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Microsoft word - pca486960_004.doc

PacifiCare SignatureValue®
Offered by PacifiCare of California
15-30/100%
HMO Schedule of Benefits
These services are covered as indicated when authorized through your Primary Care Physician in your Participating Medical Group. General Features
Specialist/Nonphysician Health Care Practitioner Office Visits3 (Member required to obtain referral to specialist or nonphysician health care practitioner, except for OB/GYN Physician services and Emergency/Urgently Needed Services) (Only one hospital Copayment per day is applicable. If a transfer to another facility is necessary, you are not responsible for the additional hospital admission Copayment for that day) (Autologous (self-donated) blood limited up to $120.00 per unit) (Medically Necessary services required outside geographic area served by your Participating Medical Group. Please consult your brochure for additional details. Copayment waived if admitted) Benefits Available While Hospitalized as an Inpatient
(Donor searches limited to $15,000 per procedure) Balance (if any) is the responsibility of the Member (Prognosis of life expectancy of one year or less) (Only one hospital Copayment per day is applicable. If a transfer to another facility is necessary, you are not responsible for the additional hospital admission Copayment for that day) (Autologous (self-donated) blood limited up to $120.00 per unit) (After mastectomy and complications from mastectomy) Benefits Available While Hospitalized as an Inpatient (Continued)
(As required by state law, coverage includes treatment for
Severe Mental Illness (SMI) of adults and children and the
treatment of Serious Emotional Disturbance of Children (SED).
Please refer to your Supplement to the PacifiCare
Combined Evidence of Coverage and Disclosure Form for
a description of this coverage.)
(Only one hospital Copayment per day is applicable. If a
transfer to another facility is necessary, you are not responsible
for the additional hospital admission Copayment for that day.)
(Including physical, occupational and speech therapy) (Up to 100 consecutive calendar days from the first treatment per disability) (Only one hospital Copayment per day is applicable. If a transfer to another facility is necessary, you are not responsible for the additional hospital admission Copayment for that day.) (Medical/medication and surgical) 1st trimester – After 20 weeks, not covered unless Medically Necessary, such as the mother’s life is in jeopardy or fetus is not viable. Benefits Available on an Outpatient Basis
Specialist/Nonphysician Health Care Practitioner Office Visit (Only one ambulance Copayment per trip may be applicable. If a subsequent ambulance transfer to another facility is necessary, you are not responsible for the additional ambulance Copayment) Balance (if any) is the responsibility of the Member (Additional Copayment for outpatient surgery or inpatient hospital benefits and outpatient rehabilitation therapy may (Additional Copayment for outpatient surgery or inpatient hospital benefits may apply) (Physician office visit Copayment may apply) ($5,000 annual benefit maximum per calendar year) Durable Medical Equipment for the Treatment of Pediatric Asthma (Includes nebulizers, peak flow meters, face masks and tubing for the Medically Necessary treatment of pediatric asthma of Dependent children under the age of 19. Does not apply to the annual Durable Medical Equipment benefit maximum.) Benefits Available on an Outpatient Basis (Continued)
Family Planning/Voluntary Termination of Pregnancy (Additional Copayment for inpatient hospital benefits may apply if performed on an inpatient basis.) Insertion/Removal of Intra-Uterine Device (IUD) Specialist/Nonphysician Health Care Practitioner Office Visit Specialist/Nonphysician Health Care Practitioner Office Visit Specialist/Nonphysician Health Care Practitioner Office Visit (Limited to one Depo-Provera injection every 90 days.) (Medical/medication and surgical) 1st trimester – After 20 weeks, not covered unless Medically Necessary, such as the mother’s life is in jeopardy or fetus is not viable. $5,000 Benefit Maximum every three years. Limited to a single hearing aid (including repair/replacement) every three years. Depending upon where the covered health service is Limited to a single hearing aid during the entire period of time provided, benefits for bone anchored hearing aid will be the member is enrolled in the Health Plan (per lifetime). Repairs the same as those stated under each covered health and/or replacements are not covered, except for malfunctions. service category in this Schedule of Benefits Deluxe model and upgrades that are not medically necessary are not covered. Specialist/Nonphysician Health Care Practitioner Office Visit3 (Prognosis of life expectancy of one year or less) (For children under two years of age, refer to Well-Baby Care) PCP Office Visit Specialist/Nonphysician Health Care Practitioner Office Visit (Infusion Therapy is a separate Copayment in addition to a home health care or an office visit Copayment. Copayment applies per 30 days or treatment plan, whichever is shorter) Benefits Available on an Outpatient Basis (Continued)
Injectable Drugs (Outpatient Injectable Medications and Self- (Copayment not applicable to allergy serum, immunizations, birth control, Infertility and insulin. The Self-Injectable medications Copayment applies per 30 days or treatment plan, whichever is shorter. Please see the PacifiCare Combined Evidence of Coverage and Disclosure Form for more information on these benefits, if any. Office visit Copayment may also apply) (When available through or authorized by your Participating Medical Group) (As required by state law, coverage includes treatment for
Severe Mental Illness (SMI) of adults and children and the
treatment of Serious Emotional Disturbance of Children (SED).
Please refer to your Supplement to the PacifiCare
Combined Evidence of Coverage and Disclosure Form for a
description of this coverage.)

