Plan Basics

Healthcare can be intricate but AvMed wants to ensure you understand your benefits. This information is important to help you become familiar with your health plan.

With AvMed Individual Health, you may choose from an extensive, strong network of participating health care service providers. In-network benefits will provide you the most value for your health care dollars.

• More than 21,000 physicians, specialists and hospitals provide AvMed members access to quality medical care in every major metropolitan area of the state.
• You can access AvMed’s providers on our Web site at www.avmed.org

Although you are not required to select a Primary Care Physician, AvMed encourages you to develop a unique and valuable relationship with one. A primary care physician will oversee and coordinate your health care needs.

AvMed In-Network Providers/Facilities
Consists of AvMed network providers within the AvMed service area. Typically, your out-of-pocket expenses will be lowest when care is received from AvMed providers in the AvMed Network. Covered services will be paid at the highest level of your plan benefits.

PHCS National Network Providers/Facilities
Our national network partner, Private Healthcare Systems (PHCS), is a supplemental network available to you at your in-network benefit level. These providers and facilities are available to you outside of AvMed’s service area, either in Florida or nationwide. This will help keep your out-of-pocket expenses lower than if you were seeking care from an out-of-network provider.

Out-of-Network Providers/Facilities
As an AvMed Individual Health member, you also have the option of going to hospitals and physicians outside both AvMed networks and the PHCS network, anywhere in the United States. Your out-of-pocket expenses would be highest in this case, regardless of whether you receive care in or out of the AvMed service area. Covered services will be paid at the lowest level of your plan benefits. Because there are no contracts with these providers, you may be billed the difference between the billed charge and the usual, reasonable and customary fee allowance covered by your plan.

Preventive Care
AvMed strongly believes that preventive health is the cornerstone to staying healthy. That is why your plans do not make Preventive Care services subject to your in-network calendar year deductible. AvMed truly wants our members to take an active role in managing their health and wellness. We encourage you to get the proper age and gender specific screenings and immunizations to keep you healthy and prevent future health problems. Some of the most common covered Preventive Care Services are:

• Annual physicals including labs
• Child and adult immunizations
• Well child care
• Screening services
• Mammography
• Well Woman Exams (PAP)
• PSA tests for males

AvMed Easy
The AvMed Easy Plan offers predictable out-of-pocket costs and a broad network of providers. This plan is easy to use and features: co-payment only, no co-insurance, direct access to specialists without referrals, emergency worldwide coverage and no waiting period for preventives services.

AvMed Elite
The AvMed Elite Plan offers access to any doctor or visit any hospital, anywhere in the United States. Co-payments, deductibles and co-insurance vary depending on the network selected.

AvMed HSA-Qualified
The AvMed HSA-Qualified Plan is a high-deductible health plan (HDHP) that can be paired with a Health Savings Account (HSA)¹. An HSA is a tax-free account that you can use as a long-term savings fund for health care expenses. The AvMed HSA-Qualified Plan puts you in control. Use AvMed’s easy Online consumer Tools to make informed and cost-conscious health care decisions.

• Subject to IRS regulation

Terms You Should Know
Co-payment: A fixed fee paid by you to the provider for covered medical services.

Co-Insurance: a percentage you must pay toward the cost of covered services once the deductible has been met. The co-insurance amount will vary depending on the network selected.

Deductible: An annual deductible is the amount you pay for covered services before the plan will begin to pay for these services. A new deductible must be met each calendar year. You must meet your in-network deductible separate than your out-of-network deductible. Deductible amounts can be found on your Schedule of Benefits.

Out-of-Pocket Max: To protect you from catastrophic costs, AvMed's plans include an annual out-of-pocket max to protect you. The out-of-pocket max is the total amount per calendar year you will pay for covered services, after you have met your deductible. After the out-of-pocket is met, AvMed will pay 100% of your covered services until the following calendar year.

• Note: Certain services in your plan may not count towards your out-of-pocket max; see your Schedule of Benefits for more information on your plan design.