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877-280-0010 — www.avalonhealthcare.comAVAfp04 04/06
Plans for Small and Mid-Sized Companies
1
At Avalon Healthcare we believe that rapid
change is coming in the way Floridians will buy
and use their healthcare insurance. Employers
are looking for better ways to manage healthcare
costs while continuing to provide appropriate
coverage for employees. Consumers are taking
charge of their own healthcare both physically
and financially.
In response to this monumental change,
employers are giving their employees new kinds
of health insurance coverage like the Avalon High
Deductible Focus Health Benefit Plans and Avalon
Focus HSA Health Benefit Plans. With the help
of these new plans they are providing new tools
that allow employees to make personal, educated
healthcare decisions.
Avalon acts both as an insurer and as a conduit
for employers and Members seeking:
The best possible care at an affordable price
Plan designs in tune with today's
healthcare marketplace
Tools to manage care from the consumer
perspective
Important answers to healthcare questions such
as what doctors or hospitals to visit, how claims
are paid and who is responsible for paying
them, and detailed information on new plan
designs and benefits available
How best to plan for future healthcare
spending through health savings tools
such as Health Savings Accounts (HSAs)
The Future is NowAvalon Healthcare offers a variety of PPO health
benefit plan options for any size employer
looking for a logical, affordable approach to
providing health benefits without breaking the
bank. With the help of their brokers, employers
can sign up for Avalon High Deductible Focus
Plans or Avalon Focus HSA plans.
And under Florida law, employers without health
insurance coverage and with less than 50
employees can now offer their employees the
option of buying individual insurance coverage
through their employer. So, individuals seeking
greater personal control of their own healthy
lifestyles can purchase our Avalon IFOCUS
Health Benefit Plans.
For more information on these plans visit:
www.avalonhealthcare.com/individual
877-280-0010 — www.avalonhealthcare.com2
Focusing on the Future of Healthcare
Technology Designed to Help, not Hinder
Technology has changed the way we live and work.
Employers need faster, more economical ways to
manage their business, providing less hassle and
paperwork whenever possible. They want health
insurance products and services that address changing
technology needs yet are simple to manage and
understand. Avalon provides paperless on-line
solutions that are easy to access and navigate.
Services offered on-line include:
Employer application and submission
Hospital, doctor and lab directory searches
Modifying employee coverages
Pharmacy searches and tools
Bill and claims status review
Premium payment options
Access to Health Savings Accounts
for each employee
Outstanding Customer Service is Critical
We know employers and Members don't want to
waste time chasing down outstanding medical
claims or solving protracted billing problems.
They need fast, efficient answers from a real
person, immediately. That's why when you call
Avalon for assistance you are connected to a
live voice.
While Avalon offers a variety of services on-line
we continue to support our employers, producers
and Members through traditional means. Call us.
E-mail us. Send information through the U.S.
mail. We'll respond quickly and with the right
answers. Most importantly, when seeking
service support, brokers, employers and Members
will always get a rapid response to help them
solve problems or answer questions whenever
they call.
Call a Nurse 24-7:
Optum™ Connect24 Services: Access for
all Avalon Members to a toll-free telephone
number to connect to a live nurse 24 hours
a day, seven days a week, 365 days a year.
877-843-5071
Visit Avalon’s Learning Center to find helpful
health information for all Avalon Members.
The Future Requires New Ways of Thinking about Healthcare
877-280-0010 — www.avalonhealthcare.com3
4
Information that Educates
Avalon Members can visit the Avalon Learning Center
on the Avalon Healthcare website to gain access to a
multitude of web locations that provide important
information on healthcare, managing and maximizing
healthcare costs and understanding new consumer
savings tools related to the consumer directed Health
Benefit Plans offered by Avalon. They include:
Answers to health information through the
WebMDTM website
Answers and advice on financial information
tied to health savings accounts (HSAs) through
multiple web links including the Federal
Government’s HSA web page and through
HSA Bank
E-mail access to Avalon for questions on
insurance and HSA banking products
Access to the Avalon CareSupport Program
Better CostControls
Avalon Members
are responsible for paying deductibles before
benefits become available. As a Member, you
want to be sure that the care you receive is the
highest quality at an affordable price. With the
Avalon CareSupport Program, we work with our
Members and their providers to help find the most
appropriate care setting at the right price. Your
primary care physician or specialist may be sending
you to a hospital or lab that costs considerably
more for identical services that can be rendered
at a less expensive location with equal or better
outcomes.
