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) Primary Care Physician means any Participating Physician licensed under Chapter 458 (physician) or 459 (osteopath), Florida Statutes, who is engaged in family practice, pediatrics, internal medicine, obstetrics/gynecology, or any specialty physician from time to time designated by AvMed as a 'Primary Care Physician' in AvMed's current list of physicians and Hospitals. 2.48 Private Duty Nursing means services provided by registered nurses, licensed practical nurses, or any other trained attendant whose services ordinarily are rendered to, and restricted ta, a particular Member by arrangements between the Member and the private-duty nurse or attendant. Such persons are engaged or paid by an individual Member or by someone acting on their behalf, including a hospital that initially incurs the costs and looks to the Member for reimbursement for such services. 2.47 ') 2.49 Private Healthcare Systems (PIICS) means a proprietary Preferred Provider Organization with whom A vMed has entered into an agreement to provide Medical Services outside A vMed's Service Area. The Point of Service Plan provides access to the PHCS provider network as defined herein. Members' Co- payment, deductible and Co-insurance responsibilities are outlined in the Schedule of Benefits. Relevant Document means any documentation that: 2.50 c~) 2.50.01 Was relied upon in making a benefit detennination; Was submitted, considered or generated in the course of making a benefit determination, without regard to whether it was relied upon in making the detennination; Demonstrates compliance with the Plan's administrative process; and Constitutes a statement of policy or guidance with respect to the Plan concerning the Adverse Benefit Determination for the Claimant's diagnosis, without regard to whether such advice or statement was relied upon in making the Adverse Benefit Detennination. Self-Administered Injectable Medication means a medication that has been approved by the FDA for self-injection and is administered by subcutaneous injection or a medication for which there are instructions to the patient for self-injection in the manufacturer's prescribing infonnation (package insert). ) 2.50.02 2.50.03 2.50.04 2.51 2.52 Service Area means those counties in the State of Florida where AvMed has been approved to conduct business by the Agency for Health Care Administration (AHCA). 2.53 Sound Natural Tooth means a tooth that is whole or properly restored (restoration with amalgams only) and is not in need of the treatment provided for any reason other than an accidental injury. For purposes of this Plan, a tooth previously restored with a crown inlay, oolay, or porcelain restoration, or treated by endodontics, is not considered a sound natural tooth. 2.54 Specialty Health Care Physician means any physician licensed under Chapters 458 (physician), 459 (osteopath), 460 (chiropractor) or 461 (podiatrist), Florida Statutes, other than the Member's chosen Primary Care Physician. 2.55 Subscriber means a person who meets all applicable requirements of Section 3.01, enroIls in the Plan, and for whom the premium prepayment required by Part VI has actually been received by AvMed. 2.56 Subscribing Group means a corporation, partnership, limited liability company or other legal entity (and its wholly-owned subsidiaries) that negotiates and agrees to contract for the health services and benefits provided herein for its eligible employees. 2.57 Total Disability means a totally disabling condition resulting from an illness or injury which prevents the Member from engaging in any employment or occupation for which he may otherwise become qualified by reason of education, training, or experience, and for which the Member is under the regular care of a physician. 7 A V-CHOICE-2009 MP-5320 (10/09)