STATE STANDARD 20-40/400D HMO SCHEDULE OF BENEFITS
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1 CALIFORNIA STATE STANDARD 20-40/400D HMO SCHEDULE OF BENEFITS These services are covered as indicated when authorized through your Primary Care Physician in your Participating Medical Group. General Features Calendar Year Deductible 0 Maximum Benefits Unlimited Annual Copayment Maximum 1 $5,000/individual (3 individual maximum per family) s $20 Copayment s 2 $40 Copayment (Member required to obtain referral to specialist or other licensed health care practitioner, except for OB/GYN Physician services and Emergency/Urgently Needed Services) Hospital Benefits (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.) Blood and Blood Products (Autologous (self-donated) blood up to $ per unit) Emergency Services $100 Copayment (Copayment not waived if admitted) Urgently Needed Services $100 Copayment (Medically Necessary services required outside geographic area served by your Participating Medical Group. Please consult your brochure for additional details. Copayment not waived if admitted) Pre-Existing Conditions All conditions covered, provided they are covered benefits Benefits Available While Hospitalized as an Inpatient Alcohol, Drug or Other Substance Abuse Detoxification Bone Marrow Transplants (Donor searches limited to $15,000 per procedure) Cancer Clinical Trials 3 Hospice Services (Prognosis of life expectancy of one year or less) Hospital Benefits (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.) Mastectomy/Breast Reconstruction (After mastectomy and complications from mastectomy) Maternity Care Paid at negotiated rate Balance (if any) is the responsibility of the Member
2 Benefits Available While Hospitalized as an Inpatient (Continued) Mental Health Services (As required by state law, coverage includes treatment for Severe Mental Illnesses (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) Newborn Care 4 Physician Care Reconstructive Surgery Rehabilitation Care (Including physical, occupational and speech therapy) Skilled Nursing Facility Care $200 per day (Up to 100 consecutive calendar days from the first treatment per disability) Voluntary Termination of Pregnancy (Medical/medication and surgical) 1st trimester $125 Copayment 2nd trimester $125 Copayment After 20 weeks, 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 Detoxification Allergy Testing/Treatment (Serum is covered) Ambulance (Only one ambulance Copayment per trip may be applicable. If a subsequent ambulance transfer to another facility is necessary, you are not responsible for additional ambulance Copayment) Cancer Clinical Trials 3, Cochlear Implant Device (Additional Copayment for outpatient surgery or inpatient hospital benefits and outpatient rehabilitation therapy may apply.) Crisis Intervention Dental Treatment Anesthesia (Additional charges for outpatient and inpatient surgery may apply) Dialysis (Physician office visit Copayment may apply) Durable Medical Equipment ($5,000 annual benefit maximum per calendar year) Family Planning/Voluntary Termination of Pregnancy Vasectomy Tubal Ligation (Additional Copayment for inpatient hospital benefits may apply if performed on an inpatient basis.) Insertion/Removal of Intra-Uterine Device (IUD) - - Intra-Uterine Device (IUD) $50 Copayment Paid at negotiated rate Balance (if any) is the responsibility of the Member 5 Not covered $40 per treatment $50 Copayment 5 $50 Copayment $100 Copayment $50 Copayment
3 Benefits Available on an Outpatient Basis (Continued) Removal of Norplant - - Depo-Provera Injection - - Depo-Provera Medication (Limited to one Depo-Provera injection every 90 days) $35 Copayment Voluntary Termination of Pregnancy (Medical/medication and surgical) - 1st trimester $125 Copayment - 2nd trimester $125 Copayment - After 20 weeks, not covered unless mother s life is in jeopardy or fetus is not viable. Health Education Services Hearing Screening 2 Home Health Care $10 Copayment per visit (Up to 100 visits per calendar year) Hospice Services (Prognosis of life expectancy of one year or less) Immunizations (For children under two years of age, refer to Well-Baby Care) Infertility Services Not covered Infusion Therapy $50 Copayment 5 (Infusion therapy is a separate Copayment in addition to a home health or a facility Copayment. Copayment applies per 30 days or treatment plan, whichever is shorter) Injectable Drugs (Outpatient Injectable Medications and Self- $100 Copayment per visit 5 Injectable Medications) (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 or the group Subscriber Agreement for more information on these benefits, if any.) Laboratory Services (When available through and authorized by your Participating Medical Group) Maternity Care, Tests and Procedures Mental Health Services (As required by state law, coverage includes treatment for Severe Mental Illnesses (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) Oral Surgery Services $50 Copayment 5
4 Benefits Available on an Outpatient Basis (Continued) Outpatient Medical Rehabilitation Therapy at a Participating Free- Standing or Outpatient Facility (Including physical, occupational and speech therapy) Outpatient Surgery at a Participating Free-Standing or Outpatient $200 per day 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.) Physician Care (For children under two years of age, refer to Well-Baby Care) Prosthetics and Corrective Appliances $50 Copayment per item 5 Radiation Therapy Standard: (Photon beam radiation therapy) Complex: $400 Copayment 5 (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.) Radiological Procedures Standard: Specialized scanning and imaging procedures: (Examples include but are not limited to, CT, SPECT, PET, MRA and MRI with or without contrast media) Vision Screening/Refractions Well-Baby Care (Preventive health service, including immunizations 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.) 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) $100 Copayment per procedure 5
5 1 Annual Copayment Maximum does not include Copayments for durable medical equipment, pharmacy and supplemental benefits. 2 Copayments for audiologist and podiatrist visits will be the same as for the PCP. Cancer Clinical Trial Services require preauthorization by PacifiCare. If you participate in a Cancer Clinical Trail 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 3 Copayments, coinsurance or deductibles. 4 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. 5 In instances where the negotiated rate is less than your Copayment, you will pay only the negotiated rate. 6 Copayment applies regardless of whether this benefit is performed on an inpatient or outpatient basis. If performed on an inpatient basis, additional inpatient Copayment, if any, will apply. 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.
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