Jacksonville area: Enrollment Code:
HW1 Self Only HW2 Self and Family
Orlando area: Enrollment Code:
GP1 Self Only GP2 Self and Family
South Florida area: Enrollment Code:
EM1 Self Only EM2 Self and Family
Tampa area: Enrollment Code:
H51 Self Only H52 Self and Family
AVMED Health Plan http: / / www. avmed. org
RI 73-126
For changes
in benefts
see page
7.
This Plan has full accreditation from the NCQA. See the 2001 Guide for
more information on NCQA.
This Plan has accreditation with com-mendation
from the JCAHO. See the
2001 Guide for more information on JCAHO.
2001 A H E A L T H P L A N D E M 1
1
Page 2 3
2001
AvMed Health Plan 2 Table of Contents
Table of Contents
Introduction…………………………………………………………………................................................................
4
Plain
Language………………………………………………………………...............................................................
4
Section 1. Facts about this HMO
plan..........................................................................................................................
5
How we pay providers
.................................................................................................................................
5
Patients' Bill of Rights
.................................................................................................................................
5
Service Area
................................................................................................................................................
6
Section 2. How we change for
2001………………………………………..
............................................................... 7
Program-wide changes
................................................................................................................................
7
Changes to this Plan
....................................................................................................................................
7
Section 3. How you get care …………...
.....................................................................................................................
8
Identification cards
......................................................................................................................................
8
Where you get covered care
........................................................................................................................
8
Plan
providers........................................................................................................................................
8
Plan facilities
.........................................................................................................................................
8
What you must do to get covered
care.........................................................................................................
8
Primary care
..........................................................................................................................................
9
Specialty care
........................................................................................................................................
9
Hospital
care........................................................................................................................................
10
Circumstances beyond our control
............................................................................................................
10
Services requiring our prior approval
........................................................................................................
10
Section 4. Your costs for covered services
.................................................................................................................
12
Copayments.........................................................................................................................................
12
Deductible
...........................................................................................................................................
12
Coinsurance.........................................................................................................................................
12
Your out-of-pocket
maximum...................................................................................................................
12
Section 5.
Benefits…………………………………………………………..............................................................
13
Overview
...................................................................................................................................................
13
(a) Medical services and supplies provided by physicians and other health
care professionals........... 14
(b) Surgical and anesthesia services
provided by physicians and other health care professionals ....... 21
(c)
Services provided by a hospital or other facility, and ambulance services
..................................... 24
(d) Emergency services/
accidents.........................................................................................................
26
(e) Mental health and substance abuse
benefits....................................................................................
28
(f) Prescription drug benefits
...............................................................................................................
30
(g) Special features
...............................................................................................................................
32
(h) Dental benefits
................................................................................................................................
33
(i) Non-FEHB benefits available to Plan members
............................................................................. 34
Section 6. General exclusions --things we don't cover
.............................................................................................
35 2
2 Page 3 4
2001 AvMed Health Plan 3 Table of Contents
Section 7. Filing a claim for covered services
............................................................................................................
36
Section 8. The disputed claims process
......................................................................................................................
37
Section 9. Coordinating benefits with other coverage
................................................................................................
39
When you have…
Other health coverage
.......................................................................................................................
39
Original
Medicare.............................................................................................................................
39
Medicare managed care plan
............................................................................................................
41
TRICARE/ Workers'Compensation/
Medicaid.........................................................................................
41
Other Government
agencies....................................................................................................................
42
When others are responsible for
injuries.................................................................................................
42
Section 10. Definitions of terms we use in this brochure
...........................................................................................
43
Section 11. FEHB facts
..............................................................................................................................................
44
Coverage
information........................................................................................................................
44
No pre-existing condition
limitation.............................................................................................
44
Where you get information about enrolling in the FEHB
Program.............................................. 44
Types of coverage
available for you and your
family................................................................... 44
When benefits and premiums
start................................................................................................
45
Your medical and claims records are
confidential........................................................................
45
When you retire
...........................................................................................................................
45
When you lose benefits
.......................................................................................................................
45
When FEHB coverage
ends..........................................................................................................
45
Spouse equity coverage
...............................................................................................................
45
Temporary Continuation of Coverage (TCC)
..............................................................................
45
Enrolling in TCC
..........................................................................................................................
45
Converting to individual
coverage...............................................................................................
46
Getting a Certificate of Group Health Plan Coverage
................................................................. 46
Inspector General
Advisory...............................................................................................................
46
Department of Defense/ FEHB Demonstration
Project................................................................................................
47
Index
................................................................................................................................................................
49
Summary of
benefits....................................................................................................................................................
51
Rates…………………………………………………………………………………………………………..
Back cover 3
3 Page
4 5
2001 AvMed Health Plan Introduction/ Plain Language 4
Introduction
AvMed, Inc.
9400 South Dadeland Boulevard
Miami, FL 33156
This brochure describes the benefits of AvMed Health Plan under our contract
(CS 1955) with the Office of
Personnel Management (OPM), as authorized by
the Federal Employees Health Benefits law. This brochure is the
official
statement of benefits. No oral statement can modify or otherwise affect the
benefits, limitations, and
exclusions of this brochure.
If you are enrolled in this Plan, you are 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. You do not have a
right to
benefits that were available before January 1, 2001, unless those
benefits are also shown in this brochure.
OPM negotiates benefits and rates with each plan annually. Benefit changes
are effective January 1, 2001, and are
summarized on page 51. Rates are
shown 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. In response, a team
of health plan
representatives and OPM staff worked cooperatively to make
this brochure clearer. Except for necessary technical
terms, we use common
words. "You" means the enrollee or family member; "we" means
AvMed Health Plan.
The plain language team reorganized the brochure and the way we describe our
benefits. When you compare this Plan
with other FEHB plans, you will find
that the brochures have the same format and similar information to make
comparisons easier.
If you have comments or suggestions about
how to improve this brochure, let
us know. Visit OPM's "Rate Us"
feedback area at www. opm. gov/ insure or e-mail us at fehbwebcomments@ opm. gov or write
to OPM at Insurance
Planning and Evaluation Division, P. O. Box 436,
Washington, DC 20044-0436. 4
4 Page 5 6
2001 AvMed Health Plan Section 1 5
Section 1. Facts about this
HMO plan
This Plan is a health maintenance organization (HMO). We
require you to see specific physicians, hospitals, and
other providers that
contract with us. These Plan providers coordinate your health care services.
HMOs emphasize preventive care such as routine office visits, physical exams,
well-baby care, and immunizations, in
addition to treatment for illness and
injury. Our providers follow generally accepted medical practice when
prescribing any course of treatment.
When you receive services from Plan providers, you will not have to submit
claim forms or pay bills. You only pay
the copayments described in this
brochure. When you receive emergency services from non-Plan providers, 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.
How we pay providers
We contract with individual physicians,
medical groups, and hospitals to provide the benefits in this brochure. These
Plan providers accept a negotiated payment from us, and you will only be
responsible for your copayments.
Patients' Bill of Rights
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 whom
AvMed contracts. AvMed contracts with
approximately nine thousand one
hundred fifty (9, 150) doctors and eighty-five (85) 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 Specialty Care below for
services that
you can receive without a referral from your primary doctor.
OPM requires that all FEHB Plans comply with the Patients' Bill of Rights,
recommended by the President's Advisory
Commission on Consumer Protection
and Quality in the Health Care Industry. You may get information about us,
our networks, providers, and facilities. OPM's FEHB website (www. opm. gov/ insure) lists the
specific types of
information that we must make available to you.
If you want more information about us, call 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. 5
5 Page 6 7
2001 AvMed Health Plan Section 1 6
Service
Area
To enroll with us, you must live or work in our service area. This
is where our providers practice. Our service area is:
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. 6
6 Page
7 8
2001 AvMed Health Plan Section 2
7
Section 2. How we change for 2001
Program-wide changes
The plain language team reorganized the brochure and the way we describe
our benefits. We hope this will make it easier for you to compare plans.
This year, the Federal Employees Health Benefits Program is implementing
network mental health and substance abuse parity. This means that your coverage
for mental health, substance abuse, medical, surgical,
and hospital services
from providers in our plan network will be the same with regard to copays and
day/ visit
limitations when you follow a treatment plan that we approve.
Previously, we placed higher patient cost
sharing and shorter day or visit
limitations on mental health and substance abuse services than we did on
services to treat physical illness, injury, or disease.
Many healthcare organizations have turned their attention this past year to
improving healthcare quality and patient safety. OPM asked all FEHB plans to
join them in this effort. You can find out more about patient
safety on the OPM website, www. opm. gov/ insure. To improve your healthcare,
take these five steps:
Speak up if you have questions or concerns. Keep a
list of all the medicines you take.
Make sure you get the results of any test or procedure. Talk with your doctor
and health care team about your options if you need hospital care.
Make sure
you understand what will happen if you need surgery.
