Enrollment codes for this Plan:
Arizona A31 Self Only
A32 Self and Family
California CY1 Self Only
CY2 Self and Family
Nevada K91 Self Only
K92 Self and Family
Oklahoma 2N1 Self Only
2N2 Self and Family
Oregon 7Z1 Self Only
7Z2 Self and Family
Texas GF1 Self Only
GF2 Self and Family
Washington WB1 Self Only
WB2 Self and Family
RI 73-105
http:// www. pacificare. com
For changes in benef its,
see page
10
These plans have Commendable or Excellent Accreditation from the NCQA. See
the 2002
Guide for more information on NCQA. 1
1 Page 2 3
2
2 Page
3 4
3 2002 PacifiCare Health Plans
Table of Contents
Table of Contents
PacifiCare Health Plans
2002
Introduction
...................................................................................................................................................................
5
Plain
Language................................................................................................................................................................
5
Inspector General Advisory
............................................................................................................................................
6
Section 1. Facts about this HMO plan
...........................................................................................................................
7
How we pay
providers...................................................................................................................................
7
Your
Rights....................................................................................................................................................
7
Service
Area...............................................................................................................................................
8-9
Section 2. How we change for 2002
............................................................................................................................
10
Program-wide
changes................................................................................................................................
10
Changes to this
Plan....................................................................................................................................
10
Section 3. How you get care
........................................................................................................................................
11
Identification cards
.....................................................................................................................................
11
Where you get covered
care........................................................................................................................
11
Plan providers
.......................................................................................................................................
11
Plan facilities
........................................................................................................................................
11
What you must do to get covered
care........................................................................................................
11
Primary
care..........................................................................................................................................
11
Specialty
care........................................................................................................................................
11
Hospital care
.........................................................................................................................................
12
Circumstances beyond our
control..............................................................................................................
13
Services requiring our prior approval
.........................................................................................................
13
Section 4. Your costs for covered
services...................................................................................................................
14
Copayments
..........................................................................................................................................
14
Deductible.............................................................................................................................................
14
Coinsurance
..........................................................................................................................................
14
Your out-of-pocket
maximum.....................................................................................................................
14
Section 5. Benefits
.......................................................................................................................................................
15
Overview.....................................................................................................................................................
15
(a) Medical services and supplies provided by physicians and other health
care professionals ..... 16-23
(b) Surgical and anesthesia services provided
by physicians and other health care professionals.. 24-27
(c) Services
provided by a hospital or other facility, and ambulance
services................................ 28-29
(d) Emergency services/
accidents
....................................................................................................
30-31
(e) Mental health and substance abuse
benefits...............................................................................
32-33
(f) Prescription drug
benefits...........................................................................................................
34-36
(g) Special features
................................................................................................................................
37
Health Improvement Programs
PacifiCare Perks SM
Program
Eye Glasses and Hearing Aids
Centers of
Excellence 3
3 Page
4 5
4 2002 PacifiCare Health Plans
Table of Contents
Table of Contents
PacifiCare Health Plans
2002
(h) Dental benefits
............................................................................................................................
38-39
(i) Non-FEHB benefits available to Plan members
..............................................................................
40
Section 6. General exclusions things we don't cover
.............................................................................................
41
Section 7. Filing a claim for covered services
.............................................................................................................
42
Section 8. The disputed claims
process..................................................................................................................
43-44
Section 9. Coordinating benefits with other
coverage.................................................................................................
45
When you have
Other health coverage
.........................................................................................................................
45
Original Medicare
...............................................................................................................................
45
Medicare managed care plan
..............................................................................................................
47
TRICARE/ Workers' Compensation/ Medicaid
.........................................................................................
48
Other Government agencies
.....................................................................................................................
48
When others are responsible for
injuries..................................................................................................
48
Section 10. Definitions of terms we use in this brochure
..........................................................................................
49
Section 11. FEHB facts
..............................................................................................................................................
50
Coverage
information..................................................................................................................................
50
No pre-existing condition limitation
....................................................................................................
50
Where you get information about enrolling in the FEHB
Program..................................................... 50
Types of coverage available for you and your
family...........................................................................
50
When benefits and premiums start
.......................................................................................................
51
Your medical and claims records are
confidential................................................................................
51
When you retire
....................................................................................................................................
51
When you lose
benefits...............................................................................................................................
51
When FEHB coverage
ends..................................................................................................................
51
Spouse equity coverage
........................................................................................................................
51
Temporary Continuation of Coverage
(TCC).......................................................................................
52
Converting to individual
coverage........................................................................................................
52
Getting a Certificate of Group Health Plan Coverage
......................................................................... 52
Long Term Insurance is coming later in 2002
..............................................................................................................
54
Department of Defense/ FEHB Demonstration Project
................................................................................................
55
Index..............................................................................................................................................................................
57
Summary of
benefits.....................................................................................................................................................
58
Rates
........................................................................................................................................................................
59-60 4
4 Page 5 6
5
PacifiCare Health Plans
5995 Plaza Drive
Cypress, CA 90630
This brochure describes the benefits of PacifiCare Health Plans under our
contract (CS 1937) with the Office of
Personnel Management (OPM), as
authorized by the Federal Employees Health Benefits law. This brochure is the
official statement of benefits. No oral statement can modify or otherwise
affect the benefits, limitations, and
exclusions of this brochure.
If you are enrolled in this Plan you are entitled to the benefits described
in this brochure. If you are enrolled for
Self and Family coverage, each
eligible family member is also entitled to these benefits. You do not have a
right to
benefits that were available before January 1, 2002, unless those
benefits are also shown in this brochure.
OPM negotiates benefits and rates with each plan annually. Benefit changes
are effective January 1, 2002, and are
summarized on page 10. Rates are
shown at the end of this brochure.
Teams of Government and health plans' staff worked on all FEHB brochures to
make them responsive, accessible,
and understandable to the public. For
instance,
Except for necessary technical terms, we use common words. For instance,
"you" means the enrollee or family
member; "we" means PacifiCare.
We limit acronyms to ones you know. FEHB is the Federal Employees Health
Benefits Program. OPM is the
Office of Personnel Management. If we use
others, we tell you what they mean first.
Our brochure and other FEHB plans' brochures have the same format and
similar descriptions to help you
compare plans.
If you have comments or suggestions about how to improve the structure of
this brochure, let OPM know. Visit
OPM's "Rate Us" feedback area at www.
opm. gov/ insure or e-mail OPM at fehbwebcomments@ opm. gov. You may
also
write to the OPM at the Office of Personnel Management, Office of Insurance
Planning and Evaluation
Division, 1900 E Street NW, Washington, DC
20415-3650.
2002 PacifiCare Health Plans Introduction/ Plain Language
Introduction
PacifiCare Health Plans 2002
Plain Language 5
5 Page
6 7
6
Stop health care fraud!
Fraud increases the cost of health care for everyone. If you suspect that a
physician, pharmacy, or hospital has charged you for services
you did not
receive, billed you twice for the same service, or
misrepresented any
information, do the following:
Call the provider and ask for an explanation. There may be an
error.
If the provider does not resolve the matter, call us at
1( 800)
531-3341 and explain the situation.
If we do not resolve the issue, call
or write
THE HEALTH CARE FRAUD HOTLINE
(202) 418-3300
The United States
Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street, NW, Room 6400
Washington, DC 20415
Penalties for Fraud Anyone who falsifies a claim to obtain FEHB
Program benefits can
be prosecuted for fraud. Also, the Inspector General
may investigate
anyone who uses an ID card if the person tries to obtain
services for
someone who is not an eligible family member, or is no longer
enrolled in the Plan and tries to obtain benefits. Your agency may also
take administrative action against you.
2002 PacifiCare Health Plans Inspector General Advisory
Inspector General Advisory
PacifiCare Health Plans 2002 6
6 Page 7 8
7
This Plan is a health maintenance organization
(HMO). We require you to see specific physicians, hospitals, and
other
providers that contract with us. These Plan providers coordinate your health
care services.
HMO's emphasize preventive care such as routine office visits, physical
exams, well-baby care, and immunizations,
in addition to treatment for
illness and injury. Our providers follow generally accepted medical practice
when
prescribing any course of treatment.
When you receive services from Plan providers, you will not have to submit
claim forms or pay bills. You only pay
the copayments, coinsurance, and
deductibles described in this brochure. When you receive emergency services
from non-Plan providers, you may have to submit claim forms.
You should join an HMO because you prefer the plan's benefits, not because
a particular provider is
available. You cannot change plans because a
provider leaves our Plan. We cannot guarantee that any one
physician,
hospital, or other provider will be available and/ or remain under contract with
us.
How we pay providers
We contract with individual physicians,
medical groups, and hospitals to provide the benefits in this brochure.
These Plan providers accept a negotiated payment from us, and you will only
be responsible for your copayments or
coinsurance.
Your Rights
OPM requires that all FEHB Plans provide certain
information to their FEHB members. You may get information
about us, our
networks, providers, and facilities. OPM's FEHB website (www. opm. gov/ insure)
lists the specific
types of information that we must make available to you.
Some of the required information is listed below.
PacifiCare Health Systems has been in existence since 1975. We were founded
by the Lutheran Hospital Society
now called UniHealth America. We began
operating as a Federally qualified Health Maintenance Organization
(HMO) in
1978.
PacifiCare is a for profit organization.
If you want more information about us, call 1( 800) 531-3341, or write to
5995 Plaza Drive MS CY 20-303,
Cypress, CA 90630. You may also contact us by
fax at (714) 226-3575 or visit our website at www. pacificare. com.
2002 PacifiCare Health Plans Section I
Section 1. Facts about this HMO plan
PacifiCare Health Plans
2002 7
7 Page 8 9
8
Service Area
To enroll in this Plan,
you must live or work in our service area. This is where our providers practice.
Our service areas are:
ARIZONA
Serving: Maricopa and Pima
counties and Apache Junction identified by the following zip codes:
85217,
85219, 85278 and 85220
CALIFORNIA
Serving Northern and Southern California:
Alameda,
Contra Costa, Fresno, Kern, Los Angeles (except Catalina Island), Marin, Orange,
Sacramento, San
Diego, San Francisco, San Joaquin, San Mateo, Santa Barbara,
Santa Clara, Santa Cruz, Solano, Sonoma,
Stanislaus, Ventura, Yolo, and
portions of the following counties as defined by zip codes:
El Dorado: 95682, 95726
Imperial: 92227, 92231-33, 92243-44, 92249,
93350, 92251, 92257, 92259, 92273, 92281
Placer: 95602-04, 95626, 95631,
95648, 95650, 95658, 95661, 95663, 95668, 95677, 95678, 95681, 95703,
95713,
95717, 95722, 95736, 95746, 95747, 95765
Riverside: 91718-20, 91752, 91760, 92201-03, 92210, 92211, 92220, 92223,
92225-26, 92230, 92234-36,
92239-41, 92253-55, 92258, 92260-64, 92270,
92272, 92274-76, 92282, 92292, 92302-03, 92313, 92320,
92330-31, 92343-44,
92348, 92353, 92355, 92360, 92362, 92367, 92369-70, 92379-81, 92383, 92387-88,
92390, 92395, 92396, 92500-99
San Bernardino: 91701, 91708-10, 91729-30, 91737, 91739, 91743, 91758-59,
91761-64, 91784, 91785-816,
92252, 92256, 92277, 92278, 92284, 92285, 92286,
92301, 92305, 92307-08, 92310-18, 92321, 92322,
92324-27, 92329, 92333-37,
92339-42, 92345-47, 92350, 92352, 92354, 92356-59, 92365, 92368, 92369,
92371-78, 92382, 92385, 92386, 92391-94, 92397-99, 92400-99
NEVADA
Serving Clark County Nevada identified by the following
cities and zip codes:
Blue Diamond, Boulder City, Bunkerville, Cal/ Nev/
Ari, Henderson, Jean, Indian Springs, Las Vegas, Logandale,
Mesquite, Moapa,
Mt. Charleston North Las Vegas, Nellis AFB, Overton and Searchlight.
Clark: 88901-88905, 89004-89007, 89009, 89011-12, 89014-16, 89018, 89019,
89021, 89024-27, 89030-33,
89036, 89039-40, 89046, 89052, 89070,
89100-89135, 89137-39, 89141-56, 89158-60, 89163, 89164, 89170,
89177,
89180, 89185, 89191, 89193, 89195 and 89199
2002 PacifiCare Health Plans Section I
PacifiCare Health Plans 2002 8
8 Page 9 10
9
OKLAHOMA
Serving Central and Northeastern Oklahoma:
The counties of:
Canadian, Cleveland, Creek, Logan, Oklahoma, Pottawatomie, Rogers, Tulsa and
Wagoner.
