A Health Maintenance Organization
Serving: South Florida
Enrollment in this Plan is limited. You must live or work in our
Geographic service area to enroll. See page 6 for requirements.
Enrollment Codes for this Plan:
ML1 Self Only
ML2 Self and Family
AvMed Health Plan -
South FL http: / / www. avmed. com
RI 73-815
Authorized for distribution by the:
For changes
in benefts
see page 7.
This Plan has Commendable
accreditation from the NCQA.
See the 2003 Guide for more
information on accreditation.
2003 A H E A L T H P L A N D ME
SPECI AL NOTICE: AvMed split their FEHB cont ract int o t wo separate
cont racts ef fect ive 2003. AvMed -South Region received a new enrollment
code ML and AvMed -North Region retained the enrollment code EM. Any
current Federal member under enrollment code EM that resides in the counties
assigned to the South Region must change plans during open season. AvMed
members in the South Region that wish to remain with AvMed for contract year
2003 must make a posit ive elect ion into AvMed Health Plan-South Region,
enrollment code ML, during open season.
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Dear Federal Employees Health Benefits Program Participant:
I am pleased to present this Federal Employees Health Benefits (FEHB) Program plan brochure for 2003. The brochure explains all the benefits this health plan offers to its enrollees. Since
benefits can vary from year to year, you should review your plan's brochure every Open Season. Fundamentally, I believe that FEHB participants are wise enough to determine the care
options best suited for themselves and their families.
In keeping with the President's health care agenda, we remain committed to providing FEHB members with affordable, quality health care choices. Our strategy to maintain quality and cost
this year rested on four initiatives. First, I met with FEHB carriers and challenged them to contain costs, maintain quality, and keep the FEHB Program a model of consumer choice and
on the cutting edge of employer-provided health benefits. I asked the plans for their best ideas to help hold down premiums and promote quality. And, I encouraged them to explore all
reasonable options to constrain premium increases while maintaining a benefits program that is highly valued by our employees and retirees, as well as attractive to prospective Federal
employees. Second, I met with our own FEHB negotiating team here at OPM and I challenged them to conduct tough negotiations on your behalf. Third, OPM initiated a comprehensive
outside audit to review the potential costs of federal and state mandates over the past decade, so that this agency is better prepared to tell you, the Congress and others the true cost of mandated
services. Fourth, we have maintained a respectful and full engagement with the OPM Inspector General (IG) and have supported all of his efforts to investigate fraud and waste within the
FEHB and other programs. Positive relations with the IG are essential and I am proud of our strong relationship.
The FEHB Program is market-driven. The health care marketplace has experienced significant increases in health care cost trends in recent years. Despite its size, the FEHB Program is not
immune to such market forces. We have worked with this plan and all the other plans in the Program to provide health plan choices that maintain competitive benefit packages and yet keep
health care affordable.
Now, it is your turn. We believe if you review this health plan brochure and the FEHB Guide you will have what you need to make an informed decision on health care for you and your
family. We suggest you also visit our web site at www. opm. gov/ insure.
Sincerely,
Kay Coles James Director
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Notice of the Office of Personnel Management's
Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT
CAREFULLY.
By law, the Office of Personnel Management (OPM), which administers the Federal Employees Health Benefits (FEHB) Program, is required to protect the privacy of your personal medical information. OPM is also required to give you this notice to tell you how
OPM may use and give out (" disclose") your personal medical information held by OPM.
OPM will use and give out your personal medical information:
. To you or someone who has the legal right to act for you (your personal representative), .
To the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy is protected, . To law enforcement officials when investigating and/ or prosecuting alleged or civil or criminal actions, and
. Where required by law.
OPM has the right to use and give out your personal medical information to administer the FEHB Program. For example:
. To communicate with your FEHB health plan when you or someone you have authorized to act on your behalf asks for our
assistance regarding a benefit or customer service issue. . To review, make a decision, or litigate your disputed claim.
. For OPM and the General Accounting Office when conducting audits.
OPM may use or give out your personal medical information for the following purposes under limited circumstances:
. For Government healthcare oversight activities (such as fraud and abuse investigations), .
For research studies that meet all privacy law requirements (such as for medical research or education), and . To avoid a serious and imminent threat to health or safety.
By law, OPM must have your written permission (an "authorization") to use or give out your personal medical information for any purpose that is not set out in this notice. You may take back (" revoke") your written permission at any time, except if OPM has
already acted based on your permission.
By law, you have the right to:
. See and get a copy of your personal medical information held by OPM. .
Amend any of your personal medical information created by OPM if you believe that it is wrong or if information is missing, and OPM agrees. If OPM disagrees, you may have a statement of your disagreement added to your personal medical
information. . Get a listing of those getting your personal medical information from OPM in the past 6 years. The listing will not cover
your personal medical information that was given to you or your personal representative, any information that you authorized OPM to release, or that was given out for law enforcement purposes or to pay for your health care or a disputed claim.
. Ask OPM to communicate with you in a different manner or at a different place (for example, by sending materials to a P. O.
Box instead of your home address). . Ask OPM to limit how your personal medical information is used or given out. However, OPM may not be able to agree to
your request if the information is used to conduct operations in the manner described above. . Get a separate paper copy of this notice.
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For more information on exercising your rights set out in this notice, look at www. opm. gov/ insure on the web. You may also call 202-606-0191 and ask for OPM's FEHB Program privacy official for this purpose.
If you believe OPM has violated your privacy rights set out in this notice, you may file a complaint with OPM at the following address:
Privacy Complaints Office of Personnel Management
P. O. Box 707 Washington, DC 20004-0707
Filing a complaint will not affect your benefits under the FEHB Program. You also may file a complaint with the Secretary of the Department of Health and Human Services.
By law, OPM is required to follow the terms in this privacy notice. OPM has the right to change the way your personal medical information is used and given out. If OPM makes any changes, you will get a new notice by mail within 60 days of the change. The
privacy practices listed in this notice will be effective April 14, 2003.
