemed preventive and given an 'A' or 'B' rating in
current recommendations by the USPSTF, any service, treatment or program to lose, gain, or
g.
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maintain weight, including and without limitation, appetite suppressants, dietary regimens, food or
food supplements (except as described under Nutrition Therapy in Part IX. COVERED MEDICAL
SERVICES), and exercise programs or equipment, whether or not a part of a treatment plan for a
Condition.
11.69 Wigs or cranial prostheses.
11.70 Workers' Compensation Benefits. Any sickness or injury for which the Member is paid benefits, or
may be paid benefits if claimed, if the Member is covered or could be covered by Workers'
Compensation. In addition, if the Member enters into a settlement giving up rights to recover past
or future medical benefits under a Workers' Compensation law, AvMed will not cover past or future
Health Care Services that are the subject of or related to that settlement. Furthermore, if the
Member is covered by a Worker's Compensation program that limits benefits if other than specified
Health Care Providers are used and the Member receives care or services from a Health Care
Provider not specified by the program, AvMed will not cover the balance of any costs remaining
after the program has paid.
XII. PRESCRIPTION MEDICATION BENEFITS, LIMITATIONS AND EXCLUSIONS
See the Prescription Medication Amendment to your Contract for important information including Member
cost -sharing, Limitations and Exclusions. See also Part I I . DEFINITIONS.
12.1 Prescription Medication Definitions. For the purposes of this Contract, the following terms have the
meanings set forth below. See also Part II. Definitions.
a. Brand Medication means a Prescription Drug that is usually manufactured and sold under a
name or trademark by a pharmaceutical manufacturer or a medication that is identified as a
Brand Medication by AvMed. AvMed delegates determination of Generic/Brand status to our
Pharmacy Benefits Manager.
b. Brand Additional Charge means the additional charge that must be paid if you or your Physician
choose a Brand Medication when a Generic equivalent is available. The charge is the
difference between the cost of the Brand Medication and the Generic Medication. This charge
must be paid in addition to the non -preferred brand cost -sharing amount. The Brand Additional
Charge does not apply toward the Calendar Year Deductible or Out -of -Pocket Maximum.
c. Dental -specific Medication is medication used for dental -specific purposes including fluoride
medications and medications packaged and labeled for dental -specific purposes.
d. Formulary List means the listing of preferred and non -preferred medications as determined by
AvMed's Pharmacy and Therapeutics Committee based on the clinical efficacy, relative safety
and cost in comparison to similar medications within a therapeutic class. This multi -tiered list
establishes different levels of cost -sharing 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. Specific medications on the
Formulary List and their placement in a given therapeutic class are subject to change at any
time without prior notice to you or your approval. It is your responsibility to consult with your
Attending Physician to determine whether a medication is on the Formulary List at the time the
prescription is rendered.
e. Generic Medication means a medication that has the same active ingredient as a Brand
Medication or is identified as a Generic Medication by AvMed's Pharmacy Benefits Manager.
f. In -Network Pharmacy means a pharmacy (retail, mail order or specialty pharmacy) that has
entered into an agreement to provide Prescription Medications to AvMed Members and has
been designated as an In -Network Pharmacy. Except for emergencies, covered Prescription
Medications must be obtained at In -Network Pharmacies.
Maintenance Medication is a medication that is approved by the U.S. Food and Drug
Administration (FDA), for which the duration of therapy can reasonably be expected to exceed
one year, as determined by the Pharmacy Benefits Manager.
g.
AV-LG-COC-21 48 Achieve-LG-7636 (07/21)
h. Specialty Medications are high cost medications that are self-administered by Members. These
medications may be limited in distribution to in -network specialty pharmacies. Many of these
medications require Prior Authorization and are limited to a maximum 30 -day supply per
dispensing.
12.2 Pharmacy Coverage Criteria. Your Prescription Medication coverage includes outpatient
medications (including certain contraceptives) that require a prescription, are prescribed by a
Physician in accordance with AvMed's Coverage Criteria, and are filled at an AvMed In -Network
Pharmacy. AvMed reserves the right to make changes in Coverage Criteria for covered products
and services.
12.3 Prior Authorization and Progressive Medication Program. Your Prescription Medication coverage
may require Prior Authorization, and such Prior Authorization may include the Progressive
Medication Program for certain covered medications. The prescribing Physician or the In -Network
Pharmacy must obtain approval (prior to dispensing) from AvMed. The list of Prescription
Medications requiring Prior Authorization is subject to periodic review and modification by AvMed
and may be amended without notice. A copy of the list of covered Prescription Medications, drugs
requiring Prior Authorization and drugs that are a part of the Progressive Medication Program are
available from AvMed's Member Engagement Center or from the AvMed website. The Progressive
Medication Program encourages the use of therapeutically -equivalent lower -cost medications by
requiring certain medications to be utilized to treat a Condition prior to approving another
medication for that Condition. The Progressive Medication Program includes the first -line use of
preferred medications that are proven to be safe and effective for a given Condition and can
provide the same health benefit as more expensive non -preferred medications at a lower cost.
12.4 Cost -Sharing and Refilling Prescriptions. Your retail Prescription Drug coverage includes up to a 30 -
day supply of a medication for the cost -sharing amounts shown in your Prescription Medication
Amendment. Your prescription may be refilled via retail or mail order after 75% of your previous fill
has been used and subject to a maximum of 13 refills per year. You also have the opportunity to
obtain a 90 -day supply of Prescription Medications used for chronic Conditions including asthma,
cardiovascular disease, and diabetes, from a retail In -Network Pharmacy or via mail order for the
applicable cost -sharing per 30 -day supply.
12.5 Quantity Limits for Prescriptions. Quantity limits are set in accordance with FDA approved
prescribing limitations, general practice guidelines supported by medical specialty organizations,
or evidence -based, statistically valid clinical studies without published conflicting data. This means
that a medication -specific quantity limit may apply to Prescription Medications that have an
increased potential for over -utilization or an increased potential for a Member to experience an
adverse effect at higher doses.
12.6 Obtaining Prescribed Medications. To obtain your Prescription Medication, take your prescription
to, or have your Physician call, an AvMed In -Network Pharmacy. Present your prescription along
with your AvMed Identification Card. Pay any applicable Calendar Year Deductible and
Copayment or Coinsurance (as well as any additional charge that may apply if a Brand Medication
is chosen when a Generic equivalent is available) as described in the Prescription Medication
Amendment to this Contract. Your Physician should submit prescriptions for Specialty Medications
to AvMed's in -network specialty pharmacy.
12.7 Mail Services for Prescriptions. Mail-order Prescription Drug coverage, If available under your Plan,
includes up to a 90 -day supply of a routine Maintenance Medication for the cost -sharing amount
shown in your Prescription Medication Amendment. If the amount of medication is less than a 90 -
day supply, you will still be charged the mail order cost -sharing amount. Mail service is a benefit
option for Maintenance Medications needed for chronic or long-term health Conditions. It is often
best to get an initial prescription filled at your retail In -Network Pharmacy. Ask your Physician for an
additional prescription for a 60 -90 -day supply of your medication to be ordered through mail
service. Please refer to your Prescription Medication Amendment for cost -sharing amounts for
Prescription Medications ordered through mail services.
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12.8 Prescription Medication Benefits Disclaimer. Filling a prescription at a pharmacy is not a Claim for
benefits and is not subject to the Claims and Appeals procedures under the Employee Retirement
Income Security Act of 1974 (ERISA). However, any Prescription Medications that require Prior
Authorization will be treated as a Claim for benefits subject to the Claims and Appeals Procedures,
as outlined in this Contract.
12.9 Third -Party Assistance for Specialty Medications. If you use any third -party Copayment assistance
(sometimes also referred to as a "copay card" or "copay coupon") provided by a drug
manufacturer or any other entity to pay any applicable Calendar Year Deductible, Copayment,
or Coinsurance amounts for any Specialty Medications, you will not receive credit toward your
Calendar Year Out -of -Pocket Maximum or Calendar Year Deductible for any such assistance you
use.
XIII. REVIEW PROCEDURES AND HOW TO APPEAL A CLAIM (BENEFIT) DENIAL
13.1 Member's Rights of Review. Members have the right to a review of any complaint regarding the
services or benefits covered under this Contract. AvMed encourages the informal resolution of
complaints. If you have a complaint, you or someone you name to act on your behalf (an
authorized representative) may call AvMed's Member Engagement Center, and a Representative
will try to resolve the complaint for you over the telephone. If you ask for a written response, or if the
complaint is related to quality of care, we will respond in writing. The Member Engagement Center
can also advise you how to name your authorized representative.
13.2 Filing a Grievance. If a Member's complaint cannot be resolved informally, it may be submitted to
AvMed in writing. We call this 'filing a Grievance'. A Grievance is any complaint relating to Plan
services, other than one that involves a request (Claim) for benefits or an appeal of an Adverse
Benefit Determination. Grievances must be filed within 1 year of the occurrence of the event or
action that led to the Grievance. Grievances will be deemed to have been filed on the date
received by AvMed, and will be processed through AvMed's formal Member Grievance
Procedures. AvMed will acknowledge and investigate the Grievance and provide a written
response advising of the disposition within 60 days after receipt of the Grievance.
a. Grievances relating to Plan services may be submitted in writing to:
AvMed Member Engagement Center
P.O. Box 569008
Miami, Florida 33256-9908
Telephone: 1-800-882-8633
Fax: (305) 671-4736
b. If you are not satisfied with AvMed's final decision, you may file a written Grievance with the
Department of Financial Services (DFS) within 1 year of receipt of AvMed's final decision letter.
You also have the right to contact DFS at any time to inform them of an unresolved Grievance.
DFS may be contacted at the address below:
Florida Department of Financial Services
200 East Gaines Street
Tallahassee, Florida 32399
Telephone: 1-877-693-5236
13.3 Claims for Benefits. All Claims for benefits will be deemed to have been filed on the date received
by AvMed. If a Claim is a Pre -Service or Urgent Care Claim, a Health Professional with knowledge
of the Member's Condition will be permitted to act as the Member's authorized representative, and
will be notified of all approvals on the Member's behalf.
a. Pre -Service Claims
i. Initial Claim. AvMed will notify the Claimant of the benefit determination with respect to a
Pre -Service Claim no later than 15 days after receipt of the Claim. AvMed may extend this
period one time for up to 15 additional days, if we determine that such an extension is
necessary due to matters beyond our control, and we notify the Claimant before the
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expiration of the initial 15 -day period, of the circumstances requiring the extension of time
and the date by which we expect to render a decision.
