email this page   printer friendly

This section modified by: Amendment 12.   View Previous Language

NOTE: Refer to the section entitled “Mandatory Prescription Drug Plan” for an explanation of your prescription drug coverage unless you are a spouse of a participant enrolled in Secure Horizons. Spouses of Secure Horizons participants are covered under the Secure Horizons Prescription Drug Plan. Refer to the Secure Horizons Plan.

PacifiCare early retiree participants are covered for mental health benefits under a separate “carve out” plan. Refer to the separate Summary Plan Description listed in the Table of Contents under the heading “Mental Health and Chemical Dependency Plan – PacifiCare Early Retirees Only”.

• This benefit chart is a summary only. It does not fully describe your benefit coverage. For details on your benefit coverage, please refer to PacifiCare Health Systems, Inc., Evidence of Coverage. The Evidence of Coverage is the binding document between Health Plan and its members.
• For details on the benefit and claims review and adjudication procedures, please refer to PacifiCare Health Plan’s Evidence of Coverage or contact PacifiCare Customer Service Department at 1(800) 624-8822.  

PacifiCare Summary of Benefits for Early Retirees

Benefits and Coverage		Your Cost
General Features
Calendar Year Deductible		$0
Maximum Benefits		Unlimited
Annual Co-payment Maximum 3 individual maximum per family		$1000/Individual
Office Visits		$5 Co-payment
Hospitalization		Paid in Full
Emergency Services		$50 Co-payment waived if admitted as an inpatient
Urgently Needed Services (Medically necessary services required outside your service area. Please consult your brochure for additional details.)		$50 Co-payment waived if admitted as an inpatient
Pre-Existing Conditions		All conditions covered, provided they are covered benefits.
Benefits Available While Hospitalized as an Inpatient
Bone Marrow Transplants (Donor searches limited to $15,000 per procedure)		Paid in Full
Cancer Clinical Trials 1		Paid at contracting rate Balance (if any) is the responsibility of the member
Hospice Care (Prognosis of life expectancy of one year or less)		Paid in Full
Hospital Benefits (Autologous (self-donated) blood up to $120.00 per unit)		Paid in Full
Mastectomy/Breast Reconstruction (After mastectomy and complications from mastectomy)		Paid in Full
Maternity Care		Paid in Full
Newborn Care		Paid in Full
Physician Care		Paid in Full
Reconstructive Surgery		Paid in Full
Rehabilitation Care		Paid in Full
Skilled Nursing Care (Up to one hundred (100) consecutive calendar days from the first treatment per disability)		Paid in Full
Voluntary Interruption of Pregnancy 1 st Trimester 2 nd Trimester (12-20 weeks) After 20 weeks		$75 Co-payment $150 Co-payment Not covered unless mother’s life is in jeopardy
Benefits Available on an Outpatient Basis
Allergy Testing/Treatment (Serum is covered)	$5 Co-payment
Ambulance	Paid in Full
Attention Deficit Disorder (Medical Management)	$5 Co-payment
Cancer Clinical Trials 1	Paid at contracting rate Balance (if any) is the responsibility of the Member
Cochlear Implants	Paid in Full
Durable Medical Equipment, Corrective Appliances and Prosthetics	Paid in Full
Eligible Materials and Supplies	Paid in Full
Family Planning/Voluntary Interruption of Pregnancy Vasectomy Tubal ligation 2 Insertion/removal of intra-uterine device (IUD) Intra-Uterine Device Removal of Norplant Depo-Provera injection Depo-Provera medication (Limited to one Depo-Provera injection) Voluntary interruption of pregnancy 1 st trimester 2 nd trimester (12-20 weeks) After 20 weeks	$50 Co-payment $100 Co-payment $5 Co-payment 50% of cost Co-payment 3 $5 Co-payment $5 Co-payment $35 Co-payment $75 Co-payment $150 Co-payment Not Covered unless mother’s life is in jeopardy
Health Education Services	Paid in Full
Hearing Screening	$5 Co-payment
Hemodialysis	$5 Co-payment per treatment
Home Care (up to 100 visits per Calendar Year)	Paid in Full
Hospice Care (Prognosis of life expectancy of one year or less)	Paid in Full
Infertility Services	50% of cost Co-payment 3
Laboratory and Radiology	Paid in Full
Maternity Care, Tests and Procedures	Paid in Full
Oral Surgery Services	Paid in Full
Outpatient Rehabilitation Therapy	$5 Co-payment
Outpatient Surgery	Paid in Full
Periodic Health Evaluations Physician, laboratory, radiology and related services as recommended by the American Academy of Pediatrics (AAP) and U.S. Preventive Services Task Force and authorized through your Primary Care Physician in your Participating Medical Group to determine your health status.	$5 Co-payment
Vision Refractions	$5 Co-payment
Vision Screening	$5 Co-payment
Well-Woman Care 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.	$5 Co-payment

• Service requires pre-authorization from PacifiCare.
• This Co-payment applies regardless of whether this service is performed as an inpatient or on an outpatient basis. If this service is performed on an inpatient basis, you will also be required to pay the applicable inpatient Co-payment for your benefit plan, if any.
• Percentage Co-payment amounts are based upon PacifiCare’s contracted rate.