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2003 AvMed Health Plan 2 Table of Contents
Table of Contents
Introduction. ........................................................................................ 4
Plain Language ....................................................................................................................................................................................... 4
Stop Health Care Fraud! ......................................................................................................................................................................... 4
Section 1. Facts about this HMO plan ................................................................................................................................................... 6
How we pay providers .......................................................................................................................................................... 6
Who provides my health care?.............................................................................................................................................. 6
Your Rights........................................................................................................................................................................... 6
Service Area.......................................................................................................................................................................... 6
Section 2. How we change for 2003 ...................................................................................................................................................... 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.................................................................................................................................................................... 8
. Specialty care.................................................................................................................................................................. 9
. Hospital care ................................................................................................................................................................. 10
Circumstances beyond our control ...................................................................................................................................... 10
Services requiring our prior approval.................................................................................................................................. 10
Section 4. Your costs for covered services .......................................................................................................................................... 11
. Copayments .................................................................................................................................................................. 11
. Deductible..................................................................................................................................................................... 11
. Coinsurance .................................................................................................................................................................. 11
Your catastrophic protection out-of-pocket maximum....................................................................................................... 11
Section 5. Benefits ............................................................................................................................................................................... 12
Overview............................................................................................................................................................................. 12
(a) Medical services and supplies provided by physicians and other health care professionals .................................... 13
(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......................................................................................................................................... 29
(g) Special features ....................................................................................................................................................... 31
. Flexible benefits option ................................................................................................................................... 31
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2003 AvMed Health Plan 3 Table of Contents
. 24 hour nurse line............................................................................................................................................ 31
. Centers of Excellence for transplants/ heart surgery etc................................................................................... 31
. Disease Management....................................................................................................................................... 31
(h) Dental benefits.......................................................................................................................................................... 32
(i) Non-FEHB benefits available to Plan members....................................................................................................... 33
Section 6. General exclusions --things we don't cover........................................................................................................................ 34
Section 7. Filing a claim for covered services ..................................................................................................................................... 35
Section 8. The disputed claims process................................................................................................................................................ 36
Section 9. Coordinating benefits with other coverage ........................................................................................................................ 38
When you have other health coverage ................................................................................................................................ 38
. What is Medicare ......................................................................................................................................................... 38
. Medicare managed care plan ....................................................................................................................................... 40
. TRICARE and CHAMPVA......................................................................................................................................... 40
. Workers' Compensation............................................................................................................................................... 40
. Medicaid ..................................................................................................................................................................... 41
. Other Government agencies......................................................................................................................................... 41
. When others are responsible for injuries...................................................................................................................... 41
Section 10. Definitions of terms we use in this brochure...................................................................................................................... 42
Section 11. FEHB facts ........................................................................................................................................................................ 43
Coverage information........................................................................................................................................................ 43
. No pre-existing condition limitation ........................................................................................................................ 43
. Where you get information about enrolling in the FEHB Program.......................................................................... 43
. Types of coverage available for you and your family .............................................................................................. 43
. Children's Equity Act............................................................................................................................................... 43
. When benefits and premiums start ........................................................................................................................... 44
. When you retire........................................................................................................................................................ 44
When you lose benefits ..................................................................................................................................................... 44
. When FEHB coverage ends ..................................................................................................................................... 44
. Spouse equity coverage............................................................................................................................................ 45
. Temporary Continuation of Coverage (TCC) .......................................................................................................... 45
. Converting to individual coverage ........................................................................................................................... 45
. Getting a Certificate of Group Health Plan Coverage .............................................................................................. 45
Long term care insurance is still available............................................................................................................................................ 46
Index ............................................................................................................................................................................................ 47
Summary of benefits ............................................................................................................................................................................. 48
Rates ....................................................................................................................................................................................... Back cover
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2003 AvMed Health Plan 4 Introduction/ Plain Language/ Advisory
Introduction
This brochure describes the benefits of AvMed Health Plan under our South Florida contract (CS 2876) with the Office of Personnel Management (OPM), as authorized by the Federal Employees Health Benefits law. The address for AvMed Health
Plan administrative offices is:
AvMed Health Plan 9400 South Dadeland Boulevard
Miami, FL 33156
This brochure is the official statement of benefits. No oral statement can modify or otherwise affect the benefits, limitations, and exclusions of this brochure. It is your responsibility to be informed about your health benefits.
If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled in 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, 2003, unless those benefits are also shown in this brochure.
OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2003, and changes are summarized on page 7. Rates are shown at the end of this brochure.
Plain Language
All FEHB brochures are written in plain language to make them responsive, accessible, and understandable to the public. For instance,
. Except for necessary technical terms, we use common words. For instance, "you" means the enrollee or family member;
"we" means AvMed Health Plan.
. We limit acronyms to ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is the Office of
Personnel Management. If we use others, we tell you what they mean first.
. Our brochure and other FEHB plans' brochures have the same format and similar descriptions to help you compare plans.
If you have comments or suggestions about how to improve the structure of this brochure, let OPM know. Visit OPM's "Rate Us" feedback area at www. opm. gov/ insure
or e-mail OPM at fehbwebcomments@ opm. gov. You may also write to OPM at the
Office of Personnel Management, Office of
Insurance Planning and Evaluation Division, 1900 E Street, NW Washington, DC 20415-3650.
Stop Health Care Fraud!
Fraud increases the cost of health care for everyone and increases your Federal Employees Health Benefits (FEHB) Program premium.
OPM's Office of the Inspector General investigates all allegations of fraud, waste, and abuse in the FEHB Program regardless of the agency that employs you or from which you retired.
Protect Yourself From Fraud -Here are some things you can do to prevent fraud:
. Be wary of giving your plan identification (ID) number over the telephone or to people you do not know, except to your
doctor, other provider, or authorized plan or OPM representative. . Let only the appropriate medical professionals review your medical record or recommend services.
. Avoid using health care providers who say that an item or service is not usually covered, but they know how to bill us to get
it paid.
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2003 AvMed Health Plan 5 Introduction/ Plain Language/ Advisory
. Carefully review explanations of benefits (EOBs) that you receive from us. .
Do not ask your doctor to make false entries on certificates, bills or records in order to get us to pay for an item or service. . If you suspect that a provider has charged you for services you did not receive, billed you twice for the same service, or
misrepresented any information, do the following: . Call the provider and ask for an explanation. There may be an error.
. If the provider does not resolve the matter, call us at 800/ 882-8633 and explain the situation. .
If we do not resolve the issue:
. Do not maintain as a family member on your policy: .
your former spouse after a divorce decree or annulment is final (even if a court order stipulates otherwise); or . your child over age 22 (unless he/ she is disabled and incapable of self support).
. If you have any questions about the eligibility of a dependent, check with your personnel office if you are employed or with
OPM if you are retired. . You can be prosecuted for fraud and your agency may take action against you if you falsify a claim to obtain FEHB benefits
or try to obtain services for someone who is not an eligible family member or who is no longer enrolled in the Plan.
CALL --THE HEALTH CARE FRAUD HOTLINE 202-418-3300
OR WRITE TO: The United States Office of Personnel Management
Office of the Inspector General Fraud Hotline 1900 E Street, NW, Room 6400
Washington, DC 20415
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2003 AvMed Health Plan 6 Section 1
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. The Plan is solely responsible for the selection of these providers in your area. Contact the Plan for a copy of their most recent provider directory.
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.
Your Rights
OPM requires that all FEHB Plans provide certain information to their FEHB members. 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. Some of the required information is listed below.
AvMed Health Plan is an Individual Practice Association organization in Florida. Member's medical services are provided by a wide array of primary care doctors and specialists with whom AvMed contracts.
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.
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.
Service Area
To enroll in this Plan, you must live or work in our Service Area. This is where our providers practice. Our service area is:
South Florida area: Services from Plan providers are available in the following areas: Dade, Broward, and Palm Beach 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 benefits. We will not pay for any other health care services out of our service area unless the services have prior
plan approval.
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 Season to change plans. Contact your employing or retirement office.
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2003 AvMed Health Plan 7 Section 2
Do not rely on these change descriptions; this page is not an official statement of benefits. For that, go to Section 5 Benefits. Also, we edited and clarified language throughout the brochure; any language change not shown here is a clarification that does not change
benefits.
Program-wide changes
. We changed the address for sending disputed claims to OPM. (Section 8)
. A Notice of the Office of Personnel Management's Privacy Practices is included.
. A section on the Children's Equity Act describes when an employee is required to maintain Self and Family coverage.
. Program information on TRICARE and CHAMPVA explains how annuitants or former spouses may suspend their FEHB
Program enrollment.
. Program information on Medicare is revised.
. By law, the DoD/ FEHB Demonstration project ends on December 31, 2002.
Changes to this Plan
. We have increased the primary care physician (PCP) copay to $15 per visit.
. We have increased the Specialist physician copay to $15 per visit.
. We have increased the copay for PET, CAT Scans and MRI's to $25 per test.
. We have increased the copay for Urgent Care at participating facilities to $40 per visit.
. We have increased the copay for Urgent Care at non-participating facilities to $60 per visit.
. We have increased the copay for ER visits at participating hospitals to $75 per visit.
. We have increased the copay for ER visits at non-participating hospitals to $100 per visit.
. We have limited Infertility services, medical treatments to the diagnosis and treatment for Artificial Insemination to Intravaginal
insemination (IVI) only.
