Reso 2010-1529 - Laserfiche WebLink

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") LARGE GROUP $25/$1,000/$2,000 CALENDAR YEAR DEDUCTIBLE OUT-OF-POCKET MAXIMUM AVMED PRIMARY CARE PHYSICIAN H MATERNITY CARE AVMED SPECIAlITY HEALTH CARE PHYSICIAN SERVICES HOSPITAL OUTPATIENT SERVICES OUTPATIENT DIAGNOSTIC TESTS Benefit Summary SCHEDULE OF BENEFITS INDIVIDUAL! FAMILY The Deductible does nol apply IowaI'd the Out-oj-Pocket Maximum INDIVIDUAL! FAMILY per calendar year The Ou/.ofPockel A1aximuI11 includes Co-payments and Co- insurance amounts unless oOle/wise 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 performcd 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 . Mammogram Charges for office visits will also apply if services are performed in a Specialist's office, EMERGENCY SERVICES An emergency is the sudden and unexpected onset of a condition requiring immediate medical or surgical care. (Co-payment waived if admitted) . Emergency services at Participating Hospitals . Emergency services at non-participating Hospitals, facilities and/or physicians Avl\led must be notified within 24 hours of inpatient admission following emergency services or as soon as reasonably possible. A V-LG-25/1000/2000-09 MP-5076 (10/09) AvMED HEALTII PLANS COST TO MEMBER $1,0001 $2,000 annually $2,0001 $4,000 annually $25 per visit; not subject to Calendar Year Deductible $25 Co-payment; not subject to Calendar Year Deductible NO CHARGE $50 per visit; not subject to Calendar Year Deductible NO CHARGE, after Calendar Year Deductible NO CHARGE, after Calendar Year Deductible NO CHARGE NO CHARGE, after Calendar Y car Deductible NO CHARGE; not subject to Calendar Year Deductible NO CHARGE, after Calendar Year Deductible