Before visiting a lab, hospital or specialist, call us
at: 866-949-5700 to find out how to maximize
your healthcare dollars.
Jack trusts that the doctor has sent him to the rightfacility. But is the price appropriate for the service?How would Jack know?
Jack calls the Avalon CareSupport Program hotline at 866-949-5700 to find out if he is getting the rightdeal for an MRI.
Jack learns that the location to which his doctor hassent him charges $1,400 for an MRI, which is morethan he has in his HSA account.
Jack also learns through the Avalon CareSupportProgram that his doctor has a good relationship withanother location down the street that charges $875for the same service.
The customer support person at the AvalonCareSupport Program helps Jack contact his doctorand move the MRI to the less expensive location, with equal or better outcomes, saving Jack $525.
Jack takes $875 out of his HSA account and pays for the MRI. His out-of-pocket cost is $0.
Here’s an example of how the Avalon CareSupport Program allows Members to become their ownhealth advocate, empowering them to find the best possible care while saving money.
866-949-5700
Jack is 45 years old with a wife and three children. He has an Avalon Focus HSA compatible health benefit plan. It is a $1,250 individual/$2,500 familydeductible plan.
Jack is responsible for his $1,250 deductible but becausehe has a family plan, under HSA rules, the entire $2,500family deductible needs to be reached before any benefits become eligible. Once he and/or his familyreaches the $2,500 deductible, Avalon pays 80% ofcoverage up to his $5,000 out-of-pocket (OOP) limit.
Jack’s employer has given him a pre-taxed amount of$1,250 to put into his HSA. Jack can use the HSA moneyto cover any healthcare needs including deductibles forcoverage, and non-covered services such as eye glasses. Any money not used during the year “rolls over”into the next year.
Jack goes to the doctor and learns that he needs anMRI. His doctor sends him to a nearby location wherethe doctor has “privileges”.
Jack has no idea what an MRI costs.
877-280-0010 — www.avalonhealthcare.com
An HSA is an account that a person can put a
limited amount of money into to save for medical
expenses not covered by their High Deductible
Health Plan (HDHP). HSAs provide security,
flexibility, savings, greater consumer control,
ownership, and the portability to take your account
with you. By having an HSA a person can also gain
certain tax advantages such as tax deductions when
contributing to the account, tax-free earnings
through investments and tax-free withdrawals for
qualified medical expenses. The account can
only be setup:
When an employee has a High Deductible
Health Benefit Plan (HDHP)
If no other first dollar medical coverage
is provided
If a person is not enrolled in Medicare
If a person is not claimed as a dependent on
someone else's tax return
HSAs are portable, meaning that account holders
can keep the HSA if they change jobs, become
unemployed, move to another state or change
marital status.
Contributions to an HSA can be made by both
employers and employees. For Individual HSAs,
the Member is responsible for making their own
contribution. They are easy to open, and Avalon
Healthcare can assist in setting up coverage.
To learn more about
HSAs including answers
to frequently asked questions visit the Avalon
website and click on links to get to the U.S.
Treasury Department's full service website (found
in the Avalon Learning Center) for HSAs or through
HSA Bank.
877-280-0010 — www.avalonhealthcare.com5
What is a Health Savings Account (HSA)?
Information provided by the U.S. Department of Treasury. (2005)
This chart indicates how much money a Member can put into an HSA to offset healthcare costs not covered by their HSA compatible HDHP Plan.
6877-280-0010 — www.avalonhealthcare.com
The Avalon Healthcare website offers Members
complete access to Avalon’s product and service
offerings from:
Finding the right doctor, hospital, dentist or
pharmacy immediately
Connection to the places that help educate
Members on today’s rapidly changing
healthcare market
Complete review of Avalon HDHP and
HSA options and what they mean to
the consumer
Real time review of claims that are pending or
paid through Member-secure and employer-
secure web locations
On-line review of a personalized and secure
HSA through HSA Bank
Avalon Members can choose between two high-quality, low cost, dental plans, each providing covered benefits for traditional preventive care and discounted fees for allother services. Working with our Dental provider,MCNA Dental, Members have access to twodental plans that provide no deductibles tomeet, no limits on dental services received and no restrictions due to age or pre-existingconditions.