And portions of the following counties identified by zip code:
Muskogee: 74436
Osage: 74002, 74035, 74054, 74060
Washington: 74061,
74082
OREGON
Serving Metropolitan Portland, Salem, Corvalis,
Eugene and Southwest Washington:
Multnomah, Washington, Clackamas, Marion,
Polk, Linn, Benton, Lane, Yamhill and Columbia, and Clark
county in
Washington.
TEXAS
Serving San Antonio and Dallas/ Ft. Worth:
Atascosa,
Bandera, Bexar, Collin, Comal, Dallas, Denton, Ellis, Guadalupe, Hood, Hunt,
Johnson, Kaufmann,
Kendall, Rockwall, Tarrant, and Wise.
WASHINGTON
Serving the Puget Sound area and most of Western
Washington.
Grays Harbor, King, Lewis, Mason, Pierce, Snohomish and
Thurston.
Ordinarily, you must get your care from providers who contract with us. If
you receive care outside our service
area, we will pay only for emergency
care benefits. We will not pay for any other health care services out of our
service area unless the services have prior plan approval.
If you or a covered family member move outside of our service area, you can
enroll in another plan. If your
dependents live out of the area (for
example, if your child goes to college in another state), you should consider
enrolling in a fee-for-service plan or an HMO that has agreements with
affiliates in other areas. If you or a family
member move, you do not have
to wait until Open Season to change plans. Contact your employing or retirement
office.
2002 PacifiCare Health Plans Section I
PacifiCare Health Plans 2002 9
9 Page 10 11
10
Do not rely
on these change descriptions; this page is not an official statement of
benefits. For that, go to Section 5
Benefits. Also, we edited and clarified
language throughout the brochure; any language change not shown here is a
clarification that does not change benefits.
Program-wide changes
We increased speech therapy benefits by
removing the requirement that services must be required to restore
functional speech. (Section 5( a))
Changes to this Plan
Code A3 Your share of the non-Postal
premium will increase by 30.5% for Self Only or 63.3% for Self and Family
Code CY Your share of the non-Postal premium will increase by 16.4% for
Self Only or16.3% for Self and Family
Code GF Your share of the
non-Postal premium will increase by 13.4% for Self Only or 13.6% for Self and
Family
Code K9 Your share of the non-Postal premium will increase.
by 30.9% for Self Only or 35.2% for Self and
Family
Code WB Your share of the non-Postal premium will increase by 40.2%
for Self Only or 94.6% for Self and Family
Code 2N Your share of
the non-Postal premium will increase. by 15.3% for Self Only or 15.4% for Self
and Family
Code 7Z Your share of the non-Postal premium will
increase by 72.1% for Self Only or 72.3% for Self and Family
We now cover
certain intestinal transplants.
We now cover injectable medications and
supplies under Home Health care. You pay nothing (Section 5( a)). We
previously covered these services under the Prescription drug benefit.
2002 PacifiCare Health Plans Section 2
Section 2. How we change for 2002
PacifiCare Health Plans 2002
10
10 Page 11 12
11
Identification cards We will send you an
identification (ID) card. You should carry your ID card with you at all times.
You must show it whenever you receive services from a
Plan provider, or fill
a prescription at a Plan pharmacy. Until you receive your
ID card, use your
copy of the Health Benefits Election Form, SF-2809, your
health benefits
enrollment confirmation (for annuitants), or your Employee
Express
confirmation letter.
If you do not receive your ID card within 30 days after the effective date of
your enrollment, or if you need replacement cards, call us at 1( 800)
531-3341.
Where you get covered care You get care from "Plan providers" and
"Plan facilities." You will only pay copayments and/ or coinsurance, and you
will not have to file claims unless
you receive out of area emergency
services.
Plan providers Plan providers are physicians and other
health care professionals in our service
area that we contract with to
provide covered services to our members. We
credential Plan providers
according to national standards. We list Plan
providers in the provider
directory, which we update periodically. The list is
also on our website,
which you can also access at www. pacificare. com.
Plan facilities Plan facilities are hospitals and other facilities
in our service area that we
contract with to provide covered services to our
members. We list these in the
provider directory, which we update
periodically. The list is also on our
website.
What you must do to get It depends on the type of care you need.
First, you and each family covered care member must choose a primary care
physician. This decision is important
since your primary care physician
provides or arranges for most of your health
care. You may select a primary
care doctor by completing the Primary Care
Doctor Selection form inside your
enrollment packet.
Primary care Your primary care physician can be a family
practitioner, internist, General
Practitioner or pediatrician for children
under 18 years of age. Your primary
care physician will provide most of your
health care, or give you a referral to
see a specialist.
If you want to change primary care physicians or if your primary care
physician leaves the Plan, call us. We will help you select a new one.
Specialty care Your primary care physician will refer you to a
specialist for needed care.
When you receive a referral from your primary
care physician, you must return
to the primary care physician after the
consultation, unless your primary care
physician authorized a certain number
of visits without additional referrals. The
primary care physician must
provide or authorize all follow-up care. Do not go
to the specialist for
return visits unless your primary care physician gives you a
referral.
However, women may see an OB/ Gyn without a referral.
If you are enrolled in Plans WB or GF you may see any Woman's Healthcare
provider within the network for maternity care, reproductive health
services,
gynecological care and general examinations without a referral.
2002 PacifiCare Health Plans Section 3
Section 3. How you get care
PacifiCare Health Plans 2002 11
11 Page 12 13
12
Here are other things you should know about
specialty care:
If you need to see a specialist frequently because of a
chronic, complex, or
serious medical condition, your primary care physician
will coordinate with
your specialist and PacifiCare to develop a treatment
plan that allows you
to see your specialist for a certain number of visits
without additional
referrals. Your primary care physician will use our
criteria when creating
your treatment plan (the physician may have to get an
authorization or
approval beforehand).
If you are seeing a specialist when you enroll in our Plan, talk to your
primary care physician. Your primary care physician will decide what
treatment you need. If he or she decides to refer you to a specialist, ask
if
you can see your current specialist. If your current specialist does not
participate with us, you must receive treatment from a specialist who does.
Generally, we will not pay for you to see a specialist who does not
participate with our Plan.
If you are seeing a specialist and your specialist leaves the Plan, call
your
primary care physician, who will arrange for you to see another
specialist.
You may receive services from your current specialist until we
can make
arrangements for you to see someone else.
If you have a chronic or disabling condition and lose access to your
specialist because we:
-terminate our contract with your specialist for other than cause; or
-drop out of the Federal Employees Health Benefits (FEHB) Program
and
you enroll in another FEHB Plan; or
-reduce our service area and you enroll in another FEHB Plan,
you may be
able to continue seeing your specialist for up to 90 days after
you receive
notice of the change. Contact us or, if we drop out of the
Program, contact
your new plan.
If you are in the second or third trimester of pregnancy and you lose access
to
your specialist based on the above circumstances, you can continue to see
your
specialist until the end of your postpartum care, even if it is beyond
the 90 days.
Hospital care Your Plan primary care physician or specialist will
make necessary hospital
arrangements and supervise your care. This includes
admission to a skilled
nursing or other type of facility.
If you are in the hospital when your enrollment in our Plan begins, call our
customer service department immediately at 1( 800) 531-3341. If you are new
to the FEHB Program, we will arrange for you to receive care.
2002 PacifiCare Health Plans Section 3
PacifiCare Health Plans 2002 12
12 Page 13 14
13
If you
changed from another FEHB plan to us, your former plan will pay for
the
hospital stay until:
You are discharged, not merely moved to an alternative care center; or
The day your benefits from your former plan run out; or
The 92nd day after
you become a member of this Plan, whichever happens
first.
These provisions apply only to the benefits of the hospitalized person.
Circumstances beyond our control Under certain extraordinary
circumstances, such as natural disasters, we may have to delay your services or
we may be unable to provide them. In that case,
we will make all reasonable
efforts to provide you with the necessary care.
Services requiring our
Your primary care physician has authority to refer you for most services.
prior approval For certain services, however, your physician must obtain
approval from us.
Before giving approval, we consider if the service is
covered, medically
necessary, and follows generally accepted medical
practice.
We call this the approval process precertification. Your physician must
obtain
approval for some services such as:
Cardiovascular bypass surgery
Septoplasty
Cholecystectomy
Hysterectomy
Arthroplasty
MRIs and CTs
Growth Hormone Treatment
(GHT)
PacifiCare Health Plans may determine medical necessity by using
preauthorization programs and criteria. Our criteria are written guidelines
established by us to determine medical necessity and/ or coverage for
certain
procedure and treatments. Our criteria are based on research of
scientific
literature, collaboration with physician specialists and
compliance with federal
and national regulatory agency guidelines. Criteria
are approved by the
PacifiCare Health Care Standards and Education Committee
and are reviewed
and revised on a regular basis. Criteria are available for
review by the
member's participating physician, the member or the member's
representative.
If you do not receive prior approval you may be responsible
for charges.
Always return to your primary care physician for prior
approval.
2002 PacifiCare Health Plans Section 3
PacifiCare Health Plans 2002 13
13 Page 14 15
14
You must
share the cost of some services. You are responsible for:
Copayments
A copayment is a fixed amount of money you pay to the provider, facility or
pharmacy when you receive services.
Example: When you see your primary care physician you pay a copayment
of
$10 per office visit and when you go in the hospital, you pay nothing per
admission.
Deductible We do not have a deductible.
Coinsurance We
do not have coinsurance.
Your Catastrophic Protection After your copayments total $1,500 per
person or $3,000 per family out-of-pocket maximum enrollment in any
calendar year, you do not have to pay any more for covered
for copayments
services. However, copayments for the following services do not count toward
your out-of-pocket maximum, and you must continue to pay copayments for
these services:
Prescription Drugs
Dental Services
Chiropractic Services
Be sure to keep accurate records of your copayments since you are responsible
for informing us when you reach the maximum.
2002 PacifiCare Health Plans Section 4
Section 4. Your costs for covered services
PacifiCare Health Plans
2002 14
14 Page
15 16
15
NOTE: This benefits
section is divided into subsections. Please read the important things you should
keep in mind at the
beginning of each subsection. For more information about
our benefits, contact us at 1( 800) 531-3341 or at our website at
www.
pacificare. com.
(a) Medical services and supplies provided by physicians and other health
care professionals . . . . . . . . . . . . . . . . . 16 -23
Diagnostic and
treatment services Speech Therapy
Lab, X-ray, and other diagnostic tests
Hearing services (testing, treatment, and supplies)
Preventive care,
adult Vision services (testing, treatment, and supplies)
Preventive
care, children Foot care
Maternity care Orthopedic and prosthetic
devices
Family planning Durable medical equipment (DME)
Infertility services Home health services
Allergy care Chiropractic
Treatment therapies Educational classes and programs
Physical and
occupational therapies
(b) Surgical and anesthesia services provided by physicians and other health
care professionals. . . . . . . . . . . . . . . . 24 -27
Surgical
procedures Oral and maxillofacial surgery
Reconstructive surgery
Organ/ tissue transplants
Anesthesia
(c) Services provided by a hospital or other facility, and ambulance services
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 -29
Inpatient hospital Extended care benefits/ skilled nursing care
Outpatient hospital or ambulatory facility benefits
surgical center
Hospice care
Ambulance
(d) Emergency services/ accidents. . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 30 -31
Accidental injury Medical emergency Ambulance
(e) Mental health and substance abuse benefits . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 -33
(f) Prescription drug benefits. . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . 34 -36
(g) Special features . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . 37
Health Improvement Programs
PacifiCare Perks SM Programs
Eye Glasses and Hearing Aid
Centers of
Excellence
(h) Dental benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 38 -39
(i) Non-FEHB benefits available to Plan members . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 40
Summary of benefits . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . 58
2002 PacifiCare Health Plans Introduction/ Plain Language
Section 5. Benefits OVERVIEW
(See page 10 for how our
benefits changed this year and page 58 for a benefits summary.)
PacifiCare Health Plans 2002 15
15 Page 16 17
Diagnostic and
treatment services
Professional services of physicians $10 per office
visit
In a physicians office Nothing for inpatient services.
In an
urgent care center
During a hospital stay
In a skilled nursing
facility
Off ice medical consultations
Second surgical opinion
At home doctors house calls or visits by nurses and health aides $10 per
visit
Lab, X-ray and other diagnostic tests
Tests, such as:
Nothing if you receive these services
Blood tests during your office
visit.
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
CAT Scans/ MRI
Ultrasound
Electrocardiogram and EEG
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Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and
exclusions in this brochure and are payable only when we
determine they are
medically necessary.
Plan physicians must provide or arrange your care.
Be sure to read
Section 4, Your costs for covered services for valuable information
about how cost sharing works. Also read Section 9 about coordinating
benefits with
other coverage, including with Medicare.
