Serving: The Front Range of Colorado
Enrollment in this Plan is limited. You must live in our geographic service area to enroll. See page 6 for requirements.
Enrollment codes for this Plan:
High Option
D61 Self Only
D62 Self and Family
Standard Option
D64 Self Only
D65 Self and Family
RI 73-049
http: / / www. pacificare. com/ colorado
For changes in benefits,
see page 7
This plan has Excellent
accreditation from the NCQA.
See the 2003 Guide for more
information on accreditation.
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Dear Federal Employees Health Benefits Program Participant:
I am pleased to present this Federal Employees Health Benefits (FEHB) Program plan brochure for 2003. The brochure explains all the benefits this health plan offers to its enrollees. Since
benefits can vary from year to year, you should review your plan's brochure every Open Season. Fundamentally, I believe that FEHB participants are wise enough to determine the care
options best suited for themselves and their families.
In keeping with the President's health care agenda, we remain committed to providing FEHB members with affordable, quality health care choices. Our strategy to maintain quality and cost
this year rested on four initiatives. First, I met with FEHB carriers and challenged them to contain costs, maintain quality, and keep the FEHB Program a model of consumer choice and
on the cutting edge of employer-provided health benefits. I asked the plans for their best ideas to help hold down premiums and promote quality. And, I encouraged them to explore all
reasonable options to constrain premium increases while maintaining a benefits program that is highly valued by our employees and retirees, as well as attractive to prospective Federal
employees. Second, I met with our own FEHB negotiating team here at OPM and I challenged them to conduct tough negotiations on your behalf. Third, OPM initiated a comprehensive
outside audit to review the potential costs of federal and state mandates over the past decade, so that this agency is better prepared to tell you, the Congress and others the true cost of mandated
services. Fourth, we have maintained a respectful and full engagement with the OPM Inspector General (IG) and have supported all of his efforts to investigate fraud and waste within the
FEHB and other programs. Positive relations with the IG are essential and I am proud of our strong relationship.
The FEHB Program is market-driven. The health care marketplace has experienced significant increases in health care cost trends in recent years. Despite its size, the FEHB Program is not
immune to such market forces. We have worked with this plan and all the other plans in the Program to provide health plan choices that maintain competitive benefit packages and yet keep
health care affordable.
Now, it is your turn. We believe if you review this health plan brochure and the FEHB Guide you will have what you need to make an informed decision on health care for you and your
family. We suggest you also visit our web site at www. opm. gov/ insure.
Sincerely,
Kay Coles James Director
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Notice of the Office of Personnel Management s
Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED
AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
By law, the Office of Personnel Management ( OPM) , which administers the Federal Employees Health Benefits ( FEHB)
Program, is required to protect the privacy of your personal medical information. OPM is also required to give you this notice
to tell you how OPM may use and give out ( " disclose" ) your personal medical information held by OPM.
OPM will use and give out your personal medical information:
To you or someone who has the legal right to act or you ( your personal representative) ,
To the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy is protected,
To law enforcement officials when investigating and/ or prosecuting alleged or civil or criminal actions, and
Where required by law.
OPM has the right to use and give out your personal medical information to administer the FEHB Program. For example:
To communicate with your FEHB health plan when you or someone you have authorized to act on your behalf asks or
our assistance regarding a benefit or customer service issue.
To review, make a decision, or litigate your disputed claim.
For OPM and the General Accounting Office when conducting audits.
OPM may use or give out your personal medical information for the following purposes under limited circumstances:
For Government healthcare oversight activities ( such as fraud and abuse investigations) ,
For research studies that meet all privacy law requirements ( such as or medical research or education) , and
To avoid a serious and imminent threat to health or safety.
By law, OPM must have your written permission ( an " authorization" ) to use or give out your personal medical information for
any purpose that is not set out in this notice. You may take back ( " revoke" ) your written permission at any time, except i
OPM has already acted based on your permission.
By law, you have the right to:
See and get a copy of your personal medical information held by OPM.
Amend any of your personal medical information created by OPM if you believe that it is wrong or if information is
missing, and OPM agrees. If OPM disagrees, you may have a statement of your disagreement added to your personal
medical information.
Get a listing of those getting your personal medical information from OPM in the past 6 years. The listing will not cover
your personal medical information that was given to you or your personal representative, any information that you
authorized OPM to release, or that was given out or law enforcement purposes or to pay for your health care or a
disputed claim.
Ask OPM to communicate with you in a different manner or at a different place ( for example, by sending materials to a
P. O. Box instead of your home address) .
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Ask OPM to limit how your personal medical information is used or given out. However, OPM may not be able to agree
to your request if the information is used to conduct operations in the manner described above.
Get a separate paper copy of this notice.
For more information on exercising your rights set out in this notice, look at www. opm. gov/ insure on the web. You may also
call 202-606-0191 and ask for OPM s FEHB Program privacy official or this purpose.
If you believe OPM has violated your privacy rights set out in this notice, you may file a complaint with OPM at the
following address:
Privacy Complaints
Office of Personnel Management
P. O. Box 707
Washington, DC 20004-0707
Filing a complaint will not affect your benefits under the FEHB Program. You also may file a complaint with the Secretary of
the Department of Health and Human Services.
By law, OPM is required to ollow the terms in this privacy notice. OPM has the right to change the way your personal
medical information is used and given out. If OPM makes any changes, you will get a new notice by mail within 60 days o
the change. The privacy practices listed in this notice will be effective April 14, 2003.
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Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Plain Language . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Stop Health Care Fraud! . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Section 1. Facts about this HMO plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
How we pay providers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Your Rights. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Service Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Section 2. How we change for 2003. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Program-wide changes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Changes to this Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Section 3. How you get care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Identification cards. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Where you get covered care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Plan providers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Plan facilities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
What you must do to get covered care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Primary care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Specialty care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Hospital care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Circumstances beyond our control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Services requiring our prior approval . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Section 4. Your costs or covered services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Copayments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Deductible . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Coinsurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Your catastrophic protection out-of-pocket maximum. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Section 5. Benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
( a) Medical services and supplies provided by physicians and other health care professionals . . . . . . . . . . . . . . 13
( b) Surgical and anesthesia services provided by physicians and other health care professionals . . . . . . . . . . . . 22
( c) Services provided by a hospital or other acility, and ambulance services . . . . . . . . . . . . . . . . . . . . . . . . . . 26
( d) Emergency services/ accidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
( e) Mental health and substance abuse benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
( f) Prescription drug benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
2003 PacifiCare of Colorado Table of Contents
Table of Contents
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( g) Special eatures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Services or deaf and hearing impaired . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Health Management Programs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
24-Hour Health In ormation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Women s Health Solutions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
National Pharmacy Network . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
( h) Dental benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
( i) Non-FEHB benefits available to Plan members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Section 6. General exclusions things we don t cover . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Section 7. Filing a claim for covered services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Section 8. The disputed claims process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Section 9. Coordinating benefits with other coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
When you have other health coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
What is Medicare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Medicare managed care plan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
TRICARE and CHAMPVA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Workers Compensation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Medicaid. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Other Government agencies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
When others are responsible or injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Section 10. Definitions of terms we use in this brochure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Section 11. FEHB facts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Coverage information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
No pre-existing condition limitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Where you get information about enrolling in the FEHB Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Types of coverage available for you and your amily . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Children s Equity Act . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
When benefits and premiums start . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
When you retire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
When you lose benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
When FEHB coverage ends. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Spouse equity coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Temporary Continuation of Coverage ( TCC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Converting to individual coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Getting a Certificate of Group Health Plan Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Long term care insurance is still available . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Summary of benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Rates. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Back cover
2003 PacifiCare of Colorado Table of Contents
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This brochure describes the benefits of PacifiCare of Colorado under our contract ( CS 1761) with the Office of Personnel
Management ( OPM) , as authorized by the Federal Employees Health Benefits law. The address or PacifiCare of Colorado s
administrative offices is:
PacifiCare of Colorado
6455 South Yosemite Street
Greenwood Village, CO 80111
This brochure is the official statement of benefits. No oral statement can modify or otherwise affect the benefits, limitations,
and exclusions of this brochure. It is your responsibility to be informed about your health benefits.
If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled in Self and
Family coverage, each eligible amily member is also entitled to these benefits. You do not have a right to benefits that were
available before January 1, 2003, unless those benefits are also shown in this brochure.
OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2003, and changes are
summarized on page 7. Rates are shown at the end of this brochure.
2003 PacifiCare of Colorado Introduction/ Plain Language/ Advisory
Introduction
All FEHB brochures are written in plain language to make them responsive, accessible, and understandable to the public.
For instance,
Except or necessary technical terms, we use common words. For instance, " you" means the enrollee or amily member;
" we" means PacifiCare of Colorado.
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 ehbwebcomments@ opm. gov. You may also write to
OPM at the Office of Personnel Management, Office of Insurance Planning and Evaluation Division, 1900 E Street, NW,
Washington, DC 20415-3650.
Plain Language
Fraud increases the cost of health care for everyone and increases your Federal Employees Health Benefits ( FEHB)
Program premium.
OPM s Office of the Inspector General investigates all allegations of fraud, waste, and abuse in the FEHB Program regardless
of the agency that employs you or from which you retired.
Stop Health Care Fraud!
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5 2003 PacifiCare of Colorado Introduction/ Plain Language/ Advisory
Protect Yourself From Fraud Here are some things you can do to prevent fraud:
Be wary of giving your plan identification ( ID) number over the telephone or to people you do not know, except to your
doctor, other provider, or authorized plan or OPM representative.
Let only the appropriate medical professionals review your medical record or recommend services.
Avoid using health care providers who say that an item or service is not usually covered, but they know how to bill us to
get it paid.
Carefully review explanations of benefits ( EOBs) that you receive from us.
Do not ask your doctor to make false entries on certificates, bills or records in order to get us to pay for an item or service.
If you suspect that a provider 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 1-800-877-9777 and explain the situation.
If we do not resolve the issue:
CALL THE HEALTH CARE FRAUD HOTLINE
202-418-3300
OR WRITE TO:
The United States Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street, NW, Room 6400
Washington, DC 20415
Do not maintain as a amily member on your policy:
Your ormer spouse after a divorce decree or annulment is final ( even if a court order stipulates otherwise) ; or
Your child over age 22 ( unless he/ she is disabled and incapable of self support) .
If you have any questions about the eligibility of a dependent, check with your personnel office if you are employed or
with OPM if you are retired.
You can be prosecuted for fraud and your agency may take action against you if you falsify a claim to obtain FEHB
benefits or try to obtain services or someone who is not an eligible amily member or who is no longer enrolled in the
Plan.
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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. The Plan is solely responsible or
the selection of these providers in your area. Contact the Plan for a copy of their most recent provider directory.