. We now cover Cardiac Rehabilitation at a $20 copay per visit.
. We now require a $10 copay for generic drugs; $20 copay for preferred brand-name drugs and $30 copay for non-preferred
brand-name drugs. Mail order is a 90-day supply for 3 copayments.
Section 2. How we change for 2003
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2003 AvMed Health Plan 8 Section 3
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 800/ 882-8633 or write to us at
9400 South Dadeland Blvd., Suite 200, Miami, FL 33156. You may also request replacement cards through our website at www. avmed. com.
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.
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 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.
. 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.
What you must do to get covered care
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2003 AvMed Health Plan 9 Section 3
. Specialty care Your primary care physician will refer you to a specialist for needed care. When you
receive a referral from your primary care physician, you must return to the primary care physician after the consultation, unless your primary care physician authorized a certain
number of visits without additional referrals. The primary care physician must provide or authorize all follow-up care. Do not go to the specialist for return visits unless your
primary care physician gives you a referral. On referrals, the primary care physician 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 physician. However, you may see certain specialists without a referral.
Except in a medical emergency, or when a primary care physician has designated another doctor to see patients when he or she is unavailable, you must receive a referral from
your primary care physician before seeing any other doctor or obtaining special services. Referral to a participating specialist is given at the primary care physician's discretion; if
specialists or consultants are required beyond those participating in the Plan, the primary care physician will make arrangements for the appropriate referral. A member may
obtain covered services from a chiropractor or a podiatrist 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 physician; a member may obtain up to 5 office visits per calendar year to a Plan dermatologist for covered services.
The treatment plan will permit you to visit your specialist without the need to obtain further referrals. Requests by primary care physicians 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 folow-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.
. 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 Plan,
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2003 AvMed Health Plan 10 Section 3
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 benefits 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.
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, but not limited to, consultation by
specialists, hospitalization, Growth hormone therapy (GHT), most laboratory 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.
Services requiring our prior approval
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2003 AvMed Health Plan 11 Section 4
You must share the cost of some services. You are responsible for:
. Copayments A copayment is a fixed amount of money you pay to the provider, facility, pharmacy,
etc., when you receive services.
Example: When you see your primary care physician you pay a copayment of $15 per office visit and when you go in the hospital, you pay a $100 copay per admission.
. Deductible We do not have a deductible.
. Coinsurance We do not usually charge coinsurance; however, if you choose a non-Plan Physician for a
second medical opinion, you will be responsible for 40% of the reasonable and customary charges.
After you pay $1, 500 in copayments for Self Only enrollment, or $3, 000 for Self and Family enrollment, you do not have to make any further payments for certain services for
the rest of the year. This is called an out-of-pocket limit. However, copayments for your prescription drugs, dental services, and voluntary family planning services do not count
toward these limits, and you must continue to make these payments.
Be sure to keep accurate records of your copayments since you are responsible for informing us when you reach the maximum.
Section 4. Your costs for covered services
Your catastrophic protection out-of-pocket maximum for
deductibles, coinsurance, and copayments
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2003 AvMed Health Plan 12 Section 5
Section 5. Benefits --OVERVIEW
(See page 7 for how our benefits changed this year and page 48 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
claim 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........................................................ 13-20
. 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 . Physical and occupational therapies
. Speech therapy
. 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
. Chiropractic .
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
(f) Prescription drug benefits ........................................................................................................................................................ 29-30
(g) Special features ............................................................................................................................................................................. 31 . Flexible benefits option
. 24 Hour Nurse line
. Disease Management
. Centers of Excellence
(h) Dental benefits .............................................................................................................................................................................. 32
(i) Non-FEHB benefits available to Plan members ........................................................................................................................... 33
Summary of benefits ............................................................................................................................................................................. 48
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2003 AvMed Health Plan 13 Section 5( a)
Section 5 (a). Medical services and supplies provided by physicians and other health care professionals
I M
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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
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Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians
. In physician's office
$15 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
. Office medical consultations
No separate physician charge in addition to the applicable facility charge
. Second surgical opinion $15 per office visit Plan physician
If the Member chooses a non-Plan Physician, the Member will be responsible
for 40% of the amount of reasonable and customary charges for the second medical
opinion
At home Nothing
Not covered:
Injuries received in connection with the commission of a felony
All charges
16.
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2003 AvMed Health Plan 14 Section 5( a)
Lab, X-ray and other diagnostic tests You pay
Tests, such as:
. Blood tests
. Urinalysis
. Non-routine pap tests
. Pathology
Nothing
. X-rays
Prior authorization is required for the following:
. Non-routine Mammograms
. Ultrasound
. Electrocardiogram and EEG
$10 per test
$10 per test
$10 per test
$10 per test
Prior authorization is required for the following:
. Cat/ Pet Scans/ MRI $25 per test
Preventive care, adult
Routine screenings, such as:
. Total Blood Cholesterol once every five years
. Colorectal Cancer Screening, including
. Fecal occult blood test
. Sigmoidoscopy, screening every five years starting at age 50
Nothing if you receive these services during your office visit; otherwise, $15 per office
visit
Routine Prostate Specific Antigen (PSA) test one annually for men age 40 and older Nothing if you receive these services during your office visit; otherwise, $15 per office
visit
Routine pap test
Note: The office visit is covered if pap test is received on the same day; see Diagnosis and Treatment, above.
$15 per office 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
$15 per office 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, ages19 and
over (except as provided for under Childhood immunizations)
. Influenza vaccine, annually
. Pneumococcal vaccine, age 65 and over
$15 per office visit
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2003 AvMed Health Plan 15 Section 5( a)
Preventive care, children You pay
. Childhood immunizations recommended by the American Academy
of Pediatrics $15 per office visit
. Well-child care charges for routine examinations, immunizations and
care (through age 22)
. 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)
$15 per office visit
Maternity care
Complete maternity (obstetrical) care, such as:
. Prenatal care
. Postnatal care
Copayments are waived for maternity care.
. Delivery
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).
$100 per admission
Not covered: No more then one routine sonogram per pregnancy All charges.
Family planning
A range of voluntary family planning services, limited to:
. Voluntary sterilization (See Surgical procedures Section 5 (b))
$100 per hospital admission
Family Planning Continued on next page
18.
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2003 AvMed Health Plan 16 Section 5( a)
Family planning (continued) You pay
. Surgically implanted contraceptives
. Injectable contraceptive drugs
. Intrauterine devices (IUDs)
. Diaphragms
NOTE: We cover oral contraceptives under the prescription drug benefit.
$15 per office visit
Not covered: reversal of voluntary surgical sterilization, genetic counseling, All charges.
Infertility services
Diagnosis and treatment of infertility, such as:
. Artificial insemination:
. intravaginal insemination (IVI)
$15 per office visit
Not covered:
. Assisted reproductive technology (ART) procedures, such as:
. in vitro fertilization . embryo transfer, gamete GIFT and zygote ZIFT
. Zygote transfer
. Artificial insemination:
. intracervical insemination (ICI) . intrauterine insemination (IUI)
. Services and supplies related to excluded ART procedures
. Surgery for the enhancement of fertility
. Cost of donor sperm
. Cost of donor egg
. Fertility drugs
All charges.
Allergy care
Testing and treatment $50 per course of testing
Allergy injection $10 per office visit
Allergy serum Nothing
Not covered: provocative food testing and sublingual allergy desensitization All charges.
19.
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2003 AvMed Health Plan 17 Section 5( a)
Treatment therapies You pay
. 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: Growth hormone is covered under the prescription drug benefit.
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
before 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.
