For Employees, Retirees, (and/or Dependents) ofThe...
44
For Employees, Retirees, (and/or Dependents) of The State of Florida 2013 Health Plan Enrollment Information
Transcript of For Employees, Retirees, (and/or Dependents) ofThe...
For Employees, Retirees,(and/or Dependents) of The State of Florida2013 Health Plan Enrollment Information
Special Member Services Team For State EmployeesIf you have any questions about your plan, from benefits, to co-payments, to provider lists, you can call our special State of Florida Member Services team. These specialists are just a phone call away 24-hours a day, 7 days a week. You can reach them at 1-888-762-8633 or via email at [email protected].
Table of ContentsAvMed Overview.....................................................................................2Benefit SummaryState of Florida HMO Health Plan.............................................................7Benefit SummaryState of Florida Health Investor Health Plan.......................................11Services and Programs.......................................................................15Privacy Notice.........................................................................................26
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On Your Side, Right From The Start.AvMed is proud to be serving you and The State of Florida. Whether you’re a new or long-timemember, we know that when it comes to health care coverage, easy is better. That’s whyAvMed has created health plans that make it easy for you and your family to access the prevention and treatment services you need. We call this the AvMed Advantage, and it startsthe very first day you enroll. From plenty of choices of where to go for your health care –including one of the largest network of doctors and hospitals in Florida – to wellness programsto keep you feeling healthy, to 24-hour access to a real live person to answer questions youhave about your benefits, AvMed is on your side.
We want to help you take advantage of the AvMed Advantage, so let us know how we canserve you.
James M. ReppSenior Vice President, Sales & Marketing
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The AvMed AdvantageGet To Know Yellow.For almost 40 years, we’ve designed our health plans with our members’ input todevelop benefits, special programs, and services that address the most common requests. As a result, all our plans include what members want most, including:
• No referrals to see any in-network physician
• Access to an expanded network of doctors and hospitals that includes an extensive selection of primary care physicians (PCPs), specialists, top-ranked hospitals, and outpatient facilities throughout the state of Florida
• Retail clinic care that allows you to pay your Urgent Care Clinic co-payment at participating clinics across the state
• Member services all day, every day by phone, email, or online to answer questionsabout your plan – from benefits, to providers, to payment balances
• Wellness services to keep you healthier and reduce your overall health care costs
• Emergency coverage when you travel outside of AvMed’s network area
• 24/7 nurse on call service that connects you to a registered nurse who can answeryour important health care questions quickly and confidentially
Focused On Member SatisfactionAvMed is a not-for-profit health plan, so we’re focused on our members’ health care rather than shareholders and stock dividends. It's part of the reason AvMed is consistentlyrated higher than our competitors for overall member satisfaction, according to theNational Committee for Quality Assurance (NCQA) in the annual Consumer Assessmentof Healthcare Providers and Systems survey (CAHPS). And it’s why AvMed constantlyseeks our members’ feedback to make sure we’re doing the best job possible. You can participate in the process by completing the survey you receive after enrolling.
Get Your Ounce Of Prevention For FreeOne of the best defenses against illness – and high health care costs – is prevention. That’swhy AvMed’s benefits include preventative care services at no charge. These include but are not limited to well-woman exams, annual physicals, well-child care, immunizations,colonoscopies, mammograms, obesity screenings, diabetes and cholesterol testing, tests forSTDs, and smoking cessation counseling. If you want to know what screenings you’re dueto receive, visit www.avmed.org/go/state and log in to the “Member” section. Then, go to“Health and Wellness”, click on “Prevention and Education”, and look for the “Screening” link.
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Start With Healthy Living.Everyone enrolled in an AvMed health plan can take advantage of our HealthyLiving Programs. These wellness tools and services help you make healthierlifestyle choices – choices that can keep you feeling good and reduce your overallhealth care costs. The Healthy Living Programs include:
• Personal Health Assessment, an interactive, confidential survey that identifies potential health risks and sets improvement goals based on your personal needs; you can access it by visiting www.avmed.org/go/state,select Health and Wellness, then click on "Take Your Assessment"
• Discounts on services like fitness center memberships as well as reduced rates from participating massage therapists, acupuncturists, and other alternative medicine providers
• Reimbursements when participating in the Weight Watchers® program
• Educational materials including a subscription to our award-winning publication, AvMed Magazine
• Age and gender-based reminders for preventative screenings such as mammograms and colonoscopies
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Answers To Common Questions.AvMed recognizes that our members have a lot of questions, but there are somethat come up more often than others. We’ve answered three of the most commonquestions here to help you get the most out of your health plan from day one.
When Do I Need To Go To The ER?
When you’re experiencing symptoms like pain, nausea, or faintness, it’s hardto figure out how serious the problem is. Going to the nearest emergency roommay seem like the right choice, but more than half of all ER visits are for minorproblems that aren’t life threatening. What’s more, getting treatment in an ER is four times more expensive than getting similar treatment at an urgent carecenter. The table below lists some signs you should look for when figuring outwhere to go when you experience a medical emergency. Remember, these arejust guidelines. If you’re ever in doubt, err on the side of caution and call 9-1-1.
Urgent Care Center Emergency Room AmbulanceKnow where they are Know how to get there fast Call 9-1-1
• Ear infections • Sudden, sharp • Chest pain• Bronchitis abdominal pain • Difficulty breathing• Fever • Uncontrolled bleeding • Unconsciousness
How Do I Find The Doctors I Want?
Whether you’re looking for your family doctor or a highly recommended specialist, you can find out if they’re part of AvMed’s network by searching for their name, specialty, or location. What’s more, AvMed offers access to our partner network for members within the AvMed service area. To find the physicians you’re looking for, go to www.avmed.org/go/state or call 1-888-762-8633.
How Do I Handle My Transition of Care?
If you are new to AvMed and undergoing long-term care for a specific condition, like self-injectables or complex regular treatments, we want to make sure the transition does not interrupt your care. Fill out a Transition of Care form, and AvMed nurses will work with you to ensure continuity of care. To request a form, go to www.avmed.org/go/state and click “Forms”,or call 1-888-762-8633.
2 Convenient Ways To Become A Member.In this kit, you will find the Benefit Guides for the two AvMed Health Plans –the HMO Health Plan and Investor Health Plan available to all state of Floridaemployees and retirees. You can enroll in either plan in one of two easy ways:
OnlineClick on “peoplefirst.myflorida.com”. Type in your user ID and password.Click on “Process Elections” and follow the prompts.
By PhoneCall the People First Service Center at 1-866-663-4735 to speak with aspecialist. They’re available Monday - Friday, 8:00 a.m. to 6:00 p.m.
For Families With Multiple Insurance CarriersIf your family has more than one health insurance carrier, you need to complete a Coordination of Benefits (COB) survey to make sure all claims are handled correctly. You can request a hardcopy COB survey from your benefits administrator, from AvMed Member Services, or fill out an online form at www.avmed.org/go/state.
After You EnrollAfter you enroll, you will receive a welcome packet including a provider list,
summary of benefits, privacy notification, and your yellow AvMed ID card.
Remember you’ll need your ID card to access the majority of your benefits.
Replacing A Lost AvMed ID CardIf you lose your AvMed ID Card, just contact AvMed Member Services, and
we’ll send you a new one. Until your replacement arrives, you can print out
a temporary ID card by logging in to your account at www.avmed.org/go/state.
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Benefit SummaryState of Florida HMO Health Plan
JANUARY 2013Member Services: 1-888-762-8633
For more information about AvMed Health Plans, call Member Services at the number listed on your AvMed ID card.
7
: Sta
te o
f Flo
rida
Stan
dard
HM
O P
lan
Cov
erag
e Pe
riod:
01/
01/2
013
– 12
/31/
2013
Sum
mar
y of
Ben
efits
and
Cov
erag
e: W
hat t
his
Pla
n C
over
s &
Wha
t it C
osts
Cov
erag
e fo
r: In
divi
dual
+ F
amily
|Pla
n Ty
pe: H
MO
Que
stio
ns: C
all 1
-888
-762
-863
3 or
visi
t us a
t ww
w.av
med
.org
/go/
stat
eIf
you
are
n’t c
lear a
bout
any
of t
he u
nder
lined
term
s use
d in
this
form
, see
the
Glo
ssar
y. Y
ou c
an v
iew th
e G
loss
ary
1 of
8at
ww
w.cc
iio.cm
s.gov
or c
all 1
-888
-762
-863
3 to
requ
est a
cop
y. SF
-Sta
te o
f Flo
rida-
HM
O-1
3 SF
-350
5 (0
1/13
)
This
is o
nly
a su
mm
ary.
If y
ou w
ant m
ore
deta
il ab
out y
our c
over
age
and
cost
s, yo
u ca
n ge
t the
com
plet
e te
rms i
n th
e po
licy
or p
lan
docu
men
t at w
ww
.avm
ed.o
rg/g
o/st
ate
or b
y ca
lling
1-88
8-76
2-86
33
Impo
rtan
t Que
stio
ns
Ans
wer
s W
hy th
is M
atte
rs:
Wha
t is
the
over
all
dedu
ctib
le?
$0
See
the
char
t sta
rting
on
page
2 fo
r oth
er c
osts
for s
ervi
ces t
his p
lan c
over
s.
