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«Benefit Guide Freedom to choose. No Need to Designate a PCP. No Referrals State of Florida HMO Health Plan Health plans with your health in mind. ...»

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Benefit Guide

Freedom to choose…

No Need to Designate a PCP… No Referrals

State of Florida

HMO Health Plan

Health plans with your health in mind.

STATE OF FLORIDA

HMO

HEALTH PLAN

BENEFIT GUIDE

JANUARY 2011

Benefit Summary

STATE OF FLORIDA SCHEDULE OF COPAYMENTS COST TO MEMBER

OUT-OF-POCKET MAXIMUM $1,500 INDIVIDUAL $3,000 FAMILY

Preventive care services include, but are not limited to:

PREVENTIVE CARE NO CHARGE

Well-woman examinations, including Pap smears

NOT SUBJECT TO DEDUCTIBLE

Annual physical examinations Immunizations Well-child care and immunizations, including routine vision and hearing screenings by a pediatrician for children under 18 Screening mammograms Colorectal cancer screening, including colonoscopies HIV screening AVMED PRIMARY CARE Services at participating doctors' offices include, but are not

limited to:

PHYSICIAN $20 per visit Routine office visits Minor surgical procedures Hearing examinations AVMED SPECIALIST'S No referral or Pre-Authorization required for: $40 per visit Office visits, consultation, diagnosis, and treatment SERVICES HOSPITAL Pre-Authorization required for Inpatient care. Inpatient care at $250 per admission; 100% participating hospitals includes: coverage thereafter Room and board - unlimited days (semi-private) Physician's, specialist's and surgeon's services Anesthesia, use of operating and recovery rooms,

–  –  –

State of Florida MP-2098 (1/11) Prescription Medication Benefits $7/30/50 CO-PAYMENT with Contraceptives

DEFINITIONS

Brand medication means a Prescription Drug that is usually manufactured and sold under a name or trademark by a pharmaceutical manufacturer or a medication that is identified as a Brand medication by AvMed. AvMed delegates determination of Generic/Brand status to our Pharmacy Benefits Manager.

Brand Additional Charge means the additional charge that must be paid if you choose a Brand medication when a Generic equivalent is available. The charge is the difference between the cost of the Brand medication and the Generic medication. This charge must be paid in addition to the applicable NonPreferred Brand Co-payment. However, if the prescribing physician or other Participating Provider authorized to prescribe medications within the scope of his or her license indicates on the prescription “Brand medically necessary” or “dispense as written” for a medication for which there is a generic equivalent, the Brand medication shall be dispensed for the applicable Non-Preferred Brand Co-payment only.

Dental-specific Medication is medication used for dental-specific purposes, including but not limited to fluoride medications and medications packaged and labeled for dental-specific purposes.

Formulary List means the listing of preferred and non-preferred medications as determined by AvMed’s Pharmacy and Therapeutics Committee based on clinical efficacy, relative safety and cost in comparison to similar medications within a therapeutic class. This multi-tiered list establishes different levels of Co-payment for medications within therapeutic classes. As new medications become available, they may be considered excluded until they have been reviewed by AvMed’s Pharmacy and Therapeutics Committee.

Generic medication means a medication that has the same active ingredient as a Brand medication or is identified as a Generic medication by AvMed’s Pharmacy Benefits Manager.

Injectable Medication is a medication that has been approved by the Food and Drug Administration (FDA) for administration by one or more of the following routes: intramuscular injection, intravenous injection, intravenous infusion, subcutaneous injection, intrathecal injection, intrarticular injection, intracavernous injection or intraocular injection. Prior Authorization is required for all Injectable Medications.

Maintenance Medication is a medication that has been approved by the FDA, for which the duration of therapy can reasonably be expected to exceed one year.

Participating Pharmacy means a pharmacy (retail, mail order or specialty pharmacy) that has entered into an agreement with AvMed to provide Prescription Drugs to AvMed Members and has been designated by AvMed as a Participating Pharmacy.