$15 per office visit
Physical and occupational therapies
60 visits per year for all services combined for the services of each of the following:
. qualified physical therapists and . occupational therapists.
Note: We only cover therapy to restore bodily function when there has been a total or partial loss of bodily function due to illness or injury.
$15 per office visit
Cardiac Rehabilitation is covered for the following conditions:
. Acute myocardial infarction
. Percutaneous transluminal coronary angioplasty (PTCA)
. Repair or replacement of heart valve( s)
. Coronary artery bypass graft (CABG), or
. Heart transplant
Coverage is limited to 18 visits per year. Benefits limited to $1, 500 per contract year.
$20 per visit
Not covered:
. long-term rehabilitative therapy
. exercise programs
All charges.
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2003 AvMed Health Plan 18 Section 5( a)
Speech therapy You pay
60 visits per year for all services combined $15 per office visit
Hearing services (testing, treatment, and supplies)
. Hearing testing for children through age 17 (see Preventive care,
children) $15 per office 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, children)
. Diagnosis and treatment of diseases of the eye
$15 per office 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.
Foot care
Routine foot care when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes. $15 per office 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
. Artificial limbs and eyes; stump hose
. Externally worn breast prostheses and surgical bras, including
necessary replacements, following a mastectomy
. Internal prosthetic devices, such as artificial joints, pacemakers,
cochlear implants, and surgically implanted breast implant following mastectomy. Note: See 5( b) for coverage of the surgery to insert the
device.
$15 per office visit
Orthopedic and prosthetic devices Continued on next page
21.
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2003 AvMed Health Plan 19 Section 5( a)
Orthopedic and prosthetic devices (continued) You pay
Not covered:
. orthopedic and corrective shoes
. arch supports
. foot orthotics
. non orthopecid brace
. heel pads and heel cups
. lumbosacral supports
. corsets, trusses, elastic stockings, support hose, and other supportive
devices
. penile implants
. prosthetic replacements provided less than 3 years after the last one
we covered
All charges.
Durable medical equipment (DME)
Rental or purchase, at our option, including repair and adjustment, of durable medical equipment prescribed by your Plan physician, such as
oxygen and dialysis equipment. Under this benefit, we also cover:
. hospital beds;
. standard wheelchairs;
. crutches; and
. insulin pumps
Coverage for orthotic appliances is limited to leg, arm, back, and neck custom-made braces when related to a surgical procedure or when used
in an attempt to avoid surgery and are necessary to carry out normal activities of daily living, excluding sports activities. Coverage is
limited to the first such item; repair and replacement is not covered.
Note: In the treatment of diabetes, coverage for an insulin pump will apply towards the annual maximum limitation ($ 500) but shall not be
subject to the $50 per episode of illness limitation.
$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 care ordered by a Plan physician and provided by a
registered nurse (R. N.), licensed practical nurse (L. P. N.), licensed vocational nurse (L. V. N.), or home health aide.
. Services include oxygen therapy, intravenous therapy and
medications.
Nothing
Home health services Continued on next page
22.
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24
2003 AvMed Health Plan 20 Section 5( a)
Home health services (continued) You pay
Not covered: . nursing care requested by, or for the convenience of, the patient or
the patient's family; . home care primarily for personal assistance that does not include a
medical component and is not diagnostic, therapeutic, or rehabilitative.
All charges.
Chiropractic
. Manipulation of the spine and extremities
. Adjunctive procedures such as ultrasound, electrical muscle
stimulation, vibratory therapy, and cold pack application
$15 per office visit
Not covered: As alternative treatment All charges.
Alternative treatments
Not covered: . naturopathic services
. hypnotherapy .
biofeedback . acupuncture
. homeopath services
All charges.
Educational classes and programs
Coverage is limited to:
. Smoking Cessation Up to $100 for one smoking cessation program
per member per lifetime, including all related expenses such as drugs.
. Diabetes self-management
$15 per office visit
Not covered: Over the counter products All charges.
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2003 AvMed Health Plan 21 Section 5( b)
Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
I M
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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.).
. YOUR PHYSICIAN MUST GET PREAUTHORIZATION OF SOME SURGICAL
PROCEDURES. Please refer to the precertification information shown in Section 3 to be sure which services require precertification and identify which surgeries require precertification.
I M
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Benefit Description You pay
Surgical procedures
A comprehensive range of services, such as: . Operative procedures
. Treatment of fractures, including casting .
Normal pre-and post-operative care by the surgeon . Correction of amblyopia and strabismus
. Endoscopy procedures .
Biopsy procedures . 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 and
prosthetic devices for device coverage information.
$15 per visit to your primary care physician or participating specialist
No separate physician charge in addition to the applicable facility charge
. Voluntary sterilization (e. g., Tubal ligation, Vasectomy) .
Treatment of burns
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.
$100 per procedure
Not covered: . Reversal of voluntary sterilization
. Routine treatment of conditions of the foot; see Foot care.
All charges.
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2003 AvMed Health Plan 22 Section 5( b)
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.
$15 per visit to your primary care physician or participating specialist
No separate physician charge in addition to the applicable facility charge
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.
$15 per visit to your primary care physician or participating specialist
No separate physician charge in addition to the applicable facility charge
Not covered: . Oral / dental implants and transplants
. Procedures that involve the teeth or their supporting structures
(such as the peridontal membrane, gingiva, and alveolar bone) . Impacted wisdom teeth
All charges.
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2003 AvMed Health Plan 23 Section 5( b)
Organ/ tissue transplants You pay
Limited to: .
Cornea
. Heart
. Kidney
. Liver
. Allogeneic (donor) bone marrow transplants
. Autologous bone marrow transplants (autologous stem cell and
peripheral stem cell support) for the following conditions: acute lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's
lymphoma; advanced non-Hodgkin's lymphoma; advanced neuroblastoma; breast cancer; multiple myeloma; epithelial ovarian
cancer; and testicular, mediastinal, retroperitoneal and ovarian germ cell tumors
. Intestinal transplants (small intestine) and the small intestine with the
liver or small intestine with multiple organs such as the liver, stomach, and pancreas
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 madical and hospital expenses of the live donor when we cover the recipient.
$100 per inpatient admission
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)
Covered under the hospital admission copay
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2003 AvMed Health Plan 24 Section 5( c)
Section 5 (c). Services provided by a hospital or other facility, and ambulance services
I M
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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.
. 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 Sections 5( a) or (b).
. YOUR PHYSICIAN MUST GET PREAUTHORIZATION OF HOSPITAL STAYS. Please
refer to Section 3 to be sure which services require preauthorization.
I M
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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.
$100 per admission
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, only 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, schools .
Personal comfort items, such as telephone, television, barber services, guest meals and beds
. Private nursing care .
Blood and blood derivatives not replaced by the member
All charges.
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2003 AvMed Health Plan 25 Section 5( c)
Outpatient hospital or ambulatory surgical center You pay
. Operating, recovery, and other treatment rooms .
Prescribed drugs 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.
$100 per procedure
Not covered: blood and blood derivatives not replaced by the member All charges.
Extendedcarebenefits/ skilled nursingcarefacilitybenefits
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 is 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, including air ambulance,
when medically appropriate and ordered or authorized by a Plan doctor. Nothing
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2003 AvMed Health Plan 26 Section 5( d)
Section 5 (d). Emergency services/ accidents
I M
P O
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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.
. 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
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T
What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your life or could result in serious injury or disability, and requires immediate medical or surgical care. Some problems are emergencies
because, if not treated promptly, they might become more serious; examples include deep cuts and broken bones. Others are emergencies because they are potentially life-threatening, such as heart attacks, strokes, poisonings, gunshot wounds, or
sudden inability to breathe. There are many other acute conditions that we may determine are medical emergencies what they all have in common is the need for quick action.