We clarified the
language to show that anyone who needs a mastectomy may choose to have the
procedure performed on an inpatient basis and remain in the hospital up to 48
hours after the procedure. Previously, the
language referenced only women.
Changes to this Plan
Enrollment Code JF: Your share of the
non-Postal premium will increase by 20. 8% for Self Only or 26. 5% for Self and
Family.
Enrollment Code HW: Your share of the non-Postal premium will
increase by 15. 6% for Self Only or 23. 4% for Self and Family.
Enrollment
Code GP: Your share of the non-Postal premium will increase by 55. 2% for
Self Only or 94. 2% for Self and Family.
Enrollment Code EM: Your
share of the non-Postal premium will increase by 29. 5% for Self Only or 75. 9%
for Self and Family.
Enrollment Code H5: Your share of the non-Postal
premium will increase by 72. 4% for Self Only or 75. 5% for Self and Family. 7
7 Page 8 9
2001 AvMed Health Plan Section 3 8
Section
3. How you get care
Identification cards We will send you an
identification (ID) card when you enroll. You should carry your ID card with you
at all times. You must show it
whenever you receive services from a Plan
provider, or fill a prescription
at a Plan pharmacy. Until you receive your
ID card, use your copy of the
Health Benefits Election Form, SF-2809, your
health benefits enrollment
confirmation (for annuitants), or your Employee
Express confirmation
letter.
If you do not receive your ID card within 30 days after the effective date
of your enrollment, or if you need replacement cards, call us at
1-800-
882-8633.
Where you get covered care You get care from "Plan
providers" and "Plan facilities." You will only pay copayments,
and you will not have to file claims.
Plan providers Plan providers are physicians and other health care
professionals in our service area that we contract with to provide covered
services to our
members. We credential Plan providers according to national
standards.
All AvMed physicians are reviewed at the time of initial
application and
every two years following. The vast majority of AvMed
physicians are
board certified or board eligible in their specialty.
We list Plan providers in the provider directory, which we update
periodically. The list is also on our website.
Plan facilities Plan facilities are hospitals and other facilities in
our service area that we contract with to provide covered services to our
members. We list these
in the provider directory, which we update
periodically. The list is also
on our website.
What you must do It depends on the type of care you need. First, you
and each family member must choose a primary care physician. This decision is
important since your primary care physician provides or arranges for
most of your health care.
You can select your primary care physician by using AvMed's provider
directory. This directory is available at the time of enrollment or upon
your request by calling the Member 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 make
sure 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.
If 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. 8
8 Page
9 10
2001 AvMed Health Plan Section 3
9
Primary care Your primary care physician can be a family
practitioner, internist or pediatrician. Your primary care physician will
provide most of your
health care, or give you a referral to see a
specialist.
If you want to change primary care physicians or if your primary care
physician leaves the Plan, call us. We will help you select a new one.
Specialty care Your primary care physician will refer you to a
specialist for needed care. However, you may see certain specialists without a
referral. Except in a
medical emergency, or when a primary care doctor has
designated
another doctor to see patients when he or she is unavailable, you
must
receive a referral from your primary care doctor before 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 referral.
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 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 about 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 ahead of time.
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 90 days,
additional visits can be authorized based on the patient's medical
condition.
Here are other things you should know about specialty care:
If you need to see a specialist frequently because of a chronic, complex, or
serious medical condition, your primary care physician
will work with you
and AvMed to develop a treatment plan that
allows you to see your specialist
for a certain number of visits without
additional referrals. Your primary
care physician will use our criteria
when creating your treatment plan (the
physician may have to get an
authorization or approval beforehand).
If you are seeing a specialist when you enroll in our Plan, talk to your
primary care physician. Your primary care physician will decide
what
treatment you need. If he or she decides to refer you to a
specialist, ask
if you can see your current specialist. If your current
specialist does not
participate with us, you must receive treatment
from a specialist who does.
Generally, we will not pay for you to see
a specialist who does not
participate with our Plan. 9
9 Page 10 11
2001 AvMed
Health Plan Section 3 10
If you are seeing a specialist and your
specialist leaves the Plan, 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 someone
else.
If you have a chronic or disabling condition and lose access to your
specialist because we:
terminate our contract with your specialist for other than cause; or
drop
out of the Federal Employees Health Benefits (FEHB) Program and you enroll in
another FEHB Plan; or
reduce our service area and you enroll in another FEHB PCould not acquire
words on page 12 lan,
you may be able to continue seeing your specialist for
up to 90 days
after you receive notice of the change. Contact us or if we
drop out of
the Program, contact your new plan.
If you are in the second or third trimester of pregnancy and you lose
access to your specialist based on the above circumstances, you can
continue to see your specialist until the end of your postpartum care, even
if it is beyond the 90 days.
Hospital care Your Plan primary care physician or specialist will make
necessary hospital arrangements and supervise your care. This includes admission
to a skilled nursing or other type of facility.
If you are in the
hospital when your enrollment in our Plan begins, call
our customer service
department immediately at 1-800-882-8633. If you
are new to the FEHB
Program, we will arrange for you to receive care.
If you changed from another FEHB plan to us, your former plan will pay
for the hospital stay until:
You are discharged, not merely moved to an alternative care center; or
The day your benefits from your former plan run out; or
The 92 nd day
after you become a member of this Plan, whichever happens first.
These provisions apply only to the hospital benefit of the hospitalized
person.
Circumstances beyond our control Under certain extraordinary
circumstances, such as natural disasters, we may have to delay your services or
we may be unable to provide them.
In that case, we will make all reasonable
efforts to provide you with the
necessary care.
Services requiring our prior approval Your primary care physician has
authority to refer you for most services.
For certain services, however,
your physician must obtain approval from
us. Before giving approval, we
consider if the service is covered,
medically necessary, and follows
generally accepted medical practice.
We call this review and approval process preauthorization. Your
physician
must obtain authorization for the following services: such as, 10
10 Page 11 12
2001 AvMed Health Plan Section 3 11
consultation by specialists, hospitalization, Growth hormone therapy
(GHT), most laboratory testing, MRI, CAT SCAN, and other imaging
testing, and other comprehensive diagnostic and treatment services.
AvMed 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 the Plan's determination of
medical necessity before you may be hospitalized, referred for specialty
care or obtain follow-up care from a specialist. 11
11 Page 12 13
12 Page 13 14
2001 AvMed
Health Plan Section 5 13
Section 5. Benefits --OVERVIEW
(See page 7 for how our benefits changed this year and page 51 for
a benefits summary.)
NOTE: This benefits section is divided into subsections. Please read
the important things you should keep in mind at
the beginning of each
subsection. Also read the General Exclusions in Section 6; they apply to the
benefits in the
following subsections. To obtain claims forms, claims filing
advice, or more information about our benefits, contact us
at 1-800-882-8633
or at our website at www. avmed. com.
(a) Medical services and supplies provided by physicians and other health
care professionals ........................... 14-20
Diagnostic and
treatment services Lab, X-ray, and other diagnostic tests
Preventive care,
adult Preventive care, children
Maternity care Family planning
Infertility services Allergy care
Treatment therapies Rehabilitative
therapies
Hearing services (testing, treatment, and supplies)
Vision services
(testing, treatment, and supplies)
Foot care Orthopedic and prosthetic
devices
Durable medical equipment (DME) Home health services
Alternative
treatments Educational classes and programs
(b) Surgical and anesthesia services provided by physicians and other health
care professionals........................ 21-23
Surgical procedures
Reconstructive surgery Oral and maxillofacial surgery Organ/ tissue transplants
Anesthesia
(c) Services provided by a hospital or other facility, and
ambulance services...................................................... 24-25
Inpatient hospital Outpatient hospital or ambulatory surgical
center
Extended care benefits/ skilled nursing care facility benefits
Hospice
care Ambulance
(d) Emergency services/ accidents
.........................................................................................................................
26-27
Medical emergency Ambulance
(e) Mental health and substance abuse benefits
....................................................................................................
28-29
(f) Prescription drug
benefits................................................................................................................................
30-31
(g) Special
features.....................................................................................................................................................
32
Flexible benefit option 24 hour nurse line
Disease Management Centers of excellence
(h) Dental
benefits......................................................................................................................................................
33
(i) Non-FEHB benefits available to Plan members
...................................................................................................
34
Summary of
benefits....................................................................................................................................................
51 13
13 Page 14
15
2001 AvMed Health Plan Section 5( a) 14
Section 5 (a) Medical services and supplies provided by physicians and
other health care professionals
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Plan physicians must provide or arrange your care.
We have no calendar
year deductible.
Be sure to read Section 4, Your costs for covered
services for valuable information about how cost sharing works. Also read
Section 9 about coordinating benefits with other
coverage, including with Medicare.
