Reso 2010-1529 - Laserfiche WebLink

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") Benefit Summary, continued \-) URGENT/IMMEDIATE CARE . . . FAMILY PLANNING . . ALLERGY TREATMENTS . . AMBULANCE . . PHYSICAL, SPEECH AND . OCCUPATIONAL THERAPIES Medical Services at a participating Urgent/Immediate Care facility or services rendered after hours in your Primary Care Physician's office Medical Services at a participating retail clinic Medical Services at a non-participating Urgent/Immediate Care facility or non. participating retail clinic Voluntary family planning services Sterilization (In addition to any Outpatient Facility charge) Injections Skin testing Ambulance transport for emergency services 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 Short-term physical, speech or occupational therapy for acute conditions Coverage is limited to 30 visits per calendar year for all services combined $40 Co-payment $10 per visit $60 Co-payment $10 per visit $250 Co-payment $10 per visit $50 per course of testing $100 Co-payment $10 per visit $20 per visit $10 per visit 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. . Up to 20 days post-hospitalization care per calendar year when prescribed by physician and authorized by A vMed SKILLED NURSING FACILITIES AND REHABILITATION CENTERS CARDIAC REHABILITATION Cardiac rehabilitation is covered for the following conditions: . Acute myocardial infarction . Percutaneous transluminal coronary angioplasty (PTCA) . Repair or replacement of heart valves . Coronary artery bypass graft (CABG), or . Heart transplant Coverage is limited to 18 visits per calendar year HOME HEALTH CARE . Limited to 60 skilled visits per calendar year DURABLE MEDICAL EQUIPMENT AND ORTHOTIC APPLIANCES Equipment includes: Hospital beds . Walkers . Crutches . Wheelchairs Orthotic appliances are limited to: . Leg, arm, back and neck custom~made braces Prosthetic devices are limited to: . Artificial limbs Artificial joints . Ocular prostheses PROSTHETIC DEVICES 10% of the contracted rate, after Deductible $10 per visit Benefits limited to $1,500 per calendar year 10% of the contracted rate, after Deductible 10% of the contracted rate, after Deductible Benefits limited to $2,000 per calendar year 10% of the contracted rate, after Deductible FOR ADDITIONAL INFORMATION, PLEASE CALL: 1-800-88-AVMEO (1-800-882-8633) This Schedule of Benefits is not a contract. For specific information on Benefits, Exclusions and Limitations, please consult your AvMed Group Medical and Hospital Service Contract. A V-LG.IO/2501750/10%-09 MP-5228 (10/09)