Exclusions and Limitations

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.)

Services and benefits for care and conditions as described below shall be excluded from coverage under this plan unless specifically included as a supplemental benefit.

General Exclusions

The following services are not covered by PacifiCare:

1. All services not specifically included in the Schedule of Benefits.


2. All services which are rendered without authorization from Member’s Primary Care Physician in Member’s Participating Medical Group (except for Emergency or Urgently Needed Services, or obstetrical and gynecological physician services obtained directly from an OB/GYN or Family Practice Physician (designated by your Participating Medical Group as providing OB/GYN services) affiliated with your Participating Medical Group).


3. Any services rendered prior to Member’s start date of coverage or subsequent to the date coverage ends.


4. Services rendered by Outside Providers when the Member has refused treatment provided or authorized through Member’s Primary Care Physician in Member’s participating Medical Group.


5. Services which, in the judgment of PacifiCare, are not Medically Necessary.


6. Services which are part of a plan of treatment for a non-Covered service, which are the sole, direct and predictable consequences of such non-Covered Service as recognized by the organized medical community in the State of California; provided, however, that the Health Plan shall not exclude coverage for Medically Necessary services required to treat medical conditions that may be a consequence of non-Covered Services but are not predictable in advance, such as unexpected complications of surgery.