MCNA Dental Plan 1This more economical plan includes comprehensive preventive care including:
One routine cleaning per year
Free exams
Free X-rays
Discounts on all other procedures
25% off on all Orthodontics, Periodontics, Endodontics, Oral Surgery, and Pedodontics
MCNA Dental Plan 2This plan includes comprehensive preventive care including:
Two routine cleanings per year
Free exams
Free X-rays
Discounts on all other procedures
25% off on all Orthodontics, Periodontics, Endodontics, Oral Surgery, and Pedodontics
Dental Plan Options
ADDITIONAL TOOLS & PRODUCTS
On-line Services to Help MembersBetter Manage Their Own Care
www.avalonhealthcare.com
Plan deductibles starting at $1,000
Office co-pay visits are $25 per visit
Attractive coinsurance options
Co-pay pharmacy plans
On-line support services such as doctor, hospital and pharmacy directories
A live voice to answer questions
Plan deductibles starting from $2,000 to $5,000
Deductibles and coinsurance for office visits, hospital stays and urgent care
Co-pay pharmacy plans
Attractive coinsurance options
HRA compatible
On-line support services such as doctor, hospital and pharmacy directories
A live voice to answer questions
PPO plan designs starting at a $1,250 deductible
Compatible with a third party administered HSA
Tax advantage option through the employer with the setup of an HSA
One stop setup and management of HSA through Avalon
On-line support services such as doctor, hospital and pharmacy directories
A live voice to answer questions
AVALON HEALTHCARE PPO FOCUS HEALTH BENEFIT PLAN OPTIONS
Avalon Focus Co-Pay Benefit Plans:
Avalon Focus HSACompatible Benefit Plans:
Avalon Focus High Deductible Plans:
AV
ALO
N F
OC
US
(GRO
UP)
PLA
NS A
VA
LON
FOC
US (G
ROU
P) PLAN
S
To get a live customer service person:
Brokers call: 877-280-0010
Employers and Members call:
866-469-2347
Office hours: 8:00 am - 6:00 pm EST.
877-280-0010 — www.avalonhealthcare.com7
8
SUMMARY OF HDHP PLAN OFFERINGS
A - 1A - 2
B - 1B - 2
C - 1C - 2C - 3C - 4C - 5
D - 1D - 2D - 3D - 4D - 5D - 6
E - 1E - 2E - 3E - 4E - 5E - 6E - 7E - 8
F - 1F - 2F - 3F - 4F - 5F - 6F - 7F - 8
$1,000$1,000
$1,500$1,500
$2,000$2,000$2,000$2,000$2,000
$2,500$2,500$2,500$2,500$2,500$2,500
$3,000$3,000$3,000$3,000$3,000$3,000$3,000$3,000
$5,000$5,000$5,000$5,000$5,000$5,000$5,000$5,000
$2,000$2,000
$3,000$3,000
$4,000$4,000$4,000$4,000$4,000
$5,000$5,000$5,000$5,000$5,000$5,000
$6,000$6,000$6,000$6,000$6,000$6,000$6,000$6,000
$10,000$10,000$10,000$10,000$10,000$10,000$10,000$10,000
90%80%
80%70%
100%80%70%60%60%
100%80%70%70%60%60%
100%100%80%80%70%70%60%60%
100%100%80%80%70%70%60%60%
70%60%
60%50%
80%60%50%40%40%
80%60%50%50%40%40%
80%80%60%60%50%50%40%40%
80%80%60%60%50%50%40%40%
$1,500$2,000
$2,000$2,500
$0$2,000$3,000$4,000$4,000
$0$2,500$3,500$3,500$4,500$4,500
$0$0
$3,000$3,000$4,000$4,000$5,000$5,000
$0$0
$5,000$5,000$6,000$6,000$7,000$7,000
$5,000$6,000
$7,000$8,000
$6,000$8,000
$10,000$12,000$12,000
$7,000$10,000$12,000$12,000$14,000$14,000
$10,000$10,000$12,000$12,000$14,000$14,000$16,000$16,000
$18,000$18,000$20,000$20,000$22,000$22,000$24,000$24,000
$3,000$4,000
$4,000$5,000
$2,000$4,000$6,000$8,000$8,000
