This PacifiCare Plan is for Medicare-Eligible Retirees
| OUTPATIENT CARE | |
|---|---|
| Annual Physical Examination (includes Pap Smears) -Primary Care Physician -Specialist |
$10 copayment $20 copayment |
| Covered injectables | No charge |
| Immunizations (includes flu shots, pneumococcal vaccine, Hepatitis B injections, and all other Medicare approved immunizations) | No charge |
| Insulin | Brand copayment per prescription unit |
| Medicare-covered Immunosuppresive drugs | No charge |
| Medicare-covered Oral Chemotherapy drugs | No charge |
| Outpatient Surgical Services: -Certified Ambulatory Surgical Center -Outpatient Hospital Facility |
$125 copayment $125 copayment |
| Physician Services/Basic Health Services (includes consultation, diagnosis and treatment): -Primary Care Physician -Specialist |
$10 copayment $20 copayment |
| Radiation Therapy (routine or complex) | No charge |
| Renal Dialysis | Covered in full |
| Routine Hearing Examination: -Primary Care Physician -Specialist |
$10 copayment $20 copayment |
| HOSPITAL INPATIENT CARE | |
| Hospitalization | $250 copayment per admission |
| Skilled Nursing Facility (Medicare certified) - Days 1-20 - Days 21-100 (limit 100 days per benefit period as defined by Medicare) |
No charge $50 per day |
| PRESCRIPTION DRUGS | |
| Contracting Retail Pharmacy (per prescription for 30-day supply of drugs as prescribed by a Secure HorizonsMedicare+Choice Plan contracting physician) Generic Brand |
$10 $20 |
| Mail-Service Pharmacy (per prescription for 90-day supply) Generic Brand Name |
$20 $40 |
| MENTAL HEALTH AND CHEMICAL DEPENDENCY SERVICES | |
| Outpatient Mental Health Care/Outpatient Substance Abuse Treatment | $20 copayment |
| Inpatient Psychiatric Care/Inpatient Substance Abuse Treatment | $250 copayment per admission up to 190 days lifetime maximum in a psychiatric hospital |
| Outpatient Treatment (up to 30 visits per calendar year) | $10 copayment |
| OTHER SERVICES | |
| Ambulance (medically necessary ambulance transport) | $50 copayment |
| Chiropractic Services (Medicare benefit ONLY) - Primary Care Physician - Specialist |
$10 copayment $20 copayment |
| EMERGENCY CARE/URGENTLY NEEDED CARE | |
| Emergency Services (You may go to any emergency room if you reasonably believe you need emergency care.) | $50 copayment waived if admitted as inpatient within 24 hours for same condition |
| Non-network/Out of Area Urgent Care | $25 Copayment |
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.
www.pacificare.com
(800) 624-8822
Download your entire Health & Welfare Summary Plan Description
Download the Summary Plan Description, specific to your Pacificare Secure Horizons HMO Plan
Download your Pacificare Enrollment Form