1) If such an extension is necessary because the Claimant failed to provide sufficient
information to decide the Claim, the notice of extension will specifically describe the
required information, and the Claimant will be afforded at least 45 days from receipt
of the notice to provide the specified information.
2) In the case of a failure by a Claimant to follow AvMed's procedures for filing a Pre -
Service Claim, the Claimant will be notified of the failure and the proper procedures
to be followed, no later than five days following such failure.
3) AvMed's period for making the benefit determination will be tolled from the date the
notification of the extension is sent to the Claimant, until the date 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 will be denied.
ii. Appeal of a Pre -Service Claim. A Claimant may appeal an Adverse Benefit Determination
with respect to a Pre -Service Claim within 1 year of receiving the Adverse Benefit
Determination. AvMed will review the Claim and notify the Claimant of its determination
on review, no later than 30 days after AvMed receives the Claimant's request; except in
limited cases when AvMed provides new information to the Claimant that AvMed is
considering in the appeal, and gives the Claimant an opportunity to respond. An appeal
of an Adverse Benefit Determination with respect to a Pre -Service Claim may be submitted
to:
AvMed Member Engagement Center
P.O. Box 569008
Miami, Florida 33256-9908
Telephone: 1-800-882-8633
Fax: (305) 671-4736
b. Urgent Care Claims
i. Initial Claim. Generally, the determination of whether a Claim is an Urgent Care Claim will
be made by an individual acting on behalf of AvMed, applying the judgment of a prudent
layperson possessing an average knowledge of health and medicine. However, if a
Physician with knowledge of the Member's Condition determines that the Claim is an
Urgent Care Claim, it will be deemed urgent. Urgent Care Claims may be made orally or
in writing. AvMed will notify the Claimant of the benefit determination as soon as possible,
taking into account the medical exigencies, but no later than 72 hours after receipt of the
Urgent Care Claim.
1) If the Claimant fails to provide sufficient information to determine whether or to what
extent benefits are covered or payable under this Contract, AvMed will notify the
Claimant, no later than 24 hours after receipt of the Claim, of the specific information
necessary to complete the Claim. The Claimant will be afforded no less than 48 hours,
to provide the specified information.
2) AvMed will notify the Claimant of the benefit determination no later than 48 hours after
the earlier of: AvMed's receipt of the specified information, or the end of the period
afforded the Claimant to provide the specified information. If the Claimant fails to
supply the specified information within the 48 -hour period, the Claim will be denied.
3) AvMed may notify the Claimant of the benefit determination orally or in writing. If the
notification is provided orally, a written or electronic notification will also be provided
to the Claimant no later than three days after the oral notification.
ii. Appeal of an Urgent Care Claim. A Claimant may appeal an Adverse Benefit
Determination with respect to an Urgent Care Claim within 1 year of receiving the Adverse
Benefit Determination. AvMed will review the Claim and notify the Claimant of its benefit
determination on review as soon as possible, taking into account the medical exigencies,
but no later than 72 hours after receipt of the Claimant's request; except in limited cases
when AvMed provides new information to the Claimant that AvMed is considering in the
AV-LG-COC-21 51 Achieve-LG-7636 (07/21)
appeal, and gives the Claimant an opportunity to respond. An appeal of an Adverse
Benefit Determination with respect to an Urgent Care Claim may be submitted to AvMed's
Member Engagement Center at the address listed under Appeal of a Pre -Service Claim,
above.
c. Concurrent Care Claims
i. Any reduction or termination by AvMed of Concurrent Care (other than by an
amendment to this Contract or termination), before the end of an approved period of
time or number of treatments, will constitute an Adverse Benefit Determination. In the
event a Concurrent Care Claim results in an Adverse Benefit Determination, AvMed will
notify the Claimant at a time sufficiently in advance of the reduction or termination to
allow the Claimant to appeal and obtain a determination on review before the benefit is
reduced or terminated.
1) Any request by a Claimant that relates to an Urgent Care Claim to extend the course
of treatment beyond the period of time or number of treatments previously authorized,
will be decided as soon as possible, taking into account the medical exigencies.
AvMed will notify the Claimant of the benefit determination within 24 hours after
receipt of the Claim, provided the Claim is made to AvMed at least 24 hours before
the expiration of the prescribed period of time or number of treatments.
2) Notification and appeal of any Adverse Benefit Determination concerning a request
to extend a course of treatment, whether involving an Urgent Care Claim or not, will
be made in accordance with AvMed's review and notification procedures described
herein.
d. Post -Service Claims
i. Initial Claim. Post -Service Claims must be submitted to AvMed within 90 days from the date
of service or within one year unless the Member was legally incapacitated; otherwise the
Claim will be considered to have been waived.
1) Post -Service Claims must include all of the information listed below. If a Claim is for
services received to treat an Emergency Medical Condition or an Urgent Medical
Condition while outside the continental United States, Alaska or Hawaii, the information
must be translated into English.
a) The name of the individual who received the services;
b) The Member's name and Member ID number as they appear on the Member
Identification Card;
c) The place of service and the date of service;
d) A description of the services including any applicable procedure codes;
e) The diagnosis including any applicable diagnosis codes;
f) The provider's name and address; and
g) The amount actually charged by the provider and a copy of the paid receipts;
2) AvMed will notify the Claimant of the benefit determination no later than 30 days after
receipt of a Post -Service Claim. AvMed may extend this period one time for up to 15
additional days if we determine such an extension is necessary due to matters beyond
our control and we notify the Claimant, before the expiration of the initial 30 -day
period, of the circumstances requiring the extension of time and the date by which we
expect to render a decision.
a) If such an extension is necessary because the Claimant failed to provide sufficient
information to decide the Claim, the notice of extension will specifically describe
the required information, and the Claimant will be afforded at least 45 days from
receipt of the notice to provide the specified information.
b) AvMed's period for making the benefit determination will be tolled from the date
the notification of the extension is sent to the Claimant, until the date 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 will be denied.
AV-LG-COC-21 52 Achieve-LG-7636 (07/21)
ii. Appeal of a Post -Service Claim. A Claimant may appeal an Adverse Benefit Determination
with respect to a Post -Service Claim within 1 year of receiving the Adverse Benefit
Determination. AvMed will review the Claim and notify the Claimant of its determination
on review, no later than 60 days after receipt of the Claimant's request; except in limited
cases when AvMed provides new information to the Claimant that AvMed is considering
in the appeal, and gives the Claimant an opportunity to respond. An appeal of an Adverse
Benefit Determination with respect to a Post -Service Claim may be submitted to AvMed's
Member Engagement Center, at the address listed in Appeal of a Pre -Service Claim,
above.
13.4 Manner and Content of Initial Claims Determination Notification. AvMed will provide a Claimant
with written or electronic notification of any Adverse Benefit Determination. The notification will set
forth the following, in a manner calculated to be understood by the Claimant:
a. sufficient information to identify the Claim, including (as applicable) the date of service,
Health Care Provider, and Claim amount, as well as notice that the diagnosis and treatment
codes, along with the corresponding meaning, are available free of charge upon request;
b. the specific reason for the Adverse Benefit Determination including the denial code and its
corresponding meaning;
c. reference to the specific Contract provisions on which the determination is based;
d. 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;
e. a description of AvMed's review procedures and the applicable time limits;
f. in the case of an Adverse Benefit Determination involving an Urgent Care Claim, a description
of the expedited review process applicable to such Claim;
any internal rule, guideline, protocol or other similar criterion relied upon in making the Adverse
Benefit Determination; or a statement that a copy of such rule, guideline, protocol or other
similar criterion will be provided free of charge to the Claimant upon request;
h. if the Adverse Benefit Determination is based on whether the treatment or service is
Experimental or Investigational, or not Medically Necessary, either an explanation of the
scientific or clinical judgment for the determination, applying the terms of this Contract to the
Member's medical circumstances; or a statement that such explanation will be provided free
of charge upon request.
13.5 Review Procedure upon Appeal. In order to assure Claimants a full and fair review, AvMed's review
procedures will include the following procedures and safeguards:
a. Claimants may present evidence and submit written comments, documents, records and other
information relating to a Claim.
b. upon request and free of charge, Claimants will have reasonable access to and copies of any
Relevant Documents. Relevant Document means, any documentation that (i) was relied upon
in making a benefit determination; (ii) was submitted, considered or generated in the course of
making a benefit determination, without regard to whether it was relied upon in making the
determination; (iii) demonstrates compliance with the Plan's administrative process; and (iv)
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.
c. the review will 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 review will 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 will 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,
medication, or other item is Experimental or Investigational, or not Medically Necessary, the
g.
AV-LG-COC-21 53 Achieve-LG-7636 (07/21)
appropriate named fiduciary will consult with a Health Professional who has appropriate training
and experience in the field of medicine relevant to the medical judgment.
f. the review will 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.
the review will provide that the Health Professional engaged for purposes of a consultation will
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 will be an expedited review process available,
pursuant to which:
i. a 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, will be
transmitted between AvMed and the Claimant by telephone, facsimile or other available
similarly expeditious methods.
13.6 Manner and Content of Appeal Notification. AvMed will provide a Claimant with written or
electronic notification of its benefit determination upon review. In the case of an Adverse Benefit
Determination, AvMed will notify both the Member and the Health Professional, and the notification
will set forth all of the following as appropriate, in a manner calculated to be understood by the
Claimant:
a. the specific reasons for the Adverse Benefit Determination;
b. reference to the specific Contract provisions on which the Adverse Benefit Determination is
based;
c. a statement that the Claimant is entitled to receive reasonable access to, and copies of, any
Relevant Documents, upon request and free of charge;
d. a statement describing any voluntary appeal procedures offered by AvMed and the
Claimant's right to obtain information about such procedures, and a statement of the
Claimant's right to bring an action under ERISA Section 502(a) when applicable;
e. any internal rule, guideline, protocol, or other similar criterion relied upon in making the Adverse
Benefit Determination; or a statement that a copy of such rule, guideline, protocol or other
similar criterion will be provided free of charge to the Claimant upon request;
f. if the Adverse Benefit Determination is based on whether a treatment or service is Experimental
or Investigational, or not Medically Necessary, either an explanation of the scientific or clinical
judgment for the determination, applying the terms of the Contract to the Member's medical
circumstances; or a statement that such explanation will be provided free of charge upon
request.