PacifiCare Health Plans 2002 Section 5( a)
Section 5 (a) Medical services and supplies provided by physicians and
other health care professionals
PacifiCare Health Plans 2002
You pay Benefit Description You pay
After the calendar year deductible
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PacifiCare Health Plans 2002
Preventive care, adult You pay
Routine screenings, such as: Nothing if you receive these
Total
Blood Cholesterol once every three years services during your office visit;
Colorectal Cancer Screening, including
otherwise, $10 per office visit
-Fecal occult blood test
-Sigmoidoscopy, screening every five years
starting at age 50 $10 per office visit
Prostate Specific Antigen (PSA test) one annually for men age 40 and older
$10 per office visit
Routine pap test $10 per office visit
Note: The
office visit is covered if pap test is received on the same day;
see
Diagnosis and Treatment, above.
Routine mammogram covered for women age 35 and older, as follows: Nothing
if you receive these services
From age 35 through 39, one during this five
year period during your office visit; otherwise,
From age 40 through 64,
one every calendar year
$10 per office visit
At age 65 and older, one every two consecutive calendar years
Not
covered: Physical exams required for obtaining or continuing All charges.
employment or insurance, attending schools or camp, or travel.
Immunizations for travel
Routine immunizations, limited to: Nothing if you receive these services
Tetanus-diphtheria (Td) booster once every 10 years, ages 19 and during
your office visit; otherwise,
over (except as provided for under Childhood
immunizations). $10 per office visit
Influenza/ Pneumococcal vaccines, annually, age 65 and over.
Eye exams
to determine the need for vision correction.
Preventive care, children
Childhood immunizations recommended by
the American Academy Nothing if you receive these services
of Pediatrics
during your office visit; otherwise,
$10 per office visit
Examinations, such as: $10 per office visit
-Eye exams to determine the
need for vision correction.
-Ear exams to determine the need for hearing
correction.
-Examinations done on the day of immunizations (up to age 22
years).
Well-child care charges for routine examinations, immunizations and
care (up to age 22 years). 17
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PacifiCare Health Plans 2002
Maternity care You pay
Complete maternity (obstetrical) care,
such as: A single $10 copay for the
Prenatal care entire pregnancy.
Delivery
Postnatal care
Note: Here are some things to keep in mind:
You do not need to precertify your normal delivery; see page 28 for
other circumstances, such as extended stays for you or your baby.
You may remain in the hospital up to 48 hours after a regular
delivery
and 96 hours after a cesarean delivery. We will extend
your inpatient stay
if medically necessary.
We cover routine nursery care of the newborn child during the
covered
portion of the mother's maternity stay. We will cover other
care of an
infant who requires non-routine treatment only if we
cover the infant under
a Self and Family enrollment.
We pay hospitalization and surgeon services (delivery) the same as
for
illness and injury. See Hospital benefits (Section 5c) and
Surgery benefits
(Section 5b).
Not covered: Routine sonograms to determine fetal sex. All charges.
Family planning
A broad range of family services such as: $10
per office visit.
Voluntary sterilization Nothing for hospital visits or
Surgically implanted contraceptives (such as Norplant)
Outpatient
Surgical Center.
Injectable contraceptive drugs (such as Depo-Provera)
Intrauterine
devices (IUDs)
Diaphragms
Note: we cover oral contraceptives under the
prescription drug benefit.
Not covered: Reversal of voluntary surgical sterilization and genetic All
charges.
counseling,
Infertility services
Diagnosis and treatment of infertility, such
as: 50% of all charges
Artificial insemination:
-intravaginal
insemination (IVI)
-intracervical insemination (ICI)
-intrauterine
insemination (IUI)
Fertility drugs
Note: We cover injectable fertility
drugs under medical benefits and oral
fertility drugs under the prescription
drug benefit.
Infertility services continued on next page. 18
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19 PacifiCare Health Plans 2002 Section 5( a)
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Infertility services (Continued)
You pay
Not covered: All charges.
Assisted reproductive
technology (ART) procedures, such as:
-in vitro fertilization
-embryo
transfer gamate GIFT and zygote ZIFT
-Zygote transfer
Services and
supplies related to excluded ART procedures
Cost of donor sperm
Cost
of donor egg
Allergy care
Testing and treatment $10 per office visit
Allergy injection
Allergy serum Nothing
Not covered: provocative food testing and
sublingual allergy All charges.
desensitization.
Treatment therapies
Chemotherapy and radiation therapy $10 per
office visit
Note: High dose chemotherapy in association with autologous
bone
marrow transplants are limited to those transplants listed under
Organ/ Tissue Transplants on page 26.
Respiratory and inhalation therapy
Dialysis Hemodialysis and
peritoneal dialysis
Intravenous (IV)/ Infusion Therapy Home IV and
antibiotic therapy
Growth hormone therapy (GHT)
Note: We will only
cover GHT when we preauthorize the treatment.
We will ask you to submit
information that establishes that the GHT is
medically necessary. Ask us to
authorize GHT before you begin
treatment; otherwise, we will only cover GHT
services from the date
you submit the information. If you do not ask or if
we determine GHT
is not medically necessary, we will not cover the GHT or
related services
and supplies. See Services requiring our prior approval in
Section 3.
Not covered: All charges.
Other treatment services not listed as
covered. 19
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Section 5( a)
PacifiCare Health Plans 2002
Physical and
Occupational Therapies You pay
Physical therapy, occupational therapy
$10 per office visit
Unlimited visits for the services of each of the
following:
-qualified physical therapists;
-occupational therapists
Note: We only cover therapy to restore bodily function when there has
been a total or partial loss of bodily function or due to illness or injury.
Cardiac rehabilitation following a heart transplant, bypass surgery or $10
per outpatient visit
a myocardial infarction is provided with no day limit.
Pulmonary Rehabilitation
Not covered: All charges.
long-term rehabilitative therapy
exercise programs
Speech Therapy
Unlimited visits for the services of: $10 per
office visit copay
Qualified speech therapists
Note: All therapies are
subject to medical necessity
Hearing services (testing, treatment, and supplies)
First hearing
aid and testing only when necessitated by accidental injury $10 per office visit
copay
Hearing testing (see Preventive care)
Not covered: All charges.
all other hearing testing
all other
hearing aids
Vision services (testing, treatment, and supplies)
One pair of
eyeglasses or contact lenses to correct an impairment directly $10 per office
visit
caused by accidental ocular injury or intraocular surgery (such as for
cataracts)
Annual eye refractions $10 per office visit
Note: See preventive care
children for eye exams for children
Not covered: All charges.
Eyeglasses or contact lenses except as
shown on page 20.
Eye exercises and orthoptics
Radial keratotomy and
other refractive surgery 20
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PacifiCare Health Plans 2002
Foot care You pay
Routine foot care when you are under active
treatment for a metabolic or $10 per office visit
peripheral vascular
disease, such as diabetes.
See orthopedic and prosthetic devices for information on podiatric
shoe
inserts.
Not covered: All charges.
Cutting, trimming or removal of corns,
calluses, or the free edge of
toenails, and similar routine treatment of
conditions of the foot,
except as stated above.
Treatment of weak, strained or flat feet or bunions or spurs; and of
any instability, imbalance or subluxation of the foot (unless the
treatment is by open cutting surgery).
Orthopedic and prosthetic devices
Artificial limbs and eyes;
stump hose. Nothing
Foot Orthotics when medical criteria is met.
Externally worn breast prostheses and surgical bras, including necessary
replacements, following a mastectomy.
Internal prosthetic devices, such as artificial joints, pacemakers,
cochlear
implants, and surgically implanted breast implant following
mastectomy.
Note: See 5( b) for coverage of the surgery to insert the
device.
Corrective orthopedic appliances for non-dental treatment of
temporomandibular joint (TMJ) pain dysfunction syndrome.
Prosthetic Replacements when the device is beyond repair or the patient
requires a new device because of a physical change.
Not covered: All charges.
orthopedic and corrective shoes
arch
supports
heel pads and heel cups
lumbosacral supports
corsets,
trusses, elastic stockings, support hose, and other supportive
devices
Prosthetic replacements provided less than three years after the last one
we covered 21
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Section 5( a)
PacifiCare Health Plans 2002
Durable medical
equipment (DME) You pay
Rental or purchase, at our option, including
repair and adjustment of, such Nothing
as oxygen and dialysis equipment.
Under this benefit, we also cover durable
medical equipment prescribed by
your Plan physician such as:
Orthopedic Brace;
hospital beds;
wheelchairs;
crutches;
walkers;
insulin pumps.
Note: Call us at 1( 800) 531-3341 as soon
as your Plan physician prescribes
this equipment. We will arrange with a
health care provider to rent or sell
you durable medical equipment at
discounted rates and will tell you more
about this service when you call.
Not covered: All charges.
Specialized wheelchairs for comfort and
convenience.
Home health services
Home health care ordered by a Plan
physician and provided by a Nothing
registered nurse (R. N.), licensed
practical nurse (L. P. N.), licensed
vocational nurse (L. V. N.), or home
health aide.
Services include oxygen therapy, intravenous therapy and medications
such as injectables.
Injectable medications for home use and self-administration by patient
when approved by the Plan or your Medical Group.
Not covered: All charges.
nursing care requested by, or for the
convenience of, the patient or the
patient's family;
Services primarily for hygiene, feeding, exercising, moving the patient,
homemaking, companionship or giving oral medication.
Home care primarily for personal assistance that does not include a
medical component and is not diagnostic, theraputic or rehabilitative.
Chiropractic Care
Chiropractic services You may self refer to a
participating chiropractor for $10 per office visit
up to 30 visits each
calendar year
Manipulation of the spine and extremities
Adjunctive procedures such
as ultrasound, electrical muscle stimulation,
vibratory therapy, and cold
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Section 5( a)
PacifiCare Health Plans 2002
Alternative
treatments You pay
Note: See page 37 for the PacifiCare Perks SM
program for discounts on
these services.
Not covered: All charges.
acupuncture
naturopathic services
hypnotherapy
biofeedback
Educational classes and programs
Coverage is limited to: Nothing
Smoking Cessation including all related expenses such as Nicotine (Note:
There is a $20 Prescription
Replacement* Drug copayment for smoking
Taking Charge of Your Heart Health cessation products)
Diabetes
self-management (Taking Charge of Diabetes )
Healthy Pregnancy SM
Managing Depression 23
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Here are some important things
to keep in mind about these benefits:
Please remember that all
benefits are subject to the definitions, limitations, and
exclusions in this
brochure and are payable only when we determine they are
medically
necessary.
Plan physicians must provide or arrange your care.
We have no calendar
year deductible
Be sure to read Section 4, Your costs for covered
services for valuable information
about how cost sharing works. Also
read Section 9 about coordinating benefits with
other coverage, including
with Medicare.
The amounts listed below are for the charges billed by a physician or other
health
care professional for your surgical care. Look in section 5( c) for
charges associated
with the facility (i. e. hospital, surgical center, etc.)
YOUR PHYSICIAN MUST GET PRECERTIFICATION OF SOME SURGICAL
PROCEDURES.
Please refer to the precertification information shown in Section 3
to be
sure which services require precertification and identify which surgeries
require precertification.
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PacifiCare Health Plans 2002 Section 5( b)
Section 5 (b). Surgical and anesthesia services provided by physicians and
other health care professionals
PacifiCare Health Plans 2002
Benefit Description You pay
Surgical procedures
A
comprehensive range of services, such as: $10 per office visit; nothing for
hospital
Operative procedures visits or outpatient surgical centers
Treatment of fractures, including casting
Normal pre-and
post-operative care by the surgeon
Correction of amblyopia and strabismus
Endoscopy procedures
Biopsy procedures
Removal of tumors and
cysts
Correction of congenital anomalies (see reconstructive surgery)
Surgical treatment of morbid obesity a condition in which an individual
weighs 100 pounds or 100% over his or her normal weight according to
current underwriting standards; eligible members must be age 18 or over
Insertion of internal prosthetic devices. See 5( a) Orthopedic and
prosthetic devices for device coverage information.
Voluntary sterilization
Treatment of burns
Note: Generally, we pay
for internal prostheses (devices) according to
where the procedure is done.
For example, we pay Hospital benefits for
a pacemaker and Surgery benefits
for insertion of the pacemaker.
Surgical procedures continued on next page. 24
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25 PacifiCare Health Plans 2002 Section 5( b)
PacifiCare Health Plans 2002
Surgical procedures
(Continued) You pay
Not covered: All charges.
Reversal of voluntary sterilization
Routine treatment of conditions
of the foot; see Foot care.
Reconstructive surgery
Surgery to correct a functional defect
Nothing
Surgery to correct a condition caused by injury or illness if:
-the condition produced a major effect on the member's appearance and
-the condition can reasonably be expected to be corrected by such surgery
Surgery to correct a condition that existed at or from birth and is a
significant deviation from the common form or norm. Examples of
congenital anomalies are: protruding ear deformities; cleft lip; cleft
palate;
birth marks; webbed fingers; and webbed toes.
