Pages 1--28 from FEHB2000

Gainesville area
Enrollment Code
JF1 Self Only
JF2 Self and Family

Jacksonville area
Enrollment Code
HW1 Self Only
HW2 Self and Family

Orlando area
Enrollment Code This Plan has full accreditation from This Plan has accreditation with
GP1 Self Only the NCQA See the 2000 Guide for commendation from the JCAHO See more information on NCQA the 2000 Guide for more information
GP2 Self and Family on JCAHO

South Florida area
Enrollment Code
EM1 Self Only
EM2 Self and Family

Tampa area
Enrollment Code
H51 Self Only
H52 Self and Family Visit the OPM website at http www opm gov insure and

AvMed Health Plan's website at http www avmed com

Authorized for distribution by the
United States Office of
Personnel Management
Retirement and Insurance Service

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AvMed Health Plan 2000
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AvMed Health Plan 2000
Table of Contents
Introduction 4

Plain language 4
How to use this brochure 4
Section 1 Health Maintenance Organizations 5
Section 2 How we change for 2000 5
Section 3 How to get benefits 6
Section 4 What to do if we deny your claim or request for service 9
Section 5 Benefits 11
Section 6 General exclusions Things we don't cover 19
Section 7 Limitations Rules that affect your benefits 19
Section 8 FEHB facts 21
Inspector General Advisory Stop Healthcare Fraud 24
Summary of benefits 27
Premiums 28

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AvMed Health Plan 2000
Introduction
AvMed Inc
9400 South Dadeland Boulevard
Miami FL 33156

This brochure describes the benefits you can receive from AvMed Health Plan HMO under its contract CS 1955 with the Office of
Personnel Management OPM as authorized by the Federal Employees Health Benefits FEHB law This brochure is the official
statement of benefits on which you can rely A person enrolled in this Plan is entitled to the benefits described in this brochure If
you are enrolled for Self and Family coverage each eligible family member is also entitled to these benefits

OPM negotiates benefits and premiums with each plan annually Benefit changes are effective January 1 2000 and are shown on
page 5 Premiums are listed at the end of this brochure

Plain language
The President and Vice President are making the Government's communication more responsive accessible and understandable to the
public by requiring agencies to use plain language Health plan representatives and Office of Personnel Management staff have
worked cooperatively to make portions of this brochure clearer In it you will find common everyday words except for necessary
technical terms you and other personal pronouns active voice and short sentences

We refer to AvMed Health Plan HMO as this Plan throughout this brochure even though in other legal documents you will see a
plan referred to as a carrier

These changes do not affect the benefits or services we provide We have rewritten this brochure only to make it more
understandable

We have not re written the Benefits section of this brochure You will find new benefits language next year

How to use this brochure
This brochure has eight sections Each section has important information you should read If you want to compare this Plan's benefits
with benefits from other FEHB plans you will find that the brochures have the same format and similar information to make
comparisons easier

1 Health Maintenance Organizations HMO This Plan is an HMO Turn to this section for a brief description of HMOs and how
they work

2 How we change for 2000 If you are a current member and want to see how we have changed read this section
3 How to get benefits Make sure you read this section it tells you how to get services and how we operate
4 What to do if we deny your claim or request for service This section tells you what to do if you disagree with our decision not
to pay for your claim or to deny your request for a service

5 Benefits Look here to see the benefits we will provide as well as specific exclusions and limitations You will also find
information about non FEHB benefits

6 General exclusions Things we don't cover Look here to see benefits that we will not provide
7 Limitations Rules that affect your benefits This section describes limits that can affect your benefits
8 FEHB facts Read this for information about the Federal Employees Health Benefits FEHB Program

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AvMed Health Plan 2000
Section 1 Health Maintenance Organizations
Health maintenance organizations HMOs are health plans that require you to see Plan providers specific physicians hospitals and
other providers that contract with us These providers coordinate your health care services The care you receive includes preventative
care such as routine office visits physical exams well baby care and immunizations as well as treatment for illness and injury

When you receive services from our providers you will not have to submit claim forms or pay bills However you must pay
copayments listed in this brochure When you receive emergency services you may have to submit claim forms

You should join an HMO because you prefer the plan's benefits not because a particular provider is available You cannot change
plans because a provider leaves our Plan We cannot guarantee that any one physician hospital or other provider will be available
and or remain under contract with us Our providers follow generally accepted medical practice when prescribing any course of
treatment

Section 2 How we change for 2000
To keep your premium as low as possible OPM has set a minimum copay of 10 for all
Program wide changes primary care office visits

This year you have a right to more information about this Plan care management our
networks facilities and providers

If you have a chronic or disabling condition and your provider leaves the Plan at our
request you may continue to see your specialist for up to 90 days If your provider leaves
the Plan and you are in the second or third trimester of pregnancy you may be able to
continue seeing your OB GYN until the end of your postpartum care You have similar rights
if this Plan leaves the FEHB program See Section 3 How to get benefits for more
information

You may review and obtain copies of your medical records on request If you want copies of
your medical records ask your health care provider for them You may ask that a physician
amend a record that is not accurate not relevant or incomplete If the physician does not
amend your record you may add a brief statement to it If they do not provide you your
records call us and we will assist you

If you are over age 50 all FEHB plans will cover a screening sigmoidoscopy every five
years This screening is for colorectal cancer

Enrollment code JF Your share of the non postal premium will increase by 17.4 for Self
Changes to this Plan Only or 33.9 for Self and Family

Enrollment code HW Your share of the non postal premium will increase by 24.6 for Self
Only or 66.1 for Self and Family

Enrollment code GP Your share of the non postal premium will increase by 16.1 for Self
Only or 33.7 for Self and Family

Enrollment code EM Your share of the non postal premium will increase by 12.2 for Self
Only or 19.1 for Self and Family

Enrollment code H5 Your share of the non postal premium will increase by 24.6 for Self
Only or 67.7 for Self and Family

Office visit copay has increased to 10

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AvMed Health Plan 2000
Benefit Changes A member under eight 8 years of age may have general anesthesia and hospitalization services related to dental procedures in certain circumstances See pg 12

Coverage of durable medical equipment is no longer limited to a list of items Coverage
continues to be limited to 50 per episode of illness subject to a maximum Plan benefit
of 500 per contract year
Obesity control is covered subject to a 10 copay per visit

The benefit description for coverage of prosthetic devices has been clarified
Clarifications The allergy testing and treatment benefit description has been clarified The brochure has been clarified to show the Plan's orthotic appliance benefit

SPECIAL NOTICE Brevard and Volusia Counties have been dropped from the Plan's
service area Members living or working in these counties should select another health
plan Members who do not choose another health plan will have to travel to our Plan's
remaining service area to obtain medical care in order to receive full benefits from the
Plan

Section 3 How to get benefits
To enroll with us you must live or work in our service area This is where our providers
What is this Plan's service practice Our service area is Area

