Reso 2010-1529 - Laserfiche WebLink

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") LARGE GROUP $10/$250/$750/1 0% CALENDAR YEAR DEDUCTIBLE OUT-Of-POCKET MAXIMUM AVMED PRIMARY CARE PHYSICIAN q MATERNITY CARE AVMED SPECIALITY HEALTH CARE PHYSICIAN SERVICES HOSPITAL OUTPATIENT SERVICES OUTPATIENT DIAGNOSTIC TESTS EMERGENCY SERVICES A V-LG-IO/250/750/10%-09 MP-5228 (10/09) Benefit Summary SCHEDULE OF BENEFITS INDIVIDUAL! FAMILY The Deductible does nol apply toward the Out-of-Pocket A1aximuI1l INDIVIDUAL! FAMILY per calendar year The Oul-al-Pocket A1aximlll1l includes Co-payments and Co- insurance amounts unless othenl'ise excluded Services at Participating Physicians' offices include, but are not limited to: Routine office visits/annual well-woman examination when performed by Primary Care Physician Pediatric care and well-child care Periodic health evaluation and immunizations Diagnostic imaging, laboratory or other diagnostic services Minor surgical procedures Vision and hearing screenings for children under 18 . Initial visit . Subsequent visits Office visits Annual well-woman examination when performed by a participating Specialty Health Care Physician Additional charges will apply if Outpatient Diagnostic Tests are performed in the Specialist's Office. Inpatient care at 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 unit and other special units, general and special duty nursing . Laboratory and diagnostic imaging . Required special diets . Radiation and inhalation therapies . 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 lifetime (Not subject to Calendar Year Deductible) . CAT Scan, PET Scan, MRI . Other diagnostic imaging tests Charges for office visits will also apply if services are performed in a Specialist's office. An emergency is the sudden and unexpected onset of a condition requiring immediate medical or surgical care. (Co-payment waived ifadmiUed) . Emergency services at Participating Hospitals . Emergency services at non-participating Hospitals, facilities and/or physicians AvMed must be notified within 24 hours of inpatient admission following emergency services or as soon as reasonably possible. AvMED HEALTH PLANS COST TO MEMBER $2501 $750 annually $7501 $1,500 annually $10 per visit $10 Co-payment NO CHARGE $20 per visit $150 per admission; 100% coverage thereafter $150 Co-payment $100 Co-payment $75 Co-payment $150 Co-payment NO CHARGE 10% of the contracted rate, after Deductible $75 Co-payment