$2,000$5,000$7,000$7,000$9,000$9,000
$4,000$4,000$6,000$6,000$8,000$8,000
$10,000$10,000
$8,000$8,000
$10,000$10,000$12,000$12,000$14,000$14,000
$2,500$3,000
$3,500$4,000
$2,000$4,000$5,000$6,000$6,000
$2,500$5,000$6,000$6,000$7,000$7,000
$3,000$3,000$6,000$6,000$7,000$7,000$8,000$8,000
$5,000$5,000
$10,000$10,000$11,000$11,000$12,000$12,000
$25$25
$25$25
$25$25$25$25N/A
$25$25$25N/A$25N/A
$25N/A$25N/A$25N/A$25N/A
$25N/A$25N/A$25N/A$25N/A
BENEFITPreventive Care
Inpatient Care
Other
Riders
Adult Annual Physical ExamWell Child Care (to age 16)Well Woman CareMammography Exams (based on established guidelines)
$25 Co-pay - Deductible Waived$25 Co-pay - Deductible Waived$25 Co-pay - Deductible Waived
Covered at 100%
$25 Co-payDeductible and CoinsuranceDeductible and CoinsuranceDeductible and CoinsuranceDeductible and CoinsuranceDeductible and CoinsuranceDeductible and CoinsuranceDeductible and CoinsuranceDeductible and CoinsuranceDeductible and Coinsurance
Deductible and CoinsuranceDeductible and CoinsuranceDeductible and CoinsuranceDeductible and CoinsuranceDeductible and CoinsuranceDeductible and CoinsuranceDeductible and CoinsuranceDeductible and CoinsuranceDeductible and CoinsuranceDeductible and Coinsurance
Deductible and CoinsuranceDeductible and CoinsuranceDeductible and Coinsurance
Deductible and CoinsuranceDeductible and CoinsuranceDeductible and Coinsurance
Deductible and CoinsuranceDeductible and CoinsuranceDeductible and CoinsuranceDeductible and CoinsuranceDeductible and Coinsurance
Deductible and CoinsuranceDeductible and CoinsuranceDeductible and Coinsurance
$25 OB-GYN VisitDeductible and Coinsurance
See Rider SummarySee Rider SummarySee Rider Summary
$5 Million
Coinsurance - Deductible Waived Coinsurance - Deductible WaivedCoinsurance - Deductible Waived
Covered at 100%
PCP Office VisitsSpecialist Office VisitsEmergency Room (based on guidelines)3
Diagnostic X-Ray and LabComplex Imaging (MRI, MRA, CAT, PET)4
Surgery, Pre-Surgical TestingSecond Surgical OpinionsAllergy Testing and TreatmentChiropractic Care (15 visits/calendar year)Outpatient Rehab Services (60 visits/calendar year)4
Inpatient Hospital (semi-private room)4
Surgery, Surgical Assistant, Anesthesia 4
Skilled Nursing Facility (30 days/calendar year)4
Home Health Care (30 visits/calendar year)4
Durable Medical Equipment ($2,000 maximum/calendar year)4
Orthotics and Prosthetics ($2,000 maximum/calendar year)4
Maternity4
Ambulance Services for non-emergency transport ($2,000 per calendar year)4
Lifetime Maximum
Mental/Nervous Alcohol & Substance Abuse Prescription Drugs (administered through MedcoTM)
Member Pays Member PaysIN-NETWORK1 OUT-OF-NETWORK2
Office/Outpatient Care
1. Network varies by region. 2. Out-of-network services are those from a provider that does not participate in one of Avalon’s regional networks. 3. Must notify Avalon Medical Management within 24 hours or reasonably thereafter.4. These services require pre-certification from Avalon. Please call (866) 469-2347. Failure to pre-certify
prior to receiving services will result in a reduction in benefits by 50% of the allowed amount. NOTE: All benefit cost-sharing subject to the Allowance as defined in the Plan.
