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Summary Plan Description (SPD)
PacifiCare Secure Horizons Group Medicare Advantage Plan Summary of Benefits
- The information contained in this section is a summary only. It does not fully describe your benefit coverage. For complete disclosure on the benefits, please refer to the Secure Horizons Medicare Advantage (MA) Plan Evidence of Coverage and Disclosure Information (EOC) included in your pre-enrollment materials. If you did not receive one, you may request an Evidence of Coverage and Disclosure Information book prior to completing the Secure Horizons Group- Retiree MA Plan election form by calling the Secure Horizons MA sales department at 1-800-610-2660.
- 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) -228-2144.
- Upon joining the Secure Horizons Group Retiree MA Plan, you agree to use Contracting Medical Providers and to have your health care arranged through your Primary Care Physician (PCP). He or she will coordinate your medical care personally, guiding you to Specialists and other Contracting Medical Providers. You can select your PCP from the Provider Directory – you may choose a Family Practice, General Practice or Internal Medicine physician.
Women may also refer themselves to a women’s health specialist (for example, OB/GYN) within their Network/Contracting Medical group/IPA for annual routine and preventive services. Also, women ages 40 and over may self refer annually to a mammography-screening provider within their Network/Contracting Medical Group/IPA.
When you join the Secure Horizons Group Retiree MA Plan, you agree to a "lock in" feature that says you will receive all your medical services through a Primary Care Physician, except for Emergency Services, Urgently Needed Services, out of area renal dialysis and routine travel dialysis or covered services for which PacifiCare allows you to self-refer to Contracting Medical Providers. Your Covered Services must be provided or authorized by your PCP or Contracting Medical Group/IPA. This is a typical feature of all Medicare Advantage plans. If you go outside the health plan for routine care or any unauthorized service neither PacifiCare or Medicare will pay for your costs. To change your Primary Care Physician, call or write the Customer Service Department for assistance.Your Primary Care Physician must refer you for more specialized treatment.
If there are any discrepancies between benefits include in the SPD and the Evidence of Coverage, the Evidence of Coverage will prevail.
* Inpatient Hospital copayments are charged on a per admission basis. Original Medicare hospital benefit periods do not apply. For inpatient hospital, you are covered for an unlimited number of days as long as the hospital stay is medically necessary and authorized by PacifiCare or contracting providers. When you are admitted to an inpatient hospital and then subsequently transferred to another inpatient hospital, you pay the copayment charged for the first hospital admission. You do not pay a copayment for the second hospital admission, the copayment is waived.
** A benefit period begins the day you go to a hospital. The benefit period ends when you haven't received hospital or skilled care (in a SNF) for 60 days in a row. If you go into the hospital after one benefit period has ended, a new benefit period begins. You must pay the skilled nursing facility care copayment, if applicable, for each benefit period. There is no limit to the number of benefit periods you can have.
This is a highlight of benefits only and is not all inclusive of the Plans benefits, services, limitations or exclusions. Please refer to the enclosed Retiree Benefits Summary and your Evidence of Coverage and Disclosure Information for additional details.
Secure Horizons Group Retiree Medicare+Choice Plans are offered by PacifiCare® / PacifiCare® of Colorado, Inc. that contracts with the federal government. Anyone with Medicare Parts A and B may apply. Members must continue to pay the Medicare Part B premium and use contracting pharmacies and providers for routine care. Limitations, copayments and coinsurance will apply. Group Retiree prospects of the Secure Horizons
M+C plan must meet the eligibility requirements to enroll for group coverage. Health plan premiums and benefits may vary by employer group. Pharmacy benefits are limited to a Formulary that is subject to change without notice during the contract year. Contact PacifiCare for details.