All stages of breast reconstruction surgery following a mastectomy, See
above.
such as:
-surgery to produce a symmetrical appearance on the other breast;
-treatment of any physical complications, such as lymphedemas;
-breast
prostheses and surgical bras and replacements
(see Prosthetic devices)
Note: If you need a mastectomy, you may choose to have the procedure
performed on an inpatient basis and remain in the hospital up to 48 hours
after the procedure.
Not covered: All charges.
Cosmetic surgery any surgical procedure
(or any portion of a procedure)
performed primarily to improve physical
appearance through change in
bodily form, except repair of accidental injury
Surgeries related to sex transformation
Oral and maxillofacial surgery
Oral surgical procedures, limited
to: Nothing
Reduction of fractures of the jaws or facial bones;
Surgical correction of cleft lip, cleft palate or severe functional
malocclusion;
Removal of stones from salivary ducts;
Excision of leukoplakia or
malignancies;
Excision of cysts and incision of abscesses when done as
independent
procedures; and
Other surgical procedures that do not involve the teeth or their
supporting structures.
TMJ surgery and related non-dental treatment.
Oral and maxillofacial surgery continued on next page. 25
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26 PacifiCare Health Plans 2002 Section 5( b)
PacifiCare Health Plans 2002
Oral and maxillofacial surgery
(Continued) You pay
Not covered: All charges.
Oral
implants and transplants
Procedures that involve the teeth or their
supporting structures (such as
the periodontal membrane, gingiva, and
alveolar bone)
Organ/ tissue transplants
Limited to: Nothing
Cornea
Heart
Heart/ lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single Double
Pancreas
Allogeneic (donor) bone marrow
transplant
Autologous bone marrow transplants (autologous stem cell and
peripheral
stem cell support) for the following conditions: acute
lymphocytic or
non-lymphocytic leukemia; advanced Hodgkin's lymphoma;
advanced
non-Hodgkin's lymphoma; advanced neuroblastoma; breast cancer;
multiple myeloma; epithelial ovarian cancer; and testicular, mediastinal,
retroperitoneal and ovarian germ cell tumors
Intestinal Transplants (small intestine) and the small intestine with the
liver or small intestine with multiple organs such as liver, stomach
and
pancreas
National Transplant Program (NTP)
Limited Benefits Treatment for
breast cancer, multiple myeloma, and
epithelial ovarian cancer may be
provided in an NCI-or NIH-approved
clinical trial at a Plan-designated
center of excellence and if approved by
the Plan's medical director in
accordance with the Plan's protocols.
Note: We cover related medical and hospital expenses of the donor when
we
cover the recipient.
Not covered: All charges.
Donor screening tests and donor search
expenses, except those
performed for the actual donor
Implants of artificial organs
Transplants not listed as covered
26
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Anesthesia You pay
Professional services provided in Nothing
Hospital (inpatient)
Professional services provided in Nothing
Hospital outpatient
department
Skilled nursing facility
Ambulatory surgical center
Office 27
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PacifiCare Health Plans 2002 Section 5( c)
Section 5 (c). Services provided by a hospital or other facility,
and
ambulance services
PacifiCare Health Plans 2002
You pay Benefit Description You pay
Inpatient hospital
Room
and board, such as Nothing
ward, semiprivate, or intensive care
accommodations;
general nursing care; and
meals and special diets.
NOTE: If you want a private room when it is not medically necessary, you
pay the additional charge above the semiprivate room rate.
Other hospital services and supplies, such as: Nothing
Operating,
recovery, maternity, and other treatment rooms
Diagnostic laboratory tests
and X-rays
Administration of blood and blood products
Blood or blood
plasma
Dressings, splints, casts, and sterile tray services
Medical
supplies and equipment, including oxygen
Anesthetics, including nurse
anesthetist services
Take-home items
Medical supplies, appliances,
medical equipment, and any covered items
billed by a hospital for use at
home
Not covered: All charges.
Custodial care
Non-covered
facilities, such as nursing homes and schools
Personal comfort items, such
as telephone, television, barber services,
guest meals and beds
Private nursing care
Here are some important things to remember about these benefits:
Please remember that all benefits are subject to the definitions, limitations,
and
exclusions in this brochure and are payable only when we determine they
are
medically necessary.
Plan physicians must provide or arrange your care and you must be
hospitalized in a
Plan facility.
Be sure to read Section 4, Your costs for covered services for
valuable information
about how cost sharing works. Also read Section 9 about
coordinating benefits with
other coverage, including with Medicare.
The amounts listed below are for the charges billed by the facility (i. e.,
hospital or
surgical center) or ambulance service for your surgery or care.
Any costs associated
with the professional charge (i. e., physicians, etc.)
are covered in Section 5( a) or (b). 28
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29 PacifiCare
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PacifiCare Health Plans 2002
Outpatient hospital or ambulatory surgical center
Operating,
recovery, and other treatment rooms Nothing
Diagnostic laboratory tests,
X-rays, and pathology services
Administration of blood, blood plasma, and
other biologicals
Blood and blood plasma, if not donated or replaced
Pre-surgical testing
Dressings, casts, and sterile tray services
Medical supplies, including oxygen
Anesthetics and anesthesia service
NOTE: We cover hospital services and supplies related to dental
procedures when necessitated by a non-dental physical impairment.
We do
not cover the dental procedures.
Extended care benefits/ skilled nursing care facility benefits
Extended care benefit: We provide a wide range of benefits for full-time
Nothing
nursing care and confinement in a skilled nursing facility when your
doctor
determines it to be medically necessary. The Plan must also approve
this service.
All necessary services are covered up to 100 days per calendar year,
including:
Bed, board and general nursing care
Drugs, biologicals,
supplies, and equipment ordinarily provided or
arranged by the skilled
nursing facility when prescribed by a Plan doctor.
Not covered: All charges.
Custodial care
Homemaker Services
Hospice care
Supportive and palliative care for a terminally ill
member is covered in Nothing
the home or hospice facility when approved by
our Medical Director.
Services include:
Inpatient and outpatient care
Family counseling
These services are
provided under the direction of a Plan doctor who certifies
that the patient
is in the terminal stages of illness, with a life expectancy of
approximately six months or less.
Not covered: Independent nursing, homemaker services All charges.
Ambulance
Local professional ambulance service when
medically appropriate Nothing 29
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Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and
exclusions in this brochure.
We have no deductible
Be sure to read Section 4, Your costs for
covered services for valuable information
about how cost sharing works.
Also read Section 9 about coordinating benefits with
other coverage,
including with Medicare.
PacifiCare Health Plans 2002 Section 5( d)
Section 5 (d). Emergency services/ accidents
PacifiCare Health
Plans 2002
You pay Benefit Description You pay
After the calendar year deductible
What is a medical emergency? A medical emergency is the sudden and
unexpected onset of a condition or an injury that you believe endangers your
life or could result in serious injury or disability, and requires immediate
medical or surgical care. Some problems
are emergencies because, if not treated promptly, they might become more
serious; examples include deep cuts and
broken bones. Others are emergencies
because they are potentially life-threatening, such as heart attacks, strokes,
poisonings, gunshot wounds, or sudden inability to breathe. There are many
other acute conditions that we may
determine are medical emergencies what
they all have in common is the need for quick action.
What to do in case of emergency:
Emergencies within our service area:
If you have an emergency situation, please call your primary care
doctor. In extreme emergencies, if you are unable
to contact your doctor,
contact the local emergency system (e. g., the 911 telephone system) or go to
the nearest
hospital emergency room. Be sure to tell the emergency room
personnel that you are a Plan member so they can
notify the Plan. You or a
family member should notify the Plan within 48 hours (unless it is not
reasonably possible
to do so). It is your responsibility to notify us in a
timely manner.
If you need to be hospitalized, the Plan must be notified within 48 hours or
on the first working day following your
admission, unless it was not
reasonably possible to notify the Plan within that time. If you are hospitalized
in non-Plan
facilities and Plan doctors believe care can be better provided
in a Plan hospital, you will be transferred when
medically feasible with any
ambulance charges covered in full. Benefits are available for care from non-Plan
providers
in a medical emergency only if delay in reaching a Plan provider
would result in death, disability or significant
jeopardy to your condition.
To be covered by us you must get all follow-up care from our providers or follow
up care
must be approved by us.
Emergencies outside our service area: Benefits are available for any
medically necessary health service that is
immediately required because of
injury or unforeseen illness. If you need to be hospitalized, the Plan must be
notified within 48 hours or on the first working day following your
admission, unless it was not reasonably possible
to notify the Plan within
that time. If a Plan doctor believes care can be better provided in a Plan
hospital, you will
be transferred when medically feasible with any ambulance
charges covered in full. To be covered by this Plan, you
must get all follow
up care from plan providers or your follow up care must be approved by the Plan.
30
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Benefit Description You pay
Emergency within
our service area
Emergency care at a doctor's office $10 per office
visit
After hours care in your doctors office $10 per visit
Emergency care at an urgent care center $50 per visit
Emergency care
at a hospital, including doctors' services Note: You pay nothing if you are
admitted to the hospital.
Not covered: Elective care or non-emergency care All charges.
Emergency outside our service area
Emergency care at a
doctor's office $10 per office visit
Emergency care at an urgent care center $10 per visit
Emergency care
at a hospital, including doctors' services $50 per visit
Note: You pay
nothing if you are
admitted to the hospital.
Not covered: All charges.
Elective care or non-emergency care
Emergency care provided outside the service area if the need for care
could have been foreseen before leaving the service area.
Medical and hospital costs resulting from a full-term delivery of a baby
outside the service area.
Ambulance
Professional ambulance service, including air ambulance
services when Nothing
medically appropriate.
See 5( c) for non-emergency service.
31 PacifiCare Health Plans 2002 Section 5( d)
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When you get our approval for services and follow a treatment plan we
approve, cost-sharing
and limitations for Plan mental health and substance
abuse benefits will be no
greater than for similar benefits for other
illnesses and conditions.
Here are some important things to keep in mind about these benefits:
All benefits are subject to the definitions, limitations, and exclusions in this
brochure.
We do not have a calendar year deductible.
Be sure to read
Section 4, Your costs for covered services for valuable information
about how cost sharing works. Also read Section 9 about coordinating
benefits with
other coverage, including with Medicare.
YOU MUST GET PREAUTHORIZATION OF THESE SERVICES. See the
instructions
after the benefits description below.
You pay Benefit Description You pay
Mental health and substance abuse benefits
Diagnostic and
treatment services recommended by a Plan provider and Your cost sharing
responsibilities
contained in a treatment plan that we approve. The
treatment plan may are no greater than for other illness
include services,
drugs, and supplies described elsewhere in this brochure. or conditions.
Note: Plan benefits are payable only when we determine the care is clinically
appropriate to treat your condition and only when you receive the care as
part of a treatment plan that we approve.
Professional services, including individual or group therapy by providers
$10 per visit
such as psychiatrists, Psychologists, or clinical social
workers
Medication management
Diagnostic tests $10 per visit or test
Services provided by a
hospital or other facility Nothing
Services in approved alternative care
settings such as partial
hospitalization, half-way house, residential
treatment, full-day
hospitalization, facility based intensive outpatient
treatment
Not covered: Services we have not approved. All charges.
Note: OPM
will base its review of disputes about treatment plans on the
treatment
plan's clinical appropriateness. OPM will generally not order us to
pay or
provide one clinically appropriate treatment plan in favor of another.
32 PacifiCare Health Plans 2002 Section 5( e)
Section 5 (e). Mental health and substance abuse benefits
PacifiCare Health Plans 2002 32
32
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33
PacifiCare Health Plans 2002 Section 5( e)
PacifiCare Health Plans
2002
Mental health and substance abuse benefits (Continued)
Preauthorization To be eligible to receive these benefits you must
obtain a treatment plan and
follow the authorization processes:
If you are enrolled in CY, 2N, 7Z, GF or WB Call PacifiCare Behavioral Health
at 1( 800) 999-9585. If you are enrolled in A3 you can call Contact
Behavioral
Health at 1( 800) 888-1477. If you are enrolled in K9 call
Harmony Behavioral
Health at 1( 800) 363-4874. Customer Service department.
If you are enrolled in CY, 2N, 7Z, GF or WB you can call PacifiCare
Behavioral
Health at 1( 800) 999-9585 to get a list of providers or visit
their website at
www. pbhi. com.
If you are enrolled in A3 you can call Contact Behavioral Health at
1(
800) 888-1477 if you are enrolled in K9 you can call Harmony Behavioral
Health at 1( 800) 363-4874 to get a list of providers or visit their
websites at
www. contact. com or www. harmony. com. 33
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Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart
beginning on the
next page.
All benefits are subject to the definitions, limitations and exclusions in
this brochure
and are payable only when we determine they are medically
necessary.