This is a benefit summary. It is intended for informational purposes only, and doesnot represent a full description of benefits provided. For a complete description of
benefits and exclusions, please refer to the insurance policy certificate and schedule of benefits.
COVERAGE - Family Deductibles and OOP Maximums are equal to 2.0 times the Individual Coverage Amounts.
OUT-OF-NETWORKFOCUS
PLANSDEDUCTIBLE DEDUCTIBLECOINSURANCE COINSURANCE
PCPCO-PAY
IN-NETWORKCOINS OOP MAX COINS OOP MAX
ANNUAL OOPMAX
ANNUAL OOPMAX
9
SUMMARY OF HSA ELIGIBLE PLANS
FOCUS HSA PLANS FOR GROUPS WITH 2 - 50 ELIGIBLE EMPLOYEES
HSA - A1
HSA - B1
HSA - C1HSA - C2HSA - C3
HSA - D1HSA - D2
HSA - E1HSA - E2
HSA - F1
$1,250
$1,500
$2,000$2,000$2,000
$2,500$2,500
$3,000$3,000
$5,000
$1,250
$2,000
$0$2,000$3,000
$0$2,500
$0$2,000
$0
$2,500
$3,500
$2,000$4,000$5,000
$2,500$5,000
$3,000$5,000
$5,000
$2,500
$3,000
$4,000$4,000$4,000
$5,000$5,000
$6,000$6,000
$10,000
$2,500
$4,000
$2,000$4,000$6,000
$2,000$5,000
$2,000$4,000
$2,000
$5,000
$7,000
$6,000$8,000
$10,000
$7,000$10,000
$8,000$10,000
$12,000
Ded & Coins
Ded & Coins
Deductible
Ded & Coins
Ded & Coins
Deductible
Ded & Coins
Deductible
Ded & Coins
Deductible
80%
70%
100%80%70%
100%80%
100%80%
100%
60%
50%
80%60%50%
80%60%
80%60%
60%
OUT-OF-NETWORKIN-NETWORK
BENEFIT
Adult Annual Physical ExamWell Child Care (to age 16)Well Woman CareMammography Exams (based on established guidelines)
Deductible & CoinsuranceDeductible & CoinsuranceDeductible & CoinsuranceDeductible & CoinsuranceDeductible & CoinsuranceDeductible & CoinsuranceDeductible & CoinsuranceDeductible & CoinsuranceDeductible & CoinsuranceDeductible & Coinsurance
Deductible & CoinsuranceDeductible & CoinsuranceDeductible & CoinsuranceDeductible & CoinsuranceDeductible & CoinsuranceDeductible & CoinsuranceDeductible & CoinsuranceDeductible & CoinsuranceDeductible & CoinsuranceDeductible & Coinsurance
Deductible & CoinsuranceDeductible & CoinsuranceDeductible & Coinsurance
Deductible & CoinsuranceDeductible & CoinsuranceDeductible & Coinsurance
Deductible & CoinsuranceDeductible & CoinsuranceDeductible & CoinsuranceDeductible & CoinsuranceDeductible & Coinsurance
Deductible & CoinsuranceDeductible & CoinsuranceDeductible & Coinsurance
$25 OB-GYN VisitDeductible & Coinsurance
Coinsurance - Deductible WaivedCoinsurance - Deductible WaivedCoinsurance - Deductible Waived
Covered at 100%
$25 Co-Pay - Deductible Waived$25 Co-Pay - Deductible Waived $25 Co-Pay - Deductible Waived
Covered at 100%
PCP Office VisitsSpecialist Office VisitsEmergency Room (based on guidelines)3
Diagnostic X-Ray and LabComplex Imaging (MRI, MRA, CAT, PET)4
Surgery, Pre-Surgical TestingSecond Surgical OpinionsAllergy Testing & TreatmentChiropractic Care (15 visits/calendar year)Outpatient Rehab Services (60 visits/calendar year)4
Inpatient Hospital (semi-private room)4
Surgery, Surgical Assistant, Anesthesia4
Skilled Nursing Facility (30 days/calendar year)4
Home Health Care (30 visits/calendar year)4
Durable Medical Equipment ($2,000 maximum/calendar year)4
Orthotics and Prosthetics ($2,000 maximum/calendar year)4
Maternity4
Ambulance Services for non-emergency transp. ($2,000 per calendar year)4
Lifetime Maximum
OUT-OF-NETWORK2IN-NETWORK1
FOCUS
PLANSDEDUCTIBLE DEDUCTIBLECOINSURANCE COINSURANCE COINS OOP MAXCOINS OOP MAX
ANNUAL OOPMAX
PCP PROVISIONS
ANNUAL OOP MAX
Preventive Care Member PaysMember Pays
See Rider SummarySee Rider SummarySee Rider Summary
$5 Million
Mental/Nervous Alcohol & Substance Abuse Prescription Drugs (administered through MedcoTM)
1. Network varies by region. 2. Out-of-network services are those from a provider that does not participate in one of Avalon’s regional networks. 3. Must notify Avalon Medical Management within 24 hours or reasonably thereafter.4. These services require pre-certification from Avalon. Please call (866) 469-2347. Failure to pre-certify
prior to receiving services will result in a reduction in benefits by 50% of the allowed amount. NOTE: All benefit cost-sharing subject to the Allowance as defined in the Plan.
