IBEW-NECA

Note: PacifiCare changed its name to UHC of California and will do business as (dba) UnitedHealthcare of California, effective May 2011. (See the March 25, 2011 announcement.)

Benefits and Coverage		Your Cost
General Features
Calendar Year Deductible		$0
Maximum Benefits		Unlimited
Annual Copayment Maximum 3 individual maximum per family		$1000/Individual
Office Visits		$5 Copayment
Hospitalization		Paid in Full
Emergency Services		$50 Copayment 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 Copayment 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 (Including physical, occupational and speech therapy)		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 Copayment $150 Copayment Not covered unless mother’s life is in jeopardy or fetus is not viable
Benefits Available on an Outpatient Basis
Alcohol, Drug, or Other Substance Abuse or Addiction	(see Integrated MAP and MH&CD Benefits Program SPD)
Allergy Testing/Treatment (Serum is covered)	$5 Copayment
Ambulance	Paid in Full
Cancer Clinical Trials 1	Paid at contracting rate Balance (if any) is the responsibility of the Member
Cochlear Implants (Additional Copayment for outpatient surgery or inpatient hospital benefits may apply)	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 (IUD) Removal of Norplant Depo-Provera injection Depo-Provera medication (Limited to one Depo-Provera injection) (Limited to one Depo-Provera injection every 90 days) Voluntary interruption of pregnancy 1 st trimester 2 nd trimester (12-20 weeks) After 20 weeks	$50 Copayment $100 Copayment $5 Copayment 50% of cost Copayment 3 $5 Copayment $5 Copayment $35 Copayment $75 Copayment $150 Copayment Not Covered unless mother’s life is in jeopardy
Health Education Services	Paid in Full
Hearing Screening	$5 Copayment
Hemodialysis	$5 Copayment per treatment
Home Health Care Visits (up to 100 per calendar year)	Paid in Full
Hospice Care (Prognosis of life expectancy of one year or less)	Paid in Full
Immunizations (For children under two years of age, refer to Well-Baby Care)	$5 Copayment
Infertility Services	50% of cost Copayment 3
Laboratory and Radiology	Paid in Full
Maternity Care, Tests and Procedures	Paid in Full
Mental Health Services (see Integrated MAP and MH&CD Benefits Program SPD)	$10 Copayment per authorized session
Oral Surgery Services	Paid in Full
Outpatient Medical Rehabilitation Therapy at a Participating Free-Standing or Outpatient Facility	$5 Copayment
Outpatient Surgery at a Participating Free-Standing or Outpatient Facility	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. For children under two years of age, refer to Well-Baby Care.	$5 Copayment
Physician Care (For children under two years of age, refer to Well-Baby Care	$5 Copayment
Vision Refractions	$5 Copayment
Vision Screening	$5 Copayment
Well-Baby Care Preventive health service, including immunizations 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 for children under two years of age.	Paid in Full
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 Copayment

Service requires preauthorization from PacifiCare.
This Copayment 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 Copayment for your benefit plan, if any.
Percentage Copayment amounts are based upon PacifiCare’s contracted rate.

Except in the case of a Medically Necessary Emergency or an Urgently Needed Service (outside your Service Area), each of the above-noted benefits are covered when authorized by your Primary Care Physician in your Participating Medical Group. Where the recommended service involves hospital admission or referrals, your Physician’s recommendation may receive a second opinion review by a utilization review committee. The committee is designed to promote the efficient use of resources while maintaining quality care for a Member.

NOTE: This is not a contract – This Schedule of Benefits and its enclosures constitute only a summary of the health plan.

PacifiCare Summary of Benefits