HMOs emphasize preventive care such as routine office visits, physical exams, well-baby care, and immunizations, in addition
to treatment or illness and injury. Our providers ollow 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 and coinsurance 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 or your copayments or coinsurance. These
payment arrangements include capitation, discounted fee-for-service and case rates, as well as additional financial incentives
including bonuses and withholds.
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.
Years in existence PacifiCare of Colorado ( and its predecessors) began offering health care coverage in
Colorado in 1974.
Profit status We are a for-profit organization.
If you want more information about us, call 1-800-877-9777, or write to 6455 South Yosemite Street, Greenwood Village, CO
80111. You may also contact us by fax at 1-303-714-3977 or visit our website at www. pacificare. com/ colorado.
Service Area
To enroll in this Plan, you must live or work in our service area. This is where our providers practice. Our service area is: the
Colorado counties of Adams, Arapahoe, Boulder, Broomfield, Clear Creek, Denver, Douglas, Elbert, El Paso, Gilpin, Jefferson,
Larimer, Morgan, Park, Teller and Weld.
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 received outside the 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 ee-for-service
plan or an HMO that has agreements with affiliates in other areas. If you or a amily member move, you do not have to wait
until Open Season to change plans. Contact your employing or retirement office.
2003 PacifiCare of Colorado Section 1
Section 1. Facts about this HMO plan
9.
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Page 10
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7
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
A notice of the Office of Personnel Management s Privacy Practices is included.
A section on the Children s Equity Act describes when an employee is required to maintain Self and Family coverage.
Program information on TRICARE and CHAMPVA explains how annuitants or former spouses may suspend their FEHB
Program enrollment.
Program information on Medicare is revised.
Changes to this Plan
Your share of the High Option non-postal premium will increase by 11.7% or Self Only coverage and 9.7% or Self and
Family coverage.
Your share of the Standard Option non-postal premium will increase by 34.3% or Self Only coverage and 34.8% or Self and
Family coverage.
Specialist office visits High Option: You now pay a $ 20 copay for office visits to a specialist. Standard Option: You
now pay a $ 30 copay for office visits to a specialist.
Inpatient Hospitalization High Option: You now pay a $ 100 copay per hospital admission. Standard Option: You now
pay a $ 300 copay per hospital admission. The calendar year copay family maximum no longer applies.
Outpatient surgery High Option: You now pay a $ 50 copay per procedure or a 23-hour observation. Standard Option:
You now pay a $ 150 copay per procedure or a 23-hour observation.
Prescription drugs High Option: You now pay a $ 10 copay for generic formulary drugs, a $ 20 copay for brand name
formulary drugs and a $ 30 copay for non-formulary drugs. Standard Option: You now pay a $ 30 copay for brand name
formulary drugs and a $ 40 copay for non-formulary drugs.
Prescription drugs We now cover up to 200 test strips per 30-day supply for diabetic glucose and ketone test strips or
members who meet certain criteria.
Prosthetic arms and legs are now covered at 20% of the eligible expense, when they meet Plan criteria. The $ 1,500
annual maximum for durable medical equipment does not apply.
Lab, X-ray and other diagnostic tests We now cover SPECT scans . You pay a $ 75 copay per test under both options.
2003 PacifiCare of Colorado Section 2
Section 2. How we change for 2003
Medical foods are now covered for certain single metabolic gene disorders. Cardiac rehabilitation We now cover cardiac rehabilitation for the diagnosis of stable angina pectoris.
10.
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8
Identification cards We will send you an identification ( ID) card when you enroll. 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 1-800-877-9777.
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.
Plan providers Plan providers are physicians and other health care professionals in our 16-county
service area that we contract with to provide covered services to our members. We
credential Plan providers according to national standards.
The physicians that we contract with are either in private practice in their own
office, or participating in medical groups, practicing in conveniently located group
practice centers.
We list Plan providers in the provider directory, which we update periodically.
The list of primary care physicians is also on our website at
www. pacificare. com/ colorado.
Plan facilities Plan facilities are hospitals and other acilities 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.
What you must do to get It depends on the type of care you need. First, you and each family member must covered care choose a primary care physician ( PCP) . This decision is important since your PCP
provides or arranges or most of your health care.
Some of our participating physicians are organized into groups of primary care
physicians and specialists who have joined together to provide services. For
physicians affiliated in this manner, PCPs belong to just one group, but some
specialists may have more than one affiliation. When you need specialty care, your
PCP will most likely refer you to a specialist with whom he or she is affiliated.
PCPs typically have established relationships with other doctors to whom they ll
most likely refer patients when specialized care is needed. Referring to specialist
your PCP is amiliar with makes it easy for your PCP to communicate with both
you and your specialist and coordinate your care. Our policy is to encourage PCPs
to consider patients input in care decisions.
Primary care Your primary care physician can be a family practitioner, internist or pediatrician.
Your primary care physician will provide most of your health care, or give you a
referral to see a specialist. We contract with approximately 1, 300 primary care
physicians.
2003 PacifiCare of Colorado Section 3
Section 3. How you get care
11.
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9
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.
However, you may access care for the following benefits without a referral from
your PCP:
mental health and substance abuse benefits refer to Section 5( e) or
information on how to access these benefits.
vision care contact VSP at 1-888-426-4877.
chiropractic care go directly to a participating American Specialty Health
Networks provider.
obstetrical or gynecological care access care through your primary care
physician or go directly to a participating OB/ GYN physician.
We contract with over 3, 000 referral specialists.
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 develop a
treatment plan that allows you to see your specialist for a certain number o
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, you may discuss
whether or not it is appropriate to continue to see your current specialist. I
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 or 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.
2003 PacifiCare of Colorado Section 3
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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 acility.
If you are in the hospital when your enrollment in our Plan begins, call our
customer service department immediately at 1-800-877-9777. If you are new to
the FEHB Program, we will arrange for you to receive care.
If you changed from another FEHB plan to us, your ormer 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 ormer 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 prior approval Your primary care physician has authority to refer you for most services. 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 review and approval process preauthorization. Your physician must
obtain preauthorization for services such as:
Septoplasty
Hysterectomy
MRIs, CT, PET and SPECT scans.
Upper GI endoscopy
Colonoscopy
Knee arthroscopy
PacifiCare of Colorado 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 procedures and treatments.
Our criteria are based on research of scientific literature, collaboration with
physician specialists and compliance with ederal 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.
2003 PacifiCare of Colorado Section 3
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You must share the cost of some services. You are responsible or:
Copayments A copayment is a fixed amount of money you pay to the provider, facility,
pharmacy, etc. , when you receive services.
Example: When you see your primary care physician you pay a copayment of $ 10
( High Option) or $ 15 ( Standard Option) per office visit.
Deductible A deductible is a fixed expense you must incur or certain covered services and
supplies before we start paying benefits or them.
We do not have any deductibles on our medical benefits. Under the High
Option, dental indemnity benefits have a $ 50 individual deductible and a
$ 150 family deductible.
Coinsurance Coinsurance is the percentage of our negotiated fee that you must pay for your care.
Example: In our Plan, you pay 50% of our allowance for infertility services, or
drugs or the treatment of sexual dysfunction.
Your catastrophic protection out-of-pocket maximum for
copayments and coinsurance After your copayments, coinsurance or deductibles total $ 3,600 per person or $ 10,000 per amily enrollment in any calendar year, you do not have to pay any
more for covered services. However, your out-of-pocket expenses or the ollowing
services do not count toward your out-of-pocket maximum, and you must continue
to pay copayments or these services:
Prescription drugs
Dental services
Non-authorized/ non-covered services
Be sure to keep accurate records of your copayments and coinsurance since you
are responsible for informing us when you reach the maximum.
2003 PacifiCare of Colorado Section 4
Section 4. Your costs for covered services
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NOTE: This benefits section is divided into subsections. Please read the important things you should keep in mind at the
beginning of each subsection. Also read the General Exclusions in Section 6; they apply to the benefits in the following
subsection. To obtain claims orms, claims filing advice, or more information about our benefits, contact us at 1-800-877-9777
or at our website at www. pacificare. com/ colorado.
( a) Medical services and supplies provided by physicians and other health care professionals. . . . . . . . . . . . . . . . . . . . . . 13-21
( b) Surgical and anesthesia services provided by physicians and other health care professionals . . . . . . . . . . . . . . . . . . . . 22-25
( c) Services provided by a hospital or other acility, and ambulance services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26-28
( d) Emergency services/ accidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29-30
Medical emergency Ambulance
( e) Mental health and substance abuse benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31-32
( f) Prescription drug benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33-35
( g) Special eatures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
( h) Dental benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37-42
( i) Non-FEHB benefits available to Plan members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Summary of benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Services or deaf and hearing impaired
Health Management Programs
24-Hour Health Information
Women s Health Solutions
National Pharmacy Network
Inpatient hospital
Outpatient hospital or ambulatory surgical
center
Extended care benefits/ skilled nursing care
facility benefits
Hospice care
Ambulance
Surgical procedures
Reconstructive surgery
Oral and maxillofacial surgery
Organ/ tissue transplants
Anesthesia
Diagnostic and treatment services
Lab, X-ray and other diagnostic tests
Preventive care, adult
Preventive care, children
Maternity care
Family planning
Infertility services
Allergy care
Treatment therapies
Physical and occupational therapy
Speech therapy
Hearing services ( testing, treatment, and
supplies)
Vision services ( testing, treatment, and supplies)
Foot care
Orthopedic and prosthetic devices
Durable medical equipment ( DME)
Home health services
Chiropractic
Alternative treatments
Educational classes and programs
2003 PacifiCare of Colorado Section 5
Section 5. Benefits OVERVIEW
( See page 7 for how our benefits changed this year and page 60 for a benefits summary. )
15.
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Diagnostic and treatment services You pay -Standard Option You pay -High Option
Professional services of physicians
In physician s office $ 15 per PCP office visit $ 10 per PCP office visit
Office medical consultations $ 30 per specialist office visit $ 20 per specialist office visit
Second surgical opinion
Professional services of physicians Nothing Nothing
In an urgent care center
During a hospital stay
In a skilled nursing facility
At home when medically necessary
Not covered:
Physical examinations that are not medically All charges All charges
necessary, such as those required for obtaining
or continuing employment or insurance,
attending school or camp, or travel
Obesity treatment, except for surgical treatment
of morbid obesity
Total Parenteral Nutrition ( TPN)
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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.
2003 PacifiCare of Colorado Section 5( a)
Section 5 ( a) . Medical services and supplies provided by physicians and
other health care professionals
Benefit Description You pay
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Page 17
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Lab, X-ray and other diagnostic tests You pay Standard Option You pay High Option
Tests, such as: Nothing Nothing
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
Ultrasound
Electrocardiogram and EEG
MRIs, CT , PET and SPECT scan $ 75 copay per test$ 75 copay per test
Preventive care, adult
We cover periodic health appraisals or adults. These $ 15 per PCP office visit $ 10 per PCP office visit
visits include coverage for routine screenings, such as: $ 30 per specialist office visit $ 20 per specialist office visit
Total Blood Cholesterol
Colorectal Cancer Screening, including:
Fecal occult blood test
Sigmoidoscopy, screening
Routine Prostate Specific Antigen ( PSA) test
one annually or men age 40 and older
Routine pap test
Note: The office visit is covered if pap test is
received on the same day; see Diagnostic and
treatment services , above.