Gainesville area
Services from Plan providers are available in the following area Alachua Bradford Citrus
Columbia Dixie Gilchrist Hamilton Levy Marion Putnam Suwannee and Union Counties

Jacksonville area
Services from Plan providers are available in the following area Baker Clay Duval Nassau
and St Johns Counties

Orlando area
Services from Plan providers are available in the following area Orange Osceola and
Seminole Counties

South Florida area
Services from Plan providers are available in the following area Dade Broward and Palm
Beach Counties

Tampa area
Services from Plan providers are available in the following area Hernando Hillsborough
Lee Pasco Pinellas Polk and Sarasota Counties

Ordinarily you must get your care from providers who contract with us If you receive care
outside our service area we will pay only for emergency care We will not pay for any other
health care services

If you or a covered family member move outside of our service area you can enroll in
another plan If your dependents live out of the area for example if your child goes to
college in another state you should consider enrolling in a fee for service plan or an HMO
that has agreements with affiliates in other areas If you or a family member move you do
not have to wait until Open Enrollment Season to change plans Contact your employing or
retirement office

You must share the cost of some services This is called a copayment a set dollar amount
Please remember you must pay this amount when you receive services

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AvMed Health Plan 2000
How much do I pay for services After you pay 1,500 in copayments for Self Only enrollment or 2,500 for Self and Family

enrollment you do not have to make any further payments for certain services for the rest of
the year This is called an out of pocket limit However copayments for your prescription
drugs dental services inpatient treatment of mental conditions and substance abuse and
voluntary family planning services do not count toward these limits and you must continue to
make these payments

Be sure to keep accurate records of your copayments since you are responsible for informing
us when you reach the limits

You normally won't have to submit claims to us unless you receive emergency services from
a provider who doesn't contract with us If you file a claim please send us all of the
Do I have to submit documents remember to keep copies for your claim as soon as possible You must submit claims claims by December 31 of the year after the year you received the service Either OPM or

we can extend this deadline if you show that circumstances beyond your control prevented
you from filing on time

AvMed Health Plan is an Individual Practice Association organization in Florida Members
medical services are provided by a wide array of primary care doctors and specialists with

Who provides my health whom AvMed contracts AvMed contracts with approximately nine thousand one hundred fifty care 9,150 doctors and ninety seven 97 major hospitals in the area to provide medical care to

members

The first and most important decision each member must make is the selection of a primary
care doctor The decision is important since it is through this doctor that all other health
services particularly those of specialists are obtained It is the responsibility of your primary
care doctor to obtain any necessary authorizations from the Plan before referring you to a
specialist or making arrangements for hospitalization See How do I get specialty care below
for services that you can receive without a referral from your primary care doctor

The Plan's provider directory lists primary care doctors generally family practitioners
pediatricians and internists with their locations and phone numbers and notes whether or not
the doctor is accepting new patients Directories are updated on a regular basis and are
available at the time of enrollment or upon your request by calling the Member Provider
Services Department at 1 800 882 8633 You can also find out if your doctor participates
with this Plan by calling this number If you are interested in receiving care from a specific
provider who is listed in the directory call the provider to verify that he or she still
participates with the Plan and is accepting new patients Important note When you enroll in
this Plan services except for emergency benefits are provided through the Plan's delivery
system the continued availability and or participation of any one doctor hospital or other
provider cannot be guaranteed

Should you decide to enroll you will be asked to complete a primary care doctor selection
form and send it directly to the Plan indicating the name of the primary care doctor s
selected for you and each member of your family Members may change their doctor
selection by notifying the Plan 30 days in advance

Call us We will help you select a new one

What do I do if my primary care physician
leaves the Plan Talk to your Plan physician If you need to be hospitalized your primary care physician or specialist will make the necessary arrangements and continue to supervise your care
What do I do if I need to go into the hospital First call our customer service department at 1 800 882 8633 If you are new to the FEHB
Program we will arrange for you to receive care If you are currently in the FEHB Program

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AvMed Health Plan 2000
What do I do if I'm in the and are switching to us your former plan will pay for the hospital stay until hospital when I join this

Plan You are discharged not merely moved to an alternative care center or The day your benefits from your former plan run out or
The 92nd day after you became a member of this Plan whichever happens first
These provisions only apply to the person who is hospitalized
Your primary care physician will arrange your referral to a specialist Except in a medical
emergency or when a primary care doctor has designated another doctor to see patients when
How do I get specialty he or she is unavailable you must receive a referral from your primary care doctor before care seeing any other doctor or obtaining special services Referral to a participating specialist is

given at the primary care doctor's discretion if specialists or consultants are required beyond
those participating in the Plan the primary care doctor will make arrangements for the
appropriate referrals Services of other providers are covered only when there has been a
referral by the member's primary care doctor with the following exceptions a member may
obtain covered services from a chiropractor without a referral a woman may see her Plan
gynecologist directly once a year for an annual check up with no need to be referred by her
primary care doctor a member may obtain up to five 5 office visits per calendar year to a
Plan dermatologist for covered services

When you receive a referral from your primary care doctor you must return to the primary
care doctor after the consultation All follow up care must be provided or arranged by the
primary care doctor On referrals the primary care doctor will give specific instructions to the
consultant as to what services are authorized If additional services or visits are suggested by
the consultant you must first check with your primary care doctor Do not go to the specialist
unless your primary care doctor has arranged for the visit and the Plan has issued an
authorization for the referral in advance

If you have a chronic complex or serious medical condition that causes you to see a Plan
specialist frequently your primary care doctor will develop a treatment plan with you and
your health plan that allows an adequate number of direct access visits with that specialist
The treatment plan will permit you to visit your specialist without the need to obtain further
referrals Requests by primary care doctors for referrals to specialists are evaluated based
upon medical information given by the provider The authorization for the referral includes
the initial visit as well as the follow up visits as determined by the medical condition The
authorization is good for 90 days At the end of the 90 days additional visits can be
authorized based upon the medical condition of the patient

Your primary care physician will decide what treatment you need If they decide to refer you
to a specialist ask if you can see your current specialist If your current specialist does not
What do I do if I am participate with us you must receive treatment from a specialist who does Generally we will seeing a specialist when I not pay for you to see a specialist who does not participate with our Plan

enroll Call your primary care physician who will arrange for you to see another specialist You may
receive services from your current specialist until we can make arrangements for you to see
What do I do if my someone else specialist leaves the Plan

Please contact us if you believe your condition is chronic or disabling You may be able to
continue seeing your provider for up to 90 days after we notify you that we are terminating
But what if I have a our contract with the provider unless the termination is for cause If you are in the second serious illness and my or third trimester of pregnancy you may continue to see your OB GYN until the end of your

provider leaves the Plan postpartum care or this Plan leaves the
Program You may also be able to continue seeing your provider if your plan drops out of the FEHB Program and you enroll in a new FEHB plan Contact the new plan and explain that you