What to do in case of emergency:
Emergencies within our service area: If you are in an emergency situation, please call your primary care doctor. In extreme emergencies, if you are unable to
contact your doctor, contact the local emergency room. Be sure to tell the emergency room personnel that you are an AvMed member so they can notify AvMed. You or a family member must notify AvMed within 48 hours unless it was not
reasonable possible to do so. It is your responsibility to make sure that AvMed has been timely notified.
If you need to be hospitalized, the Plan must be notified within 48 hours or on the first working day following admission, unless is was not reasonably possible to notify AvMed within that time. If you are hospitalized in non-Plan facilities and
Plan doctors believe care can be better provided in a Plan Hospital, you will be transferred when medically feasible with any ambulance charges covered in full. Benefits are available for care for non-Plan providers in a medical emergency only if
delay in reaching a Plan provider would result in death, disability or significant jeopardy to your condition.
To be covered by this Plan, any follow-up care recommended by non-Plan providers must be approved by the Plan or provided by Plan providers.
Emergencies outside our service area:
If you need to be hospitalized, AvMed must be notified within 48 hours or on the first working day following your admission, unless it was not reasonably possible to notify AvMed within that time. If you are hospitalized in non-Plan
facilities and Plan doctors believe care can be better provided in a Plan hospital, you will be transferred when medically feasible with any ambulance charges covered in full.
To be covered by this Plan, any follow-up care recommended by non-Plan providers must be approved by the Plan or provided by Plan providers.
29.
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2003 AvMed Health Plan 27 Section 5( d)
Benefit Description You pay
Emergency within our service area
. Emergency care at a participating doctor's office $15 per visit
. Emergency care at a participating urgent care center $40 per visit
. Emergency care at a non-participating urgent care center $60 per visit
. Emergency care at a participating hospital emergency room $75 per visit
. Emergency care at a non-participating hospital emergency room $100 per visit
Not covered: Elective care or non-emergency care All charges.
Emergency outside our service area
. Emergency care at a doctor's office $60 per visit
. Emergency care at an urgent care center $60 per visit
. Emergency care at a hospital emergency room $100 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.
Air ambulance, when medically necessary and preauthorized by Medical Director or Chief Medical Officer
See 5( c) for non-emergency service.
Nothing
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2003 AvMed Health Plan 28 Section 5( e)
Preauthorization To be eligible to receive these benefits you must obtain a treatment plan and follow all of the following authorization processes:
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
Limitation We may limit your benefits if you do not obtain a treatment plan.
Section 5 (e). Mental health and substance abuse benefits
I M
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A N
T
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:
. 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.
. 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
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A N
T
Benefit Description You pay
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
$15 per visit
. Diagnostic tests $15 per visit
. Services provided by a hospital or other facility $100 per admission
. Services in approved alternative care settings such as partial
hospitalization, half-way house, residential treatment, full-day hospitalization, facility based intensive outpatient treatment $15 per visit
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.
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2003 AvMed Health Plan 29 Section 5( f)
Section 5 (f). Prescription drug benefits
I M
P O
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A N
T
Here are some important things to keep in mind about these benefits:
. We cover prescribed drugs and medications, as described in the chart beginning on the next page.
. All benefits are subject to the definitions, limitations and exclusions in this brochure and are payable
only when we determine they are medically necessary.
. 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
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T
There are important features you should be aware of. These include:
. Who can write your prescription. A licensed physician must write the prescription.
. Where you can obtain them. You must fill the prescription at a plan pharmacy, or by mail for a
maintenance medication.
. We use a Preferred Drug List. The Preferred Drug List is a list of medications in plan regulated
therapeutic classes that specifies the applicable level (or tier) of copayment. In general, generic medications will assess the lowest level copayment, preferred brand medications will assess the middle level copayment
and non-preferred brand medications will assess the third level copayment. Preferred brand medications are determined by AvMed's Pharmacy and Therapeutics Committee and are evaluated based on clinical efficacy,
relative safety and cost to the plan in comparison to similar medications within a therapeutic class.
. These are the dispensing limitations. A medication prescribed for you may have limitations. Limitations may
be administered via several methods and may be medication-specific or generalized based on drug class. Your benefit provides for covered medications per applicable copayment for an amount prescribed to treat an acute
indication, 100 dosage units for oral medications, 240 milliliters (8 oz.) of liquid, 60 grams of ointment, creams or topical preparation, one commercially prepared unit (e. g. one inhaler, one vial of ophthalmic medication or
insulin) or up to a 30-day supply, whichever is less. For example, if your prescription specifies 2 tablets twice daily, which equals #120 tablets for a 30-day supply, you will be assessed two applicable copayments. Your
prescription may be refilled via retail or mail order after 75% of your previous fill has been used.
A medication-specific quantity limit may apply for medications that have an increased potential for over-utilization or an increased potential for a patient to experience an adverse effect at higher doses. Quantity
limits are set in accordance with US Food and Drug Administration (FDA) approved prescribing limitations, general practice guidelines supported by medical specialty organizations, and/ or evidence-based, statistically
valid clinical studies without published conflicting data. A list of medication-specific quantity limits may be obtained by calling Member Services at 800/ 882-8633. The list is updated and posted to our Web site.
. Why use generic drugs? Generic drugs contain the same active ingredients and are equivalent in strength
and dosage to the original brand name product. The U. S. Food and Drug Administration sets quality standards for generic drugs to ensure that these drugs meet the same standards of quality and strength as
brand name drugs. Generic drugs cost you and your plan less money than a brand name drug.
. When you have to file a claim. If you need a prescription before you receive your Membership card, you
can fill the prescription at a participating pharmacy and submit the receipt and a copy of the prescription to AvMed for reimbursement. The copayment amount will be subtracted from the reimbursement. Please
indicate your Social Security Number on the receipt. See Section 7 for specific information.
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2003 AvMed Health Plan 30 Section 5( f)
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 or through our mail order
program:
. Drugs and medicines that by Federal law of the United States
require a physician's prescription for their purchase, except those listed as Not covered.
. Insulin .
Disposable needles and syringes for the administration of covered medications
. 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.
. Contraceptive drugs and devices
Retail Drugs
$10 Generic Drugs
$20 Preferred Brand Name Drugs
$30 Non-Preferred Brand Name Drugs
Note: If there is no generic equivalent available, you still have to pay the brand
name copayment.
Mail service is a benefit option for maintenance medications needed for chronic or long-term health conditions. It's best to get an initial
prescription filled at your retail pharmacy. Ask your physician for an additional prescription for up to a 90-day supply of your medication to
be ordered through mail service. Pay the following copayment (as well as the cost difference if you or your physician choose a Brand name
product when a Generic is available).
Mail Order Drugs
$30 Generic Drugs
$60 Preferred Brand Name Drugs
$90 Non-Preferred Brand Name Drugs
Your injectable drug prescription coverage includes the quantity sufficient to treat the acute phase of an illness or established by the
manufacturers packaging guidelines but not more than a 30 day supply per copayment or actual cost, whichever is less.
$75 Generic or Brand
Here are some things to keep in mind about our prescription drug program:
. A generic equivalent will be dispensed, if it is available. If you (or
your physician) request a brand name product when a generic equivalent is available, you will pay the cost difference between the
generic product and brand name product in addition to the applicable brand copayment.
Not covered: . Drugs and supplies for cosmetic purposes
. Drugs to enhance athletic performance .
Fertility drugs . Drugs obtained at a non-Plan pharmacy; except for out-of-area
emergencies . Vitamins, nutrients and food supplements even if a physician
prescribes or administers them . Nonprescription medicines or medicines for which there is a
nonprescription equivalent . Medical supplies such as dressing and antiseptics
. Compounded prescriptions, except pediatric preparations .