Routine mammogram covered or women age 35 Nothing Nothing
and older, as ollows:
From age 35 through 39, one during this five
year period
From age 40 through 64, one every year
At age 65 and older, one every two years
Routine immunizations, limited to: Nothing Nothing
Tetanus-diphtheria ( Td) booster once every
10 years, ages 19 and over ( except as provided
for under Childhood immunizations)
Influenza vaccine, annually
Pneumococcal vaccine, age 65 and over
Not covered: All charges All charges
Physical examinations that are not medically
necessary for medical reasons, such as those
required for obtaining or continuing employment
or insurance, attending school or camp, or travel.
2003 PacifiCare of Colorado Section 5( a)
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Preventive care, children You pay Standard Option You pay High Option
Childhood immunizations recommended by the $ 15 per office visit $ 10 per office visit
American Academy of Pediatrics
Well-child care charges or routine examinations, $ 15 per PCP office visit $ 10 per PCP office visit
immunizations and care ( up to age 22 years) $ 30 per specialist office visit $ 20 per specialist office visit
Examinations, such as:
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)
Not covered: All charges All charges
Physical examinations that are not medically
necessary for medical reasons, such as those
required for obtaining or continuing employment
or insurance, attending school or camp, or travel.
Maternity care
Complete maternity ( obstetrical) care, such as: $ 15 copay per office visit $ 10 copay per office visit
Prenatal care
Delivery
Postnatal care
Note: Here are some things to keep in mind:
You do not need to precertify your normal
delivery; see page 26 for other circumstances,
such as extended stays or 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 or illness and injury.
See Hospital benefits ( Section 5c) and Surgery
benefits ( Section 5b) .
Not covered: All charges All charges
Any procedure intended solely for sex
determination
Birthing classes
Normal delivery outside of our service area
2003 PacifiCare of Colorado Section 5( a)
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Page 19
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Family planning You pay Standard Option You pay High Option
A range of voluntary family planning services, $ 15 per PCP office visit $ 10 per PCP office visit
such as: $ 30 per specialist office visit $ 20 per specialist office visit
Voluntary sterilization ( See Surgical procedures
Section 5( b) )
Family planning counseling
Information on birth control
Injectable contraceptive drugs
Intrauterine devices ( IUDs) and implantable
contraceptive devices, including their insertion
and removal
Diaphragms and cervical caps, including their
fitting
Not covered: All charges All charges
Reversal of voluntary, surgical sterilization
Genetic counseling
Pregnancy test kits and ovulation kits
Infertility services
Diagnosis and treatment of infertility 50% 50%
Artificial insemination
intravaginal insemination ( IVI)
intracervical insemination ( ICI)
intrauterine insemination ( IUI)
This coverage is limited to members who have
been diagnosed as biologically infertile in
accordance with accepted medical practice.
Not covered: All charges All charges
Fertility drugs
Assisted reproductive technology ( ART)
procedures
in vitro fertilization
embryo transfer, GIFT and ZIFT
Services and supplies related to excluded ART
procedures
Cost related to donor sperm and donor ova
Infertility services for members who have
undergone a voluntary sterilization procedure
Allergy care
Comprehensive diagnostic allergy evaluation $ 15 per PCP office visit $ 10 per PCP office visit
including testing $ 30 per specialist office visit $ 20 per specialist office visit
Allergy injection $ 5 per visit when not in $ 5 per visit when not in
conjunction with a conjunction with a
physician s office visit physician s office visit
Allergy serum Nothing Nothing
2003 PacifiCare of Colorado Section 5( a)
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Treatment therapies You pay Standard Option You pay High Option
Chemotherapy and radiation therapy Nothing Nothing
Note: High dose chemotherapy in association with
autologous bone marrow transplants are limited to
those transplants listed under Organ/ Tissue
Transplants on page 24.
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. Your plan physician
will handle this preauthorization process.
Physical and occupational therapy
Physical therapy and occupational therapy: $ 15 per office visit $ 10 per office visit
Up to 20 visits or two months per condition, Nothing for inpatient Nothing for inpatient
whichever is greater, if significant improvement
can be expected within two months
Physical/ occupational therapy is limited to services
that assist the member to achieve and maintain self-
care and improved functioning in other activities o
daily living.
Note: We provide physical and occupational up to 20
sessions or each type of therapy per year, for the care
and treatment of congenital defects and birth
abnormalities or children up to age five ( 5) . This is
without regard to whether the condition is acute or
chronic or whether the purpose of the therapy is to
maintain or to improve functional capacity.
Cardiac rehabilitation following a heart transplant, Nothing Nothing
bypass surgery or a myocardial infarction, is provided
at an approved facility or up to 90 sessions or
short-term ollow-up care. Coverage of cardiac
rehabilitation for stable angina pectoris will be limited
to one course of treatment per plan year.
Not covered: All charges All charges
Long-term rehabilitative therapy
Special evaluation and/ or therapy for conditions
such as behavior disorders and pulmonary
rehabilitation
Speech therapy
Up to 20 visits or two months per condition, $ 15 per office visit $ 10 per office visit.
whichever is greater. Nothing for inpatient Nothing for inpatient
Speech therapy is provided when medically necessary
without regard to whether the purpose of the therapy
is to maintain or to improve functional capacity.
2003 PacifiCare of Colorado Section 5( a)
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Hearing services ( testing, treatment, You pay Standard Option You pay High Option
and supplies)
Examinations to determine the need, if any, or $ 15 per office visit $ 10 per office visit.
hearing correction.
Not covered: All charges All charges
All other hearing testing
Hearing aids, and evaluation for them
Vision services ( testing, treatment,
and supplies)
Diagnosis and treatment of diseases of the eye $ 15 per office visit $ 10 per office visit
Routine eye exams including refraction, once
every 12 months, to determine the prescription
for corrective lenses, eyeglasses or contact
lenses. You may go directly to a PacifiCare
participating VSP provider without a referral or
authorization rom VSP. For a list o participating
providers call VSP at 1-888-426-4877.
Routine visual acuity exams as part of covered
periodic health exams
We cover eyeglasses when prescribed ollowing All cost over $ 125 All cost over $ 125
cataract surgery with an intra ocular lens implant.
Eyeglasses must be obtained through participating
providers, and are covered up to $ 125 per pair, with a
limit of one pair per surgery and two pairs per lifetime.
Not covered: All charges All charges
Fitting contact lenses
Vision therapy
Radial keratotomy, keratomileusis and excimer
laser surgery
Eyeglasses or contact lenses, other than
following cataract surgery as described above
Foot care
Routine foot care when you are under active $ 15 per PCP office visit $ 10 per PCP office visit
treatment or a metabolic or peripheral vascular $ 30 per specialist office visit $ 20 per specialist office visit
disease, such as diabetes.
See orthopedic and prosthetic devices or information
on podiatric shoe inserts.
Not covered: All charges All charges
Cutting or trimming of the free edge of toenails,
and similar routine treatment of conditions of
the foot, except as stated above
Foot orthotics, except as covered under Durable
Medical Equipment
2003 PacifiCare of Colorado Section 5( a)
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Orthopedic and prosthetic devices You pay Standard Option You pay High Option
Orthopedic braces and podiatric shoe inserts $ 15 per office visit $ 10 per office visit
meeting criteria are covered up to a combined
maximum of $ 500 per member per calendar year.
Podiatric shoe inserts are covered for persons
with historical ulcers or pre-ulcerous lesions and
documented neuropathy, persistent plantar acitis
or documented neuropathy who have had
documented failure of using commercial over-
the-counter inserts prior to, or instead of surgery.
Externally worn breast prostheses and surgical
bras, including necessary replacements will be
covered following a mastectomy up to $ 500 per
member per calendar year.
Internal prosthetic devices, such as artificial
joints, pacemakers, cochlear implants, lenses
following cataract removal, and surgically
implanted breast implants ollowing
mastectomy. Note: We pay internal prosthetic
devices as hospital benefits; see Section 5( c) or
payment information. See 5( b) or coverage of
the surgery to insert the device.
External extremity prosthetics please refer to
the Durable Medical Equipment benefit for
coverage information.
Not covered: All charges All charges
Foot orthotics
Orthotic devices for podiatric use
Arch support
Prostheses for cosmetic purposes
Experimental/ investigational or cosmetic
implants
Durable medical equipment ( DME)
The following durable medical equipment is covered Nothing up to the annual $ 1,500 Nothing up to the annual $ 1,500
based on criteria established by us, up to $ 1,500 per benefit limit; all charges benefit limit; all charges
member per calendar year. The criteria may include thereafter thereafter
that the equipment must eliminate the need for
treatment in an acute care or rehabilitative facility.
Please contact us or other criteria.
Coverage is limited to:
Apnea monitors
Bilirubin lights or blankets
Bone stimulators
Continuous passive motion machines ( CPM)
External extremity prosthetics ( covered only if
the prosthesis will restore unction of the
extremity)
Feeding pumps
Hospital beds
2003 PacifiCare of Colorado Section 5( a)
Durable medical equipment ( DME) Continued on next page
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Durable medical equipment ( DME) You pay Standard Option You pay High Option
( continued)
Insulin pump supplies ( including cartridges, Nothing up to the annual $ 1,500 Nothing up to the annual $ 1,500
extension tubing, batteries, infusion sets, and benefit limit; all charges benefit limit; all charges
customary dressings provided by the pump thereafter thereafter
supplier to secure infusion sets)
Lymphedema pumps
Nebulizers
Oxygen
Positive airway pressure devices ( C-PAP)
( Bi-PAP)
Prosthetic eyes
Suction machines
Traction equipment
Ventilators
Wheelchairs
Prosthetic arms and legs are covered only if the 20% of eligible charges 20% of eligible charges
prosthesis will restore unction of the extremity.
Note: The $ 1,500 per member per year maximum
does not apply to this benefit.
One peak flow meter per member per lifetime and Nothing Nothing
one glucometer per member per lifetime.
Insulin pumps meeting criteria. Nothing Nothing
Not covered: medical supplies such as: All charges All charges
Crutches
Colostomy supplies
Catheters
Home health services
Home health services of nurses and therapists, Nothing Nothing
including intravenous fluids and medications,
when prescribed by your Plan doctor, who will
periodically review the program or continuing
appropriateness and need. .
Not covered: All charges All charges
Nursing care requested by, or for the
convenience of, the patient or the patient s
family
Home care primarily for personal assistance
that does not include a medical component and
is not diagnostic, therapeutic or rehabilitative
20 2003 PacifiCare of Colorado Section 5( a)
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Chiropractic You pay Standard Option You pay High Option
Chiropractic services up to 20 outpatient visits $ 15 per office visit $ 10 per office visit
with a participating chiropractor.