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AvMed Health Plan 2000
have a serious or chronic condition or are in your second or third trimester Your new plan
will pay for or provide your care for up to 90 days after you receive notice that your prior
plan is leaving the FEHB Program If you are in your second or third trimester your new
plan will pay for the OB GYN care you receive from your current provider until the end of
your postpartum care

The Plan will provide benefits for covered services only when the services are medically
necessary to prevent diagnose or treat your illness or condition Your Plan doctor must obtain
How do you authorize the Plan's determination of medical necessity before you may be hospitalized referred for medical services specialty care or obtain follow up care from a specialist

The Plan's experimental investigational determination process is based on authorative
information from medical literature medical consensus bodies FDA approval clinical trials
How do you decide if a and health care professionals with specialty expertise in the subject service is experimental or

Section investigational 4 What to do if we deny your claim or request for service
If we deny services or won't pay your claim you may ask us to reconsider our decision Your request must
1 Be in writing
2 Refer to specific brochure wording explaining why you believe our decision is wrong and
3 Be made within six months from the date of our initial denial or refusal We may extend this time limit if you show that you
were unable to make a timely request due to reasons beyond your control

We have 30 days from the date we receive your reconsideration request to
1 Maintain our denial in writing
2 Pay the claim
3 Arrange for a health care provider to give you the service or
4 Ask for more information

If we ask your medical provider for more information we will send you a copy of our request We must make a decision within 30
days after we receive the additional information If we do not receive the requested information within 60 days we will make our
decision based on the information we already have

You may ask OPM to review the denial after you ask us to reconsider our initial denial or
refusal OPM will determine if we correctly applied the terms of our contract when we
When may I ask OPM to denied your claim or request for service review a denial

Call us at 1 800 882 8633 and we will expedite our review

What if I have a serious or life threatening
condition and you haven't responded to my request
for service If we expedite your review due to a serious medical condition and deny your claim we will inform OPM so that they can give your claim expedited treatment too Alternatively you can
What if you have denied call OPM's health benefits Contract Division IV at 202 606 0737 between 8 a m and 5 my request for care and p m Serious or life threatening conditions are ones that may cause permanent loss of bodily
my condition is serious or functions or death if they are not treated as soon as possible life threatening
You must write to OPM and ask them to review our decision within 90 days after we uphold
our initial denial or refusal of service You may also ask OPM to review your claim if

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AvMed Health Plan 2000
Are there other time limits 1 We do not answer your request within 30 days In this case OPM must receive your

request within 120 days of the date you asked us to reconsider your claim
2 You provided us with additional information we asked for and we did not answer within
30 days In this case OPM must receive your request within 120 days of the date we
asked you for additional information

Your request must be complete or OPM will return it to you You must send the following
information

What do I send to OPM 1 A statement about why you believe our decision is wrong based on specific benefit provisions in this brochure
2 Copies of documents that support your claim such as physicians letters operative
reports bills medical records and explanation of benefits EOB forms
3 Copies of all letters you sent us about the claim
4 Copies of all letters we sent you about the claim and
5 Your daytime phone number and the best time to call

If you want OPM to review different claims you must clearly identify which documents
apply to which claim

Those who have a legal right to file a disputed claim with OPM are
1 Anyone enrolled in the Plan
Who can make the 2 The estate of a person once enrolled in the Plan and request 3 Medical providers legal counsel and other interested parties who are acting as the

enrolled person's representative They must send a copy of the person's specific written
consent with the review request

Send your request for review to Office of Personnel Management Office of Insurance
Programs Contract Division IV P O Box 436 Washington D C 20044

Where should I mail my OPM's decision is final There are no other administrative appeals If OPM agrees with our disputed claim to OPM decision your only recourse is to sue

What if OPM upholds the If you decide to sue you must file the suit against OPM in Federal court by December 31 of Plan's denial the third year after the year in which you received the disputed services or supplies
Federal law governs your lawsuit benefits and payment of benefits The Federal court will
base its review on the record that was before OPM when OPM made its decision on your
claim You may recover only the amount of benefits in dispute
What laws apply if I file a lawsuit You or a person acting on your behalf may not sue to recover benefits on a claim for

treatment services supplies or drugs covered by us until you have completed the OPM
review procedure described above

Your records and the Privacy Act
Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you and us to determine if our denial of
your claim is correct The information OPM collects during the review process becomes a permanent part of your disputed claims
file and is subject to the provisions of the Freedom of Information Act and the Privacy Act OPM may disclose this information to
support the disputed claim decision If you file a lawsuit this information will become part of the court record

Section 5 Benefits
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AvMed Health Plan 2000
Medical and Surgical A comprehensive range of preventive diagnostic and treatment services is provided by Plan Benefits doctors and other Plan providers This includes all necessary office visits you pay a 10
office visit copay but no additional copay for laboratory tests and X rays Within the Service
What is covered Area house calls will be provided if in the judgment of the Plan doctor such care is necessary and appropriate You pay nothing for a doctor's house call or for home visits by

nurses and health aides
The following services are included
Preventive care including well baby care and periodic check ups
Mammograms are covered as follows for women age 35 through age 39 one
mammogram during these five years for women age 40 through 49 one mammogram
every one or two years for women age 50 through 64 one mammogram every year and
for women age 65 and above one mammogram every two years In addition to routine
screening mammograms are covered when prescribed by the doctor as medically
necessary to diagnose or treat your illness
Routine immunizations and boosters
Hearing tests for children through age 17
Consultations by specialists
Diagnostic procedures such as laboratory tests and X rays
Complete obstetrical maternity care for all covered females including prenatal delivery
and postnatal care by a Plan doctor Copays are waived for maternity care The mother
at her option may remain in the hospital up to 48 hours after a regular delivery and 96
hours after a cesarean delivery Inpatient stays will be extended if medically necessary If
enrollment in the Plan is terminated during pregnancy benefits will not be provided after
coverage under the Plan has ended Ordinary nursery care of the newborn child during
the covered portion of the mother's hospital confinement for maternity will be covered
under either a Self Only or Self and Family enrollment other care of an infant who
requires definitive treatment will be covered only if the infant is covered under a Self
and Family enrollment
Voluntary family planning services and sterilization you pay a sterilization copay of
100 Covered abortion will require a copay of 100
Diagnosis and treatment of diseases of the eye
Allergy testing and treatment including test and treatment materials such as allergy
serum You pay 50 per course of testing
The insertion of internal prosthetic devices such as pacemakers and artificial joints
Cornea heart kidney and liver transplants allogeneic donor bone marrow transplants
autologous bone marrow transplants autologous stem cell and peripheral stem cell
support for the following conditions acute lymphocytic or non lymphocytic leukemia
advanced Hodgkin's lymphoma advanced non Hodgkin's lymphoma advanced
neuroblastoma testicular mediastinal retroperitoneal and ovarian germ cell tumors breast
cancer multiple myeloma and epithelial ovarian cancer Treatment for these conditions
may be limited to non randomized clinical trials as determined by the Plan's medical
Director Related medical and hospital expenses of the donor are covered when the
recipient is covered by the Plan
Women who undergo mastectomies may at their option have this procedure performed
on an inpatient basis and remain in the hospital up to 48 hours after the procedure
Dialysis
Chemotherapy radiation therapy and inhalation therapy
Surgical treatment of morbid obesity
Home health services of nurses and health aides including intravenous fluids and
medications when prescribed by your Plan doctor who will periodically review the
program for continuing appropriateness and need
All necessary medical or surgical care in a hospital or extended care facility from Plan
doctors and other Plan providers at no additional cost to you