Are
ther
e ot
her
dedu
ctib
les
for s
peci
fic
serv
ices
? N
o.
You
don
’t ha
ve to
mee
t ded
uctib
les
for s
pecif
ic se
rvice
s, bu
t see
the
char
t sta
rting
on
pag
e 2
for o
ther
cos
ts fo
r ser
vice
s thi
s plan
cov
ers.
Is th
ere
an o
ut–o
f–po
cket
lim
it on
my
expe
nses
?
Yes
. $1,
500
indi
vidu
al/$3
,000
fam
ily
The
out-
of-p
ocke
t lim
it is
the
mos
t you
cou
ld p
ay d
urin
g a
cove
rage
per
iod
(usu
ally
one
year
) for
you
r sha
re o
f the
cos
t of c
over
ed se
rvice
s. T
his l
imit
help
s yo
u pl
an fo
r hea
lth c
are
expe
nses
. W
hat i
s no
t inc
lude
d in
th
e ou
t–of
–poc
ket
limit?
Prem
ium
, pre
scrip
tion
copa
ymen
ts,
dedu
ctib
le, a
nd se
rvice
s thi
s plan
do
esn’
t cov
er
Eve
n th
ough
you
pay
thes
e ex
pens
es, t
hey
don’
t cou
nt to
war
d th
e out
–of–
pock
et
limit.
Is th
ere
an o
vera
ll an
nual
lim
it on
wha
t th
e pl
an p
ays?
N
o.
The
char
t sta
rting
on
page
2 d
escr
ibes
any
lim
its o
n w
hat t
he p
lan w
ill p
ay fo
r specific
cov
ered
serv
ices,
such
as o
ffice
visi
ts.
Doe
s th
is p
lan
use
a ne
twor
k of
pro
vide
rs?
Yes
. Fo
r a li
st o
f par
ticip
atin
g pr
ovid
ers,
see
ww
w.av
med
.org
/go/
stat
e or
call
1-8
88-7
62-8
633.
If y
ou u
se a
n in
-net
wor
k do
ctor
or o
ther
hea
lth c
are
prov
ider
, thi
s plan
will
pay
so
me
or a
ll of
the
cost
s of c
over
ed se
rvice
s. B
e aw
are,
your
in-n
etw
ork
doct
or o
r ho
spita
l may
use
an
out-o
f-net
wor
k pr
ovid
er fo
r som
e se
rvice
s. P
lans u
se th
e te
rm
in-n
etw
ork,
pre
ferr
ed, o
r par
ticip
atin
g fo
r pro
vide
rs in
their
net
wor
k. S
ee th
e ch
art s
tarti
ng o
n pa
ge 2
for h
ow th
is pl
an p
ays d
iffer
ent k
inds
of p
rovi
ders
. D
o I
need
a re
ferr
al to
se
e a
spec
ialis
t?
No.
Y
ou c
an se
e th
e sp
ecia
list y
ou c
hoos
e w
ithou
t per
miss
ion
from
this
plan
.
Are
ther
e se
rvic
es th
is
plan
doe
sn’t
cove
r?
Yes
. So
me
of th
e se
rvice
s thi
s plan
doe
sn’t
cove
r are
list
ed o
n pa
ge 4
. See
you
r pol
icy o
r pl
an d
ocum
ent f
or a
dditi
onal
info
rmat
ion
abou
t exc
lude
d se
rvic
es.
8
: Sta
te o
f Flo
rida
Stan
dard
HM
O P
lan
Cov
erag
e Pe
riod:
01/
01/2
013
– 12
/31/
2013
Sum
mar
y of
Ben
efits
and
Cov
erag
e: W
hat t
his
Pla
n C
over
s &
Wha
t it C
osts
Cov
erag
e fo
r: A
ll C
over
age
Tier
s|Pl
an T
ype:
HM
O
2
of 8
SF
-Sta
te o
f Flo
rida-
HM
O-1
3
•C
opay
men
ts a
re fi
xed
dolla
r am
ount
s (fo
r exa
mpl
e, $1
5) y
ou p
ay fo
r cov
ered
hea
lth c
are,
usua
lly w
hen
you
rece
ive
the
serv
ice.
•C
oins
uran
ce is
your
shar
e of
the
cost
s of a
cov
ered
serv
ice, c
alcul
ated
as a
per
cent
of t
he a
llow
ed a
mou
nt fo
r the
serv
ice. F
or e
xam
ple,
if th
e pl
an’s
allo
wed
am
ount
for a
n ov
erni
ght h
ospi
tal s
tay
is $1
,000
, you
r coi
nsur
ance
pay
men
t of 2
0% w
ould
be
$200
. Th
is m
ay c
hang
e if
you
have
n’t m
et y
our d
educ
tible
. •
The
amou
nt th
e pl
an p
ays f
or c
over
ed se
rvice
s is b
ased
on
the
allo
wed
am
ount
. If a
n ou
t-of-n
etw
ork
prov
ider
cha
rges
mor
e th
an th
e al
low
ed a
mou
nt, y
ou m
ay h
ave
to p
ay th
e di
ffere
nce.
For e
xam
ple,
if an
out
-of-n
etw
ork
hosp
ital c
harg
es $
1,50
0 fo
r an
over
nigh
t sta
y an
d th
e al
low
ed a
mou
nt is
$1,
000,
you
may
hav
e to
pay
the
$500
diff
eren
ce. (
This
is ca
lled
bala
nce
billi
ng.)
•Th
is pl
an m
ay e
ncou
rage
you
to u
se A
vMed
net
wor
k pr
ovid
ers
by c
harg
ing
you
low
er d
educ
tible
s, co
paym
ents
and
coi
nsur
ance
am
ount
s.
Your
Cos
t If Y
ou U
se a
n
Com
mon
Med
ical
Eve
nt
Serv
ices
You
May
Nee
d A
vMed
net
wor
k P
rovi
der
Out
-of-n
etw
ork
Prov
ider
Lim
itatio
ns &
Exc
eptio
ns
If y
ou v
isit
a he
alth
car
e pr
ovid
er’s
offi
ce
or c
linic
Prim
ary
care
visi
t to
treat
an
inju
ry o
r illn
ess
$20
copa
y/ v
isit
Not
Cov
ered
A
dditi
onal
char
ges w
ill a
pply
for n
on-
prev
entiv
e se
rvice
s per
form
ed in
the
Phys
ician
’s of
fice.
Spec
ialist
visi
t $4
0 co
pay/
visi
t N
ot C
over
ed
Oth
er p
ract
ition
er o
ffice
visi
t $4
0 co
pay/
visi
t for
ch
iropr
actic
serv
ices
Not
Cov
ered
Li
mite
d to
60
visit
s per
inju
ry.
Prev
entiv
e ca
re/s
cree
ning
/im
mun
izat
ion
No
Char
ge
Not
Cov
ered
N
one
If y
ou h
ave
a te
st
Diag
nost
ic te
st (x
-ray,
bloo
d w
ork)
N
o Ch
arge
N
ot C
over
ed
Certa
in se
rvice
s req
uire
prio
r au
thor
izat
ion.
Cha
rges
for o
ffice
visi
ts
will
also
app
ly if
serv
ices a
re p
erfo
rmed
in
a P
hysic
ian’s
offic
e.
Imag
ing
(CT/
PET
scan
s, M
RIs)
N
o Ch
arge
N
ot C
over
ed
If y
ou n
eed
drug
s to
trea
t yo
ur il
lnes
s or
co
nditi
on
Mor
e in
form
atio
n ab
out
pres
crip
tion
drug
co
vera
ge is
Gen
eric
drug
s $7
cop
ay/
pres
crip
tion
(reta
il);
$14
copa
y/ p
resc
riptio
n (m
ail
orde
r) N
ot C
over
ed
Pres
crip
tion
drug
cov
erag
e is
prov
ided
th
roug
h M
edco
. For
a li
st o
f pa
rticip
atin
g ph
arm
acies
, plea
se c
all
Med
co a
t 1-8
77-5
31-4
793
or v
isit
ww
w.m
edco
.com
. Co
vers
up
to a
30-
day
supp
ly fo
r ret
ail
pres
crip
tions
; 31-
90 d
ay su
pply
for m
ail
orde
r pre
scrip
tions
. Cer
tain
dru
gs
Pref
erre
d br
and
drug
s $3
0 co
pay/
pre
scrip
tion
(reta
il); $
60 c
opay
/ pr
escr
iptio
n (m
ail o
rder
) N
ot C
over
ed
Non
-pre
ferr
ed b
rand
dru
gs
$50
copa
y/ p
resc
riptio
n (re
tail)
; $10
0 co
pay/
pr
escr
iptio
n (m
ail o
rder
) N
ot C
over
ed
9
: Sta
te o
f Flo
rida
Stan
dard
HM
O P
lan
Cov
erag
e Pe
riod:
01/
01/2
013
– 12
/31/
2013
Sum
mar
y of
Ben
efits
and
Cov
erag
e: W
hat t
his
Pla
n C
over
s &
Wha
t it C
osts
Cov
erag
e fo
r: A
ll C
over
age
Tier
s|Pl
an T
ype:
HM
O
3
of 8
SF
-Sta
te o
f Flo
rida-
HM
O-1
3
Your
Cos
t If Y
ou U
se a
n
Com
mon
Med
ical
Eve
nt
Serv
ices
You
May
Nee
d A
vMed
net
wor
k P
rovi
der
Out
-of-n
etw
ork
Prov
ider
Lim
itatio
ns &
Exc
eptio
ns
avail
able
at
ww
w.m
edco
.com
.