Medicines intended for weight loss purposes
All charges.
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2003 AvMed Health Plan 31 Section 5( g)
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 1-888-866-5432 and talk with a registered nurse who will discuss treatment options and answer your health questions. Or, listen to a tape on more than 430
health topics.
Centers of Excellence for transplants/ heart
surgery/ etc.
Consult Member Services at 1-800-882-8633 to obtain a complete list of centers.
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 pregnancy
. Compass Diabetes Care Program -diabetes
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2003 AvMed Health Plan 32 Section 5( h)
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. See Section 5 (c) for inpatient hospital benefits. 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 have no other dental benefits.
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2003 AvMed Health Plan 33 Section 5( j)
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 deductibles or catastrophic
protection out-of-pocket maximums.
AvMed Value Added Services:
Massage Therapy & Up to 25 percent discount; no referrals, no claims forms, no limits. Acupuncture Call American Specialty Health Network* at 1-877-335-2746 to schedule an
appointment.
Weight Watchers Full reimbursement for all Weight Watchers fees once you reach your goal weight. Call Member Services at 1-800-882-8633 for the form to register.
Smokenders Reduced price for the Smokenders booklet/ videotape. Get your money back when you quit smoking. To order, call 1-800-828-4357.
Vitamins, Supplements, Great pricing on quality items through Ephorlife*. Order nutritional supplements, Health-Related Products exercise equipment, contact lenses
and more at special prices for AvMed members.
Go to www. Ephorlife. com/ AvMed
or call 1-866-744-5433.
AvMed's Nurse On Call 24-hour telephone line where you can speak confidentially with a registered nurse about any health concern or listen to a tape on more than 430 health topics.
1-888-866-5432
Expanded vision care Discounts on vision services are available to AvMed members. Services include: Eye exams, Eyeglasses, Contract 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.
Expanded dental benefits AvMed is making available dental services through CompBenefits/ American Dental Plan (ADP) to Federal employees for an additional premium.
CompBenefits/ ADP's benefits include NO CHARGE services for the following: Toical fluoride, Oral examinations, X-rays, Cleaning (semi-annual), Local anesthesia.
For more information on how to enroll in the Dental Plan, please call CompBenefits/ ADP at 1-800-721-0455.
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 A and
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. 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 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.
* In partnership with AvMed
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2003 AvMed Health Plan 34 Section 6
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;
. Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program; or
. Services, drugs, or supplies you receive without charge while in active military service.
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2003 AvMed Health Plan 35 Section 7
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.
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 services you receive outside of the Plan's service area --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 of the 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.
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2003 AvMed Health Plan 36 Section 8
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 3602-0749; 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, Health Benefits Contracts Division 3, 1900 E Street, NW, Washington, DC 20415-3630.
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2003 AvMed Health Plan 37 Section 8
The Disputed Claims process (Continued)
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 more than one claim, you must clearly identify which documents apply to which claim.
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 include 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.
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 or from the year in which you were denied preauthorization or prior approval. 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 may call OPM's Health Benefits Contracts Division 3 at 202/ 606-0755 between 8 a. m. and 5 p. m. eastern time.
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2003 AvMed Health Plan 38 Section 9
Section 9. Coordinating benefits with other coverage
When you have other health coverage You must tell us if you or a covered family member have coverage 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. If you or
your spouse worked for at least 10 years in Medicare-covered employment, you should be able to qualify for premium-free Part A insurance. (Someone who was a
Federal employee on January 1, 1983 or since automatically qualifies.) Otherwise, if you are age 65 or older, you may be able to buy it. Contact 1-800-MEDICARE for
more information.
. Part B (Medical Insurance). Most people pay monthly for Part B. Generally, Part B
premiums are withheld from your monthly Social Security check or your retirement check.
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 (Original Medicare) is available everywhere in the United States. It is the way everyone used to get Medicare benefits and is the way most people
get their Medicare Part A and Part B benefits now. You may go to any doctor, specialist, or hospital that accepts Medicare. The Original Medicare Plan pays its share and you pay
your share. Some things are not covered under Original Medicare, like prescription drugs.
When you are enrolled in Original Medicare along with this Plan, you still need to follow the rules in this brochure for us to cover your care.
(Primary payer chart begins on next page.)
. The Original Medicare Plan
(Part A or Part B)
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2003 AvMed Health Plan 39 Section 9
The following chart illustrates whether the Original Medicare Plan 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
OriginalMedicare This Plan
1) Are anactiveemployeewith theFederalgovernment(including whenyouora familymemberare eligibleforMedicaresolely becauseofadisability),
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 is 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, and
a) Are an annuitant, or
b) Are an active employee, or
c) Are a former spouse of an annuitant, or
d) Are a former spouse of an active employee
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2003 AvMed Health Plan 40 Section 9
. Medicare managed care plan If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from another type of Medicare+ Choice plan --a Medicare managed care plan.
These are health care choices (like HMOs) in some areas of the country. In most Medicare managed care plans, you can only go to doctors, specialists, or hospitals that
are part of the plan. Medicare managed care plans provide all the benefits that Original Medicare covers. Some cover extras, like prescription drugs. To learn more about
enrolling in a Medicare managed care plan, contact Medicare at 1-800-MEDICARE (1-800-633-4227) or at www. medicare. gov.
If you enroll in a Medicare managed care plan,
the following options are available to you:
This Plan and our Medicare managed care plan: You may enroll in our Medicare managed care plan and also remain enrolled in our FEHB plan. In this case, we do not
waive any of our copayments for your FEHB coverage.
This Plan and another plan's Medicare managed care plan: You may enroll in another plan's Medicare managed care plan and also remain enrolled in our FEHB plan.
We will still provide benefits when your Medicare managed care plan is primary, even out of the managed care plan's network and/ or service area (if you use our Plan
providers), but we will not waive any of our copayments. If you enroll in a Medicare managed care plan, tell us. We will need to know whether you are in the Original
Medicare Plan or in a Medicare managed care plan so we can correctly coordinate benefits with Medicare.
Suspended FEHB coverage to enroll in a Medicare managed care plan: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in a Medicare
managed care plan, eliminating your FEHB premium. (OPM does not contribute to your Medicare managed care plan premium.) For information on suspending your FEHB
enrollment, contact your retirement office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next open season unless you involuntarily
lose coverage or move out of the Medicare managed care plan's service area.
If you do not have one or both Parts of Medicare, you can still be covered under the FEHB Program. We will not require you to enroll in Medicare Part B and, if you can't
get premium-free Part A, we will not ask you to enroll in it.
TRICARE and CHAMPVA TRICARE is the health care program for eligible dependents of military persons, and retirees of the military. TRICARE includes the CHAMPUS program. CHAMPVA
provides health coverage to disabled Veterans and their eligible dependents. If TRICARE or CHAMPVA and this Plan cover you, we pay first. See your TRICARE or
CHAMPVA Health Benefits Advisor if you have questions about these programs.
Suspended FEHB coverage to enroll in TRICARE or CHAMPVA: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in a one of
these programs, eliminating your FEHB premium. (OPM does not contribute to any applicable plan premiums.) For information on suspending your FEHB enrollment,
contact your retirement office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose
coverage under the program.
Workers' Compensation We do not cover services that:
. you need because of a workplace-related illness or injury that the Office of Workers'
Compensation Programs (OWCP) or a similar Federal or State agency determines they must provide; or
. OWCP or a similar agency pays for through a third-party injury settlement or other
similar proceeding that is based on a claim you filed under OWCP or similar laws.