13.7 External Review. In the event of a final internal Adverse Benefit Determination, a Claimant may be
entitled to an external review of the Claim. This request must be submitted in writing on an External
Review Request form within 120 days of receipt of the Adverse Benefit Determination. The external
reviewer will render a recommendation within 45 calendar days unless the request meets expedited
criteria, in which case it will be resolved in no later than 72 hours. The external reviewer's
recommendation will be binding. The external reviewer will notify the Claimant of its decision in
writing, and the Plan will take action as appropriate to comply with such recommendation. For
detailed information about the external review process, please contact AvMed's Member
Engagement Center.
13.8 Remedies if Process "Deemed Exhausted"
a. If we continue to deny the payment, coverage, or service requested or you do not receive a
timely decision, you may be able to request an external review of your Claim by an
independent third -party, who will review the denial and issue a final decision. You may contact
g.
AV-LG-COC-21 54 Achieve-LG-7636 (07/21)
AvMed's Member Engagement Center at 1-800-882-8633 with any questions on your rights to
external review. Please understand that if you want to be informed about the legal remedies
that may be available to you and whether they are a better option for you than seeking
independent external review, you should consult a lawyer of your choice. AvMed cannot
provide you with legal advice. We can only explain the procedures for obtaining independent
external review.
b. If this Plan is subject to ERISA, please see the Addendum to this Group Medical and Hospital
Service Contract. You also have the right to seek such legal remedies as may be available to
you under ERISA Section 502 or state law.
XIV. COORDINATION OF BENEFITS
14.1 How Coordination of Benefits (COB) Works. 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
health plan, program or policy which may be subject to COB. The amount of our payment, if any,
when we coordinate benefits under this Part, is based on whether or not AvMed is the primary
payer. When AvMed is not primary, our payment for Covered Services may be reduced so that
total benefits under all your plans will not exceed 100% of the total reasonable expenses actually
incurred for Covered Services. For purposes of this Part, in the event you receive Covered Services
from an In -Network Provider, 'total reasonable expenses' will mean the amount we are obligated
to pay to the provider pursuant to the applicable provider agreement we have with such provider,
or if there is no such provider agreement, the amount we are obligated to pay the provider pursuant
to state or federal law. When AvMed is not the primary payer, and the primary payer's payment
exceeds AvMed's contracted amount, no payment will be made for such services.
14.2 Plans Subject to COB
a. Health plans, programs or policies which may be subject to COB include the following, which
will be referred to as "plans" for purposes of this Part:
i. any group or non -group health insurance contract, HMO contract, or other forms of group
or group -type coverage whether insured or uninsured;
ii. medical care components of long-term care contracts such as skilled nursing care,
medical benefits under group or individual automobile contracts; and
iii. Medicare or any other governmental plan as permitted by law.
14.3 Member's Responsibilities to Avoid Duplication of Coverage. You are responsible for providing us
with written information concerning any other coverage you or your Covered Dependents may
have. This information may be requested at the time of enrollment, by written correspondence
annually thereafter or in connection with a specific Health Care Service you receive. Information
should be provided within 30 days of a request. Information received after one year from the date
of service will not be considered. If we do not receive the information we request from you, we may
deny your Claims and you will be responsible for payment of any expenses related to such denied
Claims.
14.4 Order of Benefit Determination. If any covered person is eligible for services or benefits under two or
more plans, any plan without a COB provision is automatically designated as the primary plan.
When all applicable plans have COB provisions, the order of benefit determination will be as follows:
a. Non -Dependent or Dependent. The plan that covers the person other than as a dependent (for
example, as an employee, policyholder, Subscriber or retiree) is primary to the plan which
covers the person as a dependent.
i. 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, a plan covering a person as an
employee or subscriber is primary; a plan of an active worker covering a person as a
dependent is secondary; and Medicare is last.
b. Dependent Children Covered Under More Than One Plan
AV-LG-COC-21
55 Achieve-LG-7636 (07/21)
i. Dependent children whose parents are not separated or divorced
1) the plan of the parent whose birthday, excluding year of birth, falls earlier in the year
will be primary; or
2) if both parents have the same birthday, excluding year of birth, the plan that has
covered the parent the longest will be primary.
ii. Dependent children whose parents are separated or divorced
1) if a parent with sole parental responsibility is not remarried, the plan of the parent with
custody is primary;
2) if a parent with sole parental responsibility has remarried, the plan of the parent with
sole parental responsibility is primary; the step -parent's plan is secondary; and the plan
of the parent without parental responsibility pays last; and
3) regardless of which parent has sole parental responsibility, whenever a court order
specifies that one parent is financially responsible for the child's health care expenses,
the plan of that parent is primary.
c. However, if a plan subject to the birthday rule as stated above coordinates with an out-of-state
plan under which the plan covering a person as a dependent of a male is primary, and those
covering the person as a dependent of a female are secondary and if, as a result, the plans do
not agree on the order of benefits, the provisions of the other plan will determine the order of
benefits.
d. A plan covering a person as an employee who is neither laid off nor retired, or as that
employee's dependent, is primary to a plan covering 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 paragraph will
not apply.
e. If none of the rules in paragraphs a. through d. above determine the order of benefits, the
benefits of the plan which covered an employee or subscriber the longest will be primary.
f. If the other plan does not have rules that establish the same order of benefits as under this
Contract, the benefits under the other plan will be determined primary to the benefits under
this Contract.
If an individual is covered under a COBRA continuation plan and also under another Group
Health Insurance plan, the plan covering the person as an employee or as the employee's
dependent will be primary to the plan covering the person as a former employee or as the
former employee's dependent.
h. We will not coordinate benefits against an indemnity -type policy, an excess insurance policy, a
policy with coverage limited to specified illnesses or accidents, or a Medicare supplement
policy.
14.5 Medicare Secondary Payer Provisions. Individuals are eligible for Medicare and can be covered
under it because of age, disability or end stage renal disease (ESRD). Individuals are also eligible for
Medicare even when not covered under it if they refused it, dropped it or did not make a proper
request for it. When you are eligible for Medicare, AvMed coordinates your benefits under this plan
with the benefits Medicare pays. If you are eligible but not covered under Medicare, we may
coordinate your benefits under this Plan with the benefits Medicare would pay had you enrolled. If
you become Medicare eligible while covered under the Plan, you should visit www.medicare.gov
or contact your local Social Security office to learn about your eligibility, coverage options,
enrollment periods and necessary steps to follow to ensure that you have adequate coverage.
a. If you are eligible for Medicare due to age, have group health coverage based on you or your
spouse's current employment and the employer has 20 or more employees, the group health
plan is primary and Medicare is secondary.
b. If you are eligible for Medicare due to ESRD and have group health coverage based on you or
your spouse's current employment, the group health plan is primary for the first 30 months
beginning with the earlier of:
i. the month in which you became covered under Medicare Part A ESRD benefits; or
g.
AV-LG-COC-21 56 Achieve-LG-7636 (07/21)
ii. the first month in which you would have been covered under Medicare Part A ESRD
benefits if a timely application had been made.
iii. After 30 months, Medicare is primary and the group health plan is secondary.
c. If you are eligible for Medicare due to a disability other than ESRD, have group health coverage
based on you or a family member's current employment and the employer has:
i. 100 or more employees: the group health plan is primary and Medicare is secondary;
ii. less than 100 employees: Medicare is primary and the group health plan is secondary.
d. If you are eligible for Medicare due to age and have retiree coverage, Medicare is primary and
the group health plan (retiree coverage) is secondary.
e. If you become covered under Medicare and are still eligible and covered under a group health
plan, the employer may not offer, subsidize, procure or provide a Medicare supplement policy
to you; nor may an employer persuade you to decline or terminate your coverage under the
plan and elect Medicare as the primary payer.
14.6 Right to Receive and Release Necessary Information. 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, plan or organization release to or
obtain from any person, plan or organization any information, with respect to any Member or
applicant for subscription, which AvMed deems to be necessary for such purposes.
14.7 Facility of Payment. Whenever payments which should have been made under this Plan have been
made under any other plans, AvMed will have the right, exercisable alone and in its sole discretion,
to pay over to any organizations making such other payments any amounts AvMed determines to
be warranted in order to satisfy the intent of this provision, and amounts so paid will be deemed to
be benefits paid under this Plan.
14.8 Right of Recovery. If the amount of the payments made by AvMed is more than it should have paid
under the provisions of this Part, it may recover the excess from one or more of the persons it has
paid, or for whom it has paid, or any other person or organization that may be responsible for the
benefits or services provided for the Member. The 'amount of the payments made' includes the
reasonable cash value of any benefits provided in the form of services.
XV. SUBROGATION AND RIGHT OF RECOVERY
15.1 AvMed's Right of Subrogation and Recovery. If AvMed provides health care benefits under this
Contract for a Member for injuries or illness for which another party is or may be responsible, then
AvMed retains the right to repayment of the full cost of all such benefits. AvMed's rights of recovery
apply to any recoveries made by or on behalf of the Member from the following third -party sources,
as allowed by law, including payments made by a third -party tortfeasor or any insurance company
on behalf of the third -party tortfeasor; any payments or awards under an uninsured or underinsured
motorist coverage policy; any worker's compensation or disability award or settlement; medical
payments coverage under any automobile policy, premises or homeowners medical payments
coverage or premises or homeowners insurance coverage; any other payments from a source
intended to compensate a Member for injuries resulting from an accident or alleged negligence.
For purposes of this Contract, a tortfeasor is any party who has committed injury, or wrongful act
done willingly, negligently or in circumstances involving strict liability, but not including breach of
contract for which a civil suit can be brought.