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AvMed Health Plan 2000
Oral and maxillofacial surgery is provided for nondental surgical and hospitalization
procedures for congenital defects such as cleft lip and cleft palate and for medical or
Limited Benefits surgical procedures occurring within or adjacent to the oral cavity or sinuses including but not limited to treatment of fractures and excision of tumors and cysts All other procedures

involving the teeth or intra oral areas surrounding the teeth are not covered including any
dental care involved in treatment of temporomandibular joint TMJ pain dysfunction
syndrome

General anesthesia and hospitalization services are covered for a member who is under 8
years of age and is determined by a licensed dentist and the member's physician to require
necessary dental treatment in a hospital or ambulatory surgical center due to a significantly
complex dental condition or a developmental disability in which patient management in the
dental office has proved to be ineffective or if the member has one or more medical
conditions that would create significant or undue medical risk for the member in the course
of delivery of any necessary dental treatment or surgery if not rendered in a hospital or
ambulatory surgical center Pre authorization by AvMed is required There is no coverage for
diagnosis or treatment of dental disease

Reconstructive surgery will be provided to correct a condition resulting from a functional
defect or from an injury or surgery that has produced a major effect on the member's
appearance and if the condition can reasonably be expected to be corrected by such surgery
A patient and her attending physician may decide whether to have breast reconstruction
surgery following a mastectomy and whether surgery on the other breast is needed to produce
a symmetrical appearance

Short term rehabilitative therapy physical speech and occupational is provided on an
outpatient or inpatient basis for up to 60 days calendar per condition if significant
improvement can be expected within two months You pay a 10 copay per outpatient
session

Diagnosis and treatment of infertility including artificial insemination is covered The
following types of artificial insemination are covered intravaginal insemination IVI
intracervical insemination ICI and intrauterine insemination IUI you pay a 20 copay per
visit Surgery for the enhancement of fertility is provided You pay 100 to the surgeon and
500 to the hospital or surgicenter Cost of donor sperm is not covered Other assisted
reproductive technology ART procedures that enable a woman with otherwise untreatable
infertility to become pregnant through other artificial conception procedures such as in vitro
fertilization and embryo transfer are not covered Fertility drugs are not covered

Transitional care services provided in any licensed facility including sub acute care units or
centers ventilator dependent units and alternative care units are covered for up to a
maximum of 150 days per calendar year when confinement in a hospital or extended care
facility is not medically necessary You pay nothing

Chiropractic services are limited to spinal manipulations You pay a 10 copay per visit
Durable medical equipment such as hospital beds crutches and wheel chairs is covered
Medical supplies and devices such as corsets which do not require a prescription are not
covered The option of purchasing or renting will be determined by cost AvMed will require
that the most economical option be selected

Coverage for orthotic appliances is limited to leg arm back and neck custom made braces
when related to a surgical procedure or when used in an attempt to avoid surgery and are

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AvMed Health Plan 2000
necessary to carry out normal activities of daily living excluding sports activities Coverage is
limited to the first such item repair and or replacement is not covered All other orthotic
appliances are not covered

For Durable medical equipment and orthotic appliances you pay a 50 copay per episode of
illness Benefits are limited to a maximum of 500 per contract year

Prosthetic devices are covered limited to surgically implanted devices excluding penile
prothesis artificial limbs artificial joints breast prostheses surgical bras and ocular
protheses Coverage is limited to the initial purchase fitting or adjustment Replacement is
covered only when medically necessary due to a change in bodily configuration Replacement
of cataract lenses is covered only if there is a change in prescription which cannot be
accommodated by eyeglasses You pay nothing

Physical examinations that are not necessary for medical reasons such as those required
for obtaining or continuing employment or insurance attending school or camp or travel What is not covered
Reversal of voluntary surgically induced sterility
Surgery primarily for cosmetic purposes
Transplants not listed as covered
Hearing tests for members over age 17
Blood and blood derivatives no charge if replacement is arranged by member
Hearing aids
Foot orthotics and other external prostheses not listed above
Long term rehabilitative therapy
Homemaker services
External lenses following cataract surgery
Cardiac rehabilitation
Medical equipment not listed above

Hospital Extended Care Benefits
Hospital Care
The Plan provides a comprehensive range of benefits with no dollar or day limit when you
What is covered are hospitalized under the care of a Plan doctor You pay nothing All necessary services are covered including

Semiprivate room accommodations when a Plan doctor determines it is medically
necessary the doctor may prescribe private accommodations or private duty nursing care

Specialized care units such as intensive care or cardiac care units
Extended Care
The Plan provides a comprehensive range of benefits for up to 30 post hospital days per
calendar year when full time skilled nursing care is necessary and confinement in a skilled
nursing facility is medically appropriate as determined by a Plan doctor and approved by the
Plan You pay nothing All necessary services are covered including

Bed board and general nursing care
Drugs biologicals supplies and equipment ordinarily provided or arranged by the skilled
nursing facility when prescribed by a Plan doctor

Hospice Care
Supportive and palliative care for a terminally ill member is covered in the home or hospice

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AvMed Health Plan 2000
facility Services include inpatient and outpatient care and family counseling these services
are provided under the direction of a Plan doctor who certifies that the patient is in the
terminal stages of illness with a life expectancy of approximately six months or less

Ambulance Service
Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor

Inpatient Dental Procedures
Hospitalization for certain dental procedures is covered when a Plan doctor determines there
Limited Benefits is a need for hospitalization for reasons totally unrelated to the dental procedure the Plan will cover the hospitalization but not the cost of the professional dental services Conditions for

which hospitalization would be covered include hemophilia and heart disease the need for
anesthesia by itself is not such a condition

General anesthesia and hospitalization services related to dental procedures for children under
eight 8 years of age are covered for the following circumstances

a Member requires dental treatment in a hospital or ambulatory surgical center due to a
significantly complex dental condition or
b Member has a developmental disability in which patient management in the dental office
has proven to be ineffective or
c member has one or more medical conditions that would create significant or undue
medical risk for the member in the course of delivery of any necessary dental treatment
or surgery if not rendered in a hospital or ambulatory surgical center

Diagnosis or treatment of dental disease is not covered
Acute Inpatient Detoxification
Hospitalization for medical treatment of substance abuse is limited to emergency care
diagnosis treatment of medical conditions and medical management of withdrawal symptoms
acute detoxification if the Plan doctor determines that outpatient management is not
medically appropriate See page 16 for nonmedical substance abuse benefits