Note: You may self refer to a participating
chiropractor or the 1st visit per
neuromusculoskeletal condition or injury; however
the Plan must approve any additional treatment.
Not covered: All charges All charges
Chiropractic services for maintenance care
Biofeedback
Alternative treatments
Not covered, services such as: All charges All charges
Naturopathic services
Hypnotherapy
Biofeedback
Educational classes and programs
Smoking cessation a self-directed, self-paced $ 20 enrollment ee for $ 20 enrollment ee for
smoking cessation program or our members who smoking cessation program smoking cessation program
would like to stop smoking. After enrollment in the
program, a letter is sent to your PCP to inform him or
her of your participation.
The program includes:
Regularly scheduled motivational phone calls
with a trained smoking cessation specialist.
Educational materials to guide smokers to quit.
One of two smoking cessation aid products; a $ 20 copay per 30-day supply $ 20 copay per 30-day supply
transdermal patch for nicotine replacement
therapy, or an approved prescription drug.
Coverage of these aids is available for up to
90 days per year, limited to 3 years per lifetime.
To enroll in the smoking cessation program, or or
more information, please call 1-800-877-9777.
Not covered: special service clinics, centers, or All charges All charges
programs on an inpatient or outpatient basis, such as:
Education clinics, such as premenstrual ( PMS) ,
lactation, headache, eating disorder, senior
services and stress management
2003 PacifiCare of Colorado Section 5( a)
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Surgical procedures You pay Standard Option You pay High Option
A comprehensive range of services, such as:
Surgical services including normal pre-and
post-operative care by the surgeon
Services of a surgical assistant and
anesthesiologist when medically necessary
Correction of amblyopia and strabismis
Treatment of fractures, including casting
Removal of tumors and cysts
Endoscopy procedure
Biopsy procedure
Correction of congenital anomalies ( see
Reconstructive surgery)
Surgical treatment of morbid obesity based on
criteria established by us
Insertion of internal prosthetic devices. Note: See
Section 5 ( a) for device coverage information.
Voluntary sterilization ( e. g. , tubal ligation,
vasectomy)
Treatment of burns
Not covered: All charges All charges
Reversal of voluntary, surgically-induced sterility
Surgery primarily for cosmetic purposes
$ 10 per PCP office visit;
$ 20 per specialist office visit;
nothing for outpatient or
inpatient surgery
$ 15 per PCP office visit;
$ 30 per specialist office visit;
nothing for outpatient or
inpatient surgery
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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 or the charges billed by a physician or other health care
professional or your surgical care. Look in Section 5( c) or charges associated with the
facility ( i. e. hospital, surgical center, etc. ) .
YOUR PHYSICIAN MUST GET SOME SURGICAL PROCEDURES
PREAUTHORIZED. Please refer to the preauthorization information shown in Section 3
to be sure which services and surgeries require preauthorization.
2003 PacifiCare of Colorado Section 5( b)
Section 5 ( b) . Surgical and anesthesia services provided by physicians and
other health care professionals
Benefit Description You pay
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Reconstructive surgery You pay Standard Option You pay High Option
Surgery to correct a unctional defect
Surgery to correct a condition caused by injury
or surgery 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. Some examples o
congenital anomalies are cleft lip and cleft palate.
All stages of breast reconstruction surgery
following a mastectomy, 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 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:
Treatment of congenital conditions of the jaw
that may be demonstrated to cause actual
significant deterioration in the member s
physical condition because of inadequate
nutrition or respiration;
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.
$ 10 per PCP office visit;
$ 20 per specialist office visit;
nothing for outpatient or
inpatient surgery
$ 15 per PCP office visit;
$ 30 per specialist office visit;
nothing for outpatient or
inpatient surgery
$ 10 per PCP office visit;
$ 20 per specialist office visit;
nothing for outpatient or
inpatient surgery
$ 15 per PCP office visit;
$ 30 per specialist office visit;
nothing for outpatient or
inpatient surgery
2003 PacifiCare of Colorado Section 5( b)
Oral and maxillofacial surgery Continued on next page
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Oral and maxillofacial surgery ( continued) You pay -Standard Option You pay High Option
Not covered: All charges All charges
Orthodontic treatment, or other dental related
services for treatment of TMJ.
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:
Cornea
Heart
Heart/ lung
Kidney
Liver
Allogeneic ( donor) bone marrow and stem cell
transplants
Autologous bone marrow and stem cell
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 the liver, stomach,
and pancreas
Limited Benefits -Treatment or 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.
We also cover donor screening charges or
immediate family members to include spouses,
parents, children, siblings, and, if appropriate,
grandparents.
Not covered: All charges All charges
Transplants not listed as covered
Implants of artificial organs
$ 10 per PCP office visit;
$ 20 per specialist office visit;
nothing for outpatient or
inpatient surgery
$ 15 per PCP office visit;
$ 30 per specialist office visit;
nothing for outpatient or
inpatient surgery
2003 PacifiCare of Colorado Section 5( b)
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Anesthesia You pay -Standard Option You pay High Option
Professional services provided in: Nothing Nothing
Hospital ( inpatient)
Hospital outpatient department
Skilled nursing facility
Ambulatory surgical center
Office
2003 PacifiCare of Colorado Section 5( b)
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Inpatient hospital You pay -Standard Option You pay -High Option
Room and board, such as:
Semiprivate, or specialized care units, such as
intensive care or cardiac care units;
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 Nothing
Operating, recovery, maternity, and other
treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests and X-rays
Blood, blood plasma, and blood products if not
donated or replaced, including processing and
administration
Dressings, splints, casts, and sterile tray services
Medical supplies and equipment, including
oxygen
Anesthetics and anesthesia service when
medically necessary
$ 100 copayment per admission $ 300 copayment per admission
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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.
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 or 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) .
YOUR PHYSICIAN MUST GET PREAUTHORIZATION OF HOSPITAL
STAYS. Please refer to Section 3 to be sure which services require preauthorization.
2003 PacifiCare of Colorado Section 5( c)
Section 5 ( c) . Services provided by a hospital or other facility,
and ambulance services
Benefit Description You pay
Inpatient hospital Continued on next page
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Inpatient hospital ( continued) You pay -Standard Option You pay -High Option
Not covered: All charges All charges
Custodial care
Non-covered facilities, such as nursing homes,
schools
Special blood handling fees, wound healing
products and storage of cord blood
Personal comfort items, such as telephone,
television, articles for personal hygiene, guest
meals and beds
Private duty nursing care
Take-home drugs and supplies
Hospitalization for any dental procedures,
except for children under certain circumstances
Outpatient hospital or ambulatory
surgical center
Operating, recovery, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests, X-rays, and
pathology services
Blood, blood plasma, and blood products if not
donated or replaced, including processing and
administration
Pre-surgical testing
Dressings, casts, and sterile tray services
Medical supplies, including oxygen
Anesthetics and anesthesia service when
medically necessary
NOTE: We cover hospital services and supplies
related to dental procedures when necessitated by a
non-dental physical impairment and meeting criteria.
We do not cover the dental procedures.
Not covered: All charges All charges
Special blood handling fees, wound healing
products and storage of cord blood
Hospitalization for any dental procedures,
except for children under certain circumstances
Extended care benefits/ skilled
nursing care facility benefits
Subacute care facility services ollowing Nothing Nothing
hospitalization is covered up to 60 days per
calendar year at an approved subacute care facility.
This coverage includes:
Accommodations
Meals
$ 50 copay for outpatient
surgery or 23-hour observation
$ 150 copay for outpatient
surgery or 23-hour observation
2003 PacifiCare of Colorado Section 5( c)
Extended care benefits/ skilled nursing care facility benefits Continued on next page
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Extended care benefits/ skilled
nursing care facility benefits ( continued) You pay -Standard Option You pay -High Option
General nursing care Nothing Nothing
Medical supplies and equipment ordinarily
furnished by the facility
Prescribed drugs and biologicals
Skilled nursing facility ( SNF) : We cover up to 120 Nothing Nothing
days per calendar year when full-time skilled nursing
care is necessary and confinement in a skilled nursing
facility is medically appropriate as determined by a
Plan doctor and approved by us.
This coverage includes:
Accommodations
Meals
General nursing care
Medical supplies and equipment ordinarily
furnished by the facility
Prescribed drugs and biologicals
Not covered: All charges All charges
Custodial care
Care for chronic conditions
Private room, except when medically necessary
Personal comfort items, such as telephone,
television, articles for personal hygiene, guest
meals and beds
Private duty nursing care
Hospice care
Supportive and palliative care for a terminally ill Nothing Nothing
member is covered in 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: services such as independent nursing All charges All charges
and homemaker services
Ambulance
Medically necessary air or ground ambulance $ 25 per trip $ 25 per trip
service ordered or authorized by a Plan doctor
2003 PacifiCare of Colorado Section 5( c)
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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:
In a life or limb threatening emergency, call 911 or go to the nearest hospital emergency room or other acility or
treatment. You do not need authorization from your primary care physician before you go. True emergency care is
covered no matter where you are.
Emergencies within our service area:
If you receive emergency care and are in our service area, notify your PCP on the first business day following your
admission, so that he or she can coordinate any follow-up treatment.
When you need urgent care while you re in our service area, call your primary care physician. All physician offices
have a 24-hour answering service that will contact your PCP or his or her on-call partner. Your physician can assess
the situation and decide what type of care you need. Ask your PCP about after-hours and on-call procedures now,
before you need these services.
Emergencies outside our service area:
If you receive emergency or urgent care outside our service area, contact PacifiCare Customer Service within 48
hours, unless it was not reasonably possible to do so, to let us know what has happened and where you went or care.
We also cover ollow-up treatment to emergency care up to $ 400 per person per calendar year when that care is
delivered outside our service area.
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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.
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.
2003 PacifiCare of Colorado Section 5( d)
Section 5 ( d) . Emergency services/ accidents
Emergency services/ accidents benefits begin on the next page.
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30 2003 PacifiCare of Colorado Section 5( d)
Emergency within our service area You pay -Standard Option You pay -High Option
Emergency care at a doctor s office
During normal business hours $ 15 per PCP office visit $ 10 per PCP office visit
$ 30 per specialist office visit $ 20 per specialist office visit
After normal business hours $ 25 per visit $ 25 per visit
Emergency care at an urgent care center $ 25 per visit $ 25 per visit
Emergency room setting $ 100 per visit $ 100 per visit
Not covered: All charges All charges
Follow-up care in the emergency facility
Emergency visits made in non-life or limb
threatening situations without your PCP s
authorization
Emergency room services obtained during
normal physician office hours, except in the
event of a life or limb threatening emergency or
when preauthorized by your PCP
Emergency outside our service area
Emergency care at a doctor s office $ 25 per visit $ 25 per visit
Emergency care at an urgent care center $ 25 per visit $ 25 per visit
Emergency room setting $ 100 per visit $ 100 per visit
We cover up to $ 400 per person per calendar year or
follow-up care to emergency services received outside
the service area. These services are covered when
needed in order to prevent serious deterioration of
your health that would result from an unforeseen
illness or injury if you are temporarily absent from
our service area and receipt of your health care cannot
be delayed until your return to the service area.