. If you do not enroll in
Medicare Part A or Part B
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2003 AvMed Health Plan 41 Section 9
Once OWCP or similar agency pays its maximum benefits for your treatment, we will cover your care. You must use our providers.
Medicaid When you have this Plan and Medicaid, we pay first.
Suspended FEHB coverage to enroll in Medicaid or a similar State-sponsored program of medical assistance: If you are an annuitant or former spouse, you can
suspend your FEHB coverage to enroll in a one of these State programs, eliminating your FEHB premium. For information on suspending your FEHB enrollment, contact your
retirement office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage under the State
program.
When other Government agencies We do not cover services and supplies when a local, State, or Federal Government are responsible for your care agency directly or indirectly pays for them.
When others are responsible When you receive money to compensate you for medical or hospital care for injuries or for injuries 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.
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2003 AvMed Health Plan 42 Section 10
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.
Coinsurance See page 11.
Copayment A copayment is a fixed amount of money you pay when you receive covered services. See page 11.
Covered services Care we provide benefits for, as described in this brochure.
Custodial care Services and supplies that are furnished mainly to train or assist in the activities of daily living, such as bathing, feeding, dressing, walking, and taking oral medicines. "Custodial
Care" also means services and supplies that can be safely and adequately provided by persons other than licensed health care professionals, such as dressing changes and
catheter care or that of ambulatory patients customarily provide for themselves, such as ostomy care, measuring and recording urine and blood sugar levels, and administering
insulin. Custodial care that lasts 90 days or more is sometimes known as Long term care.
Deductible See page 11.
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 inssued 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.
Experimental or investigational services
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2003 AvMed Health PLan 43 Section 11
Section 11. FEHB facts
No pre-existing condition We will not refuse to cover the treatment of a condition that you had before you enrolled limitation 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 can answer your about enrolling in the questions, and give you a Guide
to Federal Employees Health Benefits Plans, brochures
FEHB Program for other plans, and other materials you need to make an informed decision about your FEHB coverage. These materials tell you:
. 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 you, your spouse, for you and your family 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.
Children's Equity Act OPM has implemented the Federal Employees Health Benefits Children's Equity Act of 2000. This law mandates that you be enrolled for Self and Family coverage in the
Federal Employees Health Benefits (FEHB) Program, if you are an employee subject to a court or administrative order requiring you to provide health benefits for your child( ren).
If this law applies to you, you must enroll for Self and Family coverage in a health plan that provides full benefits in the area where your children live or provide documentation
to your employing office that you have obtained other health benefits coverage for your children. If you do not do so, your employing office will enroll you involuntarily as
follows:
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2003 AvMed Health PLan 44 Section 11
. If you have no FEHB coverage, your employing office will enroll you for Self and
Family coverage in the Blue Cross and Blue Shield Service Benefit Plan's Basic Option,
. if you have a Self Only enrollment in a fee-for-service plan or in an HMO that serves
the area where your children live, your employing office will change your enrollment to Self and Family in the same option of the same plan; or
. if you are enrolled in an HMO that does not serve the area where the children live,
your employing office will change your enrollment to Self and Family in the Blue Cross and Blue Shield Service Benefit Plan's Basic Option.
As long as the court/ administrative order is in effect, and you have at least one child identified in the order who is still eligible under the FEHB Program, you cannot cancel
your enrollment, change to self only, or change to a plan that doesn't serve the area in which your children live, unless you provide documentation that you have other coverage
for the children. If the court/ administrative order is still in effect when you retire, and you have at least one child still eligible for FEHB coverage, you must continue your
FEHB coverage into retirement (if eligible) and cannot make any changes after retirement. Contact your employing office for further information.
When benefits and The benefits in this brochure are effective on January 1. If you joined this Plan during premiums start Open Season, your coverage begins on the first day of your first pay period that starts on
or after January 1. Annuitants' coverage and premiums begin on January 1. If you joined at any other time during the year, your employing office will tell you the effective
date of coverage.
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 continue to get
coverage benefits under your former spouse's enrollment. This is the case even when the court has ordered your former spouse to supply health coverage to you. But, you may be eligible
for your own FEHB coverage under the spouse equity law or Temporary Continuation of Coverage (TCC). 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. You can also download the guide from OPM's website, www. opm. gov/ insure.
. Temporary continuation of coverage (TCC) If you leave Federal service, or if you lose coverage because you no longer qualify as a
family member, you may be eligible for Temporary Continuation of Coverage (TCC). For example, you can receive TCC if you are not able to continue your FEHB enrollment
after you retire, if you lose your job, if you are a covered dependent child and you turn 22 or marry, etc.
You may not elect TCC if you are fired from your Federal job due to gross misconduct.
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2003 AvMed Health PLan 45 Section 11
Enrolling in TCC. Get the RI 79-27, which describes TCC, and the RI 70-5, the Guide to Federal Employees Health Benefits Plans for Temporary Continuation of Coverage
and Former Spouse Enrollees, from your employing or retirement office or from www. opm. gov/ insure. It explains what you have to do to enroll.
. Converting to You may convert to a non-FEHB individual policy if:
individual coverage . Your coverage under TCC or the spouse equity law ends (If you canceled your
coverage or did not pay your premium, you cannot convert);
. You decided not to receive coverage under TCC or the spouse equity law; or
. You are not eligible for coverage under TCC or the spouse equity law.
If you leave Federal service, your employing office will notify you of your right to convert. You must apply in writing to us within 31 days after you receive this notice.
However, if you are a family member who is losing coverage, the employing or retirement office will not notify you. You must apply in writing to us within 31 days
after you are no longer eligible for coverage.
Your benefits and rates will differ from those under the FEHB Program; however, you will not have to answer questions about your health, and we will not impose a waiting
period or limit your coverage due to pre-existing conditions.
. Getting a Certificate of The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a Federal
Group Health Plan Coverage law that offers limited Federal protections for health coverage availability and continuity to people who lose employer group coverage. If you leave the FEHB Program, we will
give you a Certificate of Group Health Plan Coverage that indicates how long you have been enrolled with us. You can use this certificate when getting health insurance or other
health care coverage. Your new plan must reduce or eliminate waiting periods, limitations, or exclusions for health related conditions based on the information in the
certificate, as long as you enroll within 63 days of losing coverage under this Plan. If you have been enrolled with us for less than 12 months, but were previously enrolled in other
FEHB plans, you may also request a certificate from those plans. For more information, get OPM pamphlet RI 79-27, Temporary Continuation of Coverage (TCC) under the
FEHB Program. See also the FEHB web site (www. opm. gov/ insure/ health);
refer to the "TCC and HIPAA" frequently asked questions. These highlight HIPAA rules,
such as
the requirement that Federal employees must exhaust any TCC eligibility as one condition for guaranteed access to individual health coverage under HIPAA, and have
information about Federal and State agencies you can contact for more information.
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2003 AvMed Health Plan 46 Long Term Care Insurance
Long Term Care Insurance Is Still Available!
Open Season for Long Term Care Insurance
. You can protect yourself against the high cost of long term care by applying for insurance in the Federal Long Term Care
Insurance Program. . Open Season to apply for long term care insurance through LTC Partners ends on December 31, 2002.
. If you're a Federal employee, you and your spouse need only answer a few questions about your health during Open Season. .
If you apply during the Open Season, your premiums are based on your age as of July 1, 2002. After Open Season, your premiums are based on your age at the time LTC Partners receives your application.
FEHB Doesn't Cover It
. Neither FEHB plans nor Medicare cover the cost of long term care. Also called "custodial care", long term care helps you
perform the activities of daily living such as bathing or dressing yourself. It can also provide help you may need due to a severe cognitive impairment such as Alzheimer's disease.