15.2 Members Specifically Acknowledge AvMed's Right of Subrogation. When AvMed provides health
care benefits for injuries or illnesses for which a third -party is or may be responsible, AvMed will be
subrogated to the Member's rights of recovery against any party to the extent of the full cost of all
benefits provided by AvMed, to the fullest extent permitted by law. AvMed may proceed against
any party with or without the Member's consent.
15.3 Members Specifically Acknowledge AvMed's Right of Reimbursement. This right of reimbursement
attaches, to the fullest extent permitted by law, when AvMed has provided health care benefits for
injuries or illness for which another party is or may be responsible and the Member or the Member's
AV-LG-COC-21 57 Achieve-LG-7636 (07/21)
representative has recovered any amounts from the third party or any party making payments on
the third party's behalf. By providing any benefit under this Contract, AvMed is granted an
assignment of the proceeds of any settlement, judgment or other payment received by the
Member to the extent of the full cost of all benefits provided by AvMed. AvMed's right of
reimbursement is cumulative with and not exclusive of AvMed's subrogation right and AvMed may
choose to exercise either or both rights of recovery.
15.4 Assent for Member Notification. Member and the Member's representatives further agree to:
a. notify AvMed promptly and in writing when notice is given to any third -party of the intention to
investigate or pursue a claim to recover damages or obtain compensation due to injuries or
illness sustained by the Member that may be the legal responsibility of a third -party; and
b. cooperate with AvMed and do whatever is necessary to secure AvMed's rights of subrogation
and reimbursement under this Contract; and
c. give AvMed a first -priority lien on any recovery, settlement or judgment or other source of
compensation which may be had from a third -party to the extent of the full cost of all benefits
provided by AvMed that are associated with injuries or illness for which a third -party is or may
be responsible (regardless of whether specifically set forth in the recovery, settlement, judgment
or compensation agreement); and
d. pay, as the first priority, from any recovery, settlement or judgment or other source of
compensation, any and all amounts due AvMed as reimbursement for the full cost of all benefits
provided by AvMed that are associated with injuries or illness for which a third -party is or may
be responsible (regardless of whether specifically set forth in the recovery, settlement, judgment
or compensation agreement), unless otherwise agreed to by AvMed in writing; and
e. do nothing to prejudice AvMed's rights as set forth above. This includes refraining from making
any settlement or recovery which specifically attempts to reduce or exclude the full cost of all
benefits, provided by AvMed.
15.5 Recovery of Full Cost. AvMed may recover the full cost of all benefits provided by AvMed under this
Contract without regard to any claim of fault on the part of the Member, whether by comparative
negligence or otherwise. No court costs or attorney fees may be deducted from AvMed's recovery
without the prior express written consent of AvMed. In the event the Member or the Member's
representative fails to cooperate with AvMed, the Member will be responsible for all benefits paid
by AvMed in addition to costs and attorney's fees incurred by AvMed in obtaining repayment.
XVI. DISCLAIMER OF LIABILITY AND RELATIONSHIPS BETWEEN THE PARTIES
16.1 Indemnity of Parties
a. Subscribing Group. Neither Subscribing Group nor its agents, servants or employees, nor any
Member is the agent or representative of AvMed, and none of them will be liable for any acts
or omissions of AvMed, its agents or employees, or of an in -network Hospital or Physician, or any
other person or organization with which AvMed has made or hereafter will make arrangements
for the performance of services under this Contract.
b. Members. Members will not be liable to AvMed or In -Network Providers except as specifically
set forth herein, provided all procedures set forth herein are followed.
c. AvMed. Neither AvMed nor its agents, servants or employees is the agent or representative of
the Subscribing Group, and none of them will be liable for any acts or omissions of Subscribing
Group, its agents or employees, or any other person representing or acting on behalf of the
Subscribing Group.
16.2 Relationship of AvMed and In -Network Providers. 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 will be deemed not to be a
Health Care Provider with respect to any services performed or rendered by any such independent
contractors. In -Network Providers maintain the Physician/patient relationship with Members and are
solely responsible for all Health Care Services which In -Network Providers render to Members.
AV-LG-COC-21 58 Achieve-LG-7636 (07/21)
Therefore, AvMed will 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 Professionals or any of their employees or agents who may, from
time to time, provide Health Care Services to a Member of AvMed. Furthermore, AvMed will not be
vicariously liable for any negligent act or omission of any of these independent Health Professionals
who treat a Member of AvMed.
16.3 Member's Refusal of Procedures or Treatment. Certain Members may, for personal reasons, refuse
to accept procedures or treatment recommended by in -network Physicians. 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, and the
Physician may terminate his provider relationship with the Member. If a Member refuses to accept
the medical treatment or procedure recommended by the in -network Physician and if, in the
judgment of the in -network Physician, no professionally acceptable alternative exists or if an
alternative treatment does exist but is not recommended by the in -network Physician, the in -
network Physician will advise the Member accordingly.
XVII. GENERAL PROVISIONS
17.1 Amendment. The terms of coverage and benefits to be provided by us may be amended annually
on this Contract's anniversary date, without your consent or the consent of any other person, upon
60 days prior written notice to the Subscribing Group. In the event the amendment is unacceptable
to the Subscribing Group, the Subscribing Group may terminate this Contract upon at least ten days
prior written notice to us. Any such amendment will be without prejudice to Claims filed with us and
related to Covered Services prior to the date of such amendment. No agent or other person,
except a duly authorized officer of AvMed, has the authority to modify the terms of this Contract,
or to bind us in any manner not expressly described herein, including the making of any promise or
representation, or by giving or receiving any information. The terms of coverage and benefits to be
provided by us may not be amended by the Subscribing Group unless such amendment is
evidenced in writing and signed by a duly authorized officer of AvMed.
17.2 Assignment and Delegation. Your rights and obligations arising hereunder may not be assigned,
delegated or otherwise transferred by you without our written consent. We may assign our rights
and coverage, or benefit obligations to our successor in interest or an affiliated entity without your
consent at any time. Any assignment, delegation, or transfer made in violation of this provision will
be void.
17.3 Circumstances Not Reasonably Within the Control of AvMed. In the event of circumstances not
reasonably within the control of AvMed, including major disasters and under such circumstances
as complete or partial destruction of facilities, an act of God, war, riot, civil insurrection, disability of
a significant part of a Hospital or in -network medical personnel or similar causes, if the rendition of
Health Care Services and Hospital services provided under this Contract is delayed or rendered
impractical, neither AvMed, In -Network Providers, nor any Physician will have any liability or
obligation on account of such delay or failure to provide services; however, AvMed will make a
good faith effort to arrange for the timely provision of Covered Services during such event.
17.4 Clerical Errors. Clerical errors will neither deprive any individual Member of any benefits or coverage
provided under this Group Contract nor will such errors act as authorization of benefits or coverage
for the Member that is not otherwise validly in force.
17.5 Compliance with Law. The terms of coverage and benefits to be provided by us under this Contract
will be deemed to have been modified by the parties, and will be interpreted so as to comply with
applicable State of Florida and United States laws and regulations dealing with rates, benefits,
eligibility, enrollment, termination, conversion, or other rights and duties of you, or AvMed.
17.6 Confidentiality
a. Except as otherwise specifically provided herein, and except as may be required in order for us
to administer coverage and benefits, specific medical information concerning you, received
AV-LG-COC-21
59 Achieve-LG-7636 (07/21)
by providers, will be kept confidential by us in conformity with applicable law. Such information
may be disclosed to third parties for use in connection with bona fide medical research and
education, or as reasonably necessary in connection with the administration of coverage and
benefits, specifically including our quality assurance and Care Management Programs.
Additionally, we may disclose such information to entities affiliated with us or other persons or
entities we utilize to assist in providing coverage, benefits or services under this Contract. Further,
any documents or information properly subpoenaed in a judicial proceeding, or by order of a
regulatory agency, will not be subject to this provision.
b. Our arrangements with a provider may require that we release certain Claims and medical
information about persons covered under this Contract to that provider even if treatment has
not been sought by or through that provider. By accepting coverage, you hereby authorize us
to release to providers Claims information, including related medical information, pertaining to
you in order for any such provider to evaluate your financial responsibility under this Contract.
17.7 Contracting Parties. By executing this Contract, Subscribing Group and AvMed agree to make the
Health Care Services and Hospital services specified herein available to persons who are eligible
under the provisions of Part III . ELIGIBILITY FOR COVERAGE. Subscribing Group hereby represents that
it has met the non-discrimination testing requirements under U.S. Code Section 105(h). The delivery
of benefits and services covered in this Contract will 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 Health Care 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.
17.8 Contract Review by Subscribing Group. The 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 will be deemed to
have been accepted.
17.9 Cooperation Required of You and Your Covered Dependents. You must cooperate with us, and
must execute and submit to us any consents, releases, assignments, and other documents we may
request in order to administer and exercise our rights hereunder. Failure to do so may result in the
denial of Claims and will constitute grounds for termination of coverage for cause, by us, as set forth
in Part V. TERMINATION.
17.10 Eligibility Requirements Control. The eligibility requirements set forth herein will at all times control
and no coverage contrary thereto will be effective. Coverage will not be implied due to clerical or
administrative errors if such coverage would be contrary to Part III.
17.11 Entire Agreement. This Contract, including the Group Master Application and any enrollment forms,
schedules and amendments, sets forth the exclusive and entire understanding and agreement
between you and AvMed and will be binding upon Subscribing Group, all Members, AvMed, and
any of their subsidiaries, affiliates, successors, heirs, and permitted assignees. All prior negotiations,
agreements, and understandings are superseded hereby.
17.12 Evidence of Coverage. You have been provided with this Contract as evidence of coverage.
17.13 ERISA. When this Contract is purchased by the Subscribing Group to provide benefits under a
welfare plan governed by ERISA, AvMed will 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.
17.14 Florida Agency for Health Care Administration (AHCA) Performance Outcome and Financial Data.
The performance outcome and financial data published by AHCA, pursuant to Section 408.05,
Florida Statutes, or any successor statute, located at the website address may be accessed through
the link provided on AvMed's website at www.avmed.org.