Spec
ialty
dru
gs
Pref
erre
d br
and
Spec
ialty
dr
ugs:
$30
copa
y/
pres
crip
tion
(reta
il); $
60
copa
y/ p
resc
riptio
n (m
ail
orde
r)/
Non
-pre
ferr
ed b
rand
Spe
cialty
dr
ugs:
$5
0 co
pay/
pre
scrip
tion
(reta
il); $
100
copa
y/
pres
crip
tion
ord
er)
Not
Cov
ered
requ
ire p
rior a
utho
rizat
ion
and/
or a
re
subj
ect t
o qu
antit
y lim
its. B
rand
ad
ditio
nal c
harg
e m
ay a
pply.
If y
ou h
ave
outp
atie
nt
surg
ery
Facil
ity fe
e (e
.g.,
ambu
lator
y su
rger
y ce
nter
) N
o Ch
arge
N
ot C
over
ed
Certa
in se
rvice
s req
uire
prio
r au
thor
izat
ion.
Cha
rges
for o
ffice
visi
ts
will
also
app
ly if
serv
ices a
re p
erfo
rmed
in
any
Phy
sician
’s of
fice
Phys
ician
/sur
geon
fees
N
o Ch
arge
N
ot C
over
ed
If y
ou n
eed
imm
edia
te
med
ical
att
entio
n
Em
erge
ncy
room
serv
ices
$100
cop
ay/
visit
Sa
me
as A
vMed
ne
twor
k
AvM
ed m
ust b
e no
tified
with
in 2
4 ho
urs o
f em
erge
ncy
adm
issio
n or
as
soon
as r
easo
nabl
y po
ssib
le.
Em
erge
ncy
med
ical
trans
porta
tion
No
Char
ge
Sam
e as
AvM
ed
netw
ork
Whe
n pr
e-au
thor
ized
, or i
n th
e ca
se o
f em
erge
ncy.
Urg
ent c
are
$25
copa
y/ v
isit
Sam
e as
AvM
ed
netw
ork
Non
e
If y
ou h
ave
a ho
spita
l sta
y Fa
cility
fee
(e.g
., ho
spita
l roo
m)
$250
cop
ay/
visit
N
ot C
over
ed
Prio
r aut
horiz
atio
n re
quire
d.
Phys
ician
/sur
geon
fee
No
addi
tiona
l cha
rge
Not
Cov
ered
10
: Sta
te o
f Flo
rida
Stan
dard
HM
O P
lan
Cov
erag
e Pe
riod:
01/
01/2
013
– 12
/31/
2013
Sum
mar
y of
Ben
efits
and
Cov
erag
e: W
hat t
his
Pla
n C
over
s &
Wha
t it C
osts
Cov
erag
e fo
r: A
ll C
over
age
Tier
s|Pl
an T
ype:
HM
O
4
of 8
SF
-Sta
te o
f Flo
rida-
HM
O-1
3
Your
Cos
t If Y
ou U
se a
n
Com
mon
Med
ical
Eve
nt
Serv
ices
You
May
Nee
d A
vMed
net
wor
k P
rovi
der
Out
-of-n
etw
ork
Prov
ider
Lim
itatio
ns &
Exc
eptio
ns
If y
ou h
ave
men
tal h
ealth
, be
havi
oral
he
alth
, or
subs
tanc
e ab
use
need
s
Men
tal/
Beha
vior
al he
alth
outp
atien
t ser
vice
s $2
0 co
pay/
visi
t N
ot C
over
ed
Non
e
Men
tal/
Beha
vior
al he
alth
inpa
tient
serv
ices
$250
cop
ay/
visit
N
ot C
over
ed
Prio
r aut
horiz
atio
n re
quire
d.
Subs
tanc
e us
e di
sord
er
outp
atien
t ser
vice
s $2
0 co
pay/
visi
t N
ot C
over
ed
Non
e
Subs
tanc
e us
e di
sord
er in
patie
nt
serv
ices
$250
cop
ay/
visit
N
ot C
over
ed
Prio
r aut
horiz
atio
n re
quire
d.
If y
ou a
re
preg
nant
Pren
atal
and
post
nata
l car
e $4
0 co
pay/
1st v
isit o
nly
Not
Cov
ered
Su
bseq
uent
visi
ts a
t no
char
ge.
Deli
very
and
all
inpa
tient
se
rvice
s $2
50 c
opay
/ vi
sit
Not
Cov
ered
Pr
ior a
utho
rizat
ion
requ
ired.
If y
ou n
eed
help
re
cove
ring
or
have
oth
er
spec
ial h
ealth
ne
eds
Hom
e he
alth
care
N
o Ch
arge
/ vi
sit
Not
Cov
ered
A
ppro
ved
treat
men
t plan
requ
ired.
Reha
bilit
atio
n se
rvice
s
$40
copa
y/ v
isit f
or p
hysic
al,
occu
patio
nal &
spee
ch
ther
apies
; $40
cop
ay/
visit
ap
plied
beh
avio
r ana
lysis
serv
ices t
o tre
at A
utism
Sp
ectru
m D
isord
er; $
40
copa
y/ v
isit f
or p
hysic
al,
occu
patio
nal &
spee
ch
ther
apies
to tr
eat A
utism
Sp
ectru
m D
isord
er
Not
Cov
ered
Phys
ical,
spee
ch &
occ
upat
iona
l th
erap
ies li
mite
d to
60
visit
s per
inju
ry.
Cove
rage
for a
ll se
rvice
s rela
ted
to
treat
men
t of A
utism
Spe
ctru
m D
isord
er
is lim
ited
to $
36,0
00 a
nnua
lly &
$2
00,0
00 li
fetim
e.
Hab
ilita
tion
serv
ices
Not
Cov
ered
N
ot C
over
ed
Non
e
Skill
ed n
ursin
g ca
re
No
Char
ge/
visit
N
ot C
over
ed
Lim
ited
to 6
0 da
ys p
er c
alend
ar y
ear.
Prio
r aut
horiz
atio
n re
quire
d.
Dur
able
med
ical
equi
pmen
t N
o Ch
arge
/ de
vice
N
ot C
over
ed
Non
e
Hos
pice
serv
ice
No
Char
ge/
visit
N
ot C
over
ed
Phys
ician
cer
tifica
tion
requ
ired.
Lim
ited
to 2
10 c
alend
ar d
ays p
er li
fetim
e. If
you
r chi
ld
need
s de
ntal
or
Eye
exa
m
$20
copa
y/ v
isit a
t prim
ary;
$40
copa
y/ v
isit a
t spe
cialis
t N
ot C
over
ed
Lim
ited
to o
ne e
xam
per
yea
r
11
: Sta
te o
f Flo
rida
Stan
dard
HM
O P
lan
Cov
erag
e Pe
riod:
01/
01/2
013
– 12
/31/
2013
Sum
mar
y of
Ben
efits
and
Cov
erag
e: W
hat t
his
Pla
n C
over
s &
Wha
t it C
osts
Cov
erag
e fo
r: A
ll C
over
age
Tier
s|Pl
an T
ype:
HM
O
5
of 8
SF
-Sta
te o
f Flo
rida-
HM
O-1
3
Your
Cos
t If Y
ou U
se a
n
Com
mon
Med
ical
Eve
nt
Serv
ices
You
May
Nee
d A
vMed
net
wor
k P
rovi
der
Out
-of-n
etw
ork
Prov
ider
Lim
itatio
ns &
Exc
eptio
ns
eye
care
G
lasse
s N
ot C
over
ed
Not
Cov
ered
N
one
Den
tal c
heck
-up
Not
Cov
ered
N
ot C
over
ed
Non
e
Excl
uded
Ser
vice
s &
Oth
er C
over
ed S
ervi
ces:
Serv
ices
You
r Pla
n D
oes
NO
T C
over
(Thi
s is
n’t a
com
plet
e lis
t. C
heck
you
r pol
icy
or p
lan
docu
men
t for
oth
er e
xclu
ded
serv
ices
.)
•A
cupu
nctu
re
•Ba
riatri
c su
rger
y •
Cosm
etic
surg
ery
•D
enta
l car
e
•H
abili
tatio
n se
rvice
s •
Hea
ring
aids
•In
ferti
lity
treat
men
t •
Long
-term
car
e
•N
on-e
mer
genc
y ca
re w
hen
trave
ling
outs
ide
the
U.S
. •
Priv
ate
duty
nur
sing
•Ro
utin
e fo
ot c
are
•W
eight
loss
pro
gram
s
Oth
er C
over
ed S
ervi
ces
(Thi
s is
n’t a
com
plet
e lis
t. C
heck
you
r pol
icy
or p
lan
docu
men
t for
oth
er c
over
ed s
ervi
ces
and
your
cos
ts fo
r the
se
serv
ices
.)