I M
P O
R T
A N
T
Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians
In physician's office $10 per
visit to your primary care physician or participating specialist
Professional services of physicians
In an urgent care center
During a
hospital stay
In a skilled nursing facility
Initial examination of a
newborn child covered under a family enrollment
Office medical consultations
Second surgical opinion
No separate physician charge in
addition to the applicable facility
charge
At home Nothing
Not covered: All charges. 14
14 Page 15 16
2001 AvMed Health Plan Section 5( a) 15
Lab, X-ray and other diagnostic tests You pay
Tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
Cat Scans/ MRI (prior authorization is
required)
Ultrasound (prior authorization is required)
Electrocardiogram
and EEG (prior authorization is required)
Nothing if you receive these
services during your office visit;
otherwise, $10 per visit
Preventive care, adult
Routine screenings, such as:
Blood lead
level – One annually
Total Blood Cholesterol – once every three
years, ages 19 through 64
Colorectal Cancer Screening, including
Fecal
occult blood test
Nothing if you receive these
services during your office visit;
otherwise $10 per visit
Sigmoidoscopy, screening – every five years starting at age 50 Nothing
if you receive these services during your office visit;
otherwise $10 per
visit
Prostate Specific Antigen (PSA test) – one annually for men age 40 and
older Nothing if you receive these
services during your office visit;
otherwise $10 per visit
Routine pap test
Note: The office visit is covered if pap test is
received on the same day;
see Diagnosis and Treatment, above.
$10 per visit
Routine mammogram –covered for women age 35 and older, as
follows:
From age 35 through 39, one during this five year period
From age 40
through 64, one every calendar year
At age 65 and older, one every two
consecutive calendar years
$10 per visit
Not covered: Physical exams required for obtaining or continuing
employment or insurance, attending schools or camp, or travel.
All
charges
Routine Immunizations, limited to:
Tetanus-diphtheria (Td) booster
– once every 10 years, ages 19 and over (except as provided for under
Childhood immunizations)
Influenza/ Pneumococcal vaccines, annually, age 65 and over
$10 per visit 15
15 Page
16 17
2001 AvMed Health Plan Section
5( a) 16
Preventive care, children You pay
Childhood
immunizations recommended by the American Academy of Pediatrics $10 per visit
Examinations, such as:
Eye exams through age 17 to determine the need for
vision correction.
Ear exams through age 17 to determine the need for hearing correction
Examinations done on the day of immunizations ( through age 22)
Well-child care charges for routine examinations, immunizations and care
(through age 22)
$10 per visit
Maternity care
Complete maternity (obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care
Note: Here are some things
to keep in mind:
You do not need to precertify your normal delivery; see page 10 for other
circumstances, such as extended stays for you or your baby.
You may remain in the hospital up to 48 hours after a regular delivery and 96
hours after a cesarean delivery. We will extend
your inpatient stay if
medically necessary.
We cover routine nursery care of the newborn child
during the covered portion of the mother's maternity stay. We will cover other
care of an infant who requires non-routine treatment only if we
cover the
infant under a Self and Family enrollment.
We pay hospitalization and surgeon services (delivery) the same as for
illness and injury. See Hospital benefits (Section 5c) and
Surgery benefits (Section 5b).
Copayments are waived for
maternity care
Not covered: Routine sonograms to determine fetal age, size or sex All
charges
Family planning
Voluntary sterilization $100 per
procedure
Surgically implanted contraceptives
Injectable contraceptive drugs
Intrauterine devices (IUDs)
$10 per visit
Not covered: reversal of voluntary surgical sterilization, genetic
counseling
All charges 16
16 Page 17 18
2001 AvMed
Health Plan Section 5( a) 17
Infertility services You pay
Diagnosis and treatment of infertility, such as:
Artificial
insemination: intravaginal insemination (IVI)
intracervical insemination (ICI) intrauterine insemination (IUI)
$20 per visit
Surgery for the enhancement of fertility $100 for physician and
$500 for
facility
Not covered:
Assisted reproductive technology (ART) procedures,
such as: in vitro fertilization
embryo transfer and GIFT Services and supplies related to excluded
ART procedures
Cost of donor sperm Fertility drugs
All charges
Allergy care
Testing and treatment
Allergy injection
$50 per course of testing
$10 per visit
Allergy
serum Nothing
Not covered: provocative food testing and sublingual
allergy
desensitization
All charge.
Treatment therapies
Chemotherapy and radiation therapy
Note:
High dose chemotherapy in association with autologous bone
marrow
transplants are limited to those transplants listed under
Organ/ Tissue
Transplants on page 23.
Respiratory and inhalation therapy
Dialysis – Hemodialysis and
peritoneal dialysis
Intravenous (IV)/ Infusion Therapy – Home IV and
antibiotic therapy
Growth hormone therapy (GHT)
Note: – We will only cover GHT when we
preauthorize the treatment.
Call 1-800-816-5465 for preauthorization. We
will ask your AvMed
physician to submit information that establishes that
the GHT is
medically necessary. Be sure your AvMed physician obtains
approval
for GHT before you begin treatment; otherwise, we will only cover
GHT services from the date you get approval. If you do not ask or if we
determine GHT is not medically necessary, we will not cover the GHT
or
related services and supplies. See Services requiring our prior
approval
in Section 3.
$10 per visit
Not covered: All charges 17
17 Page 18 19
2001 AvMed
Health Plan Section 5( a) 18
Rehabilitative therapies You pay
Physical therapy, occupational therapy and speech therapy --
up to 60
calendar days per condition for the services of each of the following:
qualified physical therapists;
speech therapists; and
occupational
therapists.
Note: We only cover therapy to restore bodily function or speech
when there has been a total or partial loss of bodily function or
functional speech due to illness or injury and where significant
improvement can be expected within 2 months.
$10 per visit
Not covered:
long-term rehabilitative therapy
cardiac rehabilitation
exercise programs
All charges
Hearing services (testing, treatment, and supplies)
Hearing
testing for children through age 17 (see Preventive care, children) $10
per visit
Not covered:
all other hearing testing hearing aids,
testing and examinations for them
All charges
Vision services (testing, treatment, and supplies)
Annual eye
refractions to determine the need for vision correction for children through age
17 (see preventive care)
Diagnosis and treatment of diseases of the eye
$10 per visit
Not covered:
all other vision testing (eye examinations and
refractions)
Eyeglasses or contact lenses (including replacement of
lenses provided during the same calendar year)
External lenses following cataract surgery
Eye exercises and
orthoptics
Radial keratotomy and other refractive surgery
All charges 18
18 Page 19 20
2001 AvMed
Health Plan Section 5( a) 19
Foot care You pay
Routine foot
care when you are under active treatment for a metabolic
or peripheral
vascular disease, such as diabetes.
$10 per visit
Not covered:
Cutting, trimming or removal of corns, calluses,
or the free edge of toenails, and similar routine treatment of conditions of the
foot,
except as stated above
Treatment of weak, strained or flat feet
or bunions or spurs; and of any instability, imbalance or subluxation of the
foot (unless the
treatment is by open cutting surgery)
Podiatric shoe inserts or
foot orthotics
All charges
Orthopedic and prosthetic devices
Prosthetic devices are covered,
limited to:
Artificial limbs
Externally worn breast prostheses and
surgical bras, including necessary replacements, following a mastectomy
Surgically implanted internal prosthetic devices, such as artificial joints,
pacemakers, and surgically implanted breast implant
following mastectomy.
Note: See 5( b) for coverage of the surgery
to insert the device.
Corrective orthopedic appliances for non-dental treatment of
temporomandibular joint (TMJ) pain dysfunction syndrome.
Nothing
Not covered:
orthopedic and corrective shoes
arch
supports
foot orthotics
heel pads and heel cups
lumbosacral supports
corsets, trusses, elastic stockings,
support hose, and other supportive devices
cochlear implants
penile implants
prosthetic
replacements provided less than 3 years after the last one we covered
All charges 19
19 Page 20 21
2001 AvMed
Health Plan Section 5( a) 20
Durable medical equipment (DME) You pay
Rental or purchase, at our option, depending on the most economical
option available. Durable medical equipment such as:
hospital beds;
crutches; and
standard wheelchairs
Coverage for orthotic appliances is limited to leg, arm, back, and neck
custom-made braces when related to a surgical procedure or when used
in
an attempt to avoid surgery and are necessary to carry out normal
activities
of daily living, excluding sports activities. Coverage is limited
to the
first such item; repair and replacement is not covered.
$50 per episode of illness
Benefits are limited to a maximum
of $500
per contract year. You
pay anything above that amount.
Not covered:
Medical supplies such as corsets which do not
require a prescription
Motorized wheelchairs Non-standard wheelchairs
All other
orthotic appliances
All charges
Home health services
Home health services of nurses and health
aides when prescribed by your Plan doctor, who will periodically review the
program for
continuing appropriateness and need.
Services include oxygen therapy, intravenous therapy and medications.
Nothing
Not covered:
nursing care requested by, or for the convenience
of, the patient or the patient's family;
nursing care primarily for hygiene, feeding, exercising, moving the
patient, homemaking, companionship or giving oral medication.