Be sure to read Section 4, Your costs for covered services for
valuable information
about how cost sharing works. Also read Section 9 about
coordinating benefits with
other coverage, including with Medicare.
You pay There are important features you should be aware of. These
include:
Who can write your prescription. A plan physician must
write the prescription
Where you can obtain them. You must fill the
prescription at a plan pharmacy, or by mail for a maintenance
medication.
We use a formulary. The PacifiCare Formulary is a list of
prescription drugs that Physicians use as a guide when
prescribing
medications for patients. The Formulary helps us provide safe, effective and
affordable prescription drugs to
PacifiCare members. We work with physicians
and pharmacists to make sure you are getting the drug therapy you need.
A
Pharmacy and Therapeutics Committee evaluates prescription drugs for safety,
effectiveness, quality treatment and
overall value. The committee considers
the safety and effectiveness of a medication before they review the cost. Our
physicians may get pre-authorization for non-formulary drugs. Your doctor
may start the pre-authorization request by
phoning or faxing it. Requests
are usually processed within ten minutes although some may take up to two (2)
working
days if we need more information from your doctor. We cover
non-Formulary drugs prescribed by a Plan doctor.
We have a closed formulary. If your physician believes a name brand
product is necessary or there is no generic available,
your physician may
prescribe a name brand drug from a formulary list. This list of name brand drugs
is a preferred list of
drugs that we selected to meet patient needs at a
lower cost. To order a prescription drug brochure, call 1( 800) 824-0428.
Non-Formulary drugs will be covered if:
No Formulary alternative is
appropriate
You have tried the Formulary drugs and they have not worked or
you have had side effects or interactions with other
drugs. The physicians
are asked to provide a copy of the medical chart notes stating treatment failure
with the
Formulary alternatives.
You have been under treatment and remain stable on a non-Formulary
prescription drug and changing to a Formulary
drug would not be medically
suitable.
Your physician provides us with documents, records, or clinical trials which
shows that use of the requested non-Formulary
drug instead of the Formulary
drug is medically necessary, as determined by PacifiCare.
34 PacifiCare Health Plans 2002 Section 5( f)
Section 5 (f). Prescription drug benefits
PacifiCare Health Plans
2002 34
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35 PacifiCare Health Plans 2002
Section 5( f)
PacifiCare Health Plans 2002
These are the
dispensing limitations.
You can get your prescription drugs at a
participating pharmacy as long as it is written by your primary care doctor or
specialist. You will get up to a 30 day supply, 2 vials of insulin or one
commercially prepared unit (i. e., one inhaler, one
vial of ophthalmic
medication, topical ointment or cream for a $5 copay per prescription unit or
refill for generic drugs or
a $15 copayment for name brand drugs when
generic substitution is not available.
A generic equivalent will be dispensed if it is available unless your
physician specifically requires a name brand. If you
receive a name brand
drug when a Federally-approved generic drug is available, and your physician has
not specified
Dispense as Written for the name brand drug, you have to pay
the difference in cost between the name brand drug and the
generic and the
$15 copay per prescription unit or refill. Drugs are prescribed by Plan doctors
and dispensed in accordance
with the Plan's drug formulary.
Prescription drugs can also be obtained through the mail order program for up
to a 90 day supply of oral medication; 6
vials of insulin; or 3 commercially
prepared units (i. e., inhaler, vials ophthalmic medication or topical ointments
or
creams). You pay a $10 copay per prescription unit or refill for
generic drugs or a $30 copayment for name brand
maintenance medications.
Call 1( 800) 531-3341 for mail order customer service.
When you have to file a claim. Please refer to Section 7 for
information on how to file a pharmacy claim, or contact
our Customer Service
Department at 1( 800) 531-3341.
Why use generic drugs? To reduce your out-of-pocket expenses! A
generic drug is the chemical equivalent of a
corresponding brand name drug.
Generic drugs are less expensive than brand name drugs; therefore, you may
reduce
your out-of-pocket costs by choosing to use a generic drug. 35
35 Page 36 37
36 PacifiCare Health Plans 2002 Section 5( f)
PacifiCare Health Plans 2002
You pay Benefit Description You
pay
Covered medications and supplies
We cover the following
medications and supplies prescribed by a Plan $5 per generic formulary
physician and obtained from a Plan pharmacy or through our mail prescription
unit or refill.
order program: $15 per brand formulary
Drugs and medicines that by Federal law of the United States require
prescription unit or refill.
a physician's prescription for their purchase,
except those listed Note: If there is no generic
as not covered equivalent
available, you will still
Insulin have to pay the brand name copay.
Diabetic supplies such as lancets and blood glucose test strips
Disposable
needles and syringes for the administration of covered
medications
Contraceptive drugs and devices
Intravenous fluids and medications for
home use (covered under
Section 5( a) Home Health Services -see page 22)
Prenatal vitamins
Oral medications prescribed to treat infertility,
or the underlying cause of
infertility including Clomiphene Citrate,
Bromocriptine Mesylate and
Dexamethasone (Injectable infertility are covered
under Section 5( a)
Infertility Services)
Limited benefits
Drugs to treat sexual dysfunction are covered when
Plan's medical
criteria is met. Contact the plan for dose limits; you pay a
50% copayment
up to the dosage limits and all charges above that.
Not covered: All Charges.
Non-prescription medicines
Drugs
obtained at a non-Plan pharmacy except for out of area emergencies.
Vitamins, nutrients and food supplements even if a physician prescribes
or administers |them( except prenatal Vitamins)
Medical supplies such as dressings and antiseptics
Diet Pills
Drugs for and supplies for cosmetic purposes (such as diet pills)
Drugs to
enhance athletic performance
Smoking cessation drugs and medication,
including nicotine patches
unless you are enrolled in our Smoking Cessation
program. (See page 37)
Diabetic supplies, except those shown above
Injectable medications
prescribed for the treatment of infertility 36
36
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37
Feature Description
PacifiCare Perks SM Program A PacifiCare
members only program which offers discounts for health clubs, alternative care,
vitamins and much more!
Hearing Aids for Children The Oklahoma Plan (2N) covers hearing aids
for children up to the age of 13 years old.
Immunizations The
Oklahoma plan (code 2N) covers immunizations 100% for children through age 18.
You won't have to pay a copay if you
don't have other services when you get
your immunization.
If you are enrolled in the California Plan (CY) or the
Washington
Plan (WB) you may receive the influenza or pneumococcal
vaccine regardless of your age.
In Arizona all members can have routine DPT, Tetanus Toxoid,
Oral
Polio, MMR, Smallpox and Hepatitis B
immunizations/ Vaccines regardless of
age.
Dental anesthesia and The Oklahoma Plan (code 2N) covers these
expenses for certain anesthesiologist costs dental procedures for
children up to age 8 or for severely emotionally
or physically disabled
individuals.
Vision Screening eyeglasses If you are enrolled in the Oklahoma Plan
(code 2N) or the Texas and contact lenses Plan (code GF) you will get a
20% discount on eyeglasses or
contact lenses.
Health Improvement You pay nothing for the following PacifiCare Health
Improvement Programs Programs:
Managing your Heart Health, Managing
Diabetes,* Smoking
Cessation, Healthy Pregnancy and Managing Depression.
*There is a $20 Prescription Drug copayment for smoking cessation
products.
Centers of excellence for Services performed at Centers of Excellence
are covered when transplants/ heart surgery/ etc. medically necessary and
preapproved. You pay $10 for outpatient
visits and nothing for inpatient
hospitalization.
Travel benefit/ Covered for emergencies only. services overseas
PacifiCare Health Plans 2002 Section 5( g)
Section 5 (g). Special features
PacifiCare Health Plans 2002 37
37 Page 38 39
Dental benefits
This dental plan has no
deductibles and no lifetime
maximums. You may see any provider you like.
Preventive and Diagnostic
Comprehensive Oral exam (one every six
months) 100% UCR All charges in
excess of the
Intraoral X-rays (one
bitewing series For all preventive scheduled amounts
of four every six
months, one full and diagnostic listed to the left
mouth per five years)
services.
Prophylaxis (one every six months)
38
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PacifiCare Health Plans 2002 Section 5( h)
Section 5 (h). Dental benefits
PacifiCare Health Plans 2002
You pay You pay
After the calendar year deductible
Accidental
injury benefit You pay
We cover restorative services and supplies necessary to promptly repair You
pay a $10 copayment
(but not replace) sound natural teeth. The need for
these services must
result from an accidental injury.
Here are some important things to keep in mind about these benefits:
For more information call PacifiCare Dental at 1( 800) 591-5915
Please remember that all benefits are subject to the definitions, limitations,
and
exclusions in this brochure and are payable only when we determine they
are
medically necessary.
There is no waiting period for eligibility
There is a $1,000 calendar
year maximum
We cover hospitalization for dental procedures only when a
non-dental physical
impairment exists which makes hospitalization necessary
to safeguard the health of
the patient; we do not cover the dental procedure
unless it is described below.
For treatment or therapy of Temporal Mandibular Joint (TMJ) disorders See
section
5 (a) Medical benefits
Be sure to read Section 4, Your costs for covered services for
valuable information
about how cost sharing works. Also read Section 9 about
coordinating benefits with
other coverage, including with Medicare.
You pay Service You pay We pay (Scheduled Amount) 38
38 Page 39 40
You pay Service You pay We pay (Scheduled Amount)
Dental benefits (Continued)
Basic and Major Services
All charges in excess
Amalgam fillings (one tooth surface, permanent
teeth) $18 of the scheduled
Amalgam fillings (two tooth surfaces, permanent
teeth) $23
amounts listed to
Porcelain with metal crown $200
the left.
Porcelain Crown $125
Single root canal $90
Bi-root canal $115
Periodontal root planing and scaling $30
Full mouth dentures $232
Partial dentures $225
Bridges: Tru-pontic type $82
Extractions $15
39 PacifiCare Health Plans 2002 Section 5( h)
PacifiCare Health Plans 2002 39
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40 PacifiCare
Health Plans 2002 Section 5( i)
PacifiCare Health Plans 2002
The
benefits on this page are not part of the FEHB contract or premium, and you
cannot file an
FEHB disputed claim about them. Fees you pay for these
services do not count toward FEHB
deductibles or out-of-pocket maximums.
PacifiCare Health Plan members can enjoy discounts on Alternative care,
vision hardware,* Lasik
surgery, Healthy baby, Weight Watchers and much more
through the PacifiCare Perks SM program.
You will get this benefit
automatically just by being a PacifiCare member.
In California, for a monthly premium, you can enroll in an HMO dental
plan and/ or a PPO Vision
hardware plan through PacifiCare Dental and Vision
as a supplement to your FEHB Plan. Call
1( 800) 228-3384 for more
information.
In Arizona, for a monthly premium, you can enroll in an HMO dental
Plan as a supplement to
your FEHB dental plan. Call 1( 800) 531-3341 for
more information. The Non-FEHB dental
benefits will not be coordinated with
the dental benefits included with your medical plan.
In Nevada you can enjoy great savings on prescription eyewear that
includes a wide selection
of glasses (or contacts) when you take advantage
of PacifiCare Vision's Eyewear Only Plan
1( 800) 228-3384.
Medicare managed care plan
If you are Medicare eligible and are
interested in enrolling in a Medicare HMO sponsored by this
Plan without
dropping your enrollment in this Plan's FEHB plan, call 1( 800) 531-3341 for
information on the benefits available under the Medicare HMO.
Medicare prepaid plan enrollment This Plan offers Medicare
recipients the opportunity to
enroll in the Plan through Medicare. As
indicated on page 4, annuitants and former spouses with
FEHB coverage and
Medicare Part B may elect to drop their FEHB coverage and enroll in a
Medicare prepaid plan when one is available in their area. They may then
later re-enroll in the
FEHB Program. Most Federal annuitants have Medicare
Part A. Those without Medicare Part A
may join this Medicare prepaid
plan but will probably have to pay for hospital coverage in addition
to the
Part B premium. Before you join the plan, ask whether the plan covers
hospital benefits and,
if so, what you will have to pay. Contact your
retirement system for information on dropping your
FEHB enrollment and
changing to a Medicare prepaid plan. Contact us at 1( 800) 531-3341 for
information on the Medicare prepaid plan and the cost of that enrollment.
*Not available in California due to regulatory requirements.
Section 5 (i). Non-FEHB benefits available to Plan members 40
40 Page 41 42
41
The exclusions in this section apply to all
benefits. Although we may list a specific service as a benefit, we will
not cover it unless your Plan doctor determines it is medically necessary to
prevent, diagnose, or treat your
illness disease, injury, or condition.