•Ch
iropr
actic
car
e •
Rout
ine
eye
care
(Adu
lt)
Your
Rig
hts
to C
ontin
ue C
over
age:
If
you
lose
cov
erag
e un
der t
he p
lan, t
hen,
dep
endi
ng u
pon
the
circu
mst
ance
s, Fe
dera
l and
Sta
te la
ws m
ay p
rovi
de p
rote
ctio
ns th
at a
llow
you
to k
eep
healt
h co
vera
ge. A
ny su
ch ri
ghts
may
be
limite
d in
dur
atio
n an
d w
ill re
quire
you
to p
ay a
pre
miu
m, w
hich
may
be
signi
fican
tly h
ighe
r tha
n th
e pr
emiu
m y
ou p
ay
whi
le co
vere
d un
der t
he p
lan. O
ther
lim
itatio
ns o
n yo
ur ri
ghts
to c
ontin
ue c
over
age
may
also
app
ly.
For m
ore
info
rmat
ion
on y
our r
ight
s to
cont
inue
cov
erag
e, co
ntac
t the
plan
at 1
-888
-762
-863
3. Y
ou m
ay a
lso c
onta
ct y
our s
tate
insu
ranc
e de
partm
ent,
the
U.S
. Dep
artm
ent o
f Lab
or, E
mpl
oyee
Ben
efits
Sec
urity
Adm
inist
ratio
n at
1-8
66-4
44-3
272
or w
ww
.dol
.gov
/ebs
a, or
the
U.S
. Dep
artm
ent o
f Hea
lth a
nd
Hum
an S
ervi
ces a
t 1-8
77-2
67-2
323
x615
65 o
r ww
w.cc
iio.cm
s.gov
.
Your
Grie
vanc
e an
d A
ppea
ls R
ight
s:
12
: Sta
te o
f Flo
rida
Stan
dard
HM
O P
lan
Cov
erag
e Pe
riod:
01/
01/2
013
– 12
/31/
2013
Sum
mar
y of
Ben
efits
and
Cov
erag
e: W
hat t
his
Pla
n C
over
s &
Wha
t it C
osts
Cov
erag
e fo
r: A
ll C
over
age
Tier
s|Pl
an T
ype:
HM
O
6
of 8
SF
-Sta
te o
f Flo
rida-
HM
O-1
3
If y
ou h
ave
a co
mpl
aint o
r are
diss
atisf
ied w
ith a
den
ial o
f cov
erag
e fo
r clai
ms u
nder
you
r plan
, you
may
be
able
to a
ppea
l or f
ile a
gri
evan
ce.
For
ques
tions
abo
ut y
our r
ight
s, th
is no
tice,
or a
ssist
ance
, you
can
con
tact
AvM
ed’s
Mem
ber S
ervi
ces D
epar
tmen
t at 1
-888
-762
-863
3.
For p
lans s
ubjec
t to
ERI
SA, y
ou m
ay a
lso c
onta
ct th
e U
.S. D
epar
tmen
t of L
abor
, Em
ploy
ee B
enef
its S
ecur
ity A
dmin
istra
tion
at 1
-866
-444
-327
2 or
w
ww
.dol
.gov
/ebs
a, or
the
U.S
. Dep
artm
ent o
f Hea
lth a
nd H
uman
Ser
vice
s at 1
-877
-267
-232
3 x6
1565
or w
ww
.cciio
.cms.g
ov.
Lang
uage
Acc
ess
Serv
ices
: Pa
ra o
bten
er a
siste
ncia
en E
spañ
ol, l
lame
al 1-
888-
762-
8633
. ––
––––
––––
––––
––––
––––
To se
e exa
mples
of h
ow th
is pla
n mi
ght c
over
costs
for a
samp
le me
dical
situa
tion,
see th
e nex
t pag
e.–––
––––
––––
––––
––––
–––
13
: Sta
te o
f Flo
rida
Stan
dard
HM
O P
lan
Cov
erag
e Pe
riod:
01/
01/2
013
– 12
/31/
2013
Cov
erag
e Ex
ampl
es
Cov
erag
e fo
r: A
ll C
over
age
Tier
s|Pl
an T
ype:
HM
O
7
of 8
SF
-Sta
te o
f Flo
rida-
HM
O-1
3
Hav
ing
a ba
by
(nor
mal
deliv
ery)
M
anag
ing
type
2 d
iabe
tes
(rout
ine
main
tena
nce
of
a w
ell-c
ontro
lled
cond
ition
)
Abo
ut th
ese
Cov
erag
e Ex
ampl
es:
Thes
e ex
ampl
es sh
ow h
ow th
is pl
an m
ight
cov
er
med
ical c
are
in g
iven
situ
atio
ns. U
se th
ese
exam
ples
to se
e, in
gen
eral,
how
muc
h fin
ancia
l pr
otec
tion
a sa
mpl
e pa
tient
mig
ht g
et if
they
are
co
vere
d un
der d
iffer
ent p
lans.
Am
ount
ow
ed to
pro
vide
rs: $
7,54
0 Pl
an p
ays
$7,1
20
Patie
nt p
ays
$420
Sam
ple
care
cos
ts:
Hos
pita
l cha
rges
(mot
her)
$2,7
00Ro
utin
e ob
stet
ric c
are
$2,1
00H
ospi
tal c
harg
es (b
aby)
$9
00A
nest
hesia
$9
00La
bora
tory
test
s $5
00Pr
escr
iptio
ns
$200
Radi
olog
y $2
00V
accin
es, o
ther
pre
vent
ive
$40
Tot
al
$7,5
40 Pa
tient
pay
s:
dedu
ctib
les
$0Co
pays
$3
00Co
insu
ranc
e $0
Lim
its o
r exc
lusio
ns
$120
Tot
al
$420
Am
ount
ow
ed to
pro
vide
rs: $
5,40
0 Pl
an p
ays
$4,2
00
Patie
nt p
ays
$1,2
00
Sam
ple
care
cos
ts:
Pres
crip
tions
$2
,900
M
edica
l Equ
ipm
ent a
nd S
uppl
ies
$1,3
00
Offi
ce V
isits
and
Pro
cedu
res
$700
E
duca
tion
$300
La
bora
tory
test
s $1
00
Vac
cines
, oth
er p
reve
ntiv
e $1
00
Tot
al
$5,4
00
Patie
nt p
ays:
de
duct
ibles
$0
Co
pays
$1
,100
Co
insu
ranc
e $0
Li
mits
or e
xclu
sions
$1
00
Tot
al
$1,2
00
This
isno
t a c
ost
estim
ator
.
Don
’t us
e th
ese
exam
ples
to
estim
ate
your
act
ual c
osts
un
der t
his p
lan. T
he a
ctua
l ca
re y
ou re
ceiv
e w
ill b
e di
ffere
nt fr
om th
ese
exam
ples
, and
the
cost
of
that
car
e w
ill a
lso b
e di
ffere
nt.
See
the
next
pag
e fo
r im
porta
nt in
form
atio
n ab
out
thes
e ex
ampl
es.
14
: Sta
te o
f Flo
rida
Stan
dard
HM
O P
lan
Cov
erag
e Pe
riod:
01/
01/2
013
– 12
/31/
2013
Cov
erag
e Ex
ampl
es
Cov
erag
e fo
r: A
ll C
over
age
Tier
s|Pl
an T
ype:
HM
O
Que
stio
ns: C
all 1
-888
-762
-863
3 or
visi
t us a
t ww
w.av
med
.org
/go/
stat
eIf
you
are
n’t c
lear
abo
ut a
ny o
f the
und
erlin
ed te
rms u
sed
in th
is fo
rm, s
ee th
e G
loss
ary.
You
can
vie
w th
e G
loss
ary
8 of
8at
ww
w.cc
iio.cm
s.gov
or c
all 1
-888
-762
-863
3 to
requ
est a
cop
y.
SF-S
tate
of F
lorid
a-H
MO
-13
Q
uest
ions
and
ans
wer
s ab
out t
he C
over
age
Exam
ples
: W
hat a
re s
ome
of th
e as
sum
ptio
ns b
ehin
d th
e C
over
age
Exam
ples
?
•Co
sts d
on’t
incl
ude
prem
ium
s. •
Sam
ple
care
cos
ts a
re b
ased
on
natio
nal
aver
ages
supp
lied
by th
e U
.S.
Dep
artm
ent o
f Hea
lth a
nd H
uman
Se
rvic
es, a
nd a
ren’
t spe
cific
to a
pa
rticu
lar g
eogr
aphi
c ar
ea o
r hea
lth p
lan.
•
The
patie
nt’s
cond
ition
was
not
an
excl
uded
or p
reex
istin
g co
nditi
on.
•A
ll se
rvic
es a
nd tr
eatm
ents
star
ted
and
ende
d in
the
sam
e co
vera
ge p
erio
d.
•Th
ere
are
no o
ther
med
ical
expe
nses
for
any
mem
ber c
over
ed u
nder
this
plan
. •
Out
-of-p
ocke
t exp
ense
s are
bas
ed o
nly
on tr
eatin
g th
e co
nditi
on in
the
exam
ple.
•Th
e pa
tient
rece
ived
all
care
from
in-
netw
ork
prov
ider
s . If
the
patie
nt h
ad
rece
ived
car
e fr
om o
ut-o
f-net
wor
k pr
ovid
ers ,
cost
s wou
ld h
ave
been
hig
her.