Personal comfort items such as telephone and television
Blood and blood derivatives no charge if replacement is arranged by member
What is not covered Custodial care rest cures domiciliary or convalescent care

Emergency Benefits
A medical emergency is the sudden and unexpected onset of a condition or an injury that you
believe endangers your life or could result in serious injury or disability and requires
What is a medical immediate medical or surgical care Some problems are emergencies because if not treated emergency promptly they might become more serious examples include deep cuts and broken bones

Others are emergencies because they are potentially life threatening such as heart attacks
strokes poisonings gunshot wounds or sudden inability to breathe There are many other
acute conditions that the Plan may determine are medical emergencies what they all have
in common is the need for quick action

If you are in an emergency situation please call your primary care doctor In extreme
emergencies if you are unable to contact your doctor contact the local emergency system
Emergencies within the e g the 911 telephone system or go to the nearest hospital emergency room Be sure to tell Service Area the emergency room personnel that you are a Plan member so they can notify the Plan You

or a family member must notify the Plan within 48 hours unless it was not reasonably
possible to do so It is your responsibility to ensure that the Plan has been timely notified

If you need to be hospitalized the Plan must be notified within 48 hours or on the first
working day following your admission unless it was not reasonably possible to notify the
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AvMed Health Plan 2000
Plan within that time If you are hospitalized in non Plan facilities and Plan doctors believe
care can be better provided in a Plan hospital you will be transferred when medically
feasible with any ambulance charges covered in full Benefits are available for care for nonPlan
providers in a medical emergency only if delay in reaching a Plan provider would result
in death disability or significant jeopardy to your condition

To be covered by this Plan any follow up care recommended by non Plan providers must be
approved by the Plan or provided by Plan providers

Reasonable charges for emergency services to the extent the services would have been
covered if received from Plan providers
Plan pays 30 per hospital emergency room visit at participating hospitals and per visit at Plan urgent

care centers or 50 per emergency room visit at non participating hospitals and visits to nonparticipating
You pay urgent care centers for emergency services that are covered benefits of this Plan

Benefits are available for any medically necessary health service that is immediately required
because of injury or unforeseen illness

If you need to be hospitalized the Plan must be notified within 48 hours or on the first
working day following your admission unless it was not reasonably possible to notify the
Plan within that time If a Plan doctor believes care can be better provided in a Plan hospital
Emergencies outside the you will be transferred when medically feasible with any ambulance charges covered in full Service Area

To be covered by this Plan any follow up care recommended by non Plan providers must be
approved by the Plan or provided by Plan providers

Reasonable charges for emergency care services to the extent the services would have been
covered if received from Plan providers

50 per hospital emergency room visit or urgent care center visit for emergency services that
Plan pays are covered benefits of this Plan

Emergency care at a doctor's office or an urgent care center
You pay Emergency care as an outpatient or inpatient at a hospital including doctors services Ambulance service approved by the Plan

What is covered Elective care or non emergency care Emergency care provided outside the Service Area if the need for care could have been
foreseen before leaving the Service Area
Medical and hospital costs resulting from a normal full term delivery of a baby outside
What is not covered the Service Area

With your authorization the Plan will pay benefits directly to the providers of your emergency
care upon receipt of their claims Physician claims should be submitted on the HCFA 1500
claim form If you are required to pay for the services submit itemized bills and your receipts
remember to keep copies to the Plan along with an explanation of the services and the
Filing claims for non Plan identification information from your ID card Payment will be sent to you or the provider if providers you did not pay the bill unless the claim is denied If it is denied you will receive notice of

the decision including the reasons for the denial and the provisions of the contract on which
denial was based If you disagree with the Plan's decision you may request reconsideration in
accordance with the disputed claims procedure described on page 9

Mental Conditions Substance Abuse Benefits
The medical management of mental conditions will be covered under this Plan's Medical and
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AvMed Health Plan 2000
Surgical Benefits provisions Related drug costs will be covered under this Plan's Prescription
Drug Benefits and any costs for psychological testing or psychotherapy will be covered under
this Plan's Mental Conditions Benefits Office visits for the medical aspects of treatment do
Mental Conditions not count toward the 40 outpatient Mental Conditions visit limit

To the extent shown below this Plan provides the following services necessary for the
diagnosis and treatment of acute psychiatric conditions including treatment of mental illness
or disorders

Diagnostic evaluation
Psychological testing
Psychiatric treatment including individual and group therapy
Hospitalization including inpatient professional services
What is covered Up to 40 visits to Plan doctors consultants or other psychiatric personnel each calendar year

you pay a 20 copay for each covered visit all charges thereafter
Up to 30 days of hospitalization each calendar year you pay 100 per day to the hospital
Outpatient Care and 20 per inpatient visit by a doctor for the first 30 days all charges thereafter

Care for psychiatric conditions which in the professional judgment of Plan doctors are
Inpatient Care not subject to significant improvement through relatively short term treatment Psychiatric evaluation or therapy on court order or as a condition of parole or probation

unless determined by a Plan doctor to be necessary and appropriate
What is not covered Psychological testing that is not medically necessary to determine the appropriate treatment of a short term psychiatric condition

This Plan provides medical and hospital services such as acute detoxification services for the
medical nonpsychiatric aspects of substance abuse including alcoholism and drug addiction
the same as for any other illness or condition Services for the psychiatric aspects are
Substance Abuse provided in conjunction with the Mental conditions benefits shown above Outpatient visits What is covered to Plan providers for treatment are covered as well as inpatient services necessary for

diagnosis and treatment The Mental conditions benefits visit day limitations and copayments
apply to any covered substance abuse care

Treatment not authorized by a Plan doctor

Prescription Drug Benefits What is not covered
Prescriptions drugs prescribed by a Plan or referral doctor and obtained at a Plan pharmacy
will be dispensed for up to a 30 day supply or 100 unit dosage whichever is less 240
milliliters of liquid 8 oz 60 grams of ointment creams or topical preparation or one
commercially prepared unit e g one inhaler one vial ophthalmic medication or insulin You
What is covered pay a 5 copay per prescription unit or refill for generic drugs or for name brand drugs when no generic equivalent is available Members who request name brand drugs when a generic is

available must pay the 5 copay plus the difference in cost between the name brand and
generic drugs

Drugs are prescribed by Plan doctors and dispensed in accordance with the Plan's Drug
Formulary The Drug Formulary is a list of commonly prescribed medications that have been
chosen by the Pharmacy and Therapeutic Committee based on a drug's effectiveness and cost
The Pharmacy and Therapeutic Committee will evaluate any needed additions or deletions to

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AvMed Health Plan 2000
the formulary Upon a participating provider's request specific medications can be evaluated
on a case by case basis to be added to the formulary Non formulary drugs will be covered
when prescribed by a Plan doctor It is the prescribing doctor's responsibility to obtain
authorization for non formulary drugs before they are dispensed