AV-LG-COC-21 60 Achieve-LG-7636 (07/21)
17.15 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 Care
Services or other benefits under this Contract. To be entitled to such services or benefits the holder
of the card must be, in fact, a Member on whose behalf all applicable Premiums under this Contract
have actually been paid and accepted by AvMed. Please carry your Identification Card with you
at all times, and present it before Covered Services are rendered. If your Identification Card is
missing, lost, or stolen, contact AvMed's Member Engagement Center at 1-800-882-8633, or visit
AvMed's website at www.avmed.org. Member Identification Cards are AvMed's property and,
upon request, will be returned to AvMed within 30 days of the termination of your coverage.
17.16 Membership Application. Members or applicants for membership will complete and submit to
AvMed such applications or other forms or statements as AvMed may reasonably request. If a
Member or applicant fails to provide accurate information which AvMed deems material then,
upon ten days written notice, AvMed may deny membership to such individual. Any person who
knowingly and with intent to injure, defraud or deceive any insurer files a statement of Claim or an
application containing any false, incomplete or misleading information is guilty of a felony,
punishable as provided by Florida Statutes.
17.17 Minimum Enrollment Requirement. This Contract, at the sole option of AvMed, will not be accepted
if at the time of the renewal offering to the Subscribing Group the total enrollment does not result
in a predetermined minimum enrollment as established by AvMed, pursuant to Florida law. The
required minimum group enrollment is included in the Rate Letter (as defined in this Part) furnished
to the Subscribing Group.
17.18 Misrepresentation of Material Fact by Party Applying for Coverage. Time limit on certain defenses:
Fraudulent or intentional misrepresentation of material facts made by the applicant, Subscriber, or
Covered Dependents which are discovered by AvMed within two years of the issue date of the
Contract may prevent payment of benefits under this Contract and may void this Contract for the
individual making the misrepresentation or fraudulent statement. Fraudulent misstatements
discovered by AvMed at any time, may result in this Contract being voided or Claims being denied
for the individual about whom the fraudulent misstatement is made.
17.19 Misstatement of Age, Residence or Tobacco Use. If any written information has been misstated by
you, upon 30 days' notice from AvMed, the Premium amount owed under this Contract will be what
the Premium would have been had the correct information been provided to AvMed. If such
misstatement causes us to accept Premiums for a time period during which we would not have
accepted Premiums if the correct information had been stated, our only liability will be the return
of any unearned Premium. We will not provide any coverage for that time period. This right is in
addition to any other rights we may have under this Contract and applicable laws.
17.20 Modification of AvMed Provider Network and Participation Status. The AvMed Achieve Plan provider
network and the participation status of individual providers available under this Contract are
subject to change at any time without prior notice to you or your approval. Additionally, we may
at any time terminate or modify the terms of any provider contract, and may enter into additional
provider contracts, without prior notice to or approval by you. It is your responsibility to determine
whether a Health Care Provider is an In -Network Provider at the time the Health Care Service is
rendered.
17.21 Non -Waiver. Any failure by us at any time, or from time to time, to enforce or to require the strict
adherence to any of the terms or conditions described herein, will in no event constitute a waiver
of any such terms or conditions. Further, it will not affect our right at any time to enforce or avail
ourselves of any such remedies as we may be entitled to under applicable law or this Contract.
17.22 Notices. Any notice required or permitted hereunder will be deemed given if hand delivered or if
mailed by the United States Postal Service, postage prepaid, and addressed as listed below. Such
notice will be deemed effective as of the date delivered or so deposited in the mail.
a. If to us:
To the address printed on the AvMed Identification Card.
AV-LG-COC-21 61 Achieve-LG-7636 (07/21)
b. If to you:
To the latest address provided by you according to our records or to the Member's latest
address on enrollment forms actually delivered to us.
c. If to Subscribing Group:
To the address provided in the Group Master Application.
17.23 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.
17.24 Premium Tax/Surcharge. If any government entity will impose a Premium tax or surcharge, then
upon 30 days' notice from AvMed, the sums due from the Subscribing Group under the terms of this
Contract will be increased by the amount of such Premium tax or surcharge.
17.25 Promissory Estoppel. No oral statements, representations, or understanding by any person can
change, alter, delete, add, or otherwise modify the express written terms of this Contract.
17.26 Rate Letter. The term 'Rate Letter' refers to a compilation of documents which constitute AvMed's
formal notice to the Subscribing Group of: (i) the Premium rates applicable to the Subscribing
Group, (ii) the conditions under which the rates are valid, (iii) the Premium payment terms and due
dates, and (iv) the additional charge which will apply to all late Premium payments. AvMed
reserves the right to adjust (re -rate) the Premium rates to account for material changes in group
size or in the data supplied by the Subscribing Group to AvMed.
17.27 Right to Receive Necessary Information. We have the right to receive, from you and any Health
Care Provider rendering services to you, information that is reasonably necessary, as determined
by us, in order to administer the coverage and benefits we provide, subject to all applicable
confidentiality requirements listed above. By accepting coverage, you authorize every Health Care
Provider who renders services to you, to disclose to us or to entities affiliated with us, upon request,
all facts, records, and reports pertaining to your care, treatment, and physical or mental Condition,
and to permit us to copy any such records and reports so obtained.
17.28 Third -Party Beneficiary. This Contract was issued by AvMed to the Subscriber, and was entered into
solely and specifically for the benefit of AvMed and the Subscriber. The terms and provisions of the
Contract will be binding solely upon, and inure solely to the benefit of, AvMed and the Subscriber,
and no other person will have any rights, interest or claims hereunder, or be entitled to sue for a
breach hereof as a third -party beneficiary or otherwise. AvMed and the Subscriber hereby
specifically express their intent that Health Care Providers that have not entered into contracts with
AvMed to render the professional Health Care Services set forth herein will not be third -party
beneficiaries under this Contract.
AV-LG-COC-21 62 Achieve-LG-7636 (07/21)
Addendum to the AvMed Group Medical
and Hospital Service Contract
This addendum together with the benefits provisions of the AvMed Group Medical and Hospital Service
Contract (the "Contract") and the other attached documents constitute the summary plan description for this
portion of your Subscribing Group's Welfare and/or Benefit Plan (the "Plan"). To the extent there are any
inconsistencies between the provisions of this Addendum and the provisions of the Contract, the terms and
provisions of this Addendum will govern. The official Plan document contains the full Plan details. This
document does not create a contract of employment between the Subscribing Group and any employee. The
Subscribing Group reserves the right to discontinue, amend or replace this Plan at its discretion at any time
for any reason. If you have further questions about the Plan or would like a complete copy of the Plan
document, contact your human resources representative.
Statement of ERISA Rights
As a participant in the Plan, you are entitled to certain rights and protections under the Employee Retirement
Income Security Act of 1974 ("ERISA"). ERISA provides that all Plan participants shall be entitled to:
Receive Information About Your Plan and Benefits
Examine, without charge, at the Plan Administrator's office and at other specified locations, such as
worksites and union halls, all documents governing the Plan, including insurance contracts and collective
bargaining agreements, and a copy of the latest annual report (Form 5500 series), if any, filed by the Plan
with the U.S. Department of Labor and available at the Public Disclosure Room of the Employee Benefits
Security Administration.
Obtain, upon written request to the Plan Administrator, copies of documents governing the operation of the
Plan, including insurance contracts and collective bargaining agreements, and copies of the latest annual
report (Form 5500 series), if any, and updated summary plan description (SPD). The Plan Administrator may
make a reasonable charge for the copies.
Receive a summary of the Plan's annual Form 5599, if any is required by ERISA to be prepared, in which
case, the Plan Administrator is required by law to furnish each Participant with a copy of this summary
annual report.
Prudent Actions by Plan Fiduciaries
In addition to creating rights for Plan Participants, ERISA imposes duties upon the people who are
responsible for the operation of the employee benefit plan. The people who operate your Plan, called
"fiduciaries" of the Plan, have a duty to do so prudently and in the interest of you and other Plan Participants
and beneficiaries. No one, including your employer, your union, or any other person, may fire you or
otherwise discriminate against you in any way to prevent you from obtaining a Plan (pension/welfare) benefit
or exercising your rights under ERISA.
Enforce Your Rights
If your claim for a (pension/welfare) benefit is denied or ignored, in whole or in part, you have a right to
know why this was done, to obtain copies of documents relating to the decision without charge, and to appeal
any denial, all within certain time schedules. Under ERISA there are steps you can take to enforce the above
rights. For instance, if you request a copy of Plan documents or the latest annual report (Form 5500) from the
Plan and do not receive them within 30 days, you may file suit in a Federal court. In such a case, the court
may require the Plan Administrator to provide the materials and pay you up to $110 a day until you receive
the materials, unless the materials were not sent because of reasons beyond the control of the administrator.
If you have a claim for benefits which is denied or ignored in whole or in part, you may file suit in a state or
federal court. In addition, if you disagree with the Plan's decision or lack thereof concerning the qualified
status of a domestic relations order or a medical child support order, you may file suit in federal court.
If it should happen that Plan fiduciaries misuse the Plan's money, or if you are discriminated against for
asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in a
1 of 2 MP -6046 (01/18)
federal court. The court will decide who should pay court costs and legal fees. If you are successful the court
may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay
these costs and fees, for example if it finds your claim is frivolous.
Assistance with Your Questions
If you have any questions about your Plan, you should contact the Plan Administrator. If you have any
questions about this statement or about your rights under ERISA, or if you need assistance in obtaining
documents from the Plan Administrator, you should contact the nearest office of the Employee Benefits
Security Administration, U.S. Department of Labor (listed in your telephone directory), or contact the
Division of Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department
of Labor, 200 Constitution Avenue N.W., Washington, D.C. 20210. You may also obtain certain publications
about your rights and responsibilities under ERISA by calling the publications hotline of the Employee
Benefits Security Administration.
2 of 2 MP -6046 (01/18)
ERISA SUMMARY PLAN DESCRIPTION INFORMATION
Official Plan Name: City of Opa Locka
Plan Sponsor: City of Opa Locka
3400 NW 135th St Bldg B
Opa Locka, FL 33054-4708
Plan Administrator: City of Opa Locka
3400 NW 135th St Bldg B
Opa Locka, FL 33054-4708
Claims Administrator: AvMed Inc.