You Can Also Apply Later, But
. Employees and their spouses can still apply for coverage after the Federal Long Term Care Insurance Program Open Season
ends, but they will have to answer more health-related questions. . For annuitants and other qualified relatives, the number of health-related questions that you need to answer is the same during
and after the Open Season.
You Must Act to Receive an Application
. Unlike other benefit programs, YOU have to take action you won't receive an application automatically. You must request
one through the toll-free number or website listed below. . Open Season ends December 31, 2002 act NOW so you won't miss the abbreviated underwriting available to employees
and their spouses, and the July 1 "age freeze"!
Find Out More Contact LTC Partners
by calling 1-800-LTC-FEDS (1-800-582-3337) (TDD for the hearing impaired: 1-800-843-3557) or visiting www. ltcfeds. com to
get more information and to request an application.
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2003 AvMed Health Plan 47 Index
Index Do not rely on this page; it is for your convenience and may not show all pages where the terms appear.
Accidental injury 22, 32 Allergy tests 12, 16
Alternative treatment 12, 20 Allogenetic (donor) bone marrow transplant 23
Ambulance 2, 12, 24 -27 Anesthesia 2, 12, 21, 23, 25, 33
Autologous bone marrow transplant 17, 23 Biopsies 21
Blood and blood plasma 14, 24 -25 Breast cancer screening 18, 22 -23
Casts 24 -25 Catastrophic protection out-of-pocket
maximum 11, 33, 48 Changes for 2003 7
Chemotherapy 17 Chiropractic 12, 20
Cholesterol tests 14 Claims 3, 7 8, 12, 31, 33, 35 37, 39, 44
Coinsurance 2, 11, 42 Colorectal cancer screening 14
Congenital anomalies 12 -22 Contraceptive devices and drugs 16, 30
Coordination of benefits 3, 13, 21, 24, 26, 28 29, 32, 38, 44
Covered charges 24, 26 Crutches 19
Deductible 2, 11, 13, 21, 26, 32 33, 42 Definitions 3, 13, 21, 24, 26, 28 29, 32,
42, 48 Dental care 3, 11 12, 22, 25, 32 34, 48
Diagnostic services 10, 12 14, 20, 24 25, 28, 48
Disputed claims review 3, 7, 31, 33, 36 -37 Donor expenses (transplants) 23
Dressings 24 25, 30, 42 Durable medical equipment (DME) 12, 19
Educational classes and programs 12, 20 Effective date of enrollment 8, 42
Emergency 2, 6, 8 9, 12, 26 27, 35, 48 Experimental or investigational 34, 42
Eyeglasses 18, 33 Family planning 11 12, 15 -16
Fecal occult blood test 14 General Exclusions 3, 12, 34
Hearing services 12, 18 Home health services 12, 19 -20
Hospice care 12, 25
Home nursing care 25 Hospital 2, 6 8, 10 12, 15, 19,
21 28, 32 33, 35, 38, 41 42, 48, 51
Immunizations 6, 14 -15 Infertility 7, 12, 16
Inhospital physician care 12, 23, 28, 48
Inpatient Hospital Benefits 12, 24
Insulin 19, 29 30, 42 Laboratory and pathological
services 24 -25 Machine diagnostic tests 14, 24 -
25 Magnetic Resonance Imagings
(MRIs) 7, 14 Mail Order Prescription Drugs 7,
29 30, 48 Mammograms 14
Maternity Benefits 12, 15, 24 Medicaid 3, 41
Medically necessary 10, 13, 15, 17, 21, 24, 26 29, 32, 34
Medicare 3, 7, 13, 21, 24, 26, 28 29, 32 33, 35, 38 40,
46, 48 Members 3, 6, 8, 12, 21, 29, 33,
43, 49 Mental Conditions/ Substance
Abuse Benefits 2, 12, 28, 48 Newborn care 15
Non-FEHB Benefits 33 Nurse
Nurse Anesthetist 24 Registered Nurse 19, 31, 33
Nursery charges 15 Obstetrical care 15
Occupational therapy 12, 17 Office visits 6, 9, 11, 13 18, 20,
48 Oral and maxillofacial surgery 12, 22
Orthopedic devices 12, 18 19, 21
Ostomy and catheter supplies 42 Out-of-pocket expenses 2, 11,
33, 48
Outpatient facility care 12, 25, 28 Oxygen 19, 24 -25
Pap test 14 Physical examination 6, 14
Physical therapy 17 Physician 2, 6 13, 17, 19, 21 22,
24, 28 30, 35 37, 42, 48 Preauthorization 10, 17, 21, 24, 28,
36 -37 Preventive care, adult 12, 14
Preventive care, children 12, 15, 18 Prescription drugs 2, 11 12, 16
17, 19, 29 30, 35, 38, 40, 48 Preventive services 12, 14 -15
Prior approval 2, 10, 17, 34, 37 Prostate cancer screening 14
Prosthetic devices 12, 18 19, 21 -22
Psychologist 28 Radiation therapy 17
Renal dialysis 38 -39 Room and board 24
Second surgical opinion 13 Skilled nursing facility care 10, 12 13,
25, 42 Smoking cessation 20
Speech therapy 12, 18 Splints 24
Sterilization procedures 15, 21 Subrogation 41
Substance abuse 2, 12, 28, 48 Surgery 3, 12, 16, 18 19, 21 22,
24, 31 . Anesthesia 2, 12, 23, 25, 33
. Oral 12, 22, 33 . Outpatient 12, 25, 28, 48
. Reconstructive 12, 21 -22 Syringes 30
Temporary continuation of coverage 3, 44 -45
Transplants 3, 12, 17, 22 23, 31, 38 Vision services 12, 15, 18, 33, 48
Well child care 5, 15 Wheelchairs 19
Workers' compensation 3, 39 40, 44
X-rays 12, 14, 24 25, 33
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2003 AvMed Health Plan 48 Summary
Summary of benefits for AvMed Health Plan 2003
. 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: $15 primary care; $15 specialist 13
Services provided by a hospital:
. Inpatient............................................................................................
. Outpatient .........................................................................................
$100 per admission
$100 per procedure
24
25
Emergency benefits:
. In-area..............................................................................................
. Out-of-area ......................................................................................
$75 per visit (Copayment waived if admitted)
$100 per visit (Copayment waived if admitted)
27
27
Mental health and substance abuse treatment...................................... Regular cost sharing. 28
Prescription drugs ................................................................................. Retail Generic $10, Preferred Brand $20, Non-Preferred Brand $30
Mail Order Generic $30, Preferred Brand $60, Non-Preferred Brand $90
30
Dental Care ....................................................................................... No benefit. 32
Vision Care ....................................................................................... Refractions, including lens prescriptions, limited to children through age 17. $15 copay
per visit.
18
Special features: Flexible benefit option,, 24-hour nurse in, Disease Management, Centers of Excellence 31
Protection against catastrophic costs (your catastrophic protection out-of-pocket maximum) ................... Nothing after $1, 500/ Self Only or $3,000/ Family enrollment per year
Some costs do not count toward this protection
11
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2003 AvMed Health Plan 49
2003 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 a special FEHB guide is
published 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 who are not career postal employees. Refer to the applicable FEHB Guide.
Type of
Enrollment Code
Non-Postal Premium
Biweekly Monthly
Gov't Your Gov't Your Share Share Share Share
Postal Premium
Biweekly
USPS Your
Share Share
Location Information
High Option Self Only
High Option Self & Family
ML1
ML2
$94.13 $31.38 $203.96 $67.98
$249.62 $95.50 $540.84 $206.92
$111.39 $14.12
$249.70 $50.42
52.