CALIFORNIA - Pacificare Health Systems

This is not an official statement of your benefits. Please refer to the Schedules of Benefits (beginning
on page 225) in the University of California 2006 Combined Evidence of Coverage and Disclosure
Form and the Retiree Benefits Summary for additional information regarding Copayments and
Covered Services.
Copayments have been increased from $10 to $15 for the following outpatient benefits:
Medical Schedule of Benefits
Office Visit to a contracted Primary Care Provider or Specialist/
Non-Physician Health Care Practitioner
Alcohol, Drug or Other Substance Abuse Detoxification $15
Allergy Testing/Treatment (serum is included) $15
Hemodialysis $15
Vision Refractions/Screening $15
Hearing Screening $15
Immunizations $15
Mental Health Services $15
Outpatient Rehabilitation Therapy $15
Periodic Health Evaluations $15
Well-Woman Care $15
Behavioral Health Schedule of Benefits
2006 Schedule Changes
Outpatient Treatment (based upon Medical Necessity) $15
Questions? Call the Member Service Department at 1-800-228-2144,
(TDHI) 1-800-685-9355, Monday through Friday, 7:00 a.m. to 9:00 p.m.
$15
137
PART B