We do not cover the following:
Care by non-Plan providers except for
authorized referrals or emergencies (see Emergency Benefits);
Services,
drugs, or supplies you receive while you are not enrolled in this Plan;
Services, drugs, or supplies that are not medically necessary;
Services,
drugs, or supplies not required according to accepted standards of medical,
dental, or psychiatric
practice;
Experimental or investigational procedures, treatments, drugs or devices;
Services, drugs, or supplies related to abortions, except when the life of
the mother would be endangered if the
fetus were carried to term or when the
pregnancy is the result of an act of rape or incest;
Services, drugs, or supplies related to sex transformations; or
Services, drugs, or supplies you receive from a provider or facility barred from
the FEHB Program.
2002 PacifiCare Health Plans Section 6
Section 6. General exclusions things we don't cover
PacifiCare
Health Plans 2002 41
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42 43
42
When you see Plan
physicians, receive services at Plan hospitals and facilities, or obtain your
prescription drugs at
Plan pharmacies, you will not have to file claims.
Just present your identification card and pay your copayment.
You will only need to file a claim when you receive emergency services from
non-plan providers. Sometimes these
providers bill us directly. Check with
the provider. If you need to file the claim, here is the process:
Medical and hospital, In most cases, providers and facilities file
claims for you. Physicians prescription drugs, and Durable must file on
the form HCFA-1500, Health Insurance Claim Form.
Medical Equipment (DME)
Facilities will file on the UB-92 form. For claims questions and Benefits
assistance, call us at 1( 800) 531-3341.
When you must file a claim such as for out-of-area care submit it
on
the HCFA-1500 or a claim form that includes the information
shown below.
Bills and receipts should be itemized and show:
Covered member's name and ID number;
Name and address of the physician
or facility that provided the
service or supply;
Dates you received the services or supplies;
Diagnosis;
Type of
each service or supply;
The charge for each service or supply;
A copy
of the explanation of benefits, payments, or denial from
any primary payer
such as the Medicare Summary Notice
(MSN); and
Receipts, if you paid for your services.
Submit your claims to:
PacifiCare Health Plans
5995 Plaza Drive
MS CY20-303
Cypress, CA
90630
Deadline for filing your claim Send us all of the documents for your
claim as soon as possible. You must submit the claim by December 31 of the year
after the year you
received the service, unless timely filing was prevented
by
administrative operations of Government or legal incapacity, provided
the claim was submitted as soon as reasonably possible.
When we need more information Please reply promptly when we ask for
additional information. We may delay processing or deny your claim if you do not
respond.
2002 PacifiCare Health Plans Section 7
Section 7. Filing a claim for covered services
PacifiCare Health
Plans 2002 42
42 Page
43 44
43
Follow this Federal
Employees Health Benefits Program disputed claims process if you disagree with
our decision
on your claim or request for services, drugs, or supplies
including a request for preauthorization:
Step Description
1 Ask us in writing to reconsider our initial
decision. You must:
(a) Write to us within 6 months from the date of our
decision; and
(b) Send your request to us at: 5995 Plaza Drive MS. CY 20-303, Cypress, CA
90630; and
(c) Include a statement about why you believe our initial
decision was wrong, based on specific benefit
provisions in this brochure;
and
(d) Include copies of documents that support your claim, such as physicians'
letters, operative reports,
bills, medical records, and explanation of
benefits (EOB) forms.
2 We have 30 days from the date we receive your request to:
(a) Pay the
claim (or, if applicable, arrange for the health care provider to give you the
care); or
(b) Write to you and maintain our denial go to step 4; or
(c) Ask you
or your provider for more information. If we ask your provider, we will send you
a copy of
our request go to step 3.
3 You or your provider must send the information so that we receive it within
60 days of our request. We will then decide within 30 more days.
If we do
not receive the information within 60 days, we will decide within 30 days of the
date the
information was due. We will base our decision on the information
we already have.
We will write to you with our decision.
4 If you do not agree with our decision, you may ask OPM to review it.
You must write to OPM within:
90 days after the date of our letter upholding our initial decision; or
120 days after you first wrote to us if we did not answer that request
in some way within 30 days; or
120 days after we asked for additional
information.
Write to OPM at: Office of Personnel Management, Office of
Insurance Programs, Contracts Division 3,
1900 E Street NW, Washington, D.
C. 20415-3630.
2002 PacifiCare Health Plans Section 8
Section 8. The disputed claims process
PacifiCare Health Plans
2002 43
43 Page 44
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44
Send OPM the following information:
A
statement about why you believe our decision was wrong, based on specific
benefit provisions in this
brochure;
Copies of documents that support your claim, such as physicians' letters,
operative reports, bills,
medical records, and explanation of benefits (EOB)
forms;
Copies of all letters you sent to us about the claim;
Copies of all
letters we sent to you about the claim; and
Your daytime phone number and
the best time to call.
Note: If you want OPM to review different claims, you
must clearly identify which documents apply to
which claim.
Note: You are the only person who has a right to file a disputed claim with
OPM. Parties acting as your
representative, such as medical providers, must
include a copy of your specific written consent with the
review request.
Note: The above deadlines may be extended if you show that you were unable to
meet the deadline because
of reasons beyond your control.
5 OPM will review your disputed claim request and will use the information it
collects from you and us to decide whether our decision is correct. OPM will
send you a final decision within 60 days. There are no
other administrative
appeals.
6 If you do not agree with OPM's decision, your only recourse is to sue. If
you decide to sue, you must file the suit against OPM in Federal court by
December 31 of the third year after the year in which you
received the
disputed services, drugs or supplies or the year in which you were denied
precertification or
prior approval. This is the only deadline that may not
be extended.
OPM may disclose the information it collects during the review process to
support their disputed claim
decision. This information will become part of
the court record.
You may not sue until you have completed the disputed claims process.
Further, Federal law governs your
lawsuit, benefits, and payment of
benefits. The Federal court will base its review on the record that was
before OPM when OPM decided to uphold or overturn our decision. You may
recover only the amount of
benefits in dispute.
NOTE: If you have a serious or life threatening condition (one that
may cause permanent loss of bodily
functions or death if not treated as soon
as possible), and
(a) We haven't responded yet to your initial request for care or
preauthorization/ prior approval, then call us at
1( 800) 531-3341 and we
will expedite our review; or
(b) We denied your initial request for care or preauthorization/ prior
approval, then:
If we expedite our review and maintain our denial, we will
inform OPM so that they can give your claim
expedited treatment too, or
You can call OPM's Health Benefits Contracts Division 3 at (202) 606-0737
between 8 a. m. and 5 p. m.
eastern time.
2002 PacifiCare Health Plans Section 8
PacifiCare Health Plans 2002 44
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45
When you
have other health coverage You must tell us if you are covered or a family
member is covered under another group health plan or have automobile insurance
that pays health care
expenses without regard to fault. This is called
"double coverage."
When you have double coverage, one plan normally pays its
benefits in full as
the primary payer and the other plan pays a reduced
benefit as the secondary
payer. We, like other insurers, determine which
coverage is primary according
to the National Association of Insurance
Commissioners' guidelines.
When we are the primary payer, we will pay the benefits described in this
brochure.
When we are the secondary payer, we will determine our allowance. After the
primary plan pays, we will pay what is left of our allowance, up to our
regular
benefit. We will not pay more than our allowance.
What is Medicare? Medicare is a Health Insurance Program for:
People 65 years of age and older.
Some people with disabilities,
under 65 years of age.
People with End-Stage Renal Disease (permanent
kidney failure requiring
dialysis or a transplant).
Medicare has two parts:
Part A (Hospital Insurance). Most people do not
have to pay for Part A . If
you or your spouse worked for at least 10 years
in Medicare-covered
employment, you should be able to qualify for
premium-free Part A
insurance. (Someone who was a Federal employee on
January 1, 1983 or
since automatically qualifies.) Otherwise, if you are age
65 or older, you
may be able to buy it. Contact 1-800-MEDICARE for more
information.
Part B (Medical Insurance). Most people pay monthly for Part B. .
Generally, Part B premiums are withheld from your monthly Social
Security check or your retirement check.
If you are eligible for Medicare, you may have choices in how you get your
health care. Medicare + Choice is the term used to describe the various
health
plan choices available to Medicare beneficiaries. The information in
the next
few pages shows how we coordinate benefits with Medicare, depending
on the
type of Medicare managed care plan you have.
The Original Medicare Plan The Original Medicare Plan is a Medicare
plan that is available everywhere in
the United States. It is the way
everyone used to get Medicare benefits and is
the way most people get their
Medicare A and B benefits now. You may go to
any doctor, specialist, or
hospital that accepts Medicare. The Original
Medicare Plan pays its share
and you pay your share. Some things are not
covered under Original Medicare,
like prescription drugs.
When you are enrolled in Original Medicare along with this Plan, you still
need to follow the rules in this brochure for us to cover your care. Your
care
must continue to be authorized by your Plan PCP, or precertified as
required.
We will not waive any of our copayments. (Primary Payer chart
begins on next
page.)
2002 PacifiCare Health Plans Introduction/ Plain Language
Section 9. Coordinating benefits with other coverage
PacifiCare
Health Plans 2002 45
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46 47
B. When you or a covered
family member have Medicare
based on end stage renal disease (ESRD) and
46 2002 PacifiCare Health Plans Section 9
PacifiCare Health Plans 2002
The following chart illustrates whether
the Original Medicare Plan or this Plan should be the primary payer for you
according
to your employment status and other factors determined by
Medicare. It is critical that you tell us if you or a covered family
member
has Medicare coverage so we can administer these requirements correctly.
1) Are an active employee with the Federal government (including when you
or a family member are eligible for Medicare solely because of a
disability),
2) Are an annuitant,
3) Are a reemployed annuitant with the Federal
government when
a) The position is excluded from FEHB or,
b) The
position is not excluded from FEHB
(Ask your employing office which of these
applies to you.)
4) Are a Federal judge who retired under title 28, U. S.
C., or a Tax
Court judge who retired under Section 7447 of title 26, U. S.
C.
(or if your covered spouse is this type of judge),
5) Are enrolled in Part B only, regardless of your employment status,
(for Part B services) (for other services)
6) Are a former Federal employee receiving Workers' Compensation
and the
Office of Workers' Compensation Programs has determined (except for claims
that you are unable to return to duty, related to Workers'
Compensation.)
1) Are within the first 30 months of eligibility to receive Part A
benefits solely because of ESRD,
2) Have completed the 30-month ESRD coordination period and are
still
eligible for Medicare due to ESRD,
3) Become eligible for Medicare due to ESRD after Medicare became
primary
for you under another provision,
1) Are eligible for Medicare based on disability, and
a) Are an
annuitant, or
b) Are an active employee, or
c) Are a former spouse of an
annuitant, or
d) Are a former spouse of an active employee
Primary Payer Chart
A. When either you or your covered spouse are
age 65 or over and
C. When you or a covered family member have FEHB and
Then the primary
payer is
Original Medicare This Plan 46
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47
Claims process when you have the Original Medicare Plan You
probably
will never have to file a claim form when you have both our Plan
and the
Original Medicare Plan.
When we are the primary payer, we process the claim first.
When
Original Medicare is the primary payer, Medicare processes your
claim first.
In most cases, your claims will be coordinated automatically
and we will pay
the balance of covered charges. You will not need to do
anything. To find
out if you need to do something about filing your claims,
call us at 1( 800)
531-3341 or visit us on our we site at
www. pacificare. com, you can fax us
at (714) 226-3575.
We do not waive any costs when you have Medicare.
Medicare
managed care plan If you are eligible for Medicare, you may choose to enroll
in and get your
Medicare benefits from another type of Medicare + Choice
Plan A Medicare
Managed care plan. These are health care choices (like
HMO's) in some areas
of the country. In most Medicare managed care plans,
you can only go to
doctors, specialists, or hospitals that are part of the
plan. Medicare managed
care plans provide all the benefits that Original
Medicare covers. Some cover
extras, like prescription drugs. To learn more
about enrolling in a Medicare
managed care plan, contact Medicare at
1-800-MEDICARE (1( 800) 633-4227)
or at www. medicare. gov. If you enroll in
a Medicare managed care plan the
following options are available to you:
This Plan and our Medicare managed care plan: You may enroll in our
Medicare managed care plan and also remain enrolled in our FEHB plan. In
this case, we do not waive any of our copayments for your FEHB coverage.
This Plan and another plan's Medicare managed care plan: You may
enroll
in another plan's Medicare managed care plan and also remain enrolled
in our
FEHB plan. We will still provide benefits when your Medicare managed
care
plan is primary, but we will not waive any of our copayments.
If you enroll in a Medicare managed care plan, tell us. We will need to know
whether you are in the Original Medicare Plan or in a Medicare managed care
Plan so we can correctly coordinate benefits with Medicare.
Suspended FEHB coverage to enroll in a Medicare managed care plan:
If you are an annuitant or former spouse, you can suspend your FEHB
coverage to enroll in a Medicare managed care plan, eliminating your FEHB
premium. (OPM does not contribute to your Medicare managed care plan
premium.) For information on suspending your FEHB enrollment, contact
your retirement office. If you later want to re-enroll in the FEHB Program,
generally you may do so only at the next open season unless you
involuntarily
lose coverage or move out of the Medicare managed care plan
service area.