Prescription Drug means a medication that has been approved by the FDA and that can only be dispensed pursuant to a prescription according to state and federal law.

Prior Authorization means the process of obtaining approval for certain Prescription Drugs (prior to dispensing) according to AvMed’s guidelines. The prescribing physician must obtain approval from AvMed. The list of Prescription Drugs requiring Prior Authorization is subject to periodic review and modification by AvMed. A copy of the list of medications requiring Prior Authorization and the applicable criteria are available from Member Services or from the AvMed website.

–  –  –

ORDERING YOUR PRESCRIPTIONS THROUGH THE MAIL

Mail service is a benefit option for maintenance medications needed for chronic or long-term health conditions. It is best to get an initial prescription filled at your retail pharmacy. Ask your physician for an additional prescription for up to a 90-day supply of your medication to be ordered through mail service.





Up to 3 refills are allowed per prescription. Pay the following Co-payment (as well as the Brand Additional Charge if you choose a Brand product when a Generic equivalent is available).

Tier 1 Preferred Generic Medications: $ 14.00 Co-payment Tier 2 Preferred Brand Medications: (Injectable Medications $ 60.00 Co-payment are not available through mail service) Tier 3 Non-Preferred Brand or Generic Medications: $ 100.00 Co-payment AV-State of Florida-RX-10 MP-2096 (1/11) Prescription Medication Benefits, continued WHAT IS COVERED?

Your Prescription Drug coverage includes outpatient medications (including contraceptives) that require a prescription and are prescribed by your AvMed physician in accordance with AvMed’s coverage criteria. AvMed reserves the right to make changes in coverage criteria for covered products and services. Coverage criteria are medical and pharmaceutical protocols used to determine payment of products and services and are based on independent clinical practice guidelines and standards of care established by government agencies and medical/pharmaceutical societies.

Your Prescription Drug coverage may require Prior Authorization, including the Progressive Medication Program, for certain covered medications.

The Progressive Medication Program encourages the use of therapeutically-equivalent lower-cost medications by requiring certain medications to be utilized to treat a medical condition prior to approving another medication for that condition. This includes the first-line use of preferred medications that are proven to be safe and effective for a given condition and can provide the same health benefit as more expensive non-preferred medications at a lower cost.

Your retail Prescription Drug coverage includes up to a 30-day supply of a medication for the listed Co-payment. Your prescription may be refilled via retail or mail order after 75% of your previous fill has been used and subject to a maximum of 13 refills per year. You also have the opportunity to obtain a 90-day supply of medications used for chronic conditions including, but not limited to asthma, cardiovascular disease and diabetes from the retail pharmacy for the applicable Co-payment per 30-day supply. However, Prior Authorization may be required for covered medications.

Your mail-order Prescription Drug coverage includes up to a 90-day supply of a routine maintenance medication for the listed Co-payment. If the amount of medication is less than a 90-day supply, you will still be charged the listed mail order Co-payment.

Your Injectable Medication coverage extends to many injectable medications approved by the FDA. These medications must be prescribed by a physician and dispensed by a retail or specialty pharmacy. The Co-payment levels for Injectable Medications apply regardless of provider. This means that you are responsible for the appropriate Co-payment whether you receive your Injectable Medication from the pharmacy, at the physician’s office or during home health visits. Injectable Medications are limited to a 30-day supply.

Your Prescription Drug coverage includes coverage for injectable contraceptives. There is a Co-payment of $30 for each injection. If there is an office visit associated with the injection, there will be an additional Co-payment required for the office visit.

Quantity limits are set in accordance with FDA approved prescribing limitations, general practice guidelines supported by medical specialty organizations, and/or evidence-based, statistically valid clinical studies without published conflicting data. This means that a medication-specific quantity limit may apply for medications that have an increased potential for over-utilization or an increased potential for a Member to experience an adverse effect at higher doses.

