Reso 2010-1529 - Laserfiche WebLink

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I') Benefit Summary, continued URGENT/lMMEDlATE CARE Medical Services at an Urgent/Immediate Care facility or services rendered after hours in your Primary Care Physician's office . Medical Services at a retail clinic FAMILY PLANNING . Voluntary family planning services . Sterilization (In addition to any Outpatient facility Co-payment) ALLERGY TREATMENTS . Injections . Skin testing AMBULANCE . Ambulance transport for emergency services 10 . Non-emergent ambulance services are covered when the skill of medically trained personnel is required and the Member cannot be safely transported by other means PHYSICAL, SPEECH AND OCCUPATIONAL THERAPIES ShorHenn physical or occupational therapy for acute conditions. Coverage is limited to 30 visits per calendar year for all services combined Speech benefit is limited to 24 visits per calendar year DIAGNOSIS and TREATMENT OF AUTISM SPECTRUM DISORDER . Applied Behavior Analysis services . Physical, speech or occupational therapy for the treatment of Autism Spectrum Disorder Coverage for all services related to Autism Spectrum Disorder is limited to $36,000 annually and may not exceed $200,000 in total benefits. SKILLED NURSING FACILITIES and REHABILITATION CENTERS (Prior authorization requIred) Up to 20 days post-hospitalization care per calendar year when prescribed by physician and authorized by AvMed CARDIAC REHABILITATION Cardiac rehabilitation is covered for the following conditions: acute myocardial infarction, percutaneous trans luminal coronary angioplasty (PTCA), repair or replacement of heart valves, coronary artery bypass graft (CABG) or heart transplant. Coverage is limited to a maximum of 18 \'isits per calendar }'ear or $1,500, whichenr is exhausted first HOME HEALTH CARE Limited to 60 skilled visits per calendar year $40 Co-payment $40 Co-payment $60 Co-payment $20 Co-payment $20 Co-payment $60 Co-payment 20% of the contracted 20% of the contracted 40% of the Maximum rate, after Deductible rate, after Dcductible Allowablc Payment, after Deductible 20% of the contractcd 20% of the contractcd 40% of the Maximum rate, after Deductible rate, after Deductiblc Allowable Payment, after Deductible 20% of the contracted Same as Choice 20% ofthc Maximum rate, after Deductible Network benefit Allowable Payment, after Deductible 20% of the contracted 20% of the contracted 40% of the Maximum rate, after Deductible rate, after Deductible Allowable Payment, after Deductible 20% of the contracted 20% of the contracted 40% of the Maximum rate, after Deductible rate, after Deductible Allowable Payment, after Deductible $40 per visit $40 per visit 40% of the Maximum 20% of the contracted 20% of the contracted Allowable Payment, rate, after Deductible rate, after Deductible after Deductible 20% of the contracted rate, after Deductible 20% of the contracted rate, after Deductible 20% of the contracted ratc, after Deductible 20% of the contracted rate, after Deductible 20% of the contracted rate, after Deductible 20% of the contracted rate, after Deductible 40% of the Maximum Allowable Payment, after Deductible 40%ofthe Maximum Allowable Payment, after Deductible 40%ofthe Maximum Allowable Payment, after Deductible DURABLE MEDICAL EQUIPMENT AND ORTHOTIC AND ORTHOPEDIC APPLIANCES Equipment includes: . Hospital beds, walkers, crutches and \vhee1chairs Orthotic appliances are limited to: . Custom-made leg, arm, back and neck braces Benefits limited 10 combined $3,000 per calendar year PROSTHETIC DEVICES Prosthetic devices are limited to: . Artificial limbs, artificial joints and ocular prostheses ALL OTHER COVERED SERVICES 20% of the contracted rate, after Deductible 20% of the contracted rate, after Deductible 40% of the Maximum Allowable Payment, after Deductible 40%ofthe Maximum Allowable Payment, after Deductible 40% of the Maximum Allowable Payment, after Deductible PRIOR AUTHORIZATION IS REQUIRED FOR SPECIFIC COVERED SERVICES, THE PENALTY FOR NON-NOTIFICATION IS $500, FOR ADDITIONAL INFORMATION, PLEASE CALL: 1.800-88-AVMED (1-800-882-8633) This Schedule of Benefits is not a Contract. For specific infonnation on benefits, Exclusions and Limitations, please see your AvMed Choice Group Medical and Hospital Service Contract with Point of Service Rider. A Y-CHOICE-3DD-09 MP-5011 (10/09) 20% of the contracted rate, after Deductible 20% of the contracted rate, after Deductible 20% of the contracted rate, after Deductible 20% of the contracted rate, after Deductible