CALIFORNIA - Pacificare Health Systems

What is a Service Area?
PacifiCare is licensed by the California Department
of Managed Health Care to arrange for medical and
Hospital Services in certain geographic areas of
California. These service areas are defined by ZIP
codes. Please call our Customer Service department for
information about PacifiCare’s Service Area.
Notifying You of Changes in Your Plan
Amendments, modifications or termination of the
Group Agreement by either the University of California
or PacifiCare do not require the consent of a Member.
PacifiCare may amend or modify the Health Plan,
including the applicable Premiums, at any time after
sending written notice to the University of California
30 days prior to the effective date of any amendment
or modification. The University of California may also
change your Health Plan benefits during the contract
year. In accordance with PacifiCare’s Group Agreement,
the University of California is obliged to notify
employees who are PacifiCare Members of any such
amendment or modification.
Updating Your Enrollment Information
Please notify the Benefits Representative at your
campus or lab of any changes to the information you
provided on the enrollment application within 31 days
of the change. This includes changes to your name,
address, telephone number, marital status or the status
of any enrolled Family Members. For reporting changes
in marital and/or Dependent status, please see “Adding
Family Members to Your Coverage.” If you wish to
change your Primary Care Physician or Participating
Medical Group, you may contact PacifiCare’s Customer
Service department at 1-800-624-8822 or 1-800-442-
8833 (TDHI).
About Your PacifiCare Identification Card (ID)
Your PacifiCare ID card is important for identifying you
as a Member of PacifiCare. Possession of this card does
not entitle a Member to services or benefits under this
Health Plan. A Member should show this card each
time he or she visits a Primary Care Physician or, upon
referral, any other Participating Provider.
IMPORTANT NOTE: Any person using this card to
receive benefits or services for which he or she is not
entitled will be charged for such benefits or services. If
any Member permits the use of his or her identification
Member Eligibility
card by any other person, PacifiCare may immediately
terminate that Member’s membership.
Renewal and Reinstatement (Renewal
Provisions)
The University of California Group’s Group Agreement
with PacifiCare renews automatically, on a yearly basis,
subject to all terms of the Group Agreement. PacifiCare
or the University of California may change your Health
Plan benefits and Premium at renewal. If the Group
Agreement is terminated by PacifiCare, reinstatement
is subject to all terms and conditions of the Group
Agreement. In accordance with PacifiCare’s Group
Subscriber Agreement, the University of California
is required to notify employees who are PacifiCare
Members of any such amendment or modification.
Ending Coverage (Termination of Benefits)
Usually your enrollment in PacifiCare terminates when
the Subscriber or enrolled Family Member is no longer
eligible for coverage under the University of California
health benefit plan. In most instances, the University
of California determines the date in which coverage
will terminate. Coverage can be terminated, however,
because of other circumstances as well, which are
described below. Continuing coverage under this
Health Plan is subject to the terms and conditions of
the University of California’s Group Agreement with
PacifiCare.
When the Group Agreement between the University of
California and PacifiCare is terminated, all Members
covered under the Group Agreement become ineligible
for coverage on the date of termination. If the Group
Agreement is terminated by PacifiCare for nonpayment
of Premiums, coverage for all Members covered under
the Group Agreement will be terminated effective the
last day for which Premiums were received. According
to the terms of the Group Agreement, the University of
California is responsible for notifying you if and when
the Group Agreement is terminated for any reason,
including the nonpayment of Health Plan Premiums.
PacifiCare is not obligated to notify you that you are
no longer eligible or that your coverage has been
terminated.
In addition to terminating the Group Agreement,
PacifiCare may terminate a Member’s coverage for any
of the following reasons:
Questions? Call the Customer Service Department at 1-800-624-8822. 99
PART A