Wha
t doe
s a
Cov
erag
e Ex
ampl
e sh
ow?
For e
ach
treat
men
t situ
atio
n, th
e Co
vera
ge
Exa
mpl
e he
lps y
ou se
e ho
w d
educ
tible
s , co
paym
ents
, and
coi
nsur
ance
can
add
up.
It
also
help
s you
see
wha
t exp
ense
s mig
ht b
e le
ft up
to y
ou to
pay
bec
ause
the
serv
ice
or
treat
men
t isn
’t co
vere
d or
pay
men
t is l
imite
d.
Doe
s th
e C
over
age
Exam
ple
pred
ict m
y ow
n ca
re n
eeds
?
No.
Tre
atm
ents
show
n ar
e ju
st e
xam
ples
. Th
e ca
re y
ou w
ould
rece
ive
for t
his
cond
ition
cou
ld b
e di
ffer
ent b
ased
on
your
do
ctor
’s ad
vice
, you
r age
, how
serio
us y
our
cond
ition
is, a
nd m
any
othe
r fac
tors
. D
oes
the
Cov
erag
e Ex
ampl
e pr
edic
t my
futu
re e
xpen
ses?
No.
Cov
erag
e E
xam
ples
are
not
cos
t es
timat
ors.
You
can
’t us
e th
e ex
ampl
es to
es
timat
e co
sts f
or a
n ac
tual
cond
ition
. The
y ar
e fo
r com
para
tive
purp
oses
onl
y. Y
our
own
cost
s will
be
diff
eren
t dep
endi
ng o
n th
e ca
re y
ou re
ceiv
e, th
e pr
ices
you
r pr
ovid
ers
char
ge, a
nd th
e re
imbu
rsem
ent
your
hea
lth p
lan a
llow
s.
Can
I us
e C
over
age
Exam
ples
to
com
pare
pla
ns?
Yes
. Whe
n yo
u lo
ok a
t the
Sum
mar
y of
Be
nefit
s and
Cov
erag
e fo
r oth
er p
lans,
you’
ll fin
d th
e sa
me
Cove
rage
Exa
mpl
es.
Whe
n yo
u co
mpa
re p
lans,
chec
k th
e “P
atie
nt P
ays”
box
in e
ach
exam
ple.
The
small
er th
at n
umbe
r, th
e m
ore
cove
rage
th
e pl
an p
rovi
des.
Are
ther
e ot
her c
osts
I sh
ould
co
nsid
er w
hen
com
parin
g pl
ans?
Yes
. An
impo
rtant
cos
t is t
he p
rem
ium
yo
u pa
y. G
ener
ally,
the
low
er y
our
prem
ium
, the
mor
e yo
u’ll
pay
in o
ut-o
f-po
cket
cos
ts, s
uch
as c
opay
men
ts,
dedu
ctib
les ,
and
coin
sura
nce.
You
sh
ould
also
con
sider
con
tribu
tions
to
acco
unts
such
as h
ealth
savi
ngs a
ccou
nts
(HSA
s), f
lexi
ble
spen
ding
arr
ange
men
ts
(FSA
s) o
r hea
lth re
imbu
rsem
ent a
ccou
nts
(HRA
s) th
at h
elp
you
pay
out-o
f-poc
ket
expe
nses
.
15
6
Notes–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
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16
Benefit SummaryState of Florida Health Investor Health Plan
JANUARY 2013Member Services: 1-888-762-8633
For more information about AvMed Health Plans, call Member Services at the number listed on your AvMed ID card.
116
Notes–––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
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17
: Sta
te o
f Flo
rida
Hea
lth In
vest
or H
ealth
Pla
nC
over
age
Perio
d: 0
1/01
/201
3 –
12/3
1/20
13Su
mm
ary
of B
enef
its a
nd C
over
age:
Wha
t thi
s P
lan
Cov
ers
& W
hat i
t Cos
tsC
over
age
for:
Indi
vidu
al +
Fam
ily|P
lan
Type
: HM
O
Que
stio
ns: C
all 1
-888
-762
-863
3 or
visi
t us a
t ww
w.av
med
.org
/go/
stat
eIf
you
are
n’t c
lear a
bout
any
of t
he u
nder
lined
term
s use
d in
this
form
, see
the
Glo
ssar
y. Y
ou c
an v
iew th
e G
loss
ary
1 of
7at
ww
w.cc
iio.cm
s.gov
or c
all 1
-888
-762
-863
3 to
requ
est a
cop
y. SF
-Sta
te o
f Flo
rida-
HIH
P-13
SF
-349
6 (0
1/13
)
This
is o
nly
a su
mm
ary.
If y
ou w
ant m
ore
deta
il ab
out y
our c
over
age
and
cost
s, yo
u ca
n ge
t the
com
plet
e te
rms i
n th
e po
licy
or p
lan
docu
men
t at w
ww
.avm
ed.o
rg/g
o/st
ate
or b
y ca
lling
1-88
8-76
2-86
33
Impo
rtan
t Que
stio
ns
Ans
wer
s W
hy th
is M
atte
rs:
Wha
t is
the
over
all
dedu
ctib
le?
$1,2
50in
divi
dual/
$2,
500
fam
ily
Doe
sn’t
appl
y to
pre
vent
ive
care
.
You
mus
t pay
all
the
cost
s up
to th
e de
duct
ible
am
ount
bef
ore
this
plan
beg
ins t
o pa
y fo
r cov
ered
serv
ices y
ou u
se. C
heck
you
r pol
icy o
r plan
doc
umen
t to
see
whe
n th
e de
duct
ible
star
ts o
ver (
usua
lly, b
ut n
ot a
lway
s, Ja
nuar
y 1s
t). S
ee th
e ch
art
star
ting
on p
age
2 fo
r how
muc
h yo
u pa
y fo
r cov
ered
serv
ices a
fter y
ou m
eet t
he
dedu
ctib
le.
Are
ther
e ot
her
dedu
ctib
les
for s
peci
fic
serv
ices
? N
o.
You
don
’t ha
ve to
mee
t ded
uctib
les
for s
pecif
ic se
rvice
s, bu
t see
the
char
t sta
rting
on
pag
e 2
for o
ther
cos
ts fo
r ser
vice
s thi
s plan
cov
ers.
Is th
ere
an o
ut–o
f–po
cket
lim
it on
my
expe
nses
?
Yes
. $3,
000
indi
vidu
al/ $
6,00
0fa
mily
The
out-
of-p
ocke
t lim
it is
the
mos
t you
cou
ld p
ay d
urin
g a
cove
rage
per
iod
(usu
ally
one
year
) for
you
r sha
re o
f the
cos
t of c
over
ed se
rvice
s. T
his l
imit
help
s yo
u pl
an fo
r hea
lth c
are
expe
nses
. W
hat i
s no
t inc
lude
d in
th
e ou
t–of
–poc
ket
limit?
Prem
ium
, pre
scrip
tion
drug
bra
nd
addi
tiona
l cha
rges
, and
serv
ices t
his
plan
doe
sn't
cove
r.
Eve
n th
ough
you
pay
thes
e ex
pens
es, t
hey
don’
t cou
nt to
war
d th
e ou
t–of
–poc
ket
limit.
Is th
ere
an o
vera
ll an
nual
lim
it on
wha
t th
e pl
an p
ays?
N
o.
The
char
t sta
rting
on
page
2 d
escr
ibes
any
lim
its o
n w
hat t
he p
lan w
ill p
ay fo
r specific
cov
ered
serv
ices,
such
as o
ffice
visi
ts.
Doe
s th
is p
lan
use
a ne
twor
k of
pro
vide
rs?
Yes
. Fo
r a li
st o
f par
ticip
atin
g pr
ovid
ers,
see
ww
w.av
med
.org
/go/
stat
e or
call
1-8
88-7
62-8
633.
If y
ou u
se a
n in
-net
wor
k do
ctor
or o
ther
hea
lth c
are
prov
ider
, thi
s plan
will
pay
so
me
or a
ll of
the
cost
s of c
over
ed se
rvice
s. B
e aw
are,
your
in-n
etw
ork
doct
or o
r ho
spita
l may
use
an
out-o
f-net
wor
k pr
ovid
er fo
r som
e se
rvice
s. P
lans u
se th
e te
rm
in-n
etw
ork,
pre
ferr
ed, o
r par
ticip
atin
g fo
r pro
vide
rs in
their
net
wor
k. S
ee th
e ch
art s
tarti
ng o
n pa
ge 2
for h
ow th
is pl
an p
ays d
iffer
ent k
inds
of p
rovi
ders
. D
o I
need
a re
ferr
al to
se
e a
spec
ialis
t?
No.
Y
ou c
an se
e th
e sp
ecia
list y
ou c
hoos
e w
ithou
t per
miss
ion
from
this
plan
.
18
: Sta
te o
f Flo
rida
Hea
lth In
vest
or H
ealth
Pla
nC
over
age
Perio
d: 0
1/01
/201
3 –
12/3
1/20
13Su
mm
ary
of B
enef
its a
nd C
over
age:
Wha
t thi
s P
lan
Cov
ers
& W
hat i
t Cos
tsC
over
age
for:
Indi
vidu
al +
Fam
ily |
Plan
Typ
e: H
MO
2
of 7
SF
-Sta
te o
f Flo
rida-
HIH
P-13
Are
ther
e se
rvic
es th
is
plan
doe
sn’t
cove
r?