Outpatient Medical Rehabilitation Therapy at a Participating Free- (Including physical, occupational and speech therapy) PCP Office Visit Specialist/Nonphysician Health Care Practitioner Office Visit Outpatient Surgery at a Participating Free-Standing or Outpatient Surgery Facility Periodic Health Evaluations (Physician, laboratory, radiology and related services as recommended by the American Academy of Pediatrics (AAP), Advisory Committee on Immunization Practices (ACIP) and U.S. Preventive Services Task Force and authorized through your Primary Care Physician in your Participating Medical Group to determine your health status. For children under two years of age, refer to Well-Baby Care) (For children under two years of age, refer to Well-Baby Care) Specialist/Nonphysician Health Care Practitioner Office Visit (Examples include, but are not limited to, brachytherapy, radioactive implants and conformal photon beam; Copayment applies per 30 days or treatment plan, whichever is shorter; GammaKnife and stereotactic procedures are covered as outpatient surgery. Please refer to outpatient surgery for Copayment amount if any) Benefits Available on an Outpatient Basis (Continued)
Specialized scanning and imaging procedures: (Examples include but are not limited to, CT, SPECT, PET, MRA and MRI – with or without contrast media) A separate Copayment will be charged for each part of the body scanned as part of an imaging procedure. Specialist/Nonphysician Health Care Practitioner Office Visit (Preventive health service, including immunizations as recommended by the American Academy of Pediatrics (AAP), Advisory Committee on Immunization Practices (ACIP) and U.S. Preventive Services Task Force and authorized through your Primary Care Physician in your Participating Medical Group for children under two years of age. The applicable office visit Copayment applies to infants that are ill at time of services) (Includes Pap smear (by your Primary Care Physician or an OB/GYN in your Participating Medical Group) and referral by the Participating Medical Group for screening mammography as recommended by the U.S. Preventive Services Task Force) 1Annual Copayment Maximum does not include Copayments for pharmacy and supplemental benefits, except Behavioral Health Supplemental Benefits. 2When individual member meets annual copayment maximum, no further copayments are required for the year for that individual. 3Copayments for audiologist and podiatrist visits will be the same as for the PCP. 4 Cancer Clinical Trial services require preauthorization by PacifiCare. If you participate in a Cancer Clinical Trial provided by a Non- Participating Provider that does not agree to perform these services at the rate PacifiCare negotiates with Participating Providers, you will be responsible for payment of the difference between the Non-Participating Providers billed charges and the rate negotiated by PacifiCare with Participating Providers, in addition to any applicable Copayments, coinsurance or deductibles. 5 The inpatient hospital benefits Copayment does not apply to newborns when the newborn is discharged with the mother within 48 hours of the normal vaginal delivery or 96 hours of the cesarean delivery. Please see the Combined Evidence of Coverage and Disclosure Form for more details. 6In instances where the negotiated rate is less than your Copayment, you will pay only the negotiated rate. 7Bone anchored hearing aid will be subject to applicable medical/surgical categories (e.g. inpatient hospital, physician fees) only for members who meet the medical criteria specified in the Combined Evidence of Coverage and Disclosure Form. Limited to one (1) bone anchored hearing aid during the period of time the member is enrolled in the Health Plan (per lifetime). Repairs and/or replacement for a bone anchored hearing aid are not covered, except for malfunctions. Deluxe model and upgrades that are not medically necessary are not covered. Except in the case of a Medically Necessary Emergency or an Urgently Needed Service (outside geographic area served by your Participating Medical Group), each of the above-noted benefits is covered when authorized by your Participating Medical Group or PacifiCare. A Utilization Review Committee may review the request for services. Note: This is not a contract. This is a Schedule of Benefits and its enclosures constitute only a summary of the Health
Plan.
The Medical and Hospital Group Subscriber Agreement and the PacifiCare of California Combined Evidence of Coverage and Disclosure Form and additional benefit materials must be consulted to determine the exact terms and conditions of coverage. A specimen copy of the contract will be furnished upon request and is available at the PacifiCare office and your employer’s personnel office. PacifiCare’s most recent audited financial information is also available upon request. Customer Service:
800-624-8822
P.O. Box 30968
800-442-8833 (TDHI)
Salt Lake City, UT 84130-0968
www.pacificare.com

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