9400 S Dadeland Blvd.
Miami, FL 33156
Plan Year: 2021
Effective Date of Plan: 10/1/2021
Employer Identification Number: 59-6000394
Plan Type: Fully -insured welfare benefit plan: HMO
Sources of Funding for the Plan:
Benefits under the plan are provided
through a fully -insured contract with
AvMed Inc.
Sources of Contribution: Employer and Employee contributions.
The amount of the contributions are
determined by Plan Administrator.
ERISA Plan No: 501
Agent for Service of Legal Process:
Organization that Provides the Benefit:
Steven M. Ziegler
4300 NW 89th Blvd.
Gainsville, FL 32606
AvMed Inc.
9400 S Dadeland Blvd.
Miami, FL 33156
Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services Coverage Period: 10/01/2021-09/30/2022
AvMed ben °health• Large Group Achieve LH356-LG21 Coverage for: Individual or Individual + FamilyI Plan Type: HMO
The Summary of Benefits
cost for covered health
and Coverage (SBC) document will help you choose
care services. NOTE: Information about the cost of
information about your coverage, or to get a copy of the
general definitions of co mmon ter ms, such as allowed
a health plan . The SBC shows you how you and the plan would share the
this plan (called the premium) will be provided separately. This is only a
summary. For more
w ww.avmed.org. For
underlined terms see
complete terms of coverage, call 1-800-88-AVMED (1-800-882-8633) or visit
amount, balance billing, coinsurance, copayment, deductible, provider, or other
the Glossary . You can view the Glossary at www.cciio .cros.gov or call 1-800-88-AVMED (1-800-882-8633) to request a copy.
Important Questions Answers
Why This Matters:
Generally, the from to the deductible
What is the overall
deductible?
$3,500 individual / $7,000 family
you must pay all costs providers up amount
before this plan begins to pay. If you have other family members on the plan,
each family member must meet their own individual deductible until the total
a mount of deductible expenses paid by all family members meets the overall
family deductible .
Are there services covered
before you meet your
deductible?
Yes. Preventive care, office visits, certain lab tests,
This plan covers some items and services even if you haven't yet met the
diagnostic tests & imaging, certain prescription
deductible amount . But a copayment or coinsurance may apply . For example,
drugs, urgent and emergent care, and certain
this plan covers certain preventive services without cost -sharing and before you
recovery services, e. g. , habilitation and rehabilitation
meet your deductible. See a list of covered preventive services at
services, are covered before you meet your
https://www.healthcare .gov/coverage/preventive-care-benefits/ .
deductible.
Are there other deductibles
No.
You don't have to meet deductibles for specific services .
for specific services?
What the
is
is out-of-pocket
$6,350 individual / $12,700 family
The out-of-pocket limit is the most you could pay in a year for covered services .
If you have other fa mily me mbers in this plan, they have to meet their own out-of-
for this plan?
limitpocket
limits until the overall family out-of-pocket limit has been met .
What is not included in the
out-of-pocket limit?
Premiums, prescription drug brand additional
Even though you pay these expenses, they don't count toward the out-of-pocket
charges and manufacturer assistance, and health
care this plan doesn't cover.
limit.
Will you pay less if you use
a network provider?
Yes. See www. avmed.org or call 1-800-88-AVMED
(1-800-882-8633) for a list of network providers.
This plan uses a provider network . You will pay less if you use a provider in the
plan's network. You will pay the most if you use an out -of -network provider, and
you might receive a bill fro m a provider for the difference between the provider's
charge and what your plan pays (balance billing). Be aware your network
provider might use an out -of -network provider for some services (such as lab
work). Check with your provider before you get services .
Do you need a referral to
No.
You can see the specialist you choose without a referral .
see a specialist?
(DT - OMB control number: 1545-0047/Expiration DATE: 12/31/2019)(DOL - OMB control number: 1210-0147/Expiration DATE: 5/31/2022)
AVLG_H_7550_R6218_0721 (HHS - OMB control number: 0938-1146/Expiration DATE: 10/31/2022)
Page 1 of 7
All copayment and coinsurance costs sho wn in this chart are after your deductible has been met, if a deductible applies.
Common
Medical Event
What You
Services You May Need an In -Network Provider (You
will pay the least)
Will Pay
an Out of Network Provider
(You will pay the most)
Limitations, Exceptions, & Other Important
Information
If you visit a
If you
provider's a healths office or
Primary care visit to treat an
injury or illness
$25 copay/ visit
Not Covered
Additional charges may apply for non -
preventive services performed in the
Physician's office .
Specialist visit
$50 copay/ visit
Not Covered
Additional charges may apply for non -
preventive services performed in the
Physician's office .
clinic
Preventive care/screening/
No Charge
Not Covered
You may have to pay for services that aren't
preventive. Ask your provider if the services
you need are preventive . Then check what
your plan will pay for.
immunization
I If you have a test
Diagnostic test (x-ray, blood
$100 copay/ visit at
independent facilities;
$200 copay/ visit at hospital-
owned or affiliated facilities;
no charge for lab work at
participating labs
Not Covered
Charges for office visits may apply if
services are performed in a Physician's
office. Charges for certain other labs and
Specialty labs will be higher .
work)
Imaging (CT/PET scans,
MRIs)
$100 copay/ visit at
independent facilities;
$200 copay/ visit at hospital-
owned or affiliated facilities
Not Covered
Charges for office visits or
Physician/professional services may also
apply depending where services are
received.
AVLG_H_7550_R6218_0721
Pag e 2 of 7
Common
Medical Event
Services You May Need
What You Will Pay
an In -Network Provider (You an Out of Network Provider
will pay the least) ou will • a the most
Limitations, Exceptions, & Other Important
Information
If you need drugs to
treat your illness or
condition
More information about
prescription drug
coverage is available
at www.avmed.org
$20 copay/ prescription
alue generic drugs (Tier 1) (retail); $50 copay/
' prescription (mail order)
Not Covered
Generic Drugs (Tier 2)
$30 copay/ prescription
(retail); $75 copay/
prescription (mail order)
Not Covered
Preferred brand drugs (Tier 3)
$50 copay/ prescription
(retail); $125 copay/
prescription (mail order)
Not Covered
Non -Preferred brand drugs
(Tier 4)
j $100 copay/ prescription
I (retail); $250 copay/
prescription (mail order)
Not Covered
If you have outpatient
surgery
Specialty drugs (Tier 5)
Facility fee (e.g., ambulatory
surgery center)
50% coinsurance (retail only)
Not Covered
Retail charge applies per 30 -day supply.
Generic & brand drugs: covers up to a 90 -
day supply at retail pharmacies and a 60-90
day supply via mail order.
Certain drugs in all tiers require prior
authorization .
Brand additional charges may apply.
Specialty drugs available in 30 -day supply
only; not available via mail order .
20% coinsurance after
deductible
Not Covered
Prior authorization required .
Physician/surgeon fees
20% coinsurance after
deductible
Not Covered
Prior authorization required .
If you need immediate
medical attention
Emergency room care
$200 copay/ visit
$200 copay/ visit
AvMed must be notified within 24 -hours of
inpatient admission following emergency
services, or as soon as reasonably possible.
Charges are waived if admitted .
Emergency medical
transportation
$150 copay/ one way ground
transport
$150 copay/ one way ground 50% coinsurance after deductible for air and
transport 'water transportation.
Urgent care
$40 copay/ visit at urgent care
facilities; $25 copay/ visit at
retail clinics
$40 copay/ visit after
deductible at urgent care
facilities; $25 copay/ visit after
deductible at retail clinics
None
If you have a hospital
stay
Facility fee (e. g. , hospital 20% coinsurance after
room) deductible
Not Covered
I Prior authorization required .
Physician/surgeon fees
20% coinsurance after
deductible
Not Covered
I Prior authorization required .
AVLG_H_7550_R6218_0721
Page 3 of 7
Common
Medical Event
Services You May Need
What You Will Pay
an In -Network Provider (You an Out of Network Provider
will pay the least) ou will ' a the most)
Limitations, Exceptions, & Other Important
Information
If you need mental
health, behavioral
health, or substance
abuse services
If you are pregnant
Outpatient services
$25 copay/ visit
Not Covered
Prior authorization may be required .
Inpatient services
20% coinsurance after
deductible
Not Covered
Prior authorization may be required .
Office visits
Routine OB & midwife: $25
copay/ 1st visit only;
subsequent visits at no
charge
Not Covered
None
Childbirth/delivery
professional services
20% coinsurance after
deductible
Not Covered
Maternity care may include tests and
services described elsewhere in this SBC
(e .g., ultrasound) .
Childbirth/delivery facility
services
Hospital stay: 20%
coinsurance after deductible;
Birthing center: Same as
Routine OB
Not Covered
Prior authorization required .
AVLG_H_7550_R6218_0721
Page4 of7
Common
Medical Event
If you need help
recovering or have
other special health
needs
If your child needs
dental or eye care
Services You May Need
Home health care
What You Will Pay
an In -Network Provider (You an Out of Network Provider
will pay the least) ou will •a the most
$50 copay/ visit after
deductible
Not Covered
Limitations, Exceptions, & Other Important
Information
Limited to 20 skilled visits per calendar year .
Approved treatment plan required.
Rehabilitation services
$50 copay/ visit at
independent facilities;
$50 copay/ visit after
deductible at hospital -owned
or affiliated facilities;
$25 copay/ visit for
chiropractic services
Not Covered
Li mited to 35 visits per calendar year for
rehabilitative outpatient PT, OT, ST, cardiac
rehab, pulmonary rehab, and chiropractic
services combined . Cardiac and pulmonary
rehab require prior authorization .
Habilitation services
$50 copay/ visit
Not Covered
Habilitative PT, OT, and ST, when provided
for the treatment of autism spectrum
disorder and Down syndrome, are limited to
a combined maximum of 100 visits per
calendar year.
Skilled nursing care
$250 copay/ day for the first 5
days per ad mission after
deductible
Not Covered
Limited to 60 days post -hospitalization care
per calendar year . Prior authorization
required.
Durable medical equipment
$250 copay/ episode of
illness
Not Covered
Excludes vehicle modifications, home
modifications, exercise equipment, and
bathroom equipment.
Hospice services
No charge after deductible
Not Covered
Physician certification required .
Children's eye exam
$35 copay/ exam
Not Covered
Limited to one eye exa m per calendar year
to determine the need for sight correction .