Covered medications and accessories include
Drugs for which a prescription is required by law
Insulin
Disposable needles and syringes needed to inject covered prescribed medication
including insulin
Full range of FDA approved drugs prescriptions and devices for birth control
Intravenous fluids and medication for home use implantable drugs and some injectable
drugs are covered under Medical and Surgical Benefits

Drugs to treat sexual dysfunction are limited Contact the Plan for dose limits You pay the
drug copayment up to the dosage limit and all charges above that

Drugs available without a prescription or for which there is a nonprescription equivalent
Limited Benefit available Drugs obtained at a non Plan pharmacy except for out of area emergencies

Vitamins and nutritional substances that can be purchased without a prescription
What is not covered Medical supplies such as dressings and antiseptics Diabetic supplies except for needles and syringes

Drugs for cosmetic purposes
Drugs to enhance athletic performance
Drugs to aid in smoking cessation including nicotine patches
Fertility drugs

Other Benefits

The following dental services are covered when provided by participating Plan dentists to
children through age 11

Dental Care Preventive and diagnostic You Pay What is covered Oral examinations Nothing
X rays as necessary Nothing
Prophylaxis cleaning Nothing
Topical application of fluoride 10 for each application

Restorative services and supplies necessary to promptly repair but not replace sound natural
teeth are covered The need for these services must result from an accidental injury occurring
while the member is covered under the FEHB Program You pay nothing

Accidental Injury Benefit Other dental services not shown as covered

In addition to the medical and surgical benefits provided for diagnosis and treatment of
What is not covered diseases of the eye annual eye refractions which include the written lens prescription may be obtained from Plan providers for children through age 17 You pay a 10 copay per visit

Vision Care What is covered Eye exercises
Replacement for any lenses provided during the same calendar year
Eye glasses
External lenses following cataract surgery

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AvMed Health Plan 2000
What is not covered

Non FEHB Benefits Available to Plan Members

The benefits described on this page are neither offered nor guaranteed under the contract with the FEHB Program but are made
available to all enrollees and family members who are members of this Plan The cost of the benefits described on this page is not
included in the FEHB premium any charges for these services do not count toward any FEHB deductibles out of pocket maximum
copay charges etc These benefits are not subject to the FEHB disputed claims procedure

AvMed is making available dental services through American Dental Plan ADP to Federal
employees for an additional premium

ADP's benefits include NO CHARGE services for the following
Expanded dental benefits Topical fluoride

Oral exams
X rays
Cleanings semi annual
Local anesthesia

For more information on how to enroll in the Dental Plan please call ADP at 352 371
2811 or 1 800 342 5209

Discounts on vision services are available to AvMed members Services include
Eye exams
Eye glasses
Expanded vision care Contact lenses Designer glasses sun glasses etc

For details on specific services and discounts in your Service Area please call your Plan's
Membership Services Office listed on page 7 of the brochure

Additional value added services include
24 hours 7 days a week Member Service line
24 hours 7 days a week AvMed nurse help line
Weight Watchers

Medicare prepaid plan enrollment This Plan offers Medicare recipients the opportunity to enroll in the Plan through Medicare As
indicated in Section 7 annuitants and former spouses with FEHB coverage and Medicare Part B may elect to drop their FEHB
coverage and enroll in a Medicare prepaid plan when one is available in their area They may then later re enroll in the FEHB
program Most Federal annuitants have Medicare Part A Those without Medicare Part A may join this Medicare prepaid plan but
will probably have to pay for hospital coverage in addition to the Part B premium Before you join the plan ask whether the plan
covers hospital benefits and if so what you will have to pay Contact your retirement system for information on changing your FEHB
enrollment and changing to a Medicare prepaid plan Contact us at 1 800 535 9355 for information on the Medicare prepaid plan and
the cost of that enrollment

If you are Medicare eligible and are interested in enrolling in a Medicare HMO sponsored by this Plan without dropping your
enrollment in this Plan's FEHB Plan call 1 800 535 9355 for information on the benefits available under the Medicare HMO

Section 6 General exclusions Things we don't cover
The exclusions in this section apply to all benefits Although we may list a specific service as a benefit we will not cover it unless

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AvMed Health Plan 2000
your Plan doctor determines it is medically necessary to prevent diagnose or treat your illness or condition

We do not cover the following
Services drugs or supplies that are not medically necessary
Services not required according to accepted standards of medical dental or psychiatric practice
Care by non Plan providers except for authorized referrals or emergencies see Emergency Benefits
Experimental or investigational procedures treatments drugs or devices
Procedures services drugs and supplies related to abortions except when the life of the mother would be endangered if the fetus
were carried to term or when the pregnancy is the result of an act of rape or incest
Procedures services drugs and supplies related to sex transformations
Services or supplies you receive from a provider or facility barred from the FEHB Program and
Expenses you incurred while you were not enrolled in this Plan

Section 7 Limitations Rules that affect your benefits
Tell us if you or a family member is enrolled in Medicare Part A or B Medicare will
determine who is responsible for paying for medical services and we will coordinate the
payments On occasion you may need to file a Medicare claim form

Medicare If you are eligible for Medicare you may enroll in a Medicare Choice plan and also remain enrolled with us

If you are an annuitant or former spouse you can suspend your FEHB coverage and enroll in
a Medicare Choice plan when one is available in your area For information on suspending
your FEHB enrollment and changing to a Medicare Choice plan contact your retirement
office If you later want to re enroll in the FEHB Program generally you may do so only at
the next Open Enrollment Season

If you involuntarily lose coverage or move out of the Medicare Choice service area you
may re enroll in the FEHB Program at any time

If you do not have Medicare Part A or B you can still be covered under the FEHB Program
and your benefits will not be reduced We cannot require you to enroll in Medicare

For information on Medicare Choice plans contact your local Social Security Administration
SSA office or request it from SSA at 1 800 638 6833 For information on the
Medicare Choice plan offered by this Plan see above

When anyone has coverage with us and with another group health plan it is called double
coverage You must tell us if you or a family member has double coverage You must also
send us documents about other insurance if we ask for them

Other group insurance When you have double coverage one plan is the primary payer it pays benefits first The coverage other plan is secondary it pays benefits next We decide which insurance is primary
according to the National Association of Insurance Commissioners Guidelines
If we pay second we will determine what the reasonable charge for the benefit should be
After the first plan pays we will pay either what is left of the reasonable charge or our
regular benefit whichever is less We will not pay more than the reasonable charge If we are
the secondary payer we may be entitled to receive payment from your primary plan

We will always provide you with the benefits described in this brochure Remember even if
you do not file a claim with your other plan you must still tell us that you have double
coverage

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AvMed Health Plan 2000
Under certain extraordinary circumstances we may have to delay your services or be unable
to provide them In that case we will make all reasonable efforts to provide you with
necessary care

Circumstances beyond our When you receive money to compensate you for medical or hospital care for injuries or control illness that another person caused you must reimburse us for whatever services we paid for
We will cover the cost of treatment that exceeds the amount you received in the settlement If
you do not seek damages you must agree to let us try This is called subrogation If you need
When others are more information contact us for our subrogation procedures responsible for injuries