Yes
. So
me
of th
e se
rvice
s thi
s plan
doe
sn’t
cove
r are
list
ed o
n pa
ge 4
. See
you
r pol
icy o
r pl
an d
ocum
ent f
or a
dditi
onal
info
rmat
ion
abou
t exc
lude
d se
rvic
es.
•C
opay
men
ts a
re fi
xed
dolla
r am
ount
s (fo
r exa
mpl
e, $1
5) y
ou p
ay fo
r cov
ered
hea
lth c
are,
usua
lly w
hen
you
rece
ive
the
serv
ice.
•C
oins
uran
ce is
your
shar
e of
the
cost
s of a
cov
ered
serv
ice, c
alcul
ated
as a
per
cent
of t
he a
llow
ed a
mou
nt fo
r the
serv
ice. F
or e
xam
ple,
if th
e pl
an’s
allo
wed
am
ount
for a
n ov
erni
ght h
ospi
tal s
tay
is $1
,000
, you
r coi
nsur
ance
pay
men
t of 2
0% w
ould
be
$200
. Th
is m
ay c
hang
e if
you
have
n’t m
et y
our d
educ
tible
. •
The
amou
nt th
e pl
an p
ays f
or c
over
ed se
rvice
s is b
ased
on
the
allo
wed
am
ount
. If a
n ou
t-of-n
etw
ork
prov
ider
cha
rges
mor
e th
an th
e al
low
ed a
mou
nt, y
ou m
ay h
ave
to p
ay th
e di
ffere
nce.
For e
xam
ple,
if an
out
-of-n
etw
ork
hosp
ital c
harg
es $
1,50
0 fo
r an
over
nigh
t sta
y an
d th
e al
low
ed a
mou
nt is
$1,
000,
you
may
hav
e to
pay
the
$500
diff
eren
ce. (
This
is ca
lled
bala
nce
billi
ng.)
•Th
is pl
an m
ay e
ncou
rage
you
to u
se A
vMed
net
wor
k pr
ovid
ers
by c
harg
ing
you
low
er d
educ
tible
s, co
paym
ents
and
coi
nsur
ance
am
ount
s.
Your
Cos
t If Y
ou U
se a
n
Com
mon
Med
ical
Eve
nt
Serv
ices
You
May
N
eed
AvM
ed n
etw
ork
Pro
vide
r O
ut-o
f-ne
twor
k Pr
ovid
erLi
mita
tions
& E
xcep
tions
If y
ou v
isit
a he
alth
car
e pr
ovid
er’s
offi
ce
or c
linic
Prim
ary
care
visi
t to
treat
an
inju
ry o
r illn
ess
20%
coi
nsur
ance
afte
r ded
uctib
le N
ot C
over
ed
Add
ition
al ch
arge
s will
app
ly fo
r non
-pr
even
tive
serv
ices p
erfo
rmed
in th
e Ph
ysici
an’s
offic
e. Sp
ecial
ist v
isit
20%
coi
nsur
ance
afte
r ded
uctib
le N
ot C
over
ed
Oth
er p
ract
ition
er o
ffice
vi
sit
20%
coi
nsur
ance
afte
r ded
uctib
le/
chiro
prac
tic se
rvice
s N
ot C
over
ed
Lim
ited
to 6
0 vi
sits p
er in
jury
.
Prev
entiv
e ca
re/s
cree
ning
/im
mun
izat
ion
No
Char
ge
Not
Cov
ered
N
one
If y
ou h
ave
a te
st
Diag
nost
ic te
st (x
-ray,
bloo
d w
ork)
20
% c
oins
uran
ce a
fter d
educ
tible
Not
Cov
ered
Ce
rtain
serv
ices r
equi
re p
rior a
utho
rizat
ion.
Ch
arge
s for
offi
ce v
isits
will
also
app
ly if
serv
ices a
re p
erfo
rmed
in a
Phy
sician
’s of
fice.
Im
agin
g (C
T/PE
T sc
ans,
MRI
s)
20%
coi
nsur
ance
afte
r ded
uctib
le N
ot C
over
ed
19
: Sta
te o
f Flo
rida
Hea
lth In
vest
or H
ealth
Pla
nC
over
age
Perio
d: 0
1/01
/201
3 –
12/3
1/20
13Su
mm
ary
of B
enef
its a
nd C
over
age:
Wha
t thi
s P
lan
Cov
ers
& W
hat i
t Cos
tsC
over
age
for:
Indi
vidu
al +
Fam
ily |
Plan
Typ
e: H
MO
3
of 7
SF
-Sta
te o
f Flo
rida-
HIH
P-13
Your
Cos
t If Y
ou U
se a
n
Com
mon
Med
ical
Eve
nt
Serv
ices
You
May
N
eed
AvM
ed n
etw
ork
Pro
vide
r O
ut-o
f-ne
twor
k Pr
ovid
erLi
mita
tions
& E
xcep
tions
If y
ou n
eed
drug
s to
trea
t yo
ur il
lnes
s or
co
nditi
on
Mor
e in
form
atio
n ab
out
pres
crip
tion
drug
co
vera
ge is
av
ailab
le at
w
ww
.med
co.co
m.
Gen
eric
drug
s 30
% c
oins
uran
ce a
fter d
educ
tible/
pr
escr
iptio
n (re
tail
or m
ail o
rder
) N
ot C
over
ed
Pres
crip
tion
drug
cov
erag
e is
prov
ided
th
roug
h M
edco
. For
a li
st o
f par
ticip
atin
g ph
arm
acies
, plea
se c
all M
edco
at 1
-877
-531
-47
93 o
r visi
t ww
w.m
edco
.com
. Co
vers
up
to a
30-
day
supp
ly fo
r ret
ail
pres
crip
tions
; 31-
90 d
ay su
pply
for m
ail o
rder
pr
escr
iptio
ns. C
erta
in d
rugs
requ
ire p
rior
auth
oriz
atio
n an
d/or
are
subj
ect t
o qu
antit
y lim
its. B
rand
add
ition
al ch
arge
may
app
ly.
Pref
erre
d br
and
drug
s 30
% c
oins
uran
ce a
fter d
educ
tible/
pr
escr
iptio
n (re
tail
or m
ail o
rder
) N
ot C
over
ed
Non
-pre
ferr
ed b
rand
dr
ugs
50%
coi
nsur
ance
afte
r ded
uctib
le/
pres
crip
tion
(reta
il or
ord
er)
Not
Cov
ered
Spec
ialty
dru
gs
Pref
erre
d br
and
Spec
ialty
dru
gs:
30%
coi
nsur
ance
afte
r ded
uctib
le/
pres
crip
tion
(reta
il or
ord
er)/
N
on-p
refe
rred
bra
nd S
pecia
lty
drug
s:
50%
coi
nsur
ance
afte
r ded
uctib
le/
pres
crip
tion
(reta
il or
ord
er)
Not
Cov
ered
If y
ou h
ave
outp
atie
nt
surg
ery
Facil
ity fe
e (e
.g.,
ambu
lator
y su
rger
y ce
nter
)20
% c
oins
uran
ce a
fter d
educ
tible
Not
Cov
ered
Ce
rtain
serv
ices r
equi
re p
rior a
utho
rizat
ion.
Ch
arge
s for
offi
ce v
isits
will
also
app
ly if
serv
ices a
re p
erfo
rmed
in a
ny P
hysic
ian’s
offic
e Ph
ysici
an/s
urge
on fe
es
20%
coi
nsur
ance
afte
r ded
uctib
le N
ot C
over
ed
If y
ou n
eed
imm
edia
te
med
ical
att
entio
n
Em
erge
ncy
room
serv
ices
20%
coi
nsur
ance
afte
r ded
uctib
le Sa
me
as A
vMed
ne
twor
k
AvM
ed m
ust b
e no
tified
with
in 2
4 ho
urs o
f em
erge
ncy
adm
issio
n or
as s
oon
as re
ason
ably
poss
ible.
E
mer
genc
y m
edica
l tra
nspo
rtatio
n 20
% c
oins
uran
ce a
fter d
educ
tible
Sam
e as
AvM
ed
netw
ork
Whe
n pr
e-au
thor
ized
, or i
n th
e ca
se o
f em
erge
ncy.
Urg
ent c
are
20%
coi
nsur
ance
afte
r ded
uctib
le Sa
me
as A
vMed
ne
twor
k N
one
If y
ou h
ave
a ho
spita
l sta
y
Facil
ity fe
e (e
.g.,
hosp
ital
room
) 20
% c
oins
uran
ce a
fter d
educ
tible
Not
Cov
ered
Pr
ior a
utho
rizat
ion
requ
ired.