Children's glasses
Not Covered
Not Covered
None
Children's dental check-up Not Covered
Not Covered
None
AVLG_H_7550_R6218_0721
Page 5 of 7
Excluded Services & Other Covered Services:
Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)
Acupuncture
• Bariatric Surgery
• Child Dental Check Up
• Child Glasses
• Cosmetic Surgery
• Dental Care (Adult)
• Hearing Aids
• Infertility Treatment
• Long -Ter m Care
• Non -Emergency Care When Traveling Outside
the U.S.
• Private -Duty Nursing
• Routine Eye Care (Adult)
• Routine Foot Care
• Weight Loss Programs
Other Covered Services (Limitations may apply to these services. This isn't a complete list. Please see your plan document .)
• Chiropractic Care
Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends . The contact information for those agencies
is: the Florida Office of Insurance Regulation at 1-877-693-5236 or www .floir.com/consumers, the U.S. Department of Labor, Employee Benefits Security
Administration, at 1-866-444-3272 or www. dol. gov/ebsa/contactEBSA/consumerassistance.html, or the U .S . Department of Health and Human Services at 1-877-267-
2323 x61565 or www. cciio. cros.gov. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance
Marketplace. For m ore inform ation about the Marketplace, visit www .HealthCare .gov or call 1-800-318-2596 .
Your Grievance and Appeals Rights:There are agencies that can help if you have a co mplaint against your plan for a denial of a claim. This complaint is called a
grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim . Your plan documents also
provide complete information to submit a claim, appeal, or a grievance for any reason to your plan . For more information about your rights, this notice, or assistance,
contact AvMed's Member Engagement Center at 1-800-882-8633. For plans subject to ERISA, you may also contact the U .S. Department of Labor's Employee
Benefits Security Administration at 1-866-444-3272 or www. dol. gov/ebsa/healthreform. Additionally, a consumer assistance program can help you file your appeal.
Contact the Florida Department of Financial Services, Division of Consumer Services, at 1-877-693-5236 or www.floir .com/consumers.
Does this plan provide Minimum Essential Coverage? Yes.
Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid,
CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit .
Does this plan meet Minimum Value Standards? Yes.
If your plan doesn't meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace .
Language Access Services:
Para obtener asistencia en Espanol, Ilame al 1-800-882-8633.
To see examples of how this plan might cover costs for a sample medical situation, see the next section .
AVLG_H_7550_R6218_0721
Page 6 of 7
About these Coverage Examples:
This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different
depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts
(deductibles, copavments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might
pay under different health plans . Please note these coverage examples are based on self -only coverage.
Peg is Having a Baby
(9 months of in -network pre -natal care and a
hospital delivery)
The plan's overall deductible
Specialist copayment
Hospital (facility) coinsurance
Other coinsurance
This EXAMPLE event includes services like:
Specialist office visits (prenatal care)
Childbirth/delivery professional services
Childbirth/delivery facility services
Diagnostic tests (ultrasounds and blood work)
Specialist visit (anesthesia)
$3,500
$50
20%
20%
Total Example Cost
$12,700
In this example, Peg would pay:
Cost Sharing
Deductibles
Managing Joe's type 2 Diabetes
(a year of routine in -network care of a well -
controlled condition)
The plan's overall deductible
Specialist copayment
Hospital (facility) coinsurance
Other coinsurance
This EXAMPLE event includes services like:
Primary care physician office visits (including
disease education)
Diagnostic tests (blood work)
Prescription drugs
Durable medical equipment (glucose mete
$3,500
$50
20%
20%
Total Example Cost
$5,600
In this example, Joe would pay:
Mia's Simple Fracture
(in -network emergency room visit and follow up
care)
The plan's overall deductible
Specialist copayment
Hospital (facility) coinsurance
Other coinsurance
This EXAMPLE event includes services like:
Emergency room care (including medical
supplies)
Diagnostic test (x-ray)
Durable medical equipment (crutches)
Rehabilitation services (physical therap4
$3,500
$50
20%
20%
Total Example Cost
$2,800
In this example, Mia would pay:
Cost Sharing
Cost Sharing
$3,500 Deductibles
Copayments
Coinsurance
$0 Deductibles
$40
$200 Copayments
$1,000 Coinsurance
What isn't covered
Limits or exclusions
$2,000 Copayments
$0 Coinsurance
$1,200
$0
What isn't covered
What isn't covered
$60 Limits or exclusions
The total Peg would pay is
$4,760
$20 Limits or exclusions
The total Joe would pay is
$2,020
$0
The total Mia would pay is
$1,240
The plan would be responsible for the other costs of these EXAMPLE covered services.
AVLG_H_7550_R6218_0721
Page 7 of 7
Prescription Medication Benefits
$20 / $30 / $50 / $100 / 50%
AvMed
DEFINITIONS
Brand Medication means a Prescription Medication that is usually manufactured and sold under a name or trademark by a
pharmaceutical manufacturer or a medication that is identified as a Brand Medication by AvMed. AvMed delegates
determination of Generic/Brand status to AvMed's Pharmacy Benefits Manager.
Brand Additional Charge means the additional charge that must be paid if you choose a Brand Medication when a Generic
equivalent is available. The charge is the difference between the cost of the Brand Medication and the Generic Medication.
This charge must be paid in addition to the Non -preferred Brand cost -sharing. However, if the prescribing Physician or other
Participating Provider authorized to prescribe medications within the scope of his or her license indicates on the prescription
"Brand Medically Necessary" or "dispense as written" for a medication for which there is a Generic equivalent, the Brand
Medication shall be dispensed for the applicable Non -preferred Brand cost -sharing only. The Brand Additional Charge does
not apply toward the Deductible or the Out -of -Pocket Maximum.
Dental -specific Medication is medication used for dental -specific purposes, including but not limited to fluoride medications
and medications packaged and labeled for dental -specific purposes.
Formulary List means the listing of Preferred and Non -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 cost -sharing 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. Specific medications on the Formulary List and their placement in a given
therapeutic class are subject to change at any time without prior notice to you or your approval. It is your responsibility to
consult with your Attending Physician to determine whether a medication is on the Formulary List at the time the prescription
is rendered.
Generic Medication means a medication that has the same active ingredient as a Brand Medication or is identified as a
Generic Medication by AvMed's Pharmacy Benefits Manager.
Maintenance Medication is a medication that has been approved by the FDA, for which the duration of therapy can
reasonably be expected to exceed one year, as determined by AvMed's Pharmacy Benefits Manager.
Participating Pharmacy means a pharmacy (retail, mail order or specialty pharmacy) that has entered into an agreement
with AvMed to provide Prescription Medications to AvMed Members and has been designated by AvMed as a Participating
Pharmacy.
Specialty Medications are high cost medications that are self-administered by Members. These medications may be limited
in distribution to participating specialty pharmacies and Prior Authorization is often required.
HOW DOES YOUR RETAIL PRESCRIPTION COVERAGE WORK?
Cost -sharing for covered Prescription Medications (retail, mail order and specialty pharmacy), and any applicable
Prescription Medication Calendar Year Deductible, applies toward your Calendar Year Out -of -Pocket Maximum. To obtain
your Prescription Medication, take your prescription to, or have your Physician call, an AvMed Participating Pharmacy. Your
Physician should submit prescriptions for Specialty Medications to AvMed's specialty pharmacy. Present your prescription
along with your AvMed Identification Card. Once you meet any applicable Deductible (as shown on your Schedule of
Benefits), you will pay the following cost -sharing (as well as the Brand Additional Charge if you choose a Brand Medication
when a Generic equivalent is available).
Prescription Medication Retail Cost -sharing:
Tier 1
Tier 2
Tier 3
Tier 4
Ter 5
Value Generic Medications:
Generic Medications:
Preferred Brand Medications:
Non -preferred Brand or Non -preferred Generic Medications:
Specialty Medications:
$ 20.00
$ 30.00
$ 50.00
$ 100.00
50%
Copay per prescription
Copay per prescription
Copay per prescription
Copay per prescription
Coinsurance
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 a 60 -90 -day supply
of your medication to be ordered through mail service. If the amount of medication is less than a 90 -day supply, you wit still
be charged the listed mail order cost -sharing. Up to 2-3 refills are allowed per prescription. Pay the following cost -sharing (as
wet as the Brand Additional Charge if you choose a Brand Medication when a Generic equivalent is available).
AV-LG-RX-19
Page 1 of 3 MP -6218 (01/19)
Prescription Medication Benefits, continued
Prescription Medication Mail Order Cost -sharing:
Tier 1 Value Generic Medications:
Tier 2
Tier 3
Tier 4
Tier 5
Generic Medications:
Preferred Brand Medications:
Non -preferred Brand or Non -preferred Generic Medications:
Specialty Medications are not available through mail service.
$ 50.00 Copay per prescription
$ 75.00 Copay per prescription
$ 125.00 Copay per prescription
$ 250.00 Copay per prescription
WHAT IS COVERED?
• Your Prescription Medication coverage includes outpatient medications that require a prescription and are prescribed by
your Attending Physician in accordance with AvMed's Coverage Criteria. AvMed reserves the right to make changes in
Coverage Criteria for covered products and services.
• Your Prescription Medication coverage may require Prior Authorization, and such Prior Authorization may include the
Progressive Medication Program for certain covered medications. A copy of the list of covered Prescription Medications,
drugs requiring Prior Authorization and drugs that are a part of the Progressive Medication Program are available from
AvMed's Member Engagement Center or from AvMed's website. The Progressive Medication Program encourages the use
of therapeutically -equivalent lower -cost medications by requiring certain medications to be utilized to treat a medical
condition prior to approving another medication for that condition. This includes the first -line use of Preferred Medications
that are proven to be safe and effective for a given condition and can provide the same health benefit as more expensive
Non -preferred Medications at a lower cost.
• Your retail Prescription Medications coverage includes up to a 30 -day supply of a medication for the listed cost -sharing.
Your prescription may be refilled via retail or mail order after 75% of your previous fill has been used and is subject to a
maximum of 12-13 refills per year. You also have the opportunity to obtain a 90 -day supply of medications used for chronic
conditions including asthma, cardiovascular disease, and diabetes from a retail pharmacy for the applicable cost -sharing
per 30 -day supply.