If you do not enroll in Note: If you do not have one or both parts
of Medicare, you can still be
Medicare Part A or Part B covered under
the FEHB Program. We will not require you to enroll in
Medicare Part B and,
if you can't get premium-free Part A, we will not ask
you to enroll in it.
2002 PacifiCare Health Plans Section 9
PacifiCare Health Plans 2002 47
47 Page 48 49
48
TRICARE
TRICARE is the health care program for members, eligible dependents of
military persons and retirees of the military. TRICARE includes the
CHAMPUS
program. If both TRICARE and this Plan cover you, we pay first.
See your
TRICARE Health Benefits Advisor if you have questions about
TRICARE
coverage.
Workers' Compensation We do not cover services that:
you need
because of a workplace-related illness or injury that the Office of
Workers'
Compensation Programs (OWCP) or a similar Federal or State
agency determines
they must provide; or
OWCP or a similar agency pays for through a third party injury settlement
or other similar proceeding that is based on a claim you filed under OWCP
or similar laws.
Once OWCP or similar agency pays its maximum benefits for your treatment,
we will cover your care. You must use our providers.
Medicaid When you have this Plan and Medicaid, we pay first.
When other Government agencies We do not cover services and supplies
when a local, State, or Federal are responsible for your care Government
agency directly or indirectly pays for them.
When others are responsible When you receive money to compensate you
for medical or hospital care for injuries for injuries or illness caused
by another person, you must reimburse us for any
expenses we paid. However,
we will cover the cost of treatment that exceeds
the amount you received in
the settlement.
If you do not seek damages you must agree to let us try. This is called
subrogation. If you need more information, contact us for our subrogation
procedures.
2002 PacifiCare Health Plans Section 9
PacifiCare Health Plans 2002 48
48 Page 49 50
49
Calendar
year January 1 through December 31 of the same year. For new enrollees, the
calendar year begins on the effective date of their enrollment and ends on
December 31 of the same year.
Copayment A copayment is a fixed
amount of money you pay when you receive covered services. See page 14.
Coinsurance We do not have Coinsurance.
Covered services
Care we provide benefits for, as described in this brochure.
Custodial care Day to day care that can be provided by a non-medical
individual.
Experimental or Our National and Regional Medical
Committees determine Investigational Services whether or not treatments,
procedures and drugs are no longer considered
experimental or
investigational. Our determinations are based on the safety
and efficacy of
new medical procedures, technologies, devices and drugs.
Medical necessity Medical necessity refers to medical services or
hospital services that are determined by us to be:
Rendered for the treatment or diagnosis of an injury or illness; and
Appropriate for the symptoms, consistent with diagnosis, and otherwise in
accordance with sufficient scientific evidence and professionally recognized
standards; and
Not furnished primarily for the convenience of the Member, the attending
physician, or other provider of service; and
Furnished in the most economically efficient manner which may be
provided safely and effectively to the Member.
Plan allowance Plan allowance is the amount we use to determine our
payment and your coinsurance for covered services. Plans determine their
allowances in different
ways. We determine our allowance by our contracted
rate with the
participating provider.
Us/ We Us and we refer to PacifiCare Health Plans.
Yo u You
refers to the enrollee and each covered family member.
2002 PacifiCare Health Plans Section 10
Section 10. Definitions of terms we use in this brochure
PacifiCare Health Plans 2002 49
49
Page 50 51
50
No pre-existing condition We will not refuse to cover the treatment
condition that you had before you limitation enrolled in this Plan solely
because you had the condition before you enrolled.
Where you can get
information See www. opm. gov/ insure. Also, your employing or retirement
office can About enrolling in the answer your questions, and give you a
Guide to Federal Employees Health
FEHB Program Benefits
Plans, brochures for other plans, and other materials you need to make an
informed decision about:
When you may change your enrollment;
How you can cover your family
members;
What happens when you transfer to another Federal agency, go on
leave
without pay, enter military service, or retire;
When your enrollment ends; and
When the next open season for
enrollment begins.
We don't determine who is eligible for coverage and, in
most cases, cannot
change your enrollment status without information from
your employing or
retirement office.
Types of coverage available Self Only coverage is for you alone. Self
and Family coverage is for you, for you and your family your spouse, and
your unmarried dependent children under age 22, including
any foster children or stepchildren your employing or retirement office
authorizes coverage for. Under certain circumstances, you may also continue
coverage for a disabled child 22 years of age or older who is incapable of
self-support.
If you have a Self Only enrollment, you may change to a Self and Family
enrollment if you marry, give birth, or add a child to your family. You may
change your enrollment 31 days before to 60 days after that event. The Self
and Family enrollment begins on the first day of the pay period in which the
child is born or becomes an eligible family member. When you change to Self
and Family because you marry, the change is effective on the first day of
the
pay period that begins after your employing office receives your
enrollment
form; benefits will not be available to your spouse until you
marry.
Your employing or retirement office will not notify you when a family
member is no longer eligible to receive health benefits, nor will we. Please
tell
us immediately when you add or remove family members from your coverage
for any reason, including divorce, or when your child under age 22 marries
or
turns 22.
If you or one of your family members is enrolled in one FEHB plan, that
person may not be enrolled in or covered as a family member by another
FEHB plan.
2002 PacifiCare Health Plans Section 11
Section 11. FEHB facts
PacifiCare Health Plans 2002 50
50 Page 51 52
51
When benefits and The benefits in this
brochure are effective on January 1. If you joined this premiums start
Plan during Open Season, your coverage begins on the first day of your first
pay period that starts on or after January 1. Annuitants' coverage and
premiums begin on January 1. If you joined at any other time during the
year,
your employing office will tell you the effective date of coverage.
Your medical and claims We will keep your medical and claims
information confidential. Only the records are confidential following
will have access to it:
OPM, this Plan, and subcontractors when they administer this contract;
This Plan, and appropriate third parties, such as other insurance plans
and
the Office of Workers' Compensation Programs (OWCP), when
coordinating benefit payments and subrogating claims;
Law enforcement officials when investigating and/ or prosecuting alleged
civil or criminal actions;
OPM and the General Accounting Office when conducting audits;
Individuals involved in bona fide medical research or education that does
not disclose your identity; or
OPM, when reviewing a disputed claim or defending litigation about a
claim.
When you retire When you retire, you can usually stay in the FEHB
Program. Generally, you must have been enrolled in the FEHB Program for the last
five years of your
Federal service. If you do not meet this requirement, you may be eligible for
other forms of coverage, such as temporary continuation of coverage (TCC).
When you lose benefits
When FEHB coverage ends You will
receive an additional 31 days of coverage, for no additional premium,
when:
Your enrollment ends, unless you cancel your enrollment, or
You are a
family member no longer eligible for coverage.
You may be eligible for
spouse equity coverage or Temporary Continuation of
Coverage.
Spouse equity If you are divorced from a Federal employee or
annuitant, you may not
coverage continue to get benefits under your
former spouse's enrollment. But, you may
be eligible for your own FEHB
coverage under the spouse equity law. If you
are recently divorced or are
anticipating a divorce, contact your ex-spouse's
employing or retirement
office to get RI 70-5, the Guide to Federal Employees
Health Benefits Plans
for Temporary Continuation of Coverage and Former
Spouse Enrollees, or other
information about your coverage choices.
2002 PacifiCare Health Plans Section 11
PacifiCare Health Plans 2002 51
51 Page 52 53
52
Temporary Continuation If you leave Federal service, or if you lose
coverage because you no
of Coverage (TCC) longer qualify as a family
member, you may be eligible for
Temporary Continuation of Coverage (TCC).
For example, you can
receive TCC if you are not able to continue your FEHB
enrollment
after you retire, if you lose your job, if you are a covered
dependent
child and you turn 22 or marry, etc.
You may not elect TCC if you are fired from your Federal job due to
gross
misconduct.
Enrolling In TCC Get the RI 79-27, which describes TCC, and the RI
70-5,
the Guide to Federal Employees Health Benefits Plans for
Temporary
Continuation of Coverage and Former Spouse Enrollees,
from your employing or
retirement office or from
www. opm. gov/ insure. It explains what you have
to do to enroll
Converting to You may convert to a non-FEHB individual policy if:
individual coverage
Your coverage under TCC or the spouse equity
law ends. If you
canceled your coverage or did not pay your premium, you
cannot
convert;
You decided not to receive coverage under TCC or the spouse
equity law;
or
You are not eligible for coverage under TCC or the spouse equity
law.
If you leave Federal service, your employing office will notify you of
your right to convert. You must apply in writing to us within 31 days
after you receive this notice. However, if you are a family member
who
is losing coverage, the employing or retirement office will not
notify you.
You must apply in writing to us within 31 days after you
are no longer
eligible for coverage.
Your benefits and rates will differ from those under the FEHB
Program;
however, you will not have to answer questions about your
health, and we
will not impose a waiting period or limit your
coverage due to pre-existing
conditions.
Getting a Certificate of The Health Insurance Portability and
Accountability Act of 1996 Group Health Plan Coverage (HIPAA) is a
Federal law that offers limited Federal protections for
health coverage availability and continuity to people who lose
employer
group coverage. If you leave the FEHB Program, we will
give you a
Certificate of Group Health Plan Coverage that indicates
how long you have
been enrolled with us. You can use this certificate
when getting health
insurance or other health care coverage. Your new
plan must reduce or
eliminate waiting periods, limitations, or
exclusions for health related
conditions based on the information in
the certificate, as long as you
enroll within 63 days of losing
coverage under this Plan.
2002 PacifiCare Health Plans Section 11
PacifiCare Health Plans 2002 52
52 Page 53 54
53
For more
information get OPM pamphlet RI 79-27, Temporary
Continuation of Coverage
(TCC) under the FEHB Program. See also
the FEHB web site (www. opm. gov/
insure/ health); refer to the "TCC
and HIPAA" frequently asked question.
These highlight HIPAA rules,
such as the requirement that Federal employees
must exhaust any
TCC eligibility as one condition for guaranteed access to
individual
health coverage under HIPAA, and have information about Federal
and State agencies you can contact for more information.
If you have been enrolled with us for less than 12 months, but were
previously enrolled in other FEHB plans, you may also request a
certificate from those plans.
2002 PacifiCare Health Plans Section 11
PacifiCare Health Plans 2002 53
53 Page 54 55
54
Many FEHB
enrollees think their health plan and/ or Medicare covers long-term care.
Unfortunately, they are WRONG!
How are YOU planning to pay for the future
custodial or chronic care you may need? Consider buying long term care
insurance.
The Office of Personnel Management (OPM) will sponsor a high-quality long
term care insurance program effective in
October 2002. As part of its
educational effort, OPM asks you to consider these questions:
What is long term care It's insurance to help pay for long term care
services you may need if you (LTC) insurance? can't take care of yourself
because of an extended illness or injury, or an
age-related disease such as Alzheimer's.
LTC insurance can provide
broad, flexible benefits for care in a nursing
home, in an assisted living
facility, in your home, adult day care, hospice
care, and more. LTC
insurance can supplement care provided by family
members, reducing the
burden you place on them.
I'm healthy. I won't need long 76% of Americans believe they will
never need long term care, but the term care. Or, will I? facts are that
about half of them will. And it's not just the old folks. About
40% of people needing long term care are under age 65. They may need
chronic care due to a serious accident, a stroke, or developing multiple
sclerosis, etc.
We hope you will never need long term care, but you should have a plan
just in case. LTC insurance may be vital to your financial and retirement
planning.
Is long term care expensive? Yes. A year in a nursing home can exceed
$50,000 and only three 8-hour shifts a week can exceed $20,000 a year, that's
before inflation!
LTC can easily exhaust your savings but LTC insurance can protect it.
But won't my FEHB plan, Not FEHB. Look under "Not covered" in
sections 5( a) and 5( c) of your Medicare or Medicaid cover FEHB
brochure. Custodial care, assisted living, or continuing home health
my long term care? care for activities of daily living are not
covered. Limited stays in skilled nursing facilities can be covered in some
circumstances.
Medicare only covers skilled nursing home care after a hospitalization with
a 100 day limit.
Medicaid covers LTC for those who meet their state's guidelines, but
restricts covered services and where they can be received. LTC insurance
can provide choices of care and preserve your independence.
When will I get more information? Employees will get more
information from their agencies during the late summer/ early fall of 2002.
Retirees will receive information at home.
How can I find out more
about A toll-free telephone number will begin in mid-2002. You can learn
more the program NOW? about the program now at www. opm. gov/ insure/
ltc.