Ph
ysici
an/s
urge
on fe
e 20
% c
oins
uran
ce a
fter d
educ
tible
Not
Cov
ered
20
: Sta
te o
f Flo
rida
Hea
lth In
vest
or H
ealth
Pla
nC
over
age
Perio
d: 0
1/01
/201
3 –
12/3
1/20
13Su
mm
ary
of B
enef
its a
nd C
over
age:
Wha
t thi
s P
lan
Cov
ers
& W
hat i
t Cos
tsC
over
age
for:
Indi
vidu
al +
Fam
ily |
Plan
Typ
e: H
MO
4
of 7
SF
-Sta
te o
f Flo
rida-
HIH
P-13
Your
Cos
t If Y
ou U
se a
n
Com
mon
Med
ical
Eve
nt
Serv
ices
You
May
N
eed
AvM
ed n
etw
ork
Pro
vide
r O
ut-o
f-ne
twor
k Pr
ovid
erLi
mita
tions
& E
xcep
tions
If y
ou h
ave
men
tal h
ealth
, be
havi
oral
he
alth
, or
subs
tanc
e ab
use
need
s
Men
tal/
Beha
vior
al he
alth
outp
atien
t ser
vice
s 20
% c
oins
uran
ce a
fter d
educ
tible
Not
Cov
ered
N
one
Men
tal/
Beha
vior
al he
alth
inpa
tient
serv
ices
20%
coi
nsur
ance
afte
r ded
uctib
le N
ot C
over
ed
Prio
r aut
horiz
atio
n re
quire
d.
Subs
tanc
e us
e di
sord
er
outp
atien
t ser
vice
s 20
% c
oins
uran
ce a
fter d
educ
tible
Not
Cov
ered
N
one
Subs
tanc
e us
e di
sord
er
inpa
tient
serv
ices
20%
coi
nsur
ance
afte
r ded
uctib
le N
ot C
over
ed
Prio
r aut
horiz
atio
n re
quire
d.
If y
ou a
re
preg
nant
Pren
atal
and
post
nata
l ca
re
20%
coi
nsur
ance
afte
r ded
uctib
le N
ot C
over
ed
Non
e
Deli
very
and
all
inpa
tient
se
rvice
s 20
% c
oins
uran
ce a
fter d
educ
tible
Not
Cov
ered
Pr
ior a
utho
rizat
ion
requ
ired.
If y
ou n
eed
help
re
cove
ring
or
have
oth
er
spec
ial h
ealth
ne
eds
Hom
e he
alth
care
20
% c
oins
uran
ce a
fter d
educ
tible
Not
Cov
ered
A
ppro
ved
treat
men
t plan
requ
ired.
Reha
bilit
atio
n se
rvice
s 20
% c
oins
uran
ce a
fter d
educ
tible
Not
Cov
ered
Phys
ical,
spee
ch &
occ
upat
iona
l the
rapi
es
limite
d to
60
visit
s per
inju
ry.
Cove
rage
for a
ll se
rvice
s rela
ted
to tr
eatm
ent
of A
utism
Spe
ctru
m D
isord
er is
lim
ited
to
$36,
000
annu
ally
& $
200,
000
lifet
ime.
Hab
ilita
tion
serv
ices
Not
Cov
ered
N
ot C
over
ed
Non
e
Skill
ed n
ursin
g ca
re
20%
coi
nsur
ance
afte
r ded
uctib
le N
ot C
over
ed
Lim
ited
to 6
0 da
ys p
er c
alend
ar y
ear.
Prio
r au
thor
izat
ion
requ
ired.
D
urab
le m
edic
al eq
uipm
ent
20%
coi
nsur
ance
afte
r ded
uctib
le N
ot C
over
ed
Non
e
Hos
pice
serv
ice
20%
coi
nsur
ance
afte
r ded
uctib
le N
ot C
over
ed
Phys
ician
cer
tifica
tion
requ
ired.
Lim
ited
to
210
calen
dar d
ays p
er li
fetim
e. If
you
r chi
ld
need
s de
ntal
or
eye
care
Eye
exa
m
20%
coi
nsur
ance
afte
r ded
uctib
le N
ot C
over
ed
Lim
ited
to o
ne e
xam
per
yea
r G
lasse
s N
ot C
over
ed
Not
Cov
ered
N
one
Den
tal c
heck
-up
Not
Cov
ered
N
ot C
over
ed
Non
e
21
: Sta
te o
f Flo
rida
Hea
lth In
vest
or H
ealth
Pla
nC
over
age
Perio
d: 0
1/01
/201
3 –
12/3
1/20
13Su
mm
ary
of B
enef
its a
nd C
over
age:
Wha
t thi
s P
lan
Cov
ers
& W
hat i
t Cos
tsC
over
age
for:
Indi
vidu
al +
Fam
ily |
Plan
Typ
e: H
MO
5
of 7
SF
-Sta
te o
f Flo
rida-
HIH
P-13
Excl
uded
Ser
vice
s &
Oth
er C
over
ed S
ervi
ces:
Serv
ices
You
r Pla
n D
oes
NO
T C
over
(Thi
s is
n’t a
com
plet
e lis
t. C
heck
you
r pol
icy
or p
lan
docu
men
t for
oth
er e
xclu
ded
serv
ices
.)
•A
cupu
nctu
re
•Ba
riatri
c su
rger
y •
Cosm
etic
surg
ery
•D
enta
l car
e
•H
abili
tatio
n se
rvice
s •
Hea
ring
aids
•In
ferti
lity
treat
men
t •
Long
-term
car
e
•N
on-e
mer
genc
y ca
re w
hen
trave
ling
outs
ide
the
U.S
. •
Priv
ate
duty
nur
sing
•Ro
utin
e fo
ot c
are
•W
eight
loss
pro
gram
s
Oth
er C
over
ed S
ervi
ces
(Thi
s is
n’t a
com
plet
e lis
t. C
heck
you
r pol
icy
or p
lan
docu
men
t for
oth
er c
over
ed s
ervi
ces
and
your
cos
ts fo
r the
se
serv
ices
.)
•Ch
iropr
actic
car
e •
Rout
ine
eye
care
(Adu
lt)
Your
Rig
hts
to C
ontin
ue C
over
age:
If
you
lose
cov
erag
e un
der t
he p
lan, t
hen,
dep
endi
ng u
pon
the
circu
mst
ance
s, Fe
dera
l and
Sta
te la
ws m
ay p
rovi
de p
rote
ctio
ns th
at a
llow
you
to k
eep
healt
h co
vera
ge. A
ny su
ch ri
ghts
may
be
limite
d in
dur
atio
n an
d w
ill re
quire
you
to p
ay a
pre
miu
m, w
hich
may
be
signi
fican
tly h
ighe
r tha
n th
e pr
emiu
m y
ou p
ay
whi
le co
vere
d un
der t
he p
lan. O
ther
lim
itatio
ns o
n yo
ur ri
ghts
to c
ontin
ue c
over
age
may
also
app
ly.
For m
ore
info
rmat
ion
on y
our r
ight
s to
cont
inue
cov
erag
e, co
ntac
t the
plan
at 1
-888
-762
-863
3. Y
ou m
ay a
lso c
onta
ct y
our s
tate
insu
ranc
e de
partm
ent,
the
U.S
. Dep
artm
ent o
f Lab
or, E
mpl
oyee
Ben
efits
Sec
urity
Adm
inist
ratio
n at
1-8
66-4
44-3
272
or w
ww
.dol
.gov
/ebs
a, or
the
U.S
. Dep
artm
ent o
f Hea
lth a
nd
Hum
an S
ervi
ces a
t 1-8
77-2
67-2
323
x615
65 o
r ww
w.cc
iio.cm
s.gov
.
Your
Grie
vanc
e an
d A
ppea
ls R
ight
s:
If y
ou h
ave
a co
mpl
aint o
r are
diss
atisf
ied w
ith a
den
ial o
f cov
erag
e fo
r clai
ms u
nder
you
r plan
, you
may
be
able
to a
ppea
l or f
ile a
gri
evan
ce.
For
ques
tions
abo
ut y
our r
ight
s, th
is no
tice,
or a
ssist
ance
, you
can
con
tact
AvM
ed’s
Mem
ber S
ervi
ces D
epar
tmen
t at 1
-888
-762
-863
3.
For p
lans s
ubjec
t to
ERI
SA, y
ou m
ay a
lso c
onta
ct th
e U
.S. D
epar
tmen
t of L
abor
, Em
ploy
ee B
enef
its S
ecur
ity A
dmin
istra
tion
at 1
-866
-444
-327
2 or
w
ww
.dol
.gov
/ebs
a, or
the
U.S
. Dep
artm
ent o
f Hea
lth a
nd H
uman
Ser
vice
s at 1
-877
-267
-232
3 x6
1565
or w
ww
.cciio
.cms.g
ov.