• Your mail-order Prescription Medication coverage includes up to a 60 -90 -day supply of a routine Maintenance Medication
for the listed cost -sharing. If the amount of medication is less than a 60 -90 -day supply, you will still be charged the listed mail
order cost -sharing.
• Your Specialty Medication coverage extends to many injectable and high cost oral medications approved by the FDA.
These medications must be prescribed by a Physician and dispensed by a participating specialty pharmacy. Specialty
Medications are limited to a 30 -day supply.
• Quantity limits are set in accordance with FDA approved prescribing limitations, general practice guidelines supported by
medical specialty organizations, and/or evidence -based, statistically valid clinical studies without published conflicting
data. This means that a medication -specific quantity limit may apply for medications that have an increased potential for
over -utilization or an increased potential for a Member to experience an adverse effect at higher doses.
• When ordered by your Physician, and accompanied by a prescription, certain contraceptives are covered under your
Prescription Medication benefits at no cost. Please refer to the Formulary List on AvMed's website or call Member
Engagement for more details.
NOTE: Your Group Medical and Hospital Service Contract contains important information about your coverage, including your
prescription medication coverage. Please review your Contract for a full description of services, supplies and conditions of
coverage.
QUESTIONS? Call AvMed Member Engagement at: 1-800-88-AvMed (1-800-882-8633)
EXCLUSIONS AND LIMITATIONS
• Allergy serums; however, 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
subject to cost -sharing as shown on the Schedule of Benefits.
• Compounded prescriptions, except pediatric preparations.
• Cosmetic products, including hair growth, skin bleaching, sun damage and anti -wrinkle medications.
• Dental -specific Medications for dental purposes, including fluoride medications (except for children less than 5 years of
age with a non -fluorinated water supply);
• Experimental or Investigational drugs (except as required by law);
• Fertility drugs;
• Immunizations (except for those preventive immunizations for routine use in children, adolescents, and adults that have in
effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and
Prevention);
• Medical supplies, including therapeutic devices, dressings, appliances and support garments;
• Medications and immunizations for non -business related travel, including Transdermal Scopolamine;
• Medications which do not require a prescription (i.e. over-the-counter medications) or when a non-prescription alternative
is available, unless otherwise indicated on AvMed's Formulary List, or unless considered preventive and given an 'A' or 'B'
AV-LG-RX-19
Page 2 of 3 MP -6218 (01/19)
Prescription Medication Benefits, continued
rating in current recommendations of the United States Preventive Services Task Force (USPSTF), and accompanied by a
prescription from your Attending Physician;
• Medications not Included on AvMed's Formulary List;
• Medications or devices for the diagnosis or treatment of sexual dysfunction;
• Nutritional supplements except as described under Nutrition Therapy in Part IX. COVERED MEDICAL SERVICES;
• Prescription and non-prescription vitamins and minerals except prenatal vitamins;
• Prescription and non-prescription appetite suppressants and products for the purpose of weight loss;
• Replacement Prescription Drug products resulting from a lost, stolen, expired, broken or destroyed prescription order or refill.
• Third -Party Assistance for Specialty Medications. If you use any third -party copayment assistance (sometimes also referred to
as a "copay card" or "copay coupon") provided by a drug manufacturer or any other entity to pay any applicable Calendar
Year Deductible, Copayment, or Coinsurance amounts for any Specialty Medications, you will not receive credit toward your
Calendar Year Out -of -Pocket Maximum or Calendar Year Deductible for any such assistance you use.
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 medications that require Prior 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.
James M. Repp
President & COO
AV-LG-RX-19
Page 3 of 3 MP -6218 (01/19)
Amendment
DOMESTIC PARTNER - TWELVE MONTH
AvMed
As of the Effective Date, the AvMed Large Group Medical and Hospital Service Contract, Part III. ELIGIBILITY
FOR COVERAGE, is amended by the addition of the following provisions:
Dependent Eligibility will be added for a Domestic Partner and his or her children. Declaration of a Domestic
Partner relationship by the Subscriber and the Subscriber's Domestic Partner, by sworn Affidavit, will be
considered a qualifying event that triggers a special enrollment period.
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 dependent eligibility requirements of the Employer's health benefits plan.
For further information, contact AvMed Member Engagement at 1-800-882-8633.
James M. Repp
President & COO
AV-LG-DP-19 MP -3147 (01/19)
Amendment
ELECTIVE TERMINATION OF PREGNANCY
AvMed
As of the Effective Date, the AvMed Large Group Medical and Hospital Service Contract is amended as
follows:
• Elective termination of pregnancy will be a Covered Benefit when treatment and services are rendered
by an AvMed In -Network Provider, at an AvMed In -Network facility.
• Services are subject to any applicable Deductible, and facility and Physician charges. Member cost -
sharing will apply toward the Calendar Year Out -of -Pocket Maximum.
• Prior Authorization is required.
For further information, contact AvMed Member Engagement at 1-800-882-8633.
James M. Repp
President & COO
AV-LG-ETOP-19 MP -6443 (01/19)
CUSTOMER AGREEMENT
(tc'3,
City of Opa Locka
780 Fisherman St Ste 334
Opa Locka, FL 33054
August 28, 2015
Dear City of Opa Locka:
Thank you for choosing a benefits program from Metropolitan Life Insurance Company ("MetLife") and the MetLife family
of Companies. We are excited to be providing benefits for City of Opa Locka employees. To get started, please sign a
copy of this letter below and return it to Heather Witkowski.
The benefits you have chosen for your Dental and Vision are listed on the attached schedule. If your MetLife benefit
offerings change, we will reflect those changes on a new schedule.
METLIFE'S RESPONSIBILITIES:
1. MetLife will offer the benefits listed on the attached schedules ("MetLife Benefits") to all eligible individuals.
Individuals who obtain benefits are referred to as "Participants".
2. For each of the MetLife Benefits listed on the attached schedule, MetLife will provide as applicable either: a group
insurance policy and insurance certificates; individually underwritten insurance policies; a detailed benefits
schedule; or one or more administrative agreements. These documents will detail the benefits provided, costs,
effective date, and other important terms. Nothing in this letter changes any of the terms of the group or individual
insurance policies, certificates or other applicable administrative agreements.
3. MetLife will comply with all laws applicable to MetLife's activities in connection with the MetLife Benefits.
4. MetLife will provide information and materials that eligible individuals need to understand the MetLife Benefits.
5. MetLife will process eligibility information and payroll deductions in accordance with MetLife's policies and
procedures for each MetLife Benefit. MetLife will be responsible for all pricing and individual underwriting
decisions.
G. MetLife will provide account management services to City of Opa Locka and customer service to eligible
individuals.
7. MetLife will treat all non-public personal information about eligible individuals in a confidential manner and in
accordance with all applicable laws.
8. Participants no longer employed by City of Opa Locka (and where applicable, their dependents) may continue
certain benefits with MetLife in accordance with MetLife's policies and procedures.
9. MetLife will be liable to City of Opa Locka for the performance of its administrative obligations under any insurance
policy, certificate, this agreement or any other written agreement that may be entered into between MetLife and
City of Opa Locka relating to the MetLife Benefits. If MetLife uses a third party in connection with any of MetLife's
administrative obligations, MetLife will remain liable to City of Opa Locka for the performance by the third party of
those administrative obligations. The third party shall work under the control and direction of MetLife and, as
between MetLife and City of Opa Locka, MetLife shall be solely responsible for the acts, errors and omissions of
the third party.
(continued)
City of OpaLocka'S RESPONSIBILITIES:
1. City of OpaLockawill communicate the MetLife Benefits to all eligible individuals and distribute enrollment
materials. City of OpaLockawill provide MetLife with full access to the eligible population.City of OpaLockawill
perform Its administrative obligations to the fullest extent to drive maximum participation in MetLife Benefits by all
eligible individuals. Click here to enter text.
2. City of OpaLocka will process enrollments and will report to MetLife the Identity of all Participants.For certain
MetLlfe Benefits, MetLife requires that City of OpaLocka will provide a Ilst of all Eligible Employees and provide
regular updates thereto.City of OpaLockawill provide this if required to do so. MetLife andCity of OpaLocka will
agree upon the timing and format of this enrollment information.
3. City of OpaLocka will not use the name or Brand of MetLife or create or distribute materials regarding the MetLife
Benefits without MetLife's approval.
4. City of OpaLocka will comply with all laws applicable to City of OpaLocka activities in connection with the MetLife
Benefits.
5. Where Participants contribute to the cost of the MetLife Benefits, City of OpaLocka will provide payroll deductions
for amounts due in connection with the MetLife Benefits and will remit payments to MetLlfe.
6. City of OpaLocka will be responsible for any filings required by the Department of Labor or other Federal or State
agencles.Upon request, MetLife will provide applicable Information necessary to make such filings.
7. If City of OpaLocka is represented by an insurance agent or broker for purposes of a MetLife Benefit, City of
OpaLocke agrees to inform MetLife of any change in its insurance agent or broker.
8. Any act undertaken by City of OpaLocka that relates to the insurance provided by MetLife must be consistent with
the terms of such insurance and with MetLife's requirements; including but not limited to the eligibility requirements
of City of OpaLocka plan as set forth in the certificates and the applicable group policies.
9. City of OpaLocka will be liable to MetLife for the performance of its administrative obligations under any insurance
policy, certificate, this agreement or any other written agreement entered into between MetLife and City of
OpaLocka relating to the MetLife Benefits. If City of OpaLocka uses a third party in connection with any of City of
OpaLocka administrative obligations, City of OpaLocka shall remain liable to MetLife for the performance by the
third party of those administrative obligations. The third party shall work under the control and direction of City of
OpaLocka and, as between City of OpaLocka and MetLife, City of OpaLocka shall be solely responsible for the
acts, errors and omissions of the third party.
We look forward to serving your benefit needsilf the terms of this letter are acceptable to City of OpaLocka, please sign
below and return to us as directed above.
Very Truly Yours, Accepted and Agreed to:
METROPOLITAN LIFE INSURANCE COMPANY City of Opa Locka
By: By:
Title: Vice President
Title:
LAX 6-� ci