All charges
Alternative treatments
Not covered:
acupuncture
chiropractic services
naturopathic services hypnotherapy
biofeedback
All charges
Educational classes and programs
Coverage is limited to:
Diabetes self-management
$10 per visit 20
20
Page 21 22
2001
AvMed Health Plan Section 5( b) 21
Section 5 (b). Surgical and
anesthesia services provided by physicians and other health care professionals
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Plan physicians must provide or arrange your care.
We have no calendar
year deductible.
Be sure to read Section 4, Your costs for covered
services for valuable information about how cost sharing works. Also read
Section 9 about coordinating benefits with other coverage, including with
Medicare.
The amounts listed below are for the charges billed by a
physician or other health care professional for your surgical care. Look in
Section 5( c) for charges associated with the facility (i. e., hospital,
surgical
center, etc.).
YOU MUST GET PREAUTHORIZATION OF SOME SURGICAL
PROCEDURES. Please refer to the preauthorization information shown in
Section 3 to
be sure which services require preauthorization and identify which surgeries
require
preauthorization.
I M
P O
R T
A N
T
Benefit Description You pay
Surgical procedures
Treatment of
fractures, including casting Normal pre-and post-operative care by the surgeon
Correction of amblyopia and strabismus Endoscopy procedure
Biopsy
procedure Removal of tumors and cysts
Correction of congenital anomalies
(see reconstructive surgery) Surgical treatment of morbid obesity --a condition
in which an
individual weighs 100 pounds or 100% over his or her normal
weight according to current underwriting standards; eligible
members
must be age 18 or over
Insertion of internal prosthetic devices. See 5( a) – Orthopedic braces
and prosthetic devices for device coverage information.
$10 per visit
Voluntary sterilization $100 per procedure
Norplant (a surgically
implanted contraceptive) and intrauterine devices (IUDs) Note: Devices are
covered under 5( a).
Note: Generally, we pay for internal prostheses (devices) according to
where the procedure is done. For example, we pay Hospital benefits
for a
pacemaker and Surgery benefits for insertion of the pacemaker.
$10 per visit
Not covered:
Reversal of voluntary sterilization
Routine treatment of conditions of the foot; see Foot care.
Treatment of burns
All charges 21
21 Page 22 23
2001 AvMed
Health Plan Section 5( b) 22
Reconstructive surgery You pay
Surgery to correct a functional defect
Surgery to correct a
condition caused by injury or illness if:
the condition produced a major
effect on the member's appearance and
the condition can reasonably be expected to be corrected by such surgery
Surgery to correct a condition that existed at or from birth and is a
significant deviation from the common form or norm. Examples of
congenital
anomalies are: protruding ear deformities; cleft lip; cleft
palate; birth
marks; webbed fingers; and webbed toes.
All stages of breast reconstruction surgery following a mastectomy, such as:
surgery to produce a symmetrical appearance on the other breast;
treatment of any physical complications, such as lymphedemas;
breast
prostheses and surgical bras and replacements (see Prosthetic devices)
Note: If you need a mastectomy, you may choose to have the procedure
performed on an inpatient basis and remain in the hospital up to 48 hours
after the procedure.
$10 per visit
Not covered:
Cosmetic surgery – any surgical procedure
(or any portion of a procedure) performed primarily to improve physical
appearance
through change in bodily form, except repair of accidental injury
Surgeries related to sex transformation
All charges
Oral and maxillofacial surgery
Oral surgical procedures, limited
to:
Reduction of fractures of the jaws or facial bones; Surgical correction
of cleft lip, cleft palate or severe functional
malocclusion;
Removal of stones from salivary ducts; Excision of
leukoplakia or malignancies;
Excision of cysts and incision of abscesses when done as independent
procedures; and
Other surgical procedures that do not involve the teeth or
their supporting structures.
$10 per visit
Not covered:
Oral implants and transplants Procedures
that involve the teeth or their supporting structures
(such as the periodontal membrane, gingiva, and alveolar bone)
All charges 22
22 Page 23 24
2001 AvMed
Health Plan Section 5( b) 23
Organ/ tissue transplants You pay
Limited to:
Cornea Heart
Kidney Liver
Allogeneic (donor) bone marrow transplant 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; breast cancer; multiple myeloma; epithelial ovarian
cancer; and testicular, mediastinal, retroperitoneal and ovarian germ
cell tumors
Limited Benefits -Treatment for breast cancer, multiple myeloma, and
epithelial ovarian cancer may be provided in an NCI-or NIH-approved
clinical trial at a Plan-designated center of excellence and if approved
by the Plan's medical director in accordance with the Plan's protocols.
Note: We cover related medical and hospital expenses of the donor
when we
cover the recipient.
$10 per visit
Not covered:
Donor screening tests and donor search expenses,
except those performed for the actual donor
Implants of artificial organs
Transplants not listed as covered
All charges
Anesthesia
Professional services provided in –
Hospital (inpatient)
Nothing 23
23 Page 24 25
2001 AvMed
Health Plan Section 5( c) 24
Section 5 (c). Services provided by a
hospital or other facility, and ambulance services
I M
P O
R T
A
N
T
Here are some important things to remember about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are
medically necessary.
Plan physicians must provide or arrange your care
and you must be hospitalized in a Plan facility.
We have no calendar year deductible.
Be sure to read Section 4, Your
costs for covered services for valuable information about how cost sharing
works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
The
amounts listed below are for the charges billed by the facility (i. e., hospital
or surgical center) or ambulance service for your surgery or care. Any costs
associated with the professional charge (i. e., physicians, etc.) are covered
in
Section 5( a) or (b).
YOU MUST GET PREAUTHORIZATION OF HOSPITAL STAYS. Please refer to
Section 3 to be sure which services require preauthorization.
I M
P O
R T
A N
T
Benefit Description You pay
Inpatient hospital
Room and board,
such as
ward, semiprivate, or intensive care accommodations; general nursing
care; and
meals and special diets.
NOTE: If you want a private room when it is not
medically necessary,
you pay the additional charge above the semiprivate
room rate.
Nothing
Other hospital services and supplies, such as:
Operating, recovery,
maternity, and other treatment rooms Prescribed drugs and medicines
Diagnostic laboratory tests and X-rays Administration of blood and blood
products
Blood or blood plasma, if not donated or replaced Dressings,
splints, casts, and sterile tray services
Medical supplies and equipment,
including oxygen Anesthetics, including nurse anesthetist services
Take-home
items Medical supplies, appliances, medical equipment, and any covered
items
billed by a hospital for use at home
Nothing
Not covered:
Custodial care Non-covered facilities, such
as nursing homes, extended care
facilities, schools
Personal comfort items, such as telephone,
television, barber services, guest meals and beds
Private nursing care
All charges 24
24 Page 25 26
2001 AvMed
Health Plan Section 5( c) 25
Outpatient hospital or ambulatory
surgical center You pay
Operating, recovery, and other treatment rooms
Prescribed druCould not acquire words on page 26 gs and medicines
Diagnostic laboratory tests, X-rays, and pathology services Administration of
blood, blood plasma, and other biologicals
Blood and blood plasma, only if
donated or replaced Pre-surgical testing
Dressings, casts, and sterile tray
services Medical supplies, including oxygen
Anesthetics and anesthesia
service
NOTE: – We cover hospital services and supplies related to
dental
procedures when necessitated by a non-dental physical impairment. We
do not cover the dental procedures.
Nothing
Not covered: blood and blood derivatives not replaced by the member All
charges
Extended care benefits/ skilled nursing care facility
benefits
Extended care benefit: We provide 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. 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
Nothing
Not covered:
Custodial care
Residential treatment
facilities
All charges
Hospice care
We provide supportive and palliative care for a
terminally ill member in
the home or hospice facility. Services include:
inpatient and outpatient care;
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.
Nothing
Not covered:
Independent nursing homemaker services All
charges
Ambulance
Local professional ambulance service when medically
appropriate and ordered or authorized by a Plan doctor. Nothing 25
25 Page 26 27
26 Page 27 28
2001 AvMed
Health Plan Section 5( d) 27
Benefit Description You pay
Emergency within our service area
Emergency care at a doctor's office
Emergency care at a participating
urgent care center or participating hospital emergency room
Emergency care at a non-participating urgent care center or non-participating
hospital emergency room
$10 per visit
$30 per visit
$50 per visit
Not covered: Elective care or non-emergency care All charges
Emergency outside our service area
Emergency care at a doctor's office
Emergency care at an urgent care
center
Emergency care as an outpatient or inpatient at a hospital, including
doctors' services
$50 per visit
Not 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 the service area
All charges
Ambulance
Professional ambulance service when medically
appropriate.
See 5( c) for non-emergency service.