Lang
uage
Acc
ess
Serv
ices
: Pa
ra o
bten
er a
siste
ncia
en E
spañ
ol, l
lame
al 1-
888-
762-
8633
. ––
––––
––––
––––
––––
––––
To se
e exa
mples
of h
ow th
is pla
n mi
ght c
over
costs
for a
samp
le me
dical
situa
tion,
see th
e nex
t pag
e.–––
––––
––––
––––
––––
–––
22
: Sta
te o
f Flo
rida
Hea
lth In
vest
or H
ealth
Pla
nC
over
age
Perio
d: 0
1/01
/201
3 –
12/3
1/20
13C
over
age
Exam
ples
C
over
age
for:
Indi
vidu
al +
Fam
ily |
Plan
Typ
e: H
MO
6
of 7
SF
-Sta
te o
f Flo
rida-
HIH
P-13
Hav
ing
a ba
by
(nor
mal
deliv
ery)
M
anag
ing
type
2 d
iabe
tes
(rout
ine
main
tena
nce
of
a w
ell-c
ontro
lled
cond
ition
)
Abo
ut th
ese
Cov
erag
e Ex
ampl
es:
Thes
e ex
ampl
es sh
ow h
ow th
is pl
an m
ight
cov
er
med
ical c
are
in g
iven
situ
atio
ns. U
se th
ese
exam
ples
to se
e, in
gen
eral,
how
muc
h fin
ancia
l pr
otec
tion
a sa
mpl
e pa
tient
mig
ht g
et if
they
are
co
vere
d un
der d
iffer
ent p
lans.
Am
ount
ow
ed to
pro
vide
rs: $
7,54
0 Pl
an p
ays
$5,7
10
Patie
nt p
ays
$1,8
30
Sam
ple
care
cos
ts:
Hos
pita
l cha
rges
(mot
her)
$2,7
00Ro
utin
e ob
stet
ric c
are
$2,1
00H
ospi
tal c
harg
es (b
aby)
$9
00A
nest
hesia
$9
00La
bora
tory
test
s $5
00Pr
escr
iptio
ns
$200
Radi
olog
y $2
00V
accin
es, o
ther
pre
vent
ive
$40
Tot
al
$7,5
40 Pa
tient
pay
s:
dedu
ctib
les
$1,2
50Co
pays
$0
Coin
sura
nce
$430
Lim
its o
r exc
lusio
ns
$150
Tot
al
$1,8
30
Am
ount
ow
ed to
pro
vide
rs: $
5,40
0 Pl
an p
ays
$3,3
00
Patie
nt p
ays
$2,1
00
Sam
ple
care
cos
ts:
Pres
crip
tions
$2
,900
M
edica
l Equ
ipm
ent a
nd S
uppl
ies
$1,3
00
Offi
ce V
isits
and
Pro
cedu
res
$700
E
duca
tion
$300
La
bora
tory
test
s $1
00
Vac
cines
, oth
er p
reve
ntiv
e $1
00
Tot
al
$5,4
00
Patie
nt p
ays:
de
duct
ibles
$1
,250
Co
pays
$0
Co
insu
ranc
e $7
70
Lim
its o
r exc
lusio
ns
$80
Tot
al
$2,1
00
This
isno
t a c
ost
estim
ator
.
Don
’t us
e th
ese
exam
ples
to
estim
ate
your
act
ual c
osts
un
der t
his p
lan. T
he a
ctua
l ca
re y
ou re
ceiv
e w
ill b
e di
ffere
nt fr
om th
ese
exam
ples
, and
the
cost
of
that
car
e w
ill a
lso b
e di
ffere
nt.
See
the
next
pag
e fo
r im
porta
nt in
form
atio
n ab
out
thes
e ex
ampl
es.
23
: Sta
te o
f Flo
rida
Hea
lth In
vest
or H
ealth
Pla
nC
over
age
Perio
d: 0
1/01
/201
3 –
12/3
1/20
13C
over
age
Exam
ples
C
over
age
for:
Indi
vidu
al +
Fam
ily |
Plan
Typ
e: H
MO
Que
stio
ns: C
all 1
-888
-762
-863
3 or
visi
t us a
t ww
w.av
med
.org
/go/
stat
eIf
you
are
n’t c
lear a
bout
any
of t
he u
nder
lined
term
s use
d in
this
form
, see
the
Glo
ssar
y. Y
ou c
an v
iew th
e G
loss
ary
7 of
7at
ww
w.cc
iio.cm
s.gov
or c
all 1
-888
-762
-863
3 to
requ
est a
cop
y. SF
-Sta
te o
f Flo
rida-
HIH
P-13
Que
stio
ns a
nd a
nsw
ers
abou
t the
Cov
erag
e Ex
ampl
es:
Wha
t are
som
e of
the
assu
mpt
ions
beh
ind
the
Cov
erag
e Ex
ampl
es?
•Co
sts d
on’t
inclu
de p
rem
ium
s. •
Sam
ple
care
cos
ts a
re b
ased
on
natio
nal
aver
ages
supp
lied
by th
e U
.S.
Dep
artm
ent o
f Hea
lth a
nd H
uman
Se
rvice
s, an
d ar
en’t
spec
ific
to a
pa
rticu
lar g
eogr
aphi
c ar
ea o
r hea
lth p
lan.
•Th
e pa
tient
’s co
nditi
on w
as n
ot a
n ex
clude
d or
pre
exist
ing
cond
ition
. •
All
serv
ices a
nd tr
eatm
ents
star
ted
and
ende
d in
the
sam
e co
vera
ge p
erio
d.
•Th
ere
are
no o
ther
med
ical e
xpen
ses f
or
any
mem
ber c
over
ed u
nder
this
plan
. •
Out
-of-p
ocke
t exp
ense
s are
bas
ed o
nly
on tr
eatin
g th
e co
nditi
on in
the
exam
ple.
•Th
e pa
tient
rece
ived
all
care
from
in-
netw
ork
prov
ider
s . If
the
patie
nt h
ad
rece
ived
car
e fr
om o
ut-o
f-net
wor
k pr
ovid
ers ,
cost
s wou
ld h
ave
been
hig
her.
Wha
t doe
s a
Cov
erag
e Ex
ampl
e sh
ow?
For e
ach
treat
men
t situ
atio
n, th
e Co
vera
ge
Exa
mpl
e he
lps y
ou se
e ho
w d
educ
tible
s , co
paym
ents
, and
coi
nsur
ance
can
add
up.
It
also
help
s you
see
wha
t exp
ense
s mig
ht b
e lef
t up
to y
ou to
pay
bec
ause
the
serv
ice o
r tre
atm
ent i
sn’t
cove
red
or p
aym
ent i
s lim
ited.
Doe
s th
e C
over
age
Exam
ple
pred
ict m
y ow
n ca
re n
eeds
?
No.
Tre
atm
ents
show
n ar
e ju
st e
xam
ples
. Th
e ca
re y
ou w
ould
rece
ive
for t
his
cond
ition
cou
ld b
e di
ffere
nt b
ased
on
your
do
ctor
’s ad
vice
, you
r age
, how
serio
us y
our
cond
ition
is, a
nd m
any
othe
r fac
tors
. D
oes
the
Cov
erag
e Ex
ampl
e pr
edic
t my
futu
re e
xpen
ses?
No.
Cov
erag
e E
xam
ples
are
not
cos
t es
timat
ors.
You
can
’t us
e th
e ex
ampl
es to
es
timat
e co
sts f
or a
n ac
tual
cond
ition
. The
y ar
e fo
r com
para
tive
purp
oses
onl
y. Y
our
own
cost
s will
be
diffe
rent
dep
endi
ng o
n th
e ca
re y
ou re
ceiv
e, th
e pr
ices y
our
prov
ider
s ch
arge
, and
the
reim
burs
emen
t yo
ur h
ealth
plan
allo
ws.
Can
I us
e C
over
age
Exam
ples
to
com
pare
pla
ns?
Yes
. Whe
n yo
u lo
ok a
t the
Sum
mar
y of
Be
nefit
s and
Cov
erag
e fo
r oth
er p
lans,
you’
ll fin
d th
e sa
me
Cove
rage
Exa
mpl
es.
Whe
n yo
u co
mpa
re p
lans,
chec
k th
e “P
atien
t Pay
s” b
ox in
eac
h ex
ampl
e. Th
e sm
aller
that
num
ber,
the
mor
e co
vera
ge
the
plan
pro
vide
s.
Are
ther
e ot
her c
osts
I sh
ould
co
nsid
er w
hen
com
parin
g pl
ans?
Yes
. An
impo
rtant
cos
t is t
he p
rem
ium
yo
u pa
y. G
ener
ally,
the
low
er y
our
prem
ium
, the
mor
e yo
u’ll
pay
in o
ut-o
f-po
cket
cos
ts, s
uch
as c
opay
men
ts,
dedu
ctib
les,
and
coin
sura
nce.
You
sh
ould
also
con
sider
con
tribu
tions
to
acco
unts
such
as h
ealth
savi
ngs a
ccou
nts
(HSA
s), f
lexib
le sp
endi
ng a
rran
gem
ents
(F
SAs)
or h
ealth
reim
burs
emen
t acc
ount
s (H
RAs)
that
help
you
pay
out
-of-p
ocke
t ex
pens
es.
24
25
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40
SF-3612 (8/12)
2013 Health Plan Enrollment Information
*Highest overall rating of statewide plans reporting Health Maintenance Organization (HMO) and Point of Service (POS) product data to the National Committee for Quality Assurance (NCQA) for the Consumer Assessment of Healthcare Providers and Systems (CAHPS®). CAHPS® is a registered trademark of the Agency of Healthcare Research and Quality (AHRQ).
Need More Information? Get It OnlineWhether you need to know the difference between a co-payment
and co-insurance, need to find a doctor, or want more information
about your benefits, call visit www.avmed.org/go/state, or call
1-888-762-8633.