Not covered: All charges 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
normal full-term delivery of a baby outside the
service area
Ambulance
Ground or air ambulance service approved by us $ 25 per trip $ 25 per trip
You pay the appropriate
emergency benefit copay listed
in the box directly above
You pay the appropriate
emergency benefit copay listed
in the box directly above
Benefit Description You pay
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When you get our approval for services and follow a treatment lan 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 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.
YOU MUST GET PREAUTHORIZATION OF THESE SERVICES. See the
instructions after the benefits description below.
2003 PacifiCare of Colorado Section 5( e)
Section 5 ( e) . Mental health nd substance abuse benefits
Benefit Description You pay
Mental health and substance abuse benefits You pay -Standard Option You pay -High Option
Diagnostic and treatment services recommended by a
Plan provider and contained in a treatment lan that we
approve. The treatment lan may include services, drugs,
and supplies described elsewhere in this brochure.
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 lan that we approve.
Professional services, including individual or $ 15 per PCP office visit $ 10 per PCP office visit.
group therapy by providers such as psychiatrists, $ 30 per specialist office visit $ 20 per specialist office visit
psychologists, or clinical social workers
Medication management
Diagnostic tests Nothing Nothing
Services rovided by a hospital or other facility $ 300 copayment per admission $ 100 copayment per admission
Your cost sharing
responsibilities are no greater
than for other illness or
conditions.
Your cost sharing
responsibilities are no greater
than for other illness or
conditions.
Mental health and substance abuse benefits Continued on next page
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Mental health and substance abuse You pay Standard Option You pay High Option
benefits ( continued)
Not covered: All charges All charges
Psychiatric evaluation or therapy, or substance
abuse treatment, on court order or as a condition
of parole or probation, unless determined by us
to be necessary and appropriate
Services we have not approved
Note: The same exclusions contained in this
brochure that apply to other benefits apply to these
mental health and substance abuse benefits, unless
the services are ncluded in a treatment plan that we
approve. OPM s review of disputes about network
treatment plans will be based on the treatment plan s
clinical appropriateness. OPM will generally not
order one clinically appropriate treatment plan in
favor of another.
Preauthorization To be eligible to receive these benefits you must obtain a treatment lan and follow all of the following authorization processes:
PacifiCare members receive mental health or substance abuse services
through PacifiCare Behavioral Health. Simply call toll-free at 1-888-777-2735
and PacifiCare Behavioral Health will put you in touch with the right mental
health rofessional and authorize needed services.
To seek our mental health or substance abuse services, you do not need a
referral from your rimary care physician. However, please identify yourself
as a PacifiCare member when contacting PacifiCare Behavioral Health. Also,
be sure to present your PacifiCare ID card each time you visit your mental
health rofessional.
2003 PacifiCare of Colorado Section 5( e)
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There are important features you should be ware of. These include:
Who can write your prescription. A Plan physician, an approved non-Plan physician, or a licensed dentist must write
your rescription.
Where you can obtain them. You must fill the prescription at a lan pharmacy or through our mail-order rogram.
We use a formulary. The PacifiCare Formulary is a list of over 1, 600 prescription drugs that physicians use as a guide
when prescribing medications for patients. The Formulary lays an important role in roviding safe, effective and
affordable prescription drugs to PacifiCare members. It also allows us to work together with physicians and pharmacies to
ensure that our members are getting the drug therapy they need. A Pharmacy and Therapeutics Committee consisting of
physicians and pharmacists evaluates rescription drugs based on safety, effectiveness, quality treatment and overall value.
The committee considers first and foremost the safety and effectiveness of a medication before reviewing the cost. The
Formulary is updated on a regular basis. You may obtain a copy of the Formulary by calling Customer Service, or by
logging onto the PacifiCare website at www. pacificare. com/ colorado. PacifiCare uses a generic based Formulary.
Prescriptions will be filled with generics whenever possible. If you or your physician prefer a brand name product when a
formulary generic equivalent is available you will pay the non-formulary copayment.
These are the dispensing limitations. Drugs are dispensed in accordance with the Plan s drug formulary. Prescription
drugs rescribed by a Plan or referral doctor and obtained at a Plan pharmacy will be dispensed for up to a 30-day supply.
For medications that come in trade size packages, you will be responsible for one applicable copay per repackaged unit.
Non-formulary drugs will be covered when prescribed by a Plan doctor. Prior authorization is not needed because there
are different copayments for formulary and non-formulary medications. Clinical edits ( limitations) can be used for safety
reasons, quantity limitations and benefit plan exclusions.
A 90-day supply of maintenance medications can be filled through our mail-order rescription drug program. You pay 2
applicable copays per 90-day supply of tablets and capsules, or up to 4 reprepackaged units, for a covered medication.
Contact PacifiCare of Colorado s Customer Service Department at 1-800-877-9777 for more information and to receive
a mail-order form.
Why use generic drugs? Generic drugs contain the same active ingredients and are equivalent in strength and dosage to
the original brand name product. Generic drugs cost you less money than a brand name drug.
When you have to file claim. Please refer to Section 7 for information on how to file a pharmacy claim, or contact our
Customer Service Department at 1-800-877-9777.
Please Note: We do not coordinate benefits for outpatient rescription drugs.
Prescription drug benefits begin on the next page.
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Here are some important things to keep in mind about these benefits:
We cover rescribed 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.
2003 PacifiCare of Colorado Section 5( f)
Section 5 ( f) . Prescription drug benefits
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34 2003 PacifiCare of Colorado Section 5( f)
Covered medications and supplies Continued on next page
Benefit Description You pay
Covered medications and supplies You pay -Standard Option You pay -High Option
We cover the following medications and supplies
prescribed by a Plan physician and obtained from a
Plan pharmacy or through our mail-order rogram:
Drugs for which a rescription is required by law
Disposable needles and syringes for the
administration of covered prescribed medications
Commercially repared progesterone and
estrogen products
Intravenous fluids and medication for home use
are covered under Home health services .
See page 20.
Oral contraceptive drugs; contraceptive
diaphragms; and cervical caps
Coverage for implantable and injectable
contraceptives is listed under the Family
planning section located in 5( a)
The following benefit is covered, but limited:
Diabetic glucose and ketone test strips and
lancets dispensed in the manufacturer s
prepackaged unit, up to 200 test strips, or 200
lancets, per 30-days.
Insulin
Injectable drugs ( except insulin) when preauthorized $ 10 copay per rescription unit $ 10 copay per rescription unit
or refill or refill
Medical Foods ( prescription metabolic formulas and 50% of the cost 50% of the cost
their modular components) obtained from a pharmacy
for inherited enzymatic disorders caused by single
gene defects for diagnosed conditions, such as:
Phenylketonuria ( up to age 21)
Maternal phenylketonuria
( for women through age 35)
Maple syrup urine disease
Tyrosinemia
Homcystinuria
Urea cycle disorders
Hyperlysinemia
Glutaric acidemias
Methylmaonic acidemia
Propionic acidemia
A copay is applied to every two
vials of the same kind of insulin.
You can receive up to six vials
of the same kind of insulin
through the mail-order rogram
for two applicable copays.
A copay is applied to every two
vials of the same kind of insulin.
You can receive up to six vials
of the same kind of insulin
through the mail-order rogram
for two applicable copays.
Per rescription unit or
prepackaged unit, up to a
30-day supply:
Formulary Generic -$ 10Formulary
Brand -$ 20Non-
Formulary -$ 30
Per rescription unit or
prepackaged unit, up to a
30-day supply:
Formulary Generic -$ 10Formulary
Brand -$ 30Non-
Formulary -$ 40
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Covered medications and supplies You pay Standard Option You pay High Option
( continued)
The following benefit is covered, but limited:
Drugs to treat sexual dysfunction are covered
when plan criteria is met. Contact us for dose
limits.
Not covered: All charges All charges
Drugs available without a prescription or for
which there is a nonprescription equivalent
available
Drugs obtained at a non-Plan pharmacy, except
for out-of-area emergencies
Vitamins and nutritional substances that can be
purchased without a prescription
Medical supplies such as dressings and
antiseptics
Smoking cessation drugs and medication,
including nicotine patches, except through the
smoking cessation programs provided
Drugs for weight reduction
Lifestyle enhancement drugs, including but not
limited to drugs to enhance hair growth, anti-
aging and mental performance
Fertility drugs
Drugs for cosmetic purposes
Drugs to enhance athletic performance
Convenience packaged medications, including
but not limited to Insulin penfill
50% of the cost of the medication
per rescription unit or refill up
to the dosage limit; all charges
above that
50% of the cost of the medication
per rescription unit or refill up
to the dosage limit; all charges
above that
2003 PacifiCare of Colorado Section 5( f)
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36 2003 PacifiCare of Colorado Section 5( g)
TDD phone line 1-800-659-2656
PacifiCare offers health management rograms to members meeting specific
criteria, for the following disease states or illnesses:
Cancer Care Program
Congestive Heart Failure ( CHF)
Coronary Artery Disease ( CAD)
End-Stage Renal Disease ( ESRD)
Diabetes Management
Taking Charge of Depression
If you are interested in any of these programs, please contact your physician.
Members can visit the PacifiCare website at www. pacificare. com and click on the
24-Hour Health Information icon to view a wide-range of health-related
information. There are detailed sections on women s and men s health, parenting,
wellness centers, healthy lifestyles, exercise demos and more. The program
combines two features: Interactive Web Health content, with a real-time Live
Assist and 24-Hour Health Information Audio Library with Nurse Line .
The Health Information Audio Library can be accessed by calling
1-866-747-4325 on a touch-tone phone.
Internet-based information for health and wellness for yourself and your family.
The following modules are currently available by accessing www. pacificare. com.
Pregnancy to Preschool
Menopause: Understanding Your Options
PacifiCare of Colorado has contracted with a network of nationally known
pharmacies and several independent pharmacies throughout the United States,
for members needing to fill prescriptions when outside of Colorado for the
appropriate copayment.
How to use these pharmacies:
You must ask the pharmacy if they are contracted to rocess prescriptions for
PacifiCare members.
You must present your PacifiCare ID card at the time you are filling your
prescription.
The pharmacy must process the prescription electronically.
Some of the major pharmacy chains included in the network are:
Albertson s Long s K-Mart Safeway Vons
Eckerd King Sooper s Kroger Target Walgreens
Call customer service at 1-800-877-9777 for more information.