Nothing
Not covered: air ambulance All charges 27
27
Page 28 29
2001
AvMed Health Plan Section 5( e) 28
Section 5 (e). Mental health and
substance abuse benefits
I M
P O
R T
A N
T
Parity
Beginning in 2001, all FEHB plans' mental health and
substance abuse benefits will achieve
"parity" with other
benefits. This means that we will provide mental health and substance
abuse
benefits differently than in the past.
When you get our approval for services and follow a treatment plan we
approve, cost-sharing
and limitations for Plan mental health and substance
abuse benefits will be no greater than for
similar benefits for other
illnesses and conditions.
Here are some important things to keep in mind about these benefits:
All benefits are subject to the definitions, limitations, and exclusions
in this brochure.
Be sure to read Section 4, Your costs for covered
services for valuable information about how cost sharing works. Also read
Section 9 about coordinating benefits with other
coverage, including with
Medicare.
YOU MUST GET PREAUTHORIZATION OF THESE SERVICES. See the instructions
after the benefits description below.
I M
P O
R T
A N
T
Benefit Description You pay
Network mental health and substance abuse
benefits
All diagnostic and treatment services recommended
by a Plan provider and
contained in a treatment plan
that we approve. The treatment plan may
include
services, drugs and supplies described elsewhere in
this
brochure.
Note: Plan benefits are payable only when we
determine the care is
clinically appropriate to treat
your condition and only when you receive the
care
as part of a treatment plan that we approve.
Your cost sharing responsibilities are no
greater than for other illness
or conditions.
Professional services, including individual or group therapy by providers
such as
psychiatrists, psychologists, or clinical social
workers.
Medication management
$10 per visit
Network mental health and substance abuse benefits --Continued on next
page. 28
28 Page
29 30
2001 AvMed Health Plan Section
5( e) 29
Mental health and substance abuse benefits (Continued) You
pay
Diagnostic test tests $10 per visit
Services provided by a
hospital or other facility Nothingadmission)
Services in approved alternative care settings such
as partial
hospitalization, half-way house,
residential treatment, full-day
hospitalization,
facility based intensive outpatient treatment
$10 per visitdmission)
Not covered: Services we have not approved.
Note: OPM will base
its review of disputes about
treatment plans on the treatment plan's
clinical
appropriateness. OPM will generally not order us to pay
or
provide one clinically appropriate treatment plan in
favor of another.
All charges
Preauthorization To be eligible to receive benefits you must follow
your treatment plan and all the authorization processes. These include:
Pre-Authorization is required for most scheduled diagnostic
tests/
procedures and all scheduled inpatient/ outpatient surgical
procedures. It
is the responsibility of the requesting physician to
obtain authorization
prior to scheduling services. In order to check
on a referral, call AvMed
Link Line at 1-800-806-3623.
Special transitional benefit If a mental health or substance abuse
professional provider is treating you under our plan as of January 1, 2001, you
will be eligible for continued
coverage with your provider for up to 90 days
under the following
conditions:
If your mental health or substance abuse professional provider with
whom
you are currently in treatment leaves the plan at our request for
other than
cause, or
If this condition applies to you, we will allow you reasonable time to
transfer your care to a Plan mental health or substance abuse professional
provider. During the transitional period, you may continue to see your
treating provider and will not pay any more out-of-pocket than you did in
the year 2000 for services. This transitional period will begin with our
notice to you of the change in coverage and will end 90 days after you
receive our notice. If we write to you before October 1, 2000, the 90-day
period ends before January 1 and this transitional benefit does not apply.
Network limitation We may limit your benefits if you do not follow
your treatment plan. 29
29 Page
30 31
30
Page 31 32
2001
AvMed Health Plan Section 5( f) 31
Benefit Description You pay
Covered medications and supplies
We cover the following medications
and supplies prescribed by a Plan
physician and obtained from a Plan
pharmacy:
Drugs and medicines that by Federal law of the United States require a
physician's prescription for their purchase, except as
excluded below.
Insulin Disposable needles and syringes for the
administration of covered
medications, including insulin
Drugs for sexual dysfunction (see Prior
authorization below) Coverage is limited; contact AvMed for dose limits. You pay
the
drug copayment up to the dosage limit and all charges above that.
Full
range of FDA-approved drugs, prescriptions, and devices for birth control
Here are some things to keep in mind about our prescription drug
program:
A generic equivalent will be dispensed if it is available, unless your
physician specifically requires a name brand. If you receive a
name brand
drug when a Federally-approved generic drug is
available, and your physician
has not specified Dispense as Written
for the name brand drug, you have to
pay the difference in cost
between the name brand drug and the generic.
We have an open formulary. If your physician believes a name brand product is
necessary or there is no generic available, your
physician may prescribe a
name brand drug from a formulary list.
This list of name brand drugs is a
preferred list of drugs that we
selected to meet patient needs at a lower
cost.
$5 per prescription unit
Not covered:
Drugs and supplies for cosmetic purposes
Vitamins and nutritional substances that can be purchased without a
prescription
Nonprescription medicines or medicines for which there is a
nonprescription equivalent
Drugs obtained at a non-Plan pharmacy,
except for out-of-area emergencies
Medical supplies such as dressings
and antiseptics
Diabetic supplies except for needles and syringes
Drugs to enhance athletic performance
Drugs to aid in
smoking cessation, including nicotine patches
Fertility drugs
All Charges 31
31 Page 32 33
2001 AvMed
Health Plan Section 5( g) 32
Section 5 (g). Special Features
Feature Description
Flexible benefits option Under the flexible benefits option, we
determine the most effective way to provide services.
We may identify
medically appropriate alternatives to traditional care and coordinate other
benefits as a less costly alternative
benefit.
Alternative benefits are
subject to our ongoing review.
By approving an alternative benefit, we
cannot guarantee you will get it in the future.
The decision to offer an alternative benefit is solely ours, and we may
withdraw it at any time and resume regular contract benefits.
Our decision
to offer or withdraw alternative benefits is not subject to OPM review under the
disputed claims process.
24 hour nurse line For any of your health concerns, 24 hours a day, 7
days a week, you may call 1-800-866-5432 and talk with a registered nurse who
will
discuss treatment options and answer your health questions.
Disease Management Call 1-800-972-8633 for information and help with
the following: Healthy Hearts – congestive heart failure
E-Z Breath'n – asthma
Healthy Expectations – high risk
pregnancies
Centers of excellence for transplants/ heart
surgery/ etc
Consult Member Services at 800-882-8633 to obtain a complete list of
centers. 32
32 Page
33 34
2001 AvMed Health Plan Section
5( h) 33
Section 5 (h). Dental benefits
I M
P O
R T
A
N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Plan dentists must provide or arrange your care.
We have no calendar year
deductible.
We cover hospitalization for dental procedures only when a
nondental physical impairment exists which makes hospitalization necessary to
safeguard the health of the patient; we do
not cover the dental procedure unless it is described below.
Be sure to
read Section 4, Your costs for covered services for valuable information
about how cost sharing works. Also read Section 9 about coordinating benefits
with other
coverage, including with Medicare.
I M
P O
R T
A N
T
Accidental injury benefit You pay
We cover restorative services
and supplies necessary to promptly repair
(but not replace) sound natural
teeth. The need for these services must
result from an accidental injury.
Nothing
Dental benefits
We cover the following dental services when
provided by participating Plan dentists to children through age 11.
Service You pay
Preventive and Diagnostic
Oral examinations
X-rays as necessary
Prophylaxis (cleaning)
------------------------------------------------------------------------
Topical application of fluoride
Nothing
Nothing
Nothing
-----------------------------------------------------------------------
$10
per application 33
33 Page
34 35
2001 AvMed Health Plan Section 6
34
Section 5 (i). Non-FEHB benefits available to Plan members
The benefits on this page are not part of the FEHB contract or premium,
and you cannot file an FEHB disputed
claim about them. Fees you pay
for these services do not count toward FEHB out-of-pocket maximums.
Expanded dental benefits 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:
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.
Expanded vision care Discounts on vision services are available to
AvMed members. Services include:
Eye exams Eyeglasses
Contact lenses
Designer glasses, sunglasses, etc.
For details on specific services and discounts in your Service Area, please
call
your Plan's Membership Services Office listed on page 8 of the
brochure.
Additional value added services include Weight Watchers and Smokenders.
Medicare prepaid plan enrollment – This Plan offers Medicare recipients
the opportunity to enroll in the Plan through
Medicare. As indicated in
Section 9, 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. 34
34 Page 35 36
2001 AvMed
Health Plan Section 6 35
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 your Plan doctor determines it is medically necessary to prevent,
diagnose, or
treat your illness, disease, injury, or condition and we agree,
as discussed under What Services Require
Our Prior Approval
on page 10 .