Coverage is provided for smoking cessation prescription medications subject to the appropriate Co-payment. Benefit is limited up to a six month supply within any plan year and a maximum lifetime benefit of no more than nine months supplied.

QUESTIONS? Call your AvMed Member Services Department at: 1-800-88-AvMed (1-800-882-8633)

EXCLUSIONS AND LIMITATIONS

Medications which do not require a prescription (i.e. over-the-counter medications) or when a non-prescription alternative is available, unless otherwise indicated on AvMed's Formulary List.

Medications not included on AvMed's Formulary List.

Medical supplies, including therapeutic devices, dressings, appliances and support garments Replacement Prescription Drug products resulting from a lost, stolen, expired, broken or destroyed prescription order or refill Diaphragms and other contraceptive devices Fertility drugs Medications or devices for the diagnosis or treatment of sexual dysfunction Dental-specific Medications for dental purposes, including fluoride medications Prescription and non-prescription vitamins and minerals except prenatal vitamins Nutritional supplements Immunizations Allergy serums, medications administered by the Attending Physician to treat the acute phase of an illness and chemotherapy for cancer patients are covered in accordance with the Group Medical and Hospital Service Contract and may be subject to Co-payments or Co-insurance as outlined on the Schedule of Benefits Investigational and experimental drugs (except as required by Florida statute) Cosmetic products, including, but not limited to, hair growth, skin bleaching, sun damage and anti-wrinkle medications Prescription and non-prescription appetite suppressants and products for the purpose of weight loss Compounded prescriptions, except pediatric preparations Medications and immunizations for non-business related travel, including Transdermal Scopolamine Filling a prescription at a pharmacy is not a claim for benefits and is not subject to the Claims and Appeals procedures under ERISA. However, any medicines that require Prior Authorization will be treated as a claim for benefits subject to the Claims and Appeals Procedures, as outlined in the Group Medical and Hospital Service Contract.

AV-State of Florida-RX-10 MP-2096 (1/11) The following information is intended to provide a summary of services and programs offered by AvMed Health Plans. This Benefit Guide is not a contract. For specific information on benefits, exclusions and limitations, please consult your AvMed Group Medical and Hospital Service Contract or Summary Plan Description.

Welcome to AvMed AvMed Health Plans provides its members with personalized service and flexibility when choosing health care. Our benefit plans are designed with you in mind. AvMed believes in maximizing access to care by providing you with a robust provider network (in some cases, nationwide), lower out-of-pocket costs for innetwork services, a simplified claims process, plus wellness and preventive care.

You also get these programs and services:

24-hour, toll-free Member Services 24-hour, toll-free Nurse On Call program staffed by AvMed registered nurses Savings on alternative health services Discounts on eyeglasses and contact lenses AvMed’s Web site, your online resource for health and benefits information AvMed’s Online Provider Directory AvMed’s Decision Support Tools, your comprehensive set of tools designed to help you become a more informed health care consumer Disease and Complex Case Management programs for high-risk and chronic conditions Medical Excellence AvMed Physicians AvMed is committed to quality health care. We have a broad network of physicians who also work hard to keep you healthy. AvMed contracts with physicians who are in private practice and see AvMed members within certain time frames, depending upon the member’s condition. They also agree to certain standards of care for our members with regard to wait times and accessibility. To view AvMed’s standards, go to the AvMed Web site at www.avmed.org and click on Find a Doctor.

AvMed considers board certification a significant credential in evaluating physicians. Our network physicians have completed advanced training in an approved hospital residency and/or fellowship program. Requirements for physicians to become board certified are established by each specialty board. Our network physicians are identified within this online directory with a star for ‘Board Certified.’ Hospitals, Facilities & Allied Services AvMed members have access to one of the most versatile facility networks in the state, made up of hospitals, skilled nursing facilities, diagnostic centers, laboratories, ambulatory surgical centers, home health, urgent care centers, pharmacies, vision companies, durable medical equipment providers and much, much more. To be a participating provider for AvMed, health care facilities must meet rigorous credentialing standards based on quality.



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