Section 5 ( g) . Special features
Feature Description
Services for deaf and hearing impaired
Health Management Programs
24-Hour Health Information Program
Women s Health Solutions
National Pharmacy Network
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2003 PacifiCare of Colorado Section 5( h)
Section 5 ( h) . Dental benefits
Dental Benefits -High Option
Service We pay You pay
Preventive and diagnostic services, such as:
Periodic oral evaluation
Intraoral X-rays complete series ( including
bitewings)
Panoramic X-ray
Prophylaxis ( adult, every six months)
Prophylaxis ( child, every six months)
Child fluoride with rophylaxis
Adult fluoride with rophylaxis
Basic services, such as:
Amalgam one surface, permanent
Amalgam two surfaces, ermanent
Root canal anterior ( excluding final restoration)
Root canal bicuspid ( excluding final restoration)
Periodontal scaling and root laning, per quad
Removal of impacted tooth soft tissue
Major services, such as:
Complete denture maxillary
Maxillary partial denture resin base
Pontic
Crown porcelain fused to high noble metal
Please contact us for our full fee allowances and other details for High Option dental benefits.
Accidental injury benefit
We cover restorative services and supplies necessary to promptly repair ( but not replace) sound natural teeth. The need for
these services must result from an accidental injury.
Orthodontics
Please see the end of Section 5( h) for your orthodontic benefits.
100% of the Plan s fee
allowance.
80% of the Plan s fee
allowance, or the dentist s
charge.
50% of the Plan s fee allowance
or the dentist s charge.
All charges over the Plan s
fee allowance up to the
dentist s charge.
The deductible is waived for
preventive care.
$ 50 deductible and all charges
over the Plan payment up to the
dentist s charge.
$ 50 deductible and all charges
over the Plan payment up to the
dentist s charge.
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 dentists must provide or arrange your care on the Standard Option, on the High
Option you may go to any dentist you choose.
On the Standard Option there is no deductible. You pay copayments.
On the High Option the calendar year deductible is $ 50 per person/ $ 150 per family. The
deductible is waived for preventive services.
On the High Option there is a maximum benefit of $ 1,000 per member per year.
Plan orthodontists must provide or arrange your orthodontic 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.
For more information call PacifiCare Dental Administrators at 1-800-591-5915
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38 2003 PacifiCare of Colorado Section 5( h)
With our lan you receive the following comprehensive program of dental coverage through participating Plan dentists. This
listing represents a description of the benefits and exclusions. For more detailed information regarding covered services and
claims related concerns, call PacifiCare Dental Customer Services at 1-800-228-3384.
Choosing your dentist
Please select a rimary care dentist, from the list of Dental Providers available in your area, for each member of your family.
Your dental benefits and services are available only through the participating dentist you selected, except for out-of-area
emergencies. If you wish to change your rimary care dentist, call PacifiCare Dental Customer Services.
Receiving care
Member fees are due at the time of service.
NOTE: Your dentist may prescribe certain rocedures not covered under your Plan benefit. Non-member fees will be charged
for such services. Where UCR is shown, the procedure is not a covered benefit, and you pay the dentist s usual, customary
and reasonable fee for that service.
Specialty care
If you receive care from specialist, you pay a 60% member payment ( Standard Option) of the PacifiCare contracted
specialists fee schedule.
PacifiCare Dental maintains a panel of qualified Dental Specialists to provide you with the treatment that is beyond the scope
of the General Dentist. Once we have reviewed and approved the recommended specialty referral, we will coordinate the
referral to the closest specialist in your area.
Visits
Office Visit, per visit charge in addition to rocedure ( may be referred to as a $ 5
sterilization charge in some offices)
After hours visit, in addition to service provided $ 30Missed
appointment without 24 hours notice $ 20(
copay per each 30 minutes of appointment time)
Preventive
Emergency treatment, palliative $ 10Routine
teeth cleaning, once every 6 months $ 10Topical
application to age 14 $ 7
Oral Hygiene Instructions $ 0
Diagnostic ( film allowance includes exam and diagnosis)
Single, film $ 4
Additional, up to 12 films $ 3
Full mouth series ( including bite-wings, if necessary) $ 17
Intra-oral, occlusal view $ 4
Bite-wing films, 2 films $ 5
Bite-wing films, 4 films $ 9
Panographic-type film $ 20
Service You pay -Standard Option
Dental Benefits -Standard Option
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39 2003 PacifiCare of Colorado Section 5( h)
Restorative Dentistry ( fillings)
Amalgam Restorations
Primary teeth, 1 surface $ 16
Primary teeth, 2 surfaces $ 20Primary
teeth, 3 surfaces $ 25
Primary teeth, 4 or more surfaces $ 28
Permanent teeth, 1 surface $ 18
Permanent teeth, 2 surfaces $ 22
Permanent teeth, 3 surfaces $ 26
Permanent teeth, 4 or more surfaces $ 30Composite
Resins ( tooth colored fillings, fee includes acid etching and/ or bonding)
1 Surface anterior $ 202
Surfaces anterior $ 28
3 Surface anterior $ 36
4 Surfaces anterior $ 42
Pin retention, per tooth ( not including restoration) UCR
Sealants per tooth $ 10Sedative
base $ 10
Oral Surgery
Extractions ( fees include local anesthesia and routine post-operative visits)
Uncomplicated, single extraction $ 18
Each additional uncomplicated extraction $ 18
Surgical removal of an erupted tooth $ 28
Removal of impacted tooth ( soft tissue) $ 60Removal
of impacted tooth ( partially bony) $ 85
Removal of impacted tooth ( completely bony) $ 110
Other Procedures
Post-operative visit, complications ( i. e. osteitis) $ 0Biopsy
and microscopic examination UCR
Alveoloplasty ( edentulous) , per quadrant $ 85
Avleoloectomy per quadrant $ 65
Intra-oral incision and drainage of abscess ( soft tissue) UCR
Frenectomy $ 45
Removal of exostosis ( tori) UCR
Anesthesia
Additional charges for general anesthetics, nitrous oxide, anesthetists or
anesthesiologists are the responsibility of the patient
Local anesthesia $ 0
Periodontics
Periodontal maintenance procedures ( following active surgical and adjunctive $ 50periodontal
therapies)
Scaling and root laning per quadrant $ 50Full
mouth debridement $ 50Correction
of occlusion per quadrant, minor spot grinding ( equilibration not a $ 26
covered benefit)
Gingivectomy per quadrant, includes post-surgical visits $ 175
Osseous or muco-gingival surgery er quadrant ( includes post-surgical visits) $ 300
Gingivectomy treatment per tooth $ 35
Gingival flap rocedures ( includes RP) Quad UCR
Service You pay -Standard Option
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40 2003 PacifiCare of Colorado Section 5( h)
Service You pay -Standard Option
Endodontics Direct pulp capping $ 12
Therapeutic pulpotomy ( in addition to restoration) per treatment $ 20Indirect
pulp capping ( recalcification) , including temporary restoration $ 15
Root Canal Therapy Anterior RCT $ 110Bicuspid
RCT, 1-2 canals $ 160Molar
RCT, 1 canal $ 110Molar
RCT, 2 canals $ 160Molar
RCT, 3 canals $ 220Molar
RCT, 4 canals $ 250Apicoectomy
and/ or retrograde therapy-per tooth $ 180Apicoectomy,
separate procedure, per tooth $ 120Hemisection,
root amputation UCR
Crown and Bridge Crowns*
Plastic, permanent, processed $ 120Porcelain
jacket $ 260Porcelain
with metal $ 260Full
cast metal $ 2403/
4 metal $ 240Crown
build up, extensive amalgam/ composite, including pins UCR
Stainless steel, primary $ 50Stainless
steel, permanent $ 50Preformed
post and build u UCR
Cast post with core or coping UCR
Crown recementation ( or inlay) $ 15
Bridge recementation $ 20Pontics*
( artificial tooth on a fixed bridge)
Cast, metal $ 240Porcelain
with metal $ 260
* Where precious metal is used, additional copayment will be required.
Prosthetics* ( removable) Dentures*
Dentures, partial dentures and reline allowances include adjustments for a 90-day period
following installation. Fees for specialized techniques involving precision dentures,
personalization or characterization are in addition to those listed.
Complete upper or lower denture $ 300
Immediate upper or lower denture $ 320Partial
acrylic upper or lower base ( teeth/ clasps extra) $ 100
Partial, upper or lower with chrome cobalt alloy $ 350palatal
or lingual bar and acrylic saddles ( teeth/ clasps extra)
Unilateral partial base $ 100
Anterior stayplate base/ temporary $ 75
Teeth and clasps extra per unit ( for partial, stayplates, etc. ) $ 15
Denture/ partial adjustment $ 15
Office reline, cold cure acrylic $ 85
Denture reline, laboratory $ 110Tissue
conditioning, per denture UCR
Denture duplication ( jump case) , per denture $ 110Simple
stress breakers $ 30
* Additional fees will be required for laboratory services for removable prosthetics,
not to exceed $ 80.
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41 2003 PacifiCare of Colorado Section 5( h)
Service You pay -Standard Option
Repairs*
Denture/ partial resin base ( no teeth involved) $ 40Replace
missing or broken teeth, each $ 25
Replace missing or broken clasp, each $ 35
* Where precious metal is used, additional copayment will be required.
Space Maintainers
Removable, lastic $ 50Fixed,
unilateral band type $ 50Fixed,
stainless steel crown type $ 50Fixed,
lingual, palatal bar type or bilateral $ 50
What is not covered: All charges
Care by non-Plan dentists except for authorized referrals or emergencies
Cosmetic dental care
Hospital and medical charges of any kind, ncluding dental services rendered in
a hospital
General anesthesia, including intravenous or inhalation sedation, except when
medically necessary for extractions only
Loss or theft of dentures, appliances or bridgework
Dental treatment started prior to the member s eligibility to receive benefits
under this Plan or started after the member s termination
Other dental services not shown as covered
In-Area emergency
In emergency situations, PacifiCare Dental rimary care dentists shall furnish such care as needed immediately or, if
appropriate, not more than 24 hours after the request. Dental emergencies are defined as conditions where
hemorrhage, acute pain or infection of dental origin exists.
During Normal Business Hours: Contact your rimary care dental office. If you are unable to contact your
primary care dental office, lease call PacifiCare Dental at 1-800-228-3384 and a Dental Customer Services
Representative will assist you.
After Normal Business Hours: Contact your rimary care dental office. If you are unable to contact your rimary
care dental office, you may seek emergency care only at any licensed dental office. PacifiCare Dental will
reimburse you up to $ 50.
For emergency care requiring an after-hours appointment, you may be assessed a $ 30/ visit charge in addition to any
copayment.
Out-of-Area emergency
Coverage for emergency benefits outside the service area is limited to palliative treatment of infection and pain.
Definitive treatment is not covered. The out-of-area coverage reimburses the usual and customary fee up to a
maximum of $ 50 per occurrence. We must be notified within 30 days.