We do not cover the following:
Care by non-Plan providers except for authorized referrals or emergencies
(see Emergency Benefits);
Services, drugs, or supplies you receive while you are not enrolled in this
Plan;
Services, drugs, or supplies that are not medically necessary;
Services, drugs, or supplies not required according to accepted standards of
medical, dental, or psychiatric practice;
Experimental or investigational procedures, treatments, drugs or devices;
Services, drugs, or 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;
Services, drugs, or supplies related to sex transformations; or
Services, drugs, or supplies you receive from a provider or facility barred
from the FEHB Program. 35
35 Page 36 37
2001 AvMed
Health Plan Section 7 36
Section 7. Filing a claim for covered
services
When you see Plan physicians, receive services at Plan
hospitals and facilities, or obtain your prescription drugs at
Plan
pharmacies, you will not have to file claims. Just present your identification
card and pay your copayment,
coinsurance, or deductible.
You will only need to file a claim when you receive emergency services from
non-plan providers. Sometimes these
providers bill us directly. Check with
the provider. If you need to file the claim, here is the process:
Medical and hospital benefits In most cases, providers and facilities
file claims for you. Physicians must file on the form HCFA-1500, Health
Insurance Claim Form.
Facilities will file on the UB-92 form. For claims
questions and
assistance, call us at 1-800-882-8633.
When you must file a claim --such as for out-of-area care --submit it on
the HCFA-1500 or a claim form that includes the information shown
below.
Bills and receipts should be itemized and show:
Covered member's name and ID number;
Name and address physician or
facility that provided the service or supply;
Dates you received the services or supplies;
Diagnosis;
Type of each
service or supply;
The charge for each service or supply;
A copy of the
explanation of benefits, payments, or denial from any primary payer --such as
the Medicare Summary Notice
(MSN); and
Receipts, if you paid for your services.
Submit your claims to:
9400 South Dadeland Blvd., Suite 200,
Miami, FL 33156
Prescription drugs
Submit your claims to: 9400 South Dadeland
Blvd., Suite 200, Miami,
FL 33156
Deadline for filing your claim Send us all of the documents for your
claim as soon as possible (remember to keep copies). You must submit the claim
by December 31 of the year
after the year you received the service, unless
timely filing was prevented
by administrative operations of Government or
legal incapacity, provided
the claim was submitted as soon as reasonably
possible.
When we need more information Please reply promptly when we ask for
additional information. We may delay processing or deny your claim if you do not
respond. 36
36 Page
37 38
2001 AvMed Health Plan Section 8
37
Section 8. The disputed claims process
Follow this Federal
Employees Health Benefits Program disputed claims process if you disagree with
our decision on
your claim or request for services, drugs, or supplies
– including a request for preauthorization:
Step Description
1 Ask us in writing to reconsider our initial decision. You must: (a)
Write to us within 6 months from the date of our decision; and
(b) Send your
request to us at: AvMed Member Relations, P. O. Box 749, Gainesville, FL
32602-
0749; and
(c) Include a statement about why you believe our initial decision was wrong,
based on specific
benefit provisions in this brochure; and
(d) Include copies of documents that support your claim, such as physicians'
letters, operative reports,
bills, medical records, and explanation of
benefits (EOB) forms.
2 We have 30 days from the date we receive your request to: (a) Pay
the claim (or, if applicable, arrange for the health care provider to give you
the care); or
(b) Write to you and maintain our denial --go to step 4; or
(c) Ask you or your provider for more information. If we ask your provider,
we will send you a copy
of our request— go to step 3.
3 You or your provider must send the information so that we receive it
within 60 days of our request. We will then decide within 30 more days. If we do
not receive the information within 60 days, we will decide within 30 days of the
date the
information was due. We will base our decision on the information
we already have.
We will write to you with our decision.
4 If you do not agree with our decision, you may ask OPM to review it.
You must write to OPM within:
90 days after the date of our letter upholding our initial decision; or
120 days after you first wrote to us --if we did not answer that request in
some way within 30 days; or
120 days after we asked for additional
information.
Write to OPM at: Office of Personnel Management, Office of Insurance
Programs, Contracts Division 3,
P. O. Box 436, Washington, D. C. 20044-0436.
Send OPM the following information:
A statement about why you believe our
decision was wrong, based on specific benefit provisions in this brochure;
Copies of documents that support your claim, such as physicians' letters,
operative reports, bills, medical records, and explanation of benefits (EOB)
forms;
Copies of all letters you sent to us about the claim;
Copies of
all letters we sent to you about the claim; and
Your daytime phone number
and the best time to call.
Note: If you want OPM to review different claims, you must clearly identify
which documents apply to
which claim. 37
37
Page 38 39
2001
AvMed Health Plan Section 8 38
The Disputed Claims process (Continued)
Note: You are the only person who has a right to file a disputed claim with
OPM. Parties acting as your
representative, such as medical providers, must
provide a copy of your specific written consent with the
review request.
Note: The above deadlines may be extended if you show that you were unable to
meet the deadline because
of reasons beyond your control.
5 OPM will review your disputed claim request and will use the
information it collects from you and us to decide whether our decision is
correct. OPM will send you a final decision within 60 days. There are no other
administrative appeals.
6 If you do not agree with OPM's decision, your only recourse is to
sue. If you decide to sue, you must file the suit against OPM in Federal court
by December 31 of the third year after the year in which you received the
disputed services, drugs, or supplies. This is the only deadline that may not be
extended.
OPM may disclose the information it collects during the review
process to support their disputed claim
decision. This information will
become part of the court record.
You may not sue until you have completed the disputed claims process.
Further, 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 decided to uphold or overturn our decision. You may
recover only the amount of
benefits in dispute.
NOTE: If you have a serious or life threatening condition (one that
may cause permanent loss of bodily
functions or death if not treated as soon
as possible), and
(a) We haven't responded yet to your initial request for care or
preauthorization/ prior approval, then call us at 1-800-
882-8633 and we will
expedite our review; or
(b) We denied your initial request for care or preauthorization/ prior
approval, then:
If we expedite our review and maintain our denial, we will inform OPM so that
they can give your claim expedited treatment too, or
You can call OPM's Health Benefits Contracts Division 3 at 202/ 606-0755
between 8 a. m. and 5 p. m. eastern time. 38
38
Page 39 40
2001
AvMed Health Plan Section 9 39
Section 9. Coordinating benefits with
other coverage
When you have other health coverage You must tell us if
you are covered or a family member is covered under another group health plan or
have automobile insurance that pays health
care expenses without regard to
fault. This is called "double coverage."
When you have double
coverage, one plan normally pays its benefits in
full as the primary payer
and the other plan pays a reduced benefit as the
secondary payer. We, like
other insurers, determine which coverage is
primary according to the
National Association of Insurance
Commissioners' guidelines.
When we are the primary payer, we will pay the benefits described in this
brochure.
When we are the secondary payer, we will determine our allowance.
After
the primary plan pays, we will pay what is left of our allowance, up
to our
regular benefit. We will not pay more than our allowance. If we
are the
secondary payer, we may be entitled to receive payment from
your primary
plan.
What is Medicare Medicare is a Health Insurance Program for:
People 65 years of age and older.
Some people with disabilities, under
65 years of age.
People with End-Stage Renal Disease (permanent kidney
failure requiring dialysis or a transplant).
Medicare has two parts:
Part A (Hospital Insurance). Most people do not
have to pay for Part A.
Part B (Medical Insurance). Most people pay monthly
for Part B.
If you are eligible for Medicare, you may have choices in how
you get your health
care. Medicare+ Choice is the term used to describe the
various health plan choices
available to Medicare beneficiaries. The
information in the next few pages shows
how we coordinate benefits with
Medicare, depending on the type of Medicare
managed care plan you have.
The Original Medicare Plan The Original Medicare Plan is available
everywhere in the United States. It is the way most people get their Medicare
Part A and Part B benefits. You may go to any
doctor, specialist, or
hospital that accepts Medicare. Medicare pays its share and
you pay your
share. Some things are not covered under Original Medicare, like
prescription drugs.
When you are enrolled in this Plan and Original Medicare, you still need
to follow the rules in this brochure for us to cover your care.
(Primary payer chart begins on next page.) 39
39 Page 40 41
2001 AvMed Health Plan Section 9 40
The
following chart illustrates whether Original Medicare or this Plan should be the
primary payer for you according
to your employment status and other factors
determined by Medicare. It is critical that you tell us if you or a covered
family member has Medicare coverage so we can administer these requirements
correctly.
Primary Payer Chart
Then the primary payer is… A. When either
you --or your covered spouse --are age 65 or over and …
Original Medicare This Plan
1) Are an active employee with the
Federal government (including when you or
a familymember are eligible for
Medicare solelybecause of a disability), !
2) Are an annuitant, !
3) Are a reemployed annuitant with the Federal
government when…
a) The position is excluded from FEHB or
…………………………
……….. !
b) The position isCould not acquire words on page 41 not excluded from
FEHB………………………….
Ask your employing office which of these applies to you.
……………………..………
!