This is a benefit summary. It is intended for informational purposes only, and doesnot represent a full description of benefits provided. For a complete description of
benefits and exclusions, please refer to the insurance policy certificate and schedule of benefits.
COVERAGE - Family Deductibles and OOP Maximums are equal to 2.0 times the Individual Coverage Amounts.
Inpatient Care
Other
Riders
Office/Outpatient Care
10
SUMMARY OF DRUG RIDERS OPTIONAL BENEFIT RIDERS AVAILABLE WITH FOCUS HEALTH BENEFIT PLANS FOR GROUPS WITH 2 - 50 ELIGIBLE EMPLOYEES
123456789
1011121314
$0$0$0
$500$750
$1,000$1,250$1,500$1,750$2,000$2,000$2,500$3,000$5,000
$10$15$20$20$20$20$20$20$20$20$35$35$35$35
$30$50$60$60$60$60$60$60$60$60$90$90$90$90
$50$75
$100$100$100$100$100$100$100$100$200$200$200$200
$25.00$37.50$50.00$50.00$50.00$50.00$50.00$50.00$50.00$50.00$87.50$87.50$87.50$87.50
$125.00$187.50$250.00$250.00$250.00$250.00$250.00$250.00$250.00$250.00$500.00$500.00$500.00$500.00
$75$125$150$150$150$150$150$150$150$150$225$225$225$225
www.avalonhealthcare.com
FOCUS
PLANDEDUCTIBLE
NETWORKGENERIC
MAIL ORDERGENERIC
MAIL ORDERFORMULARY
MAIL ORDERNON-FORMULARY
NETWORKFORMULARY
NETWORK NON-FORMULARY
ABCDEF
$1,250$1,500$2,000$2,500$3,000$5,000
$20$20$20$20$20$20
$60$60$60$60$60$60
$100$100$100$100$100$100
$50$50$50$50$50$50
$250.00$250.00$250.00$250.00$250.00$250.00
$150$150$150$150$150$150
HSA
PLAN DEDUCTIBLE NETWORK
GENERICMAIL ORDER
GENERICMAIL ORDERFORMULARY
MAIL ORDERNON-FORMULARY
NETWORKFORMULARY
In-Patient Services:Limitation: 30 days per calendar year
Out-Patient Services:Limitation: $1,000 per calendar year
In-Patient Services:Limitation: $2,000 per per lifetime, combined w/out-Patient Services
Out-Patient Services:Limitation: 44 visits per calendar year
Plan Deductible & Coinsurance
Plan Deductible & Coinsurance
Plan Deductible & Coinsurance
Plan Deductible & Coinsurance
Plan Deductible & Coinsurance
Plan Deductible & Coinsurance
Plan Deductible & Coinsurance
Plan Deductible & Coinsurance
MENTAL HEALTH
ALCOHOL & SUBSTANCE ABUSE
OUT-OF-NETWORK
OUT-OF-NETWORK
IN-NETWORK
IN-NETWORK
BENEFIT
BENEFIT
Notes on RX Plans:Core Plans -
Any Rx Rider may be purchased with any health benefit plan.The deductible applies to retail (in-network), mail order and out-of-network charges.The Rx deductibles exist as separate from medical deductibles.There is no OOP max for Rx cost.Co-pays will not count towards the medical deductible.