Out-of-area emergencies are covered as follows:
if the member develops a condition or sustains an injury while temporarily outside of the Plan s service area;
the need for such care was not reasonably foreseeable, and;
it is not feasible for the member to call PacifiCare and present him/ herself to a PacifiCare dentist.
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42 2003 PacifiCare of Colorado Section 5( h)
Reimbursement for emergencies
Claims for emergency benefits should be filed with PacifiCare Dental Services, P. O. Box 483, Tustin, CA 92781
within 30 days after the emergency care, and must rovide sufficient information to verify entitlement to payment.
Include:
covered member s name and ID number
dentist s name
nature of roblem
date of treatment
treatment given
itemized charges
copy of receipt
Orthodontics
The orthodontic benefits described here are for both High Option and Standard Option plans.
Through a PacifiCare panel Orthodontist, plan members are eligible to receive up to a 2-year orthodontic treatment
provided by a PacifiCare contracted provider. You pay orthodontic charges of $ 2,150 for members under 19 years of
age, and $ 2,500 for members 19 years or older, plus $ 300 start-up fees, $ 250 retention fees.
What is covered
Comprehensive orthodontic care at a panel orthodontic office for a usual and customary 24 month treatment lan.
The start-up services shall include initial examination, study models, diagnosis, consultation and placement of
orthodontic appliances ( braces) .
The retention services may include impressions for post-treatment retainers, lacement of retainers, retainer
adjustments, and post-treatment supervision as needed. The normal retention fee is $ 250 and shall not exceed this
amount. This amount is limited to the customary 24 month retention phase.
The orthodontist has agreed that any course of orthodontic treatment initiated under this plan shall be completed, at
the election of the member, under the terms, conditions, and fees rovided herein, should the member become
ineligible as a Plan member rior to completion of orthodontic treatment.
A qualified member with cleft lip/ palate is not subject to the limits of this Plan and the benefit for the services of a
specialist shall apply as stated at the beginning of the dental benefit description.
Administrative Fee: If you do not keep an appointment and fail to notify the provider office of cancellation 24
hours in advance, you may be assessed a service charge.
Limitations
Orthodontic treatment must be provided by a member of the PacifiCare orthodontic panel.
Cases that are other than basic and usual may require additional charges.
If a member does not require treatment or elects not to have treatment, after the doctor has completed a diagnosis
and consultation, the patient may be charged a consultation fee of $ 85.
What is not covered
X-ray fees ( orthodontic) .
Start-up and retention as described under Orthodontic Benefits.
Lost, stolen or broken appliances.
Procedures not listed or procedures required n addition to basic, usual and customary orthodontic services
including palatal expansion devices, functional appliances and myofunctional therapy.
Work n progress ( i. e. , cases banded prior to nception of eligibility) .
Orthodontic emergencies or changes n treatment necessitated by accidents of any kind, adverse growth patterns or
poor patient cooperation.
Orthodontic treatment and/ or surgical procedures for skeletal abnormalities such as micrognathia, facial
asymmetrical and facial deformities.
Treatment related to temporomandibular joint disorders.
Any procedures considered within the field of general dentistry and those not usually performed in the orthodontic office.
Severe or mutilated malocclusions that are not amiable to deal orthodontic therapy.
Orthodontic treatment of impacted teeth requiring surgical exposure.
Cosmetic braces ( plastic, ceramic, sapphire, lingual, etc. ) .
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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 Perks SM Program
The PacifiCare Perks Program offers members discounts to:
Complementary & Alternative Care such as massage therapy and acupuncture, health and wellness products
offered at 40% below the suggested retail price, including: vitamins, minerals and daily formulas, herbal and
dietary supplements, sports nutrition products, natural body care products, and audio and video tapes on Yoga, Tai
Chi, Massage and more
Healthy Moms/ Kids discounts for Gymboree Play and Music programs, Safe Beginnings family safe products,
ClearPlan Easy fertility monitor rebate, breastfeeding accessories
Fitness & Weight Management discounts with health club memberships, DietMate weight loss aids, Spa Wish
gift certificates and more
Pharmacy and Personal Care discounts on nearly 500 top-selling name brand pharmacy and personal care
products, free shipping with a mail-order rescription
Call 1-800-877-9777 for a complete list of special services, or visit www. pacificare. com.
Supplemental Dental HMO
For a monthly premium, you can enroll in a buy-up HMO dental lan. Benefits will not be coordinated between this plan and
the dental lans included with your medical lan. Call 1-800-591-5915 for more information.
2003 PacifiCare of Colorado Section 5( i)
Section 5 ( i) . Non-FEHB benefits available to Plan members
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The exclusions in this section apply to all benefits. Although we may list a specific service as 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 and we agree, as discussed under services requiring our prior approval on page 10.
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 ractice;
Experimental or investigational rocedures, 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.
Services, drugs, or supplies you receive without charge while in active military service.
2003 PacifiCare of Colorado Section 6
Section 6. General exclusions things we don t cover
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45
When you see Plan physicians, receive services at Plan hospitals and facilities, or obtain your rescription drugs at Plan
pharmacies, you will not have to file claims. Just present your identification card and pay your copayment, coinsurance, or
deductible.
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, hospital and In most cases, providers and facilities file claims for you. Physicians must file on prescription benefits the form HCFA-1500, Health Insurance Claim Form. Facilities will file on the
UB-92 form. For claims questions and assistance, call us at 1-800-877-9777.
When you must file a claim such as for services you receive outside of the
Plan s service area submit it on the HCFA-1500 or be sure to rovide
documentation that includes all of the information shown below. Bills and receipts
should be itemized and show:
Covered member s name and ID number;
Name, address and Tax ID number of the physician or facility that rovided
the service or supply;
Dates you received the services or supplies;
Diagnosis;
Procedure code for 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
Attn: Customer Service, CO84-416
P. O. Box 6770Englewood,
CO 80155
Prescription Drugs Please mail your rescription receipts with your name and ID number to:
PacifiCare Solutions Claims Department
P. O. Box 6037
Cypress, CA 90630
Dental services Please provide the same information detailed in the bullets above.
Submit your claims to: PacifiCare Dental Services
P. O. Box 483
Tustin, CA 92781
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.
2003 PacifiCare of Colorado Section 7
Section 7. Filing a claim for covered services
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Follow this Federal Employees Health Benefits Program disputed claims rocess 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: PacifiCare
Attn: Member Appeals
P. O. Box 4306
Englewood, CO 80155-4306
Or you can fax us your request at 1-303-714-2643; 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 rovider for more information. If we ask your rovider, we will send you a copy of our
request go to step 3.
3 You or your rovider 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.
2003 PacifiCare of Colorado Section 8
Section 8. The disputed claims process
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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 roviders, 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.
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 from the year in which you were denied precertification or rior approval. This is the
only deadline that may not be extended.
OPM may disclose the information it collects during the review rocess 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 rocess. 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 reauthorization/ prior approval, then call us at
1-800-877-9777 and we will expedite our review; or
( b) We denied your initial request for care or reauthorization/ 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 III at 1-202-606-0737 between 8 a. m. and 5 p. m. eastern time.
2003 PacifiCare of Colorado Section 8
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When you have other health coverage You must tell us if you are covered or a family member is covered under another group health lan 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 lan 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 ay 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 remium-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
healthcare. Medicare + Choice is the term used to describe the various health lan
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 available everywhere in the United States. It is the
( Part A or Part B) way everyone used to get Medicare and is the way most people get their Medicare
Part A and Part 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 coordinated by your Plan PCP, and preauthorization rules still apply.
2003 PacifiCare of Colorado Section 9
Section 9. Coordinating benefits with other coverage
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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 rocess 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
then provide secondary benefits for covered charges. To find out if you need to
do something to file your claim, call us at 1-800-877-9777.
We waive some costs if the Original Medicare Plan is your primary payer
we will waive some out-of-pocket costs, as follows:
Physician office visit copayments are waived if you are enrolled in Medicare Part B.
Hospital copayments are waived if you are enrolled in Medicare
Part A.
( Primary payer chart begins on next page. )
2003 PacifiCare of Colorado Section 9
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50 2003 PacifiCare of Colorado Section 9
Please note, if your Plan physician does not participate in Medicare, you will have to file claims directly with Medicare.
The following chart illustrates whether 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 that you are ( except for claims
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. . .
B. When you or a covered family member have Medicare
based on end stage renal disease ( ESRD) and
Then the primary payer is. . .
Original Medicare This Plan
C. When you or a covered family member have FEHB and
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51
Medicare managed care plan If you are eligible for Medicare, you may choose to enroll in and get your
Medicare benefits from a Medicare managed care plan. These are health care
choices ( like HMOs) 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 lan, 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 nd 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 cost-sharing for your FEHB coverage.
This Plan nd another plan s Medicare managed care plan: You may enroll in
another lan 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, even out of the managed care plan s network and/ or service area ( if you
use our Plan roviders) , but we will not waive any of our copayments or
coinsurance. 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 and 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 s service area.
If you do not enroll in If you do not have one or both parts of Medicare, you can still be covered under
Medicare Part A or B the FEHB Program. We will not require you to enroll in Medicare Part B and, if
you can t get remium-free Part A, we will not ask you to enroll in it.
TRICARE & CHAMPVA TRICARE is the health care program for eligible dependents of military persons and retirees of the military. TRICARE includes the CHAMPUS rogram.
CHAMPVA provides health coverage to disabled Veterans and their eligible
dependents. If both TRICARE or CHAMPVA and this Plan cover you, we pay
first. See your TRICARE Health Benefits Advisor if you have questions about
TRICARE coverage.
Suspended FEHB coverage to enroll in TRICARE or CHAMPVA: If you are
an annuitant or former spouse, you can suspend your FEHB coverage to enroll in
one of these programs, eliminating your FEHB premium. ( OPM does not
contribute to any applicable plan premiums. ) 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 under the program.
2003 PacifiCare of Colorado Section 9
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52
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 roviders.
Medicaid When you have this Plan and Medicaid, we ay first.
Suspended FEHB coverage to enroll in Medicaid or a similar State-sponsored
program of medical assistance: If you are an annuitant or former spouse, you
can suspend your FEHB coverage to enroll in one of these State programs,
eliminating your FEHB 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 under the State rogram.
When other Government agencies We do not cover services and supplies when a local, State, are responsible for your care or Federal 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 for injuries injuries or illness caused by another erson, 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.
2003 PacifiCare of Colorado Section 9
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53
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.
Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care. See page 11.
Copayment A copayment is a fixed amount of money you pay when you receive covered services. See page 11.
Covered services Care we provide benefits for, as described in this brochure.
Custodial care Any skilled or non-skilled health services, or personal comfort or convenience related services, which provide general maintenance, supportive, reventive and/ or
protective care. Custodial care that lasts for 90 days or more is sometimes known
as Long Term Care.