4) Are a Federal judge who retired under title 28, U. S. C., or a Tax
Court judge who retired under Section 7447 of title 26, U. S. C. (or if
your covered spouse is this type of judge), !
5) Are enrolled in Part B only, regardless of your employment status, ! (for
Part B
services)
!
(for other
services)
6) Are a former Federal employee receiving Workers' Compensation
and the
Office of Workers' Compensation Programs has determined
that you are unable
to return to duty,
!
(except for claims
related to Workers'
Compensation.)
B. When you --or a covered family member --have Medicare
based on end
stage renal disease (ESRD) and…
1) Are within the first 30 months of eligibility to receive Part A
benefits solely because of ESRD, !
2) Have completed the 30-month ESRD coordination period and are
still
eligible for Medicare due to ESRD, !
3) Become eligible for Medicare due to ESRD after Medicare became
primary
for you under another provision, !
C. When you or a covered family member have FEHB and…
1)
Are eligible for Medicare based on disability,
a) Are an annuitant,
or…………………………………………………
………. !
b) Are an active
employee…………………………………………
……………………..
……. ! 40
40 Page
41 42
41 Page 42 43
2001 AvMed Health Plan Section 9 42
Medicaid When you have this Plan and Medicaid, we pay first.
When other Government agencies We do not cover services and supplies
when a local, State, are responsible for your care or Federal Government
agency directly or indirectly pays for them.
When others are responsible When you receive money to compensate you
for medical or hospital for injuries care for injuries or illness caused
by another person, you must reimburse
us for any expenses we paid. However,
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 more information, contact us for our
subrogation procedures. 42
42 Page 43 44
2001 AvMed
Health Plan Section 10 43
Section 10. Definitions of terms we use in
this brochure
Calendar year January 1 through December 31 of the same
year. For new enrollees, the calendar year begins on the effective date of their
enrollment and ends on
December 31 of the same year.
Copayment A copayment is a fixed amount of money you pay when you
receive covered services. See page 13.
Coinsurance See page 13.
Covered services Care we provide
benefits for, as described in this brochure.
Deductible See page 13.
Experimental or investigational
services The plan's experimental/ investigational determination process is
based
on authoritative information from medical literature, medical
consensus
bodies, FDA approval, clinical trials, and health care
professionals with
specialty expertise in the subject.
Group health coverage The form of health insurance covering groups of
persons under a master group health insurance policy issues to any one group.
Medical necessity The use of any appropriate medical treatment,
service, equipment, and/ or supply as provided by a hospital, skilled nursing
facility, physician, or
other provider which is necessary for the diagnosis,
care, and/ or
treatment of a Member's illness or injury.
Us/ We Us and we refer to AvMed Health Plan.
You You refers
to the enrollee and each covered family member. 43
43
Page 44 45
2001
AvMed Health Plan Section 11 44
Section 11. FEHB facts
No
pre-existing condition We will not refuse to cover the treatment of a
condition that you had limitation before you enrolled in this Plan solely
because you had the condition
before you enrolled.
Where you can get
information See www. opm. gov/ insure. Also, your employing or retirement
office about enrolling in the can answer your questions, and give you
a Guide to Federal Employees
FEHB Program Health Benefits Plans, brochures for other plans,
and other materials you need to make an informed decision about:
When you may change your enrollment;
How you can cover your family
members;
What happens when you transfer to another Federal agency, go on
leave without pay, enter military service, or retire;
When your enrollment ends; and
When the next open season for enrollment
begins.
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.
Types of coverage available Self Only coverage is for you alone. Self
and Family coverage is for for you and your family you, your spouse, and
your unmarried dependent children under age 22,
including any foster
children or stepchildren your employing or
retirement office authorizes
coverage for. Under certain circumstances,
you may also continue coverage
for a disabled child 22 years of age or
older who is incapable of
self-support.
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 that event.
The Self and Family enrollment begins on the first day of the pay period
in which the child is born or becomes an eligible family member. When
you change to Self and Family because you marry, the change is effective
on the first day of the pay period that begins after your employing office
receives your enrollment form; benefits will not be available to your
spouse until you marry.
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, or when your child
under
age 22 marries or turns 22.
If you or one of your family members is enrolled in one FEHB plan, that
person may not be enrolled in or covered as a family member by another
FEHB plan. 44
44 Page
45 46
2001 AvMed Health Plan Section
11 45
When benefits and The benefits in this brochure are
effective on January 1. If you are new premiums start 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 on January 1.
Your medical and claims We will keep your medical and claims
information confidential. Only records are confidential the following
will have access to it:
OPM, this Plan, and subcontractors when they administer this contract;
This Plan, and appropriate third parties, such as other insurance plans and
the Office of Workers' Compensation Programs (OWCP), when
coordinating benefit payments and 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.
When you retire When you retire, you can usually stay in the FEHB
Program. Generally, you must have been 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 (TCC).
When you lose benefits
When FEHB coverage ends You will
receive an additional 31 days of coverage, for no additional premium, when:
Your enrollment ends, unless you cancel your enrollment, or
You are a
family member no longer eligible for coverage.
You may be eligible for
spouse equity coverage or Temporary
Continuation of Coverage.
Spouse equity If you are divorced from a Federal employee or
annuitant, you may not coverage 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 RI 70-5, the
Guide to
Federal Employees Health Benefits Plans for Temporary
Continuation of
Coverage and Former Spouse Enrollees, or other
information about your
coverage choices.
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 Temporary
Continuation of Coverage (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
misconduct.
Get the RI 79-27, which describes TCC, and the RI 70-5, the Guide to
Federal Employees Health BCould not acquire words on page 46 enefits Plans
for Temporary Continuation of
Coverage and Former Spouse Enrollees, from
your employing or
retirement office or from www. opm. gov/ insure. 45
45 Page 46 47
46 Page 47 48
2001 AvMed Health Plan DoD/ FEHB Demonstration Project 47
Department of Defense/ FEHB Demonstration Project
What is it? The
Department of Defense/ FEHB Demonstration Project allows some active and retired
uniformed service members and their dependents to
enroll in the FEHB
Program. The demonstration will last for three years
and began with the 1999
open season for the year 2000. Open season
enrollments will be effective
January 1, 2001. DoD and OPM have set
up some special procedures to
implement the Demonstration Project,
noted below. Otherwise, the provisions
described in this brochure apply.
Who is eligible DoD determines who is eligible to enroll in the FEHB
Program. Generally, you may enroll if:
You are an active or retired uniformed service member and are eligible for
Medicare;
You are a dependent of an active or retired uniformed service
member and are eligible for Medicare;
You are a qualified former spouse of
an active or retired uniformed service member and you have not remarried; or
You are a survivor dependent of a deceased active or retired uniformed
service member; and
You live in one of the geographic demonstration areas.
If you are eligible to enroll in a plan under the regular Federal Employees
Health Benefits Program, you are not eligible to enroll under the
DoD/
FEHBP Demonstration Project.
The demonstration areas Dover AFB, DE Commonwealth of Puerto Rico Fort
Knox, KY Greensboro/ Winston Salem/ High Point, NC
Dallas, TX Humboldt
County, CA area
New Orleans, LA Naval Hospital, Camp Pendleton, CA
Adair
County, IA Coffee County, GA (Gainesville area only)
When you can join You may enroll under the FEHB/ DoD Demonstration
Project during the 2000 open season, November 13, 2000, through December 11,
2000.
Your coverage will begin January 1, 2001. DoD has set-up an
Information Processing Center (IPC) in Iowa to provide you with
information about how to enroll. IPC staff will verify your eligibility and
provide you with FEHB Program information, plan brochures,
enrollment
instructions and forms. The toll-free phone number for the
IPC is 1-877/
DOD-FEHB (1-877/ 363-3342).
You may select coverage for yourself (Self Only) or for you and your
family (Self and Family) during the 2000 and 2001 open seasons. Your
coverage will begin January 1 of the year following the open season
during which you enrolled.
If you become eligible for the DoD/ FEHB Demonstration Project outside
of
open season, contact the IPC to find out how to enroll and when your
coverage will begin.
DoD has a web site devoted to the Demonstration Project. You can view
information such as their Marketing/ Beneficiary Education Plan,
Frequently Asked Questions,
demonstration area locations and zip code
lists at www. tricare. osd.
mil/ fehbp. You can also view information about
the demonstration
project, including "The 2001 Guide to Federal 47
47 Page 48 49
2001 AvMed Health Plan DoD/ FEHB Demonstration Project 48
Employees Health Benefits Plans Participating in the DoD/ FEHB
Demonstration Project," on the OPM web site at www. opm. gov.
