CALIFORNIA - Pacificare Health Systems

PART A
Section 5. Your Medical Benefits
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Your Medical Benefits
Inpatient Benefits
Outpatient Benefits
Exclusions and Limitations
Other Terms of Your Medical Coverage
Terms and Definitions
This section explains your medical benefits, including
what is and isn’t covered by PacifiCare. You can find
some helpful definitions in the back of this publication.
For any Copayments that may be associated with a
benefit, you should refer to your Schedule of Benefits,
a copy of which is included with this document.
I. Inpatient Benefits*
These benefits are provided when admitted or
authorized by either the Member’s Participating
Medical Group or PacifiCare. All services must be
Medically Necessary as defined in this Combined
Evidence of Coverage and Disclosure Form.
With the exception of Emergency or Urgently
Needed Services, a Member will only be
admitted to acute care, subacute care,
transitional inpatient care and Skilled Nursing
Care Facilities that are authorized by the
Member’s Participating Medical Group under
contract with PacifiCare.
1. Alcohol, Drug or Other Substance Abuse
Detoxification – Detoxification is the medical
treatment of withdrawal from alcohol, drug
or other substance addiction. Treatment in
an acute care setting is covered for the acute
stage of alcohol, drug or other substance abuse
withdrawal when medical complications occur
or are highly probable. Detoxification is initially
covered up to 48 hours and extended when
Medically Necessary. Methadone treatment for
detoxification is not covered. Rehabilitation for
substance abuse or addiction is not covered.
(Coverage for rehabilitation of alcohol, drug or
other substance abuse or addiction is covered
as a supplemental benefit. Please see the “How
Your PacifiCare Behavioral Health Benefits Work”
section of this Combined Evidence of Coverage
and Disclosure Form.)
2. Blood and Blood Products – Blood and blood
products are covered. Autologous (self-donated),
donor-directed, and donor-designated blood
processing costs are limited to blood collected for
a scheduled procedure.
3. Bloodless Surgery – Surgical procedures
performed without blood transfusions or blood
products, including Rho(D) Immune Globulin
for Members who object to such transfusion
on religious grounds, are covered only when
available within the Member’s Participating
Medical Group.
4. Bone Marrow and Stem-Cell Transplants – Non-
Experimental/Non-Investigational autologous and
allogeneic bone marrow and stem-cell transplants
are covered. The testing of immediate blood
relatives to determine the compatibility of bone
marrow and stem cells is limited to immediate
blood relatives who are sisters, brothers, parents
and natural children. The testing for compatible
unrelated donors and costs for computerized
national and international searches for unrelated
allogeneic bone marrow or stem-cell donors
conducted through a registry are covered when
the Member is the intended recipient. Costs for
such searches are covered up to a maximum
of $15,000. A PacifiCare National Preferred
Transplant Network Facility Center approved
by PacifiCare must conduct the computerized
searches. There is no dollar limitation for
Medically Necessary donor-related clinical
transplant services once a donor is identified.
5. Cancer Clinical Trials – All Routine Patient
Care Costs related to an approved therapeutic
clinical trial for cancer (Phases I, II, III and IV)
are covered for a Member who is diagnosed
with cancer and whose Participating Treating
Physician recommends that the clinical trial has a
meaningful potential to benefit the Member.
For the purposes of this benefit, Participating
Treating Physician means a Physician who is
treating a Member as a Participating Provider
* The benefits described in Section Five will not be Covered Services unless they are determined to be Medically
Necessary by Member’s Participating Medical Group or PacifiCare and are provided by Member’s Primary Care
Physician or authorized by Member’s Participating Medical Group or PacifiCare.