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I') Benefit Summary CH.CH.5011 AvMED H E ^ L t"H-PL^NS COST TO MEMBER AvMed PHCSloulsld. Out 01 Network AvMedSmiceAleal Unlimited $2,000,000 $500/$1,000 $500/$t,000 $1,000/$2,000 $2,500/$5,000 $2,500/$5,000 $5,000/$10,000 NETWORK LIfE TIME MAXIMUM CALENDAR YEAR DEDUCTIBLE (accumulales across all benollllovels) tNDIVIDUAL / FAMtL Y 17/e Deductible does not apply IowaI'd the Olll-al-Pocket AfaTiwu//l OUT.Of.POCKET MAXIMUM (accumulales across all benefit levels) INDIVIDUAL (per calendar year) / FAMILY (per calendar year) 771i! Out-af-Pocket AlaTilllllf1l includes Co-payment and Co-insurance amounts unless othelll'ise excluded BENEfITS ARE NOT SUBJECT TO DEDUCTIBLE UNLESS OTHERWISE NOTED PREVENTIVE CARE (nol subject 10 Deductible) Preventive care services include but are not limited to: Pediatric care and well.child care . Well-woman examinations, including pap smears Preventive care provided in a physician's oflice Periodic health evaluations and immunizations l) $20 per Primary Care office visit OR $40 per Specialist office visit $20 per Primary Care office visit OR $40 per Specialist office visit 40% oFthe Maximum Allowable Payment Calendar year maximum benefit of S300 PRIMARY CARE PHYSICIAN $20 per visit $20 per visit 40% of the Maximum Allowable Payment, after Deductible MATERNITY CARE . Initial visit . Subsequent visits $40 Co-payment No Charge Same as Choice Network benefit 30% of the Maximum Allowable Payment, after Deductible SPECIALITY HEALTH CARE PHYSICIAN SERVICES Additional charges ,viII apply if Outpatient Diagnostic Tests arc performed in the Specialist oflice. $40 per visit $40 per visit 40% of the Maximum Allowable Payment, after Deductible HOSPITAL (Prior authorIzation required for Inpatlenl care) Inpatient care at Participating Hospitals includes: Room and board- unlimited days (semi~private) . Physicians', specialists' and surgeons' services Anesthesia, use of operating and recovery rooms, oxygen, drugs and medication . Intensive care units and other special units, general and special duty nursing Laboratory and diagnostic imaging Required special diets Radiation and inhalation therapies OUTPATIENT SERVICES Outpatient surgeries, including cardiac catheterizations and angioplasty Outpatient therapeutic services, including: Drug infusion therapy Injectable Drugs (Co.payment for Injectable Drug waived if incidental to same-day drug infusion therapy) Preventive and diagnostic colonoscopies (One preventive colonoscopy per Ii fetime at no charge) OUTPATIENT DIAGNOSTIC TESTS CAT SClll1, PET Scan, MRt Other diagnostic imaging tests Outpatient laboratory tests . Mammography (not subject to the Deductible) Charges for office visits \vill also apply if services are performed in a Specialist office. EMERGENCY SERVICES An emergency is the sudden and unexpected onset of a condition requiring immediate medical or surgical care. (Co-payment ,vaived if admitted) A\'Med must be notified within 24 hours ofinpalient admission followin~ emergency sen'ices or as soon as reasonably possible A V-CHOICE-3DD-09 MP-5011 (10/09) $250 per day for the first 5 days; 100% coverage thereafter 20% of the contracted rate, after Deductible 20% of the contracted rate, after Deductible No Charge No Charge $100 Co-payment $250 per day for lhe first 5 days; 100% coverage thereafter 20% of the contracted rate, after Deductible 20% of the contracted rate, after Deductible 20% of the contracted rate, after Deductible No Charge Same as Choice Net\vork benefit 40% of the Maximum Allowable Payment, after Deductible 40%ofthe Maximum Allowable Payment, after Deductible 40%ofthe Maximum Allowable Payment, after Deductible Mammography subject to Pre\'cnth:e Care maximum benefit of$300 Same as Choice Nelwork benefit