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) ) o \ I determination of whether a covered item will be paid under the DME, orthotics or prosthetics benefits will be based upon its classification as defIDed by the Centers for Medicare and Medicaid Services. See Schedule of Benefits for any Co-payments or Limitations. See Part XII for Exclusions. 10.30 Second medical opinions. The Member is entitled to a second medical opinion when he disputes the appropriateness or necessity of a surgical procedure or is subject to a serious injury or illness. 10.30.01 The Member may obtain a second medical opinion from any physician who is within AvMed's Service Area If you chose a Participating Physician, there is no prior authorization requirement. You pay only the applicable Co-payment or Deductible and Co-insurance. If you choose a non-participating physician, the service is subject to prior authorization requirements. You are also responsible for 40% of the amount of the Maximum Allowable Payment associated with the consultation. 10.30.02 Any tests that may be required to render the second medical opinion must be arranged by AvMed and performed by Participating Providers. Once a second medical opinion has been rendered, AvMed shall review and determine AvMed's obligations under the Contract and that judgment is controlling. Any treatment the Member obtains that is not authorized by AvMed shal1 he at the Member's expense. 10.30.03 AvMed may limit second medical opinions in connection with a particular diagnosis or treatment to 3 per calendar year, if AvMed deems additional opinions to be an unreasonable over-utilization by the Member. 10.31 Skilled Home Health Care Services. Home Health Care Services (as defmed in Section 3.22) are covered as outlined on the Schedule of Benefits when ordered by and under the direction of the Member's Attending Physician. Physical, occupational or speech therapy services provided in the home are limited as noted in Section 10.28. Home Health Care Services that do not include a medical, diagnostic, therapeutic or rehabilitative component, or that do not require the skill of a registered nurse, licensed practical (vocational) nurse or other healthcare personnel are not covered. Homemaker or other, Custodial Care services are not covered. 10.32 Spinal manipulations will be covered only when Medical1y Necessary and prescribed by a Participating Physician or by self-referral to a Participating Physician. 10.33 Supplies. Ostorny, urostomy and wound care supplies, and urinary catheter bags are covered when Medical1y Necessary. Provision of ostomy and urostomy supplies are lirnited to a one-month supply every 30 days. Coverage is limited to $2,500 per Contract Year, subject to applicable Co-payments and Co-Insurance. Items which are not medical supplies or which could be used by the Member or a farnily member for purposes other than ostomy care are not covered. 10.34 Urgent Care services. Al1 necessary and covered services received in Urgent Care or Immediate Care Centers or rendered in your Primary Care Physician's office after-hours for conditions as described in Section 3.50 will be covered by AvMed. See Schedule of Benefits for details. In addition, any Mernber requests for reimbursement (of payment rnade by the Member for services rendered) must be filed within 90 days after the emergency or as soon as reasonably possible but not later than one year unless the Claimant was legal1y incapacitated. 10.35 Ventilator dependent care. With prior authorization by AvMed, ventilator dependent care (see Section 3.53) is covered up to a total of 100 days lifetime maximum benefit. XI. LIMITATIONS OF BASIC BENEFITS 28 A V -Gl 00-2009 MP-5319 (10/09)