TRICARE is the health care program for members eligible dependents and retirees of the
military TRICARE includes the CHAMPUS program If both TRICARE and this Plan cover
you we are the primary payer See your TRICARE Health Benefits Advisor if you have
questions about TRICARE coverage
TRICARE We do not cover services that

You need because of a workplace related disease or injury that the Office of Workers
Compensation Programs OWCP or a similar Federal or State agency determine they
Workers compensation must provide OWCP or a similar agency pays for through a third party injury settlement or other

similar proceeding that is based on a claim you filed under OWCP or similar laws
Once the OWCP or similar agency has paid its maximum benefits for your treatment we will
provide your benefits

We pay first if both Medicaid and this Plan cover you
We do not cover services and supplies that a local State or Federal Government agency
directly or indirectly pays for
Medicaid

Section Other Government 8 FEHB FACTS Agencies

You have a right to information about your HMO

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AvMed Health Plan 2000
OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you the right to information about your
health plan its networks providers and facilities You can also find out about care management which includes medical practice
guidelines disease management programs and how we determine if procedures are experimental or investigational OPM's website
www opm gov lists the specific types of information that we must make available to you

If you want specific information about us call 1 800 882 8633 or write to 9400 South Dadeland Blvd Suite 200 Miami FL 33156
You may also contact us by fax at 305 671 4710 or visit our website at www avmed com

Your employing or retirement office can answer your questions and give you a Guide to
Federal Employees Health Benefits Plans brochures for other plans and other materials you
need to make an informed decision about

Where do I get When you may change your enrollment information about How you can cover your family members
enrolling in the FEHB What happens when you transfer to another Federal agency go on leave without pay Program enter military service or retire
When your enrollment ends and
The next Open Enrollment Season

We don't determine who is eligible for coverage and in most cases cannot change your
enrollment status without information from your employing or retirement office

The benefits in this brochure are effective on January 1 If you are new to this Plan your
coverage and premiums begin on the first day of your first pay period that starts on or after
January 1 Annuitants premiums begin January 1

When are my benefits and When you retire you can usually stay in the FEHB Program Generally you must have been premiums effective enrolled in the FEHB Program for the last five years of your Federal service If you do not
meet this requirement you may be eligible for other forms of coverage such as Temporary
Continuation of Coverage which is described later in this section
What happens when I retire Self Only coverage is for you alone Self and Family coverage is for you your spouse and

your unmarried dependent children under age 22 including any foster or step children your
employing or retirement office authorizes coverage for Under certain circumstances you may
also get coverage for a disabled child 22 years of age or older who is incapable of selfsupport
What types of coverage are available for my

family and me If you have a Self Only enrollment you may change to a Self and Family enrollment if you marry give birth or add a child to your family You may change your enrollment 31 days
before to 60 days after you give birth or add the child to your family The benefits and
premiums for your Self and Family enrollment begin on the first day of the pay period in
which the child is born or becomes an eligible family member

Your employing or retirement office will not notify you when a family member is no longer
eligible to receive health benefits nor will we Please tell us immediately when you add or
remove family members from your coverage for any reason including divorce

If you or one of your family members is enrolled in one FEHB plan that person may not be
enrolled in another FEHB plan

We will keep your medical and claims information confidential Only the following will have
access to it

OPM this Plan and subcontractors when they administer this contract

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AvMed Health Plan 2000
Are my medical and This Plan and appropriate third parties such as other insurance plans and the Office of claims records Workers Compensation Programs OWCP when coordinating benefit payment and

confidential subrogating claims Law enforcement officials when investigating and or prosecuting alleged civil or criminal
actions
OPM and the General Accounting Office when conducting audits
Individuals involved in bona fide medical research or education that does not disclose
your identity or
OPM when reviewing a disputed claim or defending litigation about a claim

We will send you an Identification ID card Use your copy of the Health Benefits Election
Information for new Form SF 2809 or the OPM annuitant confirmation letter until you receive your ID card You members can also use an Employee Express confirmation letter

Identification cards Your old plan's deductible continues until our coverage begins

What if I paid a We will not refuse to cover the treatment of a condition that you or a family member had deductible under my old
before you enrolled in this Plan solely because you had the condition before you enrolled plan

Pre existing conditions
You will receive an additional 31 days of coverage for no additional premium when When you lose
benefits Your enrollment ends unless you cancel your enrollment or You are a family member no longer eligible for coverage

What happens if my enrollment in this Plan
You may be eligible for former spouse coverage or Temporary Continuation of Coverage ends

If you are divorced from a Federal employee or annuitant you may not continue to get
benefits under your former spouse's enrollment But you may be eligible for your own FEHB
coverage under the spouse equity law If you are recently divorced or are anticipating a
divorce contact your ex spouse's employing or retirement office to get more information What is former spouse
about your coverage choices coverage

Temporary Continuation of Coverage TCC If you leave Federal service or if you lose
coverage because you no longer qualify as a family member you may be eligible for TCC
For example you can receive TCC if you are not able to continue your FEHB enrollment
after you retire You may not elect TCC if you are fired from your Federal job due to gross What is TCC
misconduct Get the RI 79 27 which describes TCC and the RI 70 5 the Guide to Federal
Employees Health Benefits Plans for Temporary Continuation of Coverage and Former
Spouse Enrollees from your employing or retirement office

You can pick a new plan
If you leave Federal service you can receive TCC for up to 18 months after you
separate
If you no longer qualify as a family member you can receive TCC for up to 36 months

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AvMed Health Plan 2000
Key points about TCC Your TCC enrollment starts after regular coverage ends If you or your employing office delay processing your request you still have to pay

premiums from the 32 nd day after your regular coverage ends even if several months
have passed
You pay the total premium and generally a 2 percent administrative charge The
government does not share your costs
You receive another 31 day extension of coverage when your TCC enrollment ends
unless you cancel your TCC or stop paying the premium
You are not eligible for TCC if you can receive regular FEHB Program benefits

If you leave Federal service your employing office will notify you of your right to enroll
under TCC You must enroll within 60 days of leaving or receiving this notice whichever is
later

Children You must notify your employing or retirement office within 60 days after your child
How do I enroll in TCC is no longer an eligible family member That office will send you information about enrolling in TCC You must enroll your child within 60 days after they become eligible for TCC or

receive this notice whichever is later
Former spouses You or your former spouse must notify your employing or retirement office
within 60 days of one of these qualifying events

Divorce
Loss of spouse equity coverage within 36 months after the divorce

Your employing or retirement office will then send your former spouse information about
enrolling in TCC Your former spouse must enroll within 60 days after the event which
qualifies them for coverage or receiving the information whichever is later

Note Your child or former spouse loses TCC eligibility unless you or your former spouse
notify your employing or retirement office within the 60 day deadline

You may convert to an individual policy if
Your coverage under TCC or the spouse equity law ends If you canceled your coverage
or did not pay your premium you cannot convert
You decided not to receive coverage under TCC or the spouse equity law or
How can I convert to You are not eligible for coverage under TCC or the spouse equity law individual coverage

