This page contains information about your Pacificare HMO Plan. Should you need it, your Plan's Group Number is:
#140167 for Active Employees
#140573 for Early Retirees
| ANNUAL COPAYMENT MAXIMUM | |
|---|---|
| 3 individual maximum per family | $1,000 per individual |
| OUTPATIENT CARE | |
| Alcohol, Drug, or Other Substance Abuse - Detoxification | No charge |
| Allergy Testing/Treatment (serum is not covered unless an allergy serum rider was purchased by your employer) | $10 copayment |
| Cancer Clinical Trials | You pay balance, if any, after payment at contracting rate |
| Dental Treatment Anesthesia (additional charges for outpatient and inpatient surgery may apply) | $10 copayment |
| Hearing Screening | $10 copayment |
| Hemodialysis (Physician office visit Copayment may apply) | $10 per treatment |
| Immunizations (for children under two years of age, refer to Well-Baby care) | No charge |
| Infertility Services | 50% copayment |
| Laboratory and Radiology (when available through and authorized by the Member's Participating Medical Group) | No charge |
| Maternity care, Tests and Procedures | No charge |
| Office Visits | $10 copayment |
| Oral Surgery Services | No charge |
| Outpatient Rehabilitation Therapy at a Participating Free-Standing or Outpatient Facility (including physical, occupational, and speech therapy) | $10 copayment |
| Outpatient surgery | No charge |
| Periodic Health Evaluations (Physician, laboratory, radiology, and related services as recommended by the American Academy of Pediatrics (AAP) and U.S. Preventative 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.) | $10 copayment |
| Physician care (for children under two years of age, refer to Well-Baby care) | No charge |
| Vision Refractions | $10 copayment |
| Vision Screening | $10 copayment |
| Well-Baby Care (preventative health service, including immunizations recommended by the American Academy of Pediatrics (AAP) and U.S. Preventative 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.) | $10 copayment |
| Well-Woman Care (includes Pap smear by your Primary Care physician or an OB/GYN in your Participating Medical Group for screening mammography as recommended by the U.S. Preventative Services Task Force.) | $10 copayment |
| HOSPITAL INPATIENT CARE | |
| Alcohol, Drug, or Other Substance Abuse - Detoxification | No charge |
| Bone Marrow Transplants (donor searches limited to $15,000 per procedure) | No charge |
| Cancer Clinical Trials | You pay balance, if any, after payment at contracting rate |
| Hospice Care (autologous (self-donated) blood up to $120.00 per unit) | No charge |
| Hospitalization | No charge |
| Mastectomy/Breast Reconstruction (after mastectomy and complications from mastectomy) | No charge |
| Maternity Care | No charge |
| Newborn Care | No charge |
| Physician care | No charge |
| Reconstructive Surgery | No charge |
| Rehabilitation Care (including physical, occupational, and speech therapy) | No charge |
| Skilled Nursing Facility (up to one hundred (100) consecutive calendar days from the first treatment per disability) | No charge |
| PRESCRIPTION DRUGS | |
| Retail Pharmacy (per Prescription Unit or up to 30 days) Generic Brand |
$10 $20 |
| Mail-Service Pharmacy (up to 3 Prescription Units or up to 90 days) Generic Brand Name |
$20 $40 |
| FAMILY PLANNING | |
| Vasectomy | $50 copayment |
| Tubal ligation | $100 copayment |
| Insertion/removal of Intra-Uterine Device (IUD) | $10 copayment |
| Intra-Uterine Device (IUD) | 50% copayment |
| Removal of Norplant | $10 copayment |
| Depo-Provera injection | $10 copayment |
| Depo-Provera medication (Limited to one Depo-Provera injection every 90 days) | $35 copayment |
| Voluntary interruption of pregnancy (medical/medication and surgical) -1st trimester -2nd trimester (12-20 weeks) -After 20 weeks |
$75 copayment $150 copayment Not covered unless mother's life is in jeopardy or fetus not viable |
| MENTAL HEALTH SERVICES | |
| Mental Health Services (As required by state law, coverage includes treatment for Severe Mental illnesses (SMI) of adults and children and for children the treatment of Serious Emotional Disturbance of Children (SED).) | $10 copayment per visit |
| Inpatient, Residential, and Day Treatment. Up to 30 days per calendar year based on the following levels of care: -Inpatient Treatment = 1 day -Residential Treatment = 70% of 1 day -Day Treatment = 60% of 1 day |
No charge |
| Outpatient Treatment (up to 30 visits per calendar year) | $10 copayment |
| Emergency | $50 copayment waived if admitted as inpatient |
| Urgently Needed Services (Medically necessary services required outside the geographic area served by your Participating Medical Group.) | $50 copayment waived if admitted as inpatient |
| SEVERE MENTAL ILLNESS BENEFIT | |
| Inpatient, Residential, and Day Treatment (Unlimited Days) | No charge |
| Outpatient Treatment (Unlimited Visits) | $10 copayment |
| Emergency | $50 copayment waived if admitted as inpatient |
| Urgently Needed Services (Medically necessary services required outside the geographic area served by your Participating Medical Group.) | $50 copayment waived if admitted as inpatient |
| CHEMICAL DEPENDENCY SERVICES | |
| Inpatient and Outpatient Treatment (Maximum Annual Benefit for detoxification and all levels of care limited to $25,000 per Calendar year; $25,000 Lifetime Maximum Benefit) | No charge |
| Emergency | $50 copayment waived if admitted as inpatient |
| Urgently Needed Services (Medically necessary services required outside the geographic area served by your Participating Medical Group.) | $50 copayment waived if admitted as inpatient |
| OTHER SERVICES | |
| Ambulance | No charge |
| Chiropractic Care | $10 Copayment per visit (30 visit annual maximum) |
| Cochlear Implants (Outpatient surgery or inpatient hospitalization and outpatient rehabilitation therapy Copayments may apply) | No charge |
| Crisis Intervention (up to twenty (20) visits for Crisis Intervention per calendar year) | $35 copayment |
| Durable Medical Equipment, Corrective Appliances and Prosthetics | No charge |
| Health Education Services | No charge |
| Home Health Care | No charge |
| Hospice Care (prognosis of life expectancy of one year or less) | No charge |
| EMERGENCY CARE/URGENTLY NEEDED CARE | |
| Emergency Services | $50 copayment waived if admitted as inpatient |
| Urgently Needed Services (Medically necessary services required outside the geographic area served by your Participating Medical Group.) | $50 copayment waived if admitted as inpatient |
This chart is only a summary. Please see the evidence of coverage or disclosure form for the selected plan for a thorough description of its benefits, limitations, exclusions and conditions of coverage.
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(800) 624-8822
Download your entire Health & Welfare Summary Plan Description
Download the Summary Plan Description, specific to your Pacificare HMO Plan
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