HSA Plans - The elected Rider must have the same deductible as the health benefit plan.
Medical Claims and Rx Claims contribute towards the health benefit plan deductible.
The Plan in-network deductible and OOP applies to retail (in-network) and mail order Rx.
The Plan out-of-network deductible and OOP applies to out-of-network charges.Rx subject to 50% of allowance.
Once Plan in-network deductible is met, co-pays do not count toward the Plan in-network OOP maximum.
NETWORKNON-FORMULARY
This is a benefit summary. It is intended for informational purposes only, and does not represent a full description of benefits provided. For a complete description of benefits and exclusions, please refer to the insurance policy certificate and schedule of benefits.
11
AGENT GUIDELINESFor Groups with 2 to 50 Eligible Employees
877-280-0010 — www.avalonhealthcare.com
Agent Guidelines for Avalon Group Health Benefit Plans
Census data must be provided on all eligible, including COBRA eligible employees. Include name, date of birth, date of
hire, gender, dependent status, and residence zip code.
An eligible employee is an employee who works full-time, having a normal work week of 25 or more hours per week, and
who has met any applicable waiting-period requirements.
Eligible employees include self-employed individuals, sole proprietors, partners of a partnership or independent
contractors, if they are actively engaged on a full-time basis in the small employer's business and included as employees
under a health care plan contract of a small employer.
Part-time, temporary, or substitute employees are not eligible.
Groups with 2-5 eligible employees: 100% of eligibles, counting those covered under another health plan sponsored
by the employer and excluding those with qualifying existing coverage, must participate in Avalon's plan.
Groups with more than 5 eligible employees require 75% participation, counting those covered under another health plan
sponsored by the employer and excluding those with qualifying existing coverage, must participate in Avalon's plan.
Employees waiving due to spousal coverage must complete the waiver section and provide proof of coverage
by providing a copy of the I.D. card.
Employer contribution must equal 50% of employee premium.
Individual coverage is not a valid waiver, unless subscriber is a current Avalon individual Member.
Eligible dependents include an employee's spouse and unmarried children up to the age of 19. Unmarried child(ren)
includes natural, stepchildren, foster, legally adopted children, proposed adoptive children, and a child under court order.
Coverage for dependent children may be extended until the end of the calendar year in which the child attains the age of
25. The child must be dependent upon the employee for support and residing with the employee, or attending school on
a regular basis.
Groups with 10 to 50 eligible employees may offer a dual option. This is when more than one Avalon medical plan is
offered to Members, an employer offers two Avalon medical plans to the employees. Each of the dual option plans has
a minimum of 5 subscribers.
Avalon will underwrite at the employer level for companies enrolling 21 – 50 employees. The employer (or lead benefits
administrator) will state to the best of his/her knowledge answers to a number of questions regarding the health status of
the company’s employees.
Avalon will underwrite using individual medical applications for groups enrolling 20 or fewer employees.
Cases will be issued as quoted, offered a reduced premium or a premium increase based on the medical statements collect-
ed by either the employer or employees. The maximum increase or decrease from standard rates on new groups is 15%.
Documentation that will allow Avalon to determine whether the group qualifies as a Florida Small Group will be required
at the time of application. Please review the Case Submission Checklist for all required information.
The group effective date must be the 1st of the month.
877-280-0010 — www.avalonhealthcare.com
Avalon Healthcare, Inc.
Rocky Point Centre
3030 North Rocky Point Drive West
Suite # 800
Tampa, Florida 33607
Florida based Avalon Healthcare is an innovative health insurance company offering consumer directed Health Benefit Plans to employers and individuals whoneed affordable healthcare and live and work in Florida.
Avalon is poised to meet the rapid changes in the Florida group health insurance market through the development of innovative new products: in and out-of-network High Deductible PPO Health Benefit Plans wrapped around Health SavingsAccounts (HSAs) and Health Reimbursement Accounts (HRAs). We call theseHealth Benefit Plans Avalon "Focus Plans" because they clearly focus on the needsof employers, employees and individuals.
Avalon Healthcare, Inc.12