If you leave Federal service your employing office will notify you if individual coverage is
available You must apply in writing to us within 31 days after you receive this notice
However if you are a family member who is losing coverage the employing or retirement
office will not notify you You must apply in writing to us within 31 days after you are no
longer eligible for coverage

Your benefits and rates will differ from those under the FEHB Program however you will
not have to answer questions about your health and we will not impose a waiting period or
limit your coverage due to pre existing conditions

If you leave the FEHB Program we will give you a Certificate of Group Health Plan
Coverage that indicates how long you have been enrolled with us You can use this certificate
when getting health insurance or other health care coverage You must arrange for the other
coverage within 63 days of leaving this Plan Your new plan must reduce or eliminate waiting
periods limitations or exclusions for health related conditions based on the information in the

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AvMed Health Plan 2000
How can I get a certificate Certificate of Group

Health Plan Coverage If you have been enrolled with us for less than 12 months but were previously enrolled in other FEHB plans you may request a certificate from them as well

Inspector General Advisory Stop Health Care Fraud
Fraud increases the cost of health care for everyone If you suspect that a physician pharmacy or hospital has charged you for
services you did not receive billed you twice for the same service or misrepresented any information do the following

Call the provider and ask for an explanation There may be an error
If the provider does not resolve the matter call us at 1 800 882 8633 and explain the situation
If we do not resolve the issue call or write

THE HEALTH CARE FRAUD HOTLINE
202 418 3300
U S Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street NW Room 6400
Washington D C 20415

Penalties for Fraud
Anyone who falsifies a claim to obtain FEHB Program benefits can be prosecuted for fraud Also the Inspector General may
investigate anyone who uses an ID card if they

Try to obtain services for a person who is not an eligible family member or
Are no longer enrolled in the Plan and try to obtain benefits

Your agency may also take administrative action against you

Summary of Benefits for AvMed Health Plan 2000
Do not rely on this chart alone All benefits are provided in full unless otherwise indicated subject to the limitations and exclusions
set forth in the brochure This chart merely summarizes certain important expenses covered by the Plan If you wish to enroll or

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AvMed Health Plan 2000
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AvMed Health Plan 2000
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AvMed Health Plan 2000
change your enrollment in this Plan be sure to indicate the correct enrollment code on your enrollment form codes appear on the
cover of this brochure ALL SERVICES COVERED UNDER THIS PLAN WITH THE EXCEPTION OF EMERGENCY
CARE ARE COVERED ONLY WHEN PROVIDED OR ARRANGED BY PLAN DOCTORS

Benefits Plan pays provides Page
Comprehensive range of medical and surgical services with no dollar or day limit Includes in hospital doctor care room and board general nursing care

private room and private care nursing if medically necessary diagnostic tests drugs and medical supplies use of operating room intensive care and
complete maternity care You pay nothing
Inpatient Care Hospital All necessary services up to 30 days per calendar year You pay nothing 13

Up to 30 days of inpatient care per year for diagnosis and treatment of acute psychiatric conditions You pay 100 per day to the hospital and 20
per inpatient visit by doctor for covered days all charges thereafter
Extended Care Covered under Mental conditions benefits 13

Mental Conditions Comprehensive range of services such as diagnosis and treatment of illness 16
or injury including specialist's care preventive care including well baby care periodic check ups and routine immunizations laboratory tests and xrays

Substance Abuse complete maternity care copays are waived for maternity care You 16 pay a 10 copay per office visit nothing per home visit by doctor
Outpatient Care All necessary visits by nurses and health aides You pay nothing 11

Up to 40 outpatient visits per year You pay a 20 copay per covered visit all charges thereafter

Home Health Care Covered under Mental conditions benefits 11
Mental Conditions Reasonable charges for services and supplies required because of a medical 16 emergency You pay a 30 copay at a participating hospitals or 50 at nonparticipating
hospitals
Substance Abuse Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy You 16

Emergency Care pay a 5 copay per prescription unit or refill for generic drugs unless no 14 generic equivalent is available Members who request a name brand drug
when a generic is available must pay the 5 copay plus the difference between the generic and name brand drug

Prescription Drugs Accidental injury benefit You pay nothing Preventive dental care for 16
children through age 11 You pay a 10 copay for each topical application of fluoride nothing for other covered services

Refractions including lens prescriptions limited to children through age 17
Dental Care You pay a 10 copay per visit 17
Copayments are required for a few benefits however after your out ofpocket expenses reach a maximum of 1,500 per Self Only or 2,500 per

Vision Care Self and Family enrollment per calendar year covered benefits will be 17 provided at 100 This copay maximum does not include copays for
prescription drugs dental services inpatient treatment of mental conditions
Out of pocket limit and substance abuse and voluntary family planning services 7

2000 Rate Information for AvMed Health Plan
Non Postal rates apply to most non postal enrollees If you are in a special enrollment category refer to the FEHB Guide for that
category or contact the agency that maintains your health benefits enrollment

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AvMed Health Plan 2000
Postal rates apply to most career U S Postal Service employees In 2000 two categories of contribution rates referred to as
Category A rates and Category B rates will apply for certain career employees If you are a career postal employee but not a
member of a special postal employment class refer to the category definitions in The Guide to Federal Employees Health Benefits
Plans for United States Postal Service Employees RI 70 2 to determine which rate applies to you

Postal rates do not apply to non career postal employees postal retirees certain special postal employment classes or associate
members of any postal employee organization Such persons not subject to postal rates must refer to the applicable Guide to Federal
Employees Health Benefits Plans

Non Postal Premium Postal Premium A Postal Premium B
Biweekly Monthly Biweekly Biweekly

Type of Code Gov't Your Gov't Your USPS Your USPS Your
Enrollment Share Share Share Share Share Share

Broward Dade Palm Beach Counties
Self Only EM1 66.80 22.26 144.72 48.24 79.04 10.02 79.04 10.02
Self and Family EM2 175.97 68.95 381.27 149.39 207.74 37.18 201.02 43.90

Gainesville Area
Self Only JF1 75.04 25.01 162.59 54.19 88.79 11.26 88.79 11.26
Self and Family JF2 175.97 99.13 381.27 214.78 207.74 67.36 201.02 74.08

Jacksonville Area
Self Only HW1 74.07 24.69 160.49 53.49 87.65 11.11 87.65 11.11
Self and Family HW2 175.97 95.63 381.27 207.20 207.74 63.86 201.02 70.58

Orlando Area
Self Only GP1 67.41 22.47 146.06 48.68 79.77 10.11 79.77 10.11
Self and Family GP2 175.97 71.20 381.27 154.27 207.74 39.43 201.02 46.15

Tampa Area
Self Only H51 72.33 24.11 156.71 52.24 85.59 10.85 85.59 10.85
Self and Family H52 175.97 89.21 381.27 193.29 207.74 57.44 201.02 64.16

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