Deductible A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for those services.
See page 11.
Experimental or
investigational services Our National and Regional Medical Committees determine 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 rocedures, technologies, devices and drugs.
Medical necessity Medical necessity refers to medical services or hospital services which 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 rovider of service; and
Furnished in the most economically efficient manner which may be provided
safely and effectively to the Member.
Plan llowance 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.
Usual Customary and Providers usual charge for furnishing treatment, service or supply; or the charge Reasonable ( UCR) the company determines to be the general rate charged by others who render or
furnish such treatment, services or supplies to persons who reside in the same
geographical area.
Us/ We Us and we refer to PacifiCare of Colorado.
2003 PacifiCare of Colorado Section 10
Section 10. Definitions of terms we use in this brochure
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54
No pre-existing condition We will not refuse to cover the treatment of a 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 about enrolling in the can answer your questions, and give you a Guide to Federal Employees
FEHB Program Health Benefits Plans , brochures for other lans, and other materials you need to make an informed decision about your FEHB coverage. These materials tell you:
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, your for you nd your family 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.
Children s Equity Act OPM has implemented the Federal Employees Health Benefits Children s Equity Act of 2000. This law mandates that you be enrolled for self and family coverage
in the Federal Employees Health Benefits ( FEHB) Program, if you are an
employee subject to a court or administrative order requiring you to rovide health
benefits for your child( ren) .
If this law applies to you, you must enroll for self and family coverage in a health
plan that rovides full benefits in the area where your children live or rovide
documentation to your employing office that you have obtained other health
2003 PacifiCare of Colorado Section 11
Section 11. FEHB facts
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55
benefits coverage for your children. If you do not do so, your employing office
will enroll you involuntarily as follows:
If you have no FEHB coverage, your employing office will enroll you for self
and family coverage in the option of the Blue Cross and Blue Shield Service
Benefit Plan that rovides the lower level of coverage;
If you have a self only enrollment in a fee-for-service plan or in an HMO that
serves the area where your children live, your employing office will change
your enrollment to self and family in the same option of the same plan; or
If you are enrolled in an HMO that does not serve the area where the children
live, your employing office will change your enrollment to self and family in
the Blue Cross and Blue Shield Service Benefit Plan s Basic Option.
As long as the court/ administrative order is in effect, and you have at least one
child identified in the order who is still eligible under the FEHB Program, you
cannot cancel your enrollment, change to self only, or change to a lan that
doesn t serve the area in which your children live, unless you provide
documentation that you have other coverage for the children. If the
court/ administrative order is still in effect when you retire, and you have at least
one child still eligible for FEHB coverage, you must continue your FEHB
coverage into retirement ( if eligible) and cannot make any changes after
retirement. Contact your employing office for further information.
When benefits and The benefits in this brochure are effective on January 1. If you joined this Plan premiums start 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.
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 coverage If you are divorced from a Federal employee or annuitant, you may not continue to
get benefits under your former spouse s enrollment. This is the case even when
the court has ordered your former spouse to supply health coverage to you. But,
you may be eligible for your own FEHB coverage under the spouse equity law or
Temporary Continuation of Coverage ( TCC) . 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. You can also download the guide from OPM s
website, www. opm. gov/ insure.
2003 PacifiCare of Colorado Section 11
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56
Temporary Continuation of If you leave Federal service, or if you lose coverage because you no longer qualify
Coverage ( TCC) 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 remium, you cannot convert;
You decided not to receive coverage under TCC or the spouse equity law ends
( if you canceled your coverage or did not pay your remium, you cannot
convert) ; 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 re-existing conditions.
Getting a Certificate of The Health Insurance Portability and Accountability Act of 1996 ( HIPAA) is Group Health Plan Coverage Federal law that offers limited Federal rotections 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 lan 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. 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.
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
questions. 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.
2003 PacifiCare of Colorado Section 11
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57
Open Season for Long Term Care Insurance
You can protect yourself against the high cost of long term care by applying for insurance in the Federal Long Term
Care Insurance Program.
Open Season to apply for long term care insurance through LTC Partners ends on December 31, 2002.
If you' re a Federal employee, you and your spouse need only answer a few questions about your health during
Open Season.
If you apply during the Open Season, your remiums are based on your age as of July 1, 2002. After Open Season,
your remiums are based on your age at the time LTC Partners receives your application.
FEHB Doesn' t Cover It
Neither FEHB plans nor Medicare cover the cost of long term care. Also called " custodial care" , long term care helps
you perform the activities of daily living such as bathing or dressing yourself. It can also rovide help you may need
due to a severe cognitive impairment such as Alzheimer s disease.
You Can Also Apply Later, But
Employees and their spouses can still apply for coverage after the Federal Long Term Care Insurance Program Open
Season ends, but they will have to answer more health-related questions.
For annuitants and other qualified relatives, the number of health-related questions that you need to answer is the
same during and after the Open Season.
You Must Act to Receive an Application
Unlike other benefit programs, YOU have to take action you won t receive an application automatically. You must
request one through the toll-free number or website listed below.
Open Season ends December 31, 2002 act NOW so you won t miss the abbreviated underwriting available to
employees and their spouses, and the July 1 " age freeze" !
Find Out More Contact LTC Partners by calling 1-800-LTC-FEDS ( 1-800-582-3337) ( TDD for the hearing impaired:
1-800-843-3557) or visiting www. ltcfeds. com to get more information and to request an application.
2003 PacifiCare of Colorado Long Term Care Insurance
Long Term Care Insurance Is Still Available!
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58 2003 PacifiCare of Colorado Index
Index
A llergy tests 16
Alternative treatment 21, 43
Ambulance 28, 30Anesthesia
25, 26
B lood and blood plasma 27
C ardiac Rehabilitation 17
Changes for 2003 7
Chemotherapy 17
Chiropractic 21
Claims 45
Coinsurance 11, 53
Colorectal cancer screening 14
Congenital anomalies 22, 23
Contraceptive devices and drugs 16, 34
Coordination of benefits 48
Copayment 11
Covered roviders 8
D eductible 11
Definitions 53
Dental care 37
Diagnostic services 13, 14
Diagnostic tests 13, 14
Dialysis 17
Disputed claims review 46
Donor expenses ( transplants) 24
Durable medical equipment ( DME) 19
E ducational classes and programs 21, 36
Effective date of enrollment 55
Emergency/ Urgent Care 29
Experimental or investigational 53
F amily lanning 16
Foot care 18
G eneral Exclusions 44
H earing services 18
Home health services 20Hospice
care 28
I dentification cards 8
Immunizations, adult 14
Immunizations, children 15
Infertility 16
Inpatient hospital 10, 26, 31
Insulin 34
L aboratory and pathological services 14, 27
M ail order rescription drugs 33
Mammograms 14
Maternity 15
Medicaid 52
Medically necessary 53
Medicare 48
Mental health 31
N ewborn care 15
O bstetrical care 15
Occupational therapy 17
Oral and maxillofacial surgery 23
Orthodontics 37, 42
Orthopedic devices 19
Out-of-pocket expenses 11
Outpatient facility care 27
Oxygen 20
P ap test 14
Physical therapy 17
Plan allowance 53
Preauthorization 10, 32
Preventive care, adult 14
Preventive care, children 15
Prescription drugs 33
Primary care physician 8
Prostate cancer screening 14
Prosthetic devices 19
R adiation therapy 17
Reconstructive surgery 23
Room and board 26, 31
S econd surgical opinion 13
Service area 6
Skilled nursing facility care 27
Smoking cessation 21
Speech therapy 17
Sterilization procedures 22
Subrogation 52
Substance abuse 31
Syringes 34
T DD phone line 36
Temporary continuation of
coverage 56
T ransplants 24
Treatment therapies 17
V ision services 18
W heelchairs 20Workers
compensation 52
X -rays 14, 26
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59 2003 PacifiCare of Colorado Notes
Notes
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64
Do not rely on this chart alone. All benefits are rovided in full unless indicated and are subject to the definitions, limita-
tions, 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 rovided or arranged by Plan physicians, except in emergencies.
Benefits You Pay Standard Option You Pay High Option Page
Medical services rovided by
physicians:
Diagnostic and treatment PCP office visit copay: $ 15 PCP office visit copay: $ 10 13
services rovided in the office Specialist office visit copay: $ 30 Specialist office visit copay: $ 20Services
rovided by a hospital:
Inpatient $ 300 copay per admission $ 100 copay per admission 26
Outpatient $ 150 copay for outpatient surgery or $ 50 copay for outpatient surgery or 26
23-hour observation 23-hour observation
Emergency benefits:
In-area $ 100 per visit $ 100 per visit 29
Out-of-area $ 100 per visit $ 100 per visit 29
Mental health and substance abuse treatment Same as any other illness or condition Same as any other illness or condition 31
Prescription drugs For a 30-day supply or trade-size For a 30-day supply or trade-size 33
package -$ 10 copay for generic package -$ 10 copay for generic
formulary prescriptions; $ 30 copay formulary prescriptions; $ 20 copay
for brand formulary prescriptions; for brand formulary prescriptions;
$ 40 copay for non-formulary $ 30 copay for non-formulary
prescriptions prescriptions
Dental Care You pay copays for most services You pay the applicable percentage of 37
including preventive, restorative, your dentist s charges, or the scheduled
orthodontic and other services. allowance, whichever is less.
Chiropractic Care $ 15 copay per visit; based on medical $ 10 copay per visit; based on medical 21
necessity; maximum of 20 visits necessity; maximum of 20 visits
per year per year
Vision Care $ 15 copay per refraction; one $ 10 copay per refraction; one 18
refraction every 12 months. refraction every 12 months.
Special features: Health management 36
rograms
Protection against catastrophic costs Nothing after $ 3,600/ person or Nothing after $ 3,600/ person or 11
( your out-of-pocket maximum) $ 10,000/ family per year $ 10,000/ family per year
Some costs do not count toward this Some costs do not count toward this
protection and you must continue to rotection and you must continue to
pay for some services. pay for some services.
60 2003 PacifiCare of Colorado Summary of Benefits
Summary of benefits for PacifiCare of Colorado -2003
63.
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$ 36.32
2003 PacifiCare of Colorado 2003 Rate Information
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 a
special FEHB guide is published 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. Refer to the applicable FEHB Guide.
2003 Rate Information for
PacifiCare of Colorado, Inc.
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
High Option
Self Only
High Option
Self and Family
D61
D62
$ 108.96
$ 249.62 $ 128.09
$ 236.08
$ 540.84
$ 78.69
$ 277.53
$ 128.94
$ 294.70
$ 16.34
$ 83.01
Standard Option
Self Only
Standard Option
Self and Family
D64
D65
$ 77.84
$ 202.34
$ 25.94
$ 67.45
$ 168.65
$ 438.41
$ 56.21
$ 146.14
$ 92.10
$ 239.44
$ 11.68
$ 30.35
64.