2002 PacifiCare Health Plans Long Term Care Insurance
PacifiCare Health Plans 2002
Long Term Care Insurance Is Coming
Later in 2002! 54
54 Page
55 56
55
What is it? The
Department of Defense/ FEHB Demonstration Project allows some active and retired
uniformed service members and their dependents to enroll in the
FEHB
Program. The demonstration will last for three years and began with the
1999
open season for the year 2002. Open season enrollments will be effective
January 1, 2002. DoD and OPM have set up some special procedures to
implement the Demonstration Project, noted below. Otherwise, the provisions
described in this brochure apply.
Who is eligible DoD determines who is eligible to enroll in the FEHB
Program. Generally, you may enroll if:
You are an active or retired uniformed service member and are eligible for
Medicare;
You are a dependent of an active or retired uniformed service member and
are eligible for Medicare;
You are a qualified former spouse of an active or retired uniformed service
member and you have not remarried; or
You are a survivor dependent of a deceased active or retired uniformed
service member; and
You live in one of the geographic demonstration areas.
If you are
eligible to enroll in a plan under the regular Federal Employees
Health
Benefits Program, you are not eligible to enroll under the DoD/ FEHBP
Demonstration Project.
The demonstration areas Dover AFB, DE Commonwealth of PuertoRico
Fort Knox, KY Greensboro/ Winston Salem/ High Point, NC
Dallas, TX Humboldt County, CA area
New Orleans, LA Naval
Hospital, Camp Pendleton, CA
Adair County, IA Coffee County, GA
When you can join You may enroll under the FEHB/ DoD Demonstration
Project during the 2001 open season, November 12, 2001, through December 10,
2001. Your coverage
will begin January 1, 2002. DoD has set-up an Information Processing Center
(IPC) in Iowa to provide you with information about how to enroll. IPC staff
will verify your eligibility and provide you with FEHB Program information,
plan brochures, enrollment instructions and forms. The toll-free phone
number
for the IPC is 1-877-DOD-FEHB (1( 877) 363-3342).
You may select coverage for yourself (Self Only) or for you and your family
(Self and Family) during open seasons. Your coverage will begin January 1 of
the year following the open season during which you enrolled.
If you become eligible for the DoD/ FEHB Demonstration Project outside of
open season, contact the IPC to find out how to enroll and when your
coverage will begin.
DoD has a web site devoted to the Demonstration Project. You can view
information such as their Marketing/ Beneficiary Education Plan, Frequently
Asked Questions, demonstration area locations and zip code lists at
www.
tricare. osd. mil/ fehbp. You can also view information about the
demonstration project, including "The 2002 Guide to Federal Employees
Health Benefits Plans Participating in the DoD/ FEHB Demonstration Project,"
on the OPM web site at www. opm. gov.
2002 PacifiCare Health Plans Department of Defense
Department of Defense/ FEHB Demonstration Project
PacifiCare
Health Plans 2002 55
55 Page
56 57
56
Temporary Continuation
See Section 11, FEHB Facts; it explains temporary continuation of of
Coverage (TCC) coverage (TCC). Under this DoD/ FEHB Demonstration Project
the
only individual eligible for TCC is one who ceases to be eligible as a
"member of family" under your self and family enrollment. This
occurs
when a child turns 22, for example, or if you divorce and your
spouse does
not qualify to enroll as an unremarried former spouse
under title 10, United
States Code. For these individuals, TCC begins
the day after their
enrollment in the DoD/ FEHB Demonstration
Project ends. TCC enrollment
terminates after 36 months or the end
of the Demonstration Project,
whichever occurs first. You, your child,
or another person must notify the
IPC when a family member loses
eligibility for coverage under the DoD/ FEHB
Demonstration Project.
TCC is not available if you move out of a DoD/ FEHB Demonstration
Project
area, you cancel your coverage, or your coverage is
terminated for any
reason. TCC is not available when the
demonstration project ends.
Other features The 31-day extension of coverage and right to convert
do not apply to the DoD/ FEHB Demonstration Project.
2002 PacifiCare Health Plans Department of Defense
PacifiCare Health Plans 2002 56
56 Page 57 58
57
Do not rely
on this page; it is for your convenience and may not show all pages where the
terms appear.
Accidental injury 25, 30, 38
Allergy tests 19
Allogenic Bone Marrow Transplant 26
Alternative treatment 23
Ambulance 28, 29, 30, 31
Anesthesia 24, 27, 29, 37
Autologous bone
marrow transplant
19, 26
Biopsies 24
Birthing centers 18
Blood
and blood plasma 16, 17, 28,
29, 36
Breast cancer screening 17
Casts
28, 29
Catastrophic protection 58
Changes for 2002 10
Chemotherapy
19
Childbirth 18, 28
Chiropractic 14, 22
Cholesterol tests 10, 17
Circumcision 18
Claims 22, 23, 44, 47, 51
Coinsurance 7, 11, 14, 47,
49
Colorectal cancer screening 17
Congenital anomalies 24, 25
Contraceptive devices and drugs 18,
36
Coordination of benefits 46
Covered charges 14
Covered providers 7
Crutches 22
Deductible 14
Definitions 49
Dental care 14, 21, 29, 37, 38, 39, 40
Diagnostic
services 16, 28, 29, 32, 38
Disputed claims review 10, 40, 43,
44, 51
Donor expenses (transplants) 26-27
Dressings 28, 29, 36
Durable
medical equipment (DME)
22, 42
Educational classes and programs 23
Effective date of enrollment 11, 49, 51
Emergency 7, 9, 11, 30-31, 41,
42
Experimental or investigational 41, 49
Eyeglasses 20, 21, 37
Family planning 10, 18
Fecal occult blood test 17
General Exclusions 41
Hearing services 17,
20, 37
Home health services 22, 36, 54
Hospice care 29, 54
Home
nursing care 22
Hospital 12, 28-29
Immunizations 7, 17, 37
Infertility 10, 18, 19, 36
In-hospital physician care 16
Inpatient
Hospital Benefits 28-29
Insulin 35, 36
Laboratory and pathological
services
16
Machine diagnostic tests 16, 28-29
Magnetic Resonance
Imaging (MRIs)
13, 16
Mail Order Prescription Drugs 34-36
Mammograms
16
Maternity Benefits 18, 28
Medicaid 48, 54
Medically necessary 13,
30, 41
Medicare 40, 45, 47, 54
Members 7, 50
Mental Conditions/
Substance Abuse
Benefits 32
Neurological testing 32
Newborn care 18
Non-FEHB Benefits 40
Nurse
Licensed Practical Nurse 22
Nurse
Anesthetist 28
Nurse Midwife 18
Nurse Practitioner 17
Psychiatric
Nurse 32-33
Registered Nurse 22
Nursery charges 18
Obstetrical care
18
Occupational therapy 20
Ocular injury 20
Office visits 7
Oral
and maxillofacial surgery 26
Orthopedic devices 21, 22
Ostomy and
catheter supplies 21, 22
Out-of-pocket expenses 14
Outpatient facility
care 29
Oxygen 22, 28, 29
Pap test 16, 17
Physical examination 16
Physical therapy 20
Physician 11
Pre-admission testing 28
Precertification 13
Preventive care, adult 17
Preventive care, children 17
Prescription
drugs 34-36
Preventive services 7, 17
Prior approval 13, 44
Prostate
cancer screening 17
Prosthetic devices 21, 24, 25
Psychologist 32
Psychotherapy 32
Radiation therapy 19
Renal dialysis 19, 22, 45
Room and board 28
Second surgical opinion 16
Skilled nursing
facility care 29
Smoking cessation 23, 36, 37
Speech therapy 10, 20
Splints 28
Sterilization procedures 18, 25
Subrogation 48
Substance abuse 32, 33
Surgery 24
o Anesthesia 27
o Oral 26
o Outpatient 29
Syringes 36
Temporary continuation of coverage
52
Transplants 26-27
Treatment Therapies 19
Vision services
20-21
Well child care 17
Wheelchairs 22
Workers' compensation 46,
48, 51
X-rays 16, 28, 29, 38
2002 PacifiCare Health Plans Introduction/ Plain Language
Index
PacifiCare Health Plans 2002 57
57 Page 58 59
Summary of benefits for the PacifiCare
Health Plans 2002
58 2002 PacifiCare Health Plans
Summary of benefits
PacifiCare Health Plans 2002
Do not rely on this chart alone.
All benefits are provided in full unless indicated and are subject to the
definitions,
limitations, and exclusions in this brochure. On this page we
summarize specific expenses we cover; for more detail,
look inside.
If you want to enroll or change your enrollment in this Plan, be sure to
put the correct enrollment code from the cover
on your enrollment form.
We only cover services provided or arranged by Plan physicians, except in
emergencies.
Benefits You Pay Page
Medical services provided by physicians:
Diagnostic and treatment services provided in the office . . . . .
. . Office visit copay: $10 primary care; 16-23 $10 specialist
Eye Exams
Services provided by a hospital:
Inpatient. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . Nothing per admission 28
Outpatient . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $10
copay per office visit 29
Emergency benefits:
In-area . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . $50 per emergency room
visit 31
Out-of-Area . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . $50 per emergency room visit 31
Mental health and substance abuse treatment . . . . . . . . . . . . . . . . .
. Regular benefits 32-33
Prescription drugs . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . $5 copay for generic formulary 34-36
prescriptions
$15 for brand formulary
prescriptions
Dental Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . Nothing for preventive services; 38-39
scheduled
allowance for other
services
Vision Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . Discounts for frames and lenses 37
through the
PacifiCare Perks SM
program.
Eye Exams . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . $10 copayment per office visit 20-21
Protection against
catastrophic costs Nothing after $1,500/ Self Only or 14
(your out-of-pocket
maximum) . . . . . . . . . . . . . . . . . . . . . . . . . . . . $3,000/ Family
enrollment per
calendar year
Some costs do not count toward
this protection 58
58 Page 59 60
Arizona: Maricopa, Pima County and Apache
Junction
59
Non-Postal rates apply to most non-Postal enrollees. If you are in a
special enrollment category,
refer to the FEHB Guide for that category or
contact the agency that maintains your health
benefits enrollment.
Postal rates apply to career Postal Service employees. Most employees
should refer to the FEHB
Guide for United States Postal Service Employees,
RI 70-2. Different postal rates apply and
special FEHB guides are published
for Postal Service Nurses, RI 70-2B; and for Postal Service
Inspectors and
Office of Inspector General (OIG) employees (see RI 70-2IN).
Postal rates do not apply to non-career postal employees, postal retirees, or
associate members of
any postal employee organization who are not career
postal employees. Refer to the applicable
FEHB Guide.
2002 PacifiCare Health Plans 2002 Rate Information
PacifiCare Health Plans 2002
2002 Rate Information for
PacifiCare Health Plans
Non-Postal Premium Postal Premium
Biweekly Monthly Biweekly
Type
of
Enrollment Code
Gov't
Share
Your
Share
Gov't
Share
Your
Share
USPS
Share
Your
Share
Self Only
Self and Family
A31
A32
California: Northern and Southern California
Self Only
Self and Family
CY1
CY2
Nevada: Las Vegas/ Clark County
Self Only
High Option
Self and Family
K91
K92
$86.99 $29.00 $188.48 $62.83 $102.94 $13.05
$223.41 $101.66 $484.06
$220.26 $263.75 $61.32
$70.04 $23.34 $151.74 $50.58 $82.87 $10.51
$182.63 $60.87 $395.69
$131.89 $216.11 $27.39
$88.57 $29.52 $191.90 $63.96 $104.80 $13.29
$223.41 $77.30 $484.06
$167.48 $263.75 $36.96
Continued on next page. 59
59 Page 60
60
PacifiCare Health Plans 2002
2002 PacifiCare Health Plans 2002 Rate Information
Oklahoma:
Central and Northeastern Oklahoma
Self Only
Self and Family
2N1
2N2
Oregon: Metro Portland, Salem, Corvalis, Eugene and Southwest
Washington
Self Only
Self and Family
7Z1
7Z2
Texas: San Antonio, Dallas/ Ft. Worth
Self Only
Self and Family
GF1
GF2
Washington: Puget Sound/ Most West Washington
Self Only
Self and Family
WB1
WB2
$76.82 $25.61 $166.45 $55.48 $90.91 $11.52
$200.87 $66.95 $435.21
$145.07 $237.69 $30.13
$97.86 $69.05 $212.03 $149.61 $115.52 $51.39
$223.41 $146.40 $484.06
$317.20 $263.75 $106.06
$74.71 $24.90 $161.87 $53.95 $88.40 $11.21
$195.32 $65.10 $423.18
$141.06 $231.12 $29.30
$97.86 $33.01 $212.03 $71.52 $115.52 $15.35
$223.41 $119.68 $484.06
$259.30 $263.75 $79.34
Non-Postal Premium Postal Premium
Biweekly Monthly Biweekly
Type
of
Enrollment Code
Gov't
Share
Your
Share
Gov't
Share
Your
Share
USPS
Share
Your
Share 60