TCC eligibility See Section 11, FEHB Facts; it explains temporary
continuation of coverage (TCC). Under this DoD/ FEHB Demonstration Project the
only
individual eligible for TCC is one who ceases to be eligible as a
"member
of family" under your self and family enrollment. This
occurs when a
child turns 22, for example, or if you divorce and your spouse
does not
qualify to enroll as an unremarried former spouse under title 10,
United
States Code. For these individuals, TCC begins the day after their
enrollment in the DoD/ FEHB Demonstration Project ends. TCC
enrollment
terminates after 36 months or the end of the Demonstration
Project,
whichever occurs first. You, your child, or another person must
notify the
IPC when a family member loses eligibility for coverage under
the DoD/ FEHB
Demonstration Project.
TCC is not available if you move out of a DoD/ FEHB Demonstration
Project
area, you cancel your coverage, or your coverage is terminated
for any
reason. TCC is not available when the demonstration project
ends.
Other features The 31-day extension of coverage and right to convert
do not apply to the DoD/ FEHB Demonstration Project. 48
48 Page 49 50
2001 AvMed Health Plan Index 49
Index
Do not rely on this page; it is for your convenience and does not
explain your benefit coverage.
Accidental injury 22, 33 Allergy tests
13, 17
Alternative treatment 13, 20 Ambulance 2, 13, 24, 25-27
Anesthesia 2, 13, 21, 23, 25, 34 Autologous bone marrow
transplant 17,
23 Blood and blood plasma 15, 24-25
Breast cancer screening 19, 22-23
Casts 24-25
Catastrophic protection 51 Changes for 2001 2, 7
Chemotherapy 17 Claims 3, 8, 13, 36-38, 40, 45
Coinsurance 2, 12, 43
Colorectal cancer screening 15
Congenital anomalies 21-22 Contraceptive
devices and drugs 16, 21
Coordination of benefits 3, 14, 21, 24, 26, 28, 30,
33, 39
Crutches 20
Deductible 2, 12, 14, 21, 24, 26, 28, 30, 33,
39
Definitions 3, 14, 21, 24, 26, 28, 30, 33, 43, 51
Dental care 2, 12, 13,
19, 22, 25, 33-35, 51
Diagnostic services 11, 13-14, 28, 33, 51
Disputed
claims process 3, 32, 34, 37-38, 45
Donor expenses (transplants) 23
Dressings 24-25, 31
Durable medical equipment (DME) 13, 20
Educational classes and programs 13, 20
Effective date of
enrollment 8, 43 Emergency 2, 5-6, 8-9, 13, 26-27,
32, 35-36, 51
Experimental or investigational
35, 43 Eyeglasses 18, 34
Family
planning 12-13, 16 Fecal occult blood test 15
General Exclusions
2, 35 Hearing services 13, 18
Home health services 13, 20 Hospice
care 13, 25
Home nursing care 13, 20, 24-25
Hospital 2, 5, 7-8, 10-14, 16, 20-27, 29, 33-34, 36, 39, 41-43,
46-47,
49, 51 Immunizations 5, 15-16
Infertility 13, 17 Inhospital physician
care 24
Inpatient Hospital Benefits 7, 13, 16, 22-25, 27, 29, 51
Insulin
30-31 Laboratory and pathological
services 11, 24-25 Machine
diagnostic tests 15, 24-
25, 28-29 Magnetic Resonance Imagings
(MRIs)
11, 15 Mammograms 15
Maternity Benefits 13, 16, 24 Medicaid 3, 41
Medically necessary 10-11, 14, 16-17, 21, 24, 30, 33, 35
Medicare 3, 14,
21, 24, 26, 28, 30, 33-34, 36, 39-41, 47
Members 2, 5, 8, 13, 21, 34, 44, 47
Mental Conditions/ Substance Abuse Benefits 2, 7, 31, 28-
29, 51
Newborn care 14, 16 Non-FEHB Benefits 2, 13, 34
Nurse 13, 16, 20 Nurse Anesthetist 24
Registered Nurse 32 Nursery charges
16
Obstetrical care 16 Occupational therapy 18
Office visits 5,
9, 12, 15, 51 Oral and maxillofacial surgery
13, 22 Orthopedic devices 13,
19, 21
Out-of-pocket expenses 2, 12, 29, 34, 51
Outpatient facility care
13, 25, 27, 29, 51
Oxygen 20, 24-25 Pap test 15
Physical
examination 5, 15 Physical therapy 18
Physician 2, 5, 8-10, 12-14, 17, 21,
24, 29-31, 36-37,
43, 46, 51
Preauthorization 10, 17, 21, 24, 29, 37-38
Preventive care, adult 5, 13,
15
Preventive care, children 5, 13, 16, 18, 33
Prescription drugs 13,
30, 36, 39, 41, 51
Preventive services 51 Prior approval 2, 10, 17,
35,
38 Prostate cancer screening 15
Prosthetic devices 13, 19, 21-22
Psychologist 28 Radiation therapy 17
Rehabilitation therapies 18
Room and board 24 Second surgical opinion 14
Skilled nursing facility care 10, 13-14, 25, 43
Smoking cessation 31
Speech therapy 18
Splints 24 Sterilization procedures
16, 21 Subrogation
42
Substance abuse 2, 7, 13, 28-29, 51
Surgery 7, 13, 16-22, 24, 32
Anesthesia 2, 13, 21, 23, 25, 34
Oral 13, 22 Outpatient 13, 25, 27,
29, 51 Reconstructive 13, 21-
22 Syringes 31
Temporary
continuation of coverage 3, 45, 48
Transplants 13, 17, 22-23, 32
Treatment therapies 13, 17
Vision services 13, 18, 34, 51
Well child care 16 Wheelchairs 20
Workers' compensation 40-41, 45
X-rays 13, 15, 24-25, 33-3 49
49 Page 50 51
2001 AvMed
Health Plan 50 50
50 Page
51 52
2001 AvMed Health Plan Summary
51
Summary of benefits for the AvMed Health Plan -2001
Do
not rely on this chart alone. All benefits are provided in full unless
indicated and are subject to the
definitions, limitations, and exclusions in
this brochure. On this page we summarize specific expenses we cover;
for
more detail, look inside.
If you want to enroll or change your enrollment in this Plan, be sure to put
the correct enrollment code from the
cover on your enrollment form.
We only cover services provided or arranged by Plan physicians, except in
emergencies.
Benefits You Pay Page
Medical services provided by physicians:
Diagnostic and treatment services provided in the office.................
Office visit copay: $10 primary care; $10 specialist 14
Services provided by a hospital:
Inpatient
...........................................................................................
Outpatient
.........................................................................................
"Nothing" 24
25
Emergency benefits:
In-area
.............................................................................................
Out-of-area
......................................................................................
$30 per visit
$50 per visit
27
27
Mental health and substance abuse treatment
..................................... Regular cost sharing. 28
Prescription
drugs
.................................................................................
$5 per prescription unit 31
Dental
Care.......................................................................................
Preventive dental care for children
through age 11. $10 per topical
application.
33
Vision
Care.......................................................................................
Refractions, including lens
prescriptions, limited to children
through
age 17. $10 copay per
visit
34
Special features: Flexible benefit option, 24-hour nurse line, Disease
Management, Centers of Excellence 32
Protection against catastrophic costs
(your out-of-pocket maximum)
........................................................
Nothing after $1,500/ Self Only or
$2,500/ Family enrollment per year
Some costs do not count toward
this protection
12 51
51 Page
52 53
52
2001 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.
Postal rates apply to career Postal Service employees. Most employees
should refer to the FEHB Guide for United
States Postal Service Employees,
RI 70-2. Different postal rates apply and special FEHB guides are published for
Postal Service Nurses and Tool & Die employees (see RI 70-2B); and for
Postal Service Inspectors and Office of
Inspector General (OIG) employees
(see RI 70-2IN).
Postal rates do not apply to non-career postal employees, postal retirees, or
associate members of any postal employee
organization. Refer to the
applicable FEHB Guide.
Non-Postal Premium Postal Premium
Biweekly Monthly Biweekly
Type
of Enrollment Code Gov't Share Your Share Gov't Share Your Share USPS Share Your
Share
South Florida
Self Only EM1 $86.47 $28.82 $187.35 $62.45 $102.22
$13.07
Self and Family EM2 $195.82 $121.31 $424.28 $262.84 $231.17 $85.96
Orlando
Self Only GP1 $86.59 $34.88 $187.61 $75.58 $102.22 $19.25
Self and Family GP2 $195.82 $138.25 $424.28 $299.54 $231.17 $102.90
Tampa
Self Only H51 $86.59 $41.56 $187.61 $90.05 $102.22 $25.93
Self and Family H52 $195.82 $156.58 $424.28 $339.25 $231.17 $121.23
Jacksonville
Self Only HW1 $85.60 $28.53 $185.46 $61.82 $101.29 $12.84
Self and Family HW2 $195.82 $118.03 $424.28 $255.73 $231.17 $82.68
Gainesville
Self Only JF1 $86.59 $30.22 $187.61 $65.48 $102.22 $14.59
Self and Family JF2 $195.82 $125.37 $424.28 $271.63 $231.17 $90.02 52
52 Page 53 54
53
53 Page 54
54