CALIFORNIA - Pacificare Health Systems
CALIFORNIA - Pacificare Health Systems
CALIFORNIA - Pacificare Health Systems
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<strong>CALIFORNIA</strong><br />
University of California<br />
Medical Schedule of Benefits<br />
These services are covered as indicated when prior-authorized by your Primary Care Physician or<br />
your Contracting Medical Group/IPA.<br />
General Features<br />
Deductible –0–<br />
Maximum Benefits Unlimited<br />
Annual Copayments Maximum Three (3) Inpatient Copayments per<br />
person per Calendar Year<br />
Office Visits $15 Copayment<br />
Hospitalization $250 per admission<br />
Emergency Services<br />
$50 Copayment<br />
(waived if admitted as an inpatient)<br />
Urgently Needed Services<br />
(Medically Necessary Services required outside your<br />
Service Area; waived if admitted as an inpatient)<br />
$50 Copayment<br />
Pre-Existing Conditions All conditions covered provided they<br />
are covered benefits<br />
Benefits Available While Hospitalized as an Inpatient<br />
Alcohol, Drug or Other Substance Abuse or Addiction<br />
$250 per admission<br />
(detoxification only)<br />
Bone Marrow Transplant<br />
$250 per admission<br />
(donor searches limited to $15,000 per procedure)<br />
Hospice Care<br />
Paid in full<br />
(Members must elect Hospice Care under Medicare)<br />
Hospital Benefits<br />
$250 per admission<br />
(autologous (self-donated) blood up to $120.00 per unit)<br />
Mastectomy/Breast Reconstruction<br />
$250 per admission<br />
(after a mastectomy and complications from a mastectomy)<br />
Physician Care Paid in full<br />
Rehabilitation Care $250 per admission<br />
Skilled Nursing Care<br />
Paid in full<br />
(up to one-hundred (100) days per Medicare Benefit Period)<br />
Benefits Available on an Outpatient Basis<br />
Alcohol, Drug or Other Substance Abuse or Addiction (detoxification<br />
only)<br />
$15 Copayment<br />
Allergy Testing/Treatment (serum is included) $15 Copayment<br />
Ambulance Paid in full<br />
Attention Deficit Disorder (Medical Management) $15 Copayment<br />
Breast Cancer Screening, Diagnosis and Treatment $15 Copayment<br />
Cochlear Implants Paid in full<br />
Dental Treatment Anesthesia Paid in full<br />
Diabetes Management and Treatment $15 Copayment<br />
Durable Medical Equipment, Corrective Appliances and Prosthetics Paid in full<br />
Eligible Materials and Supplies Paid in full<br />
Questions? Call the Customer Service Department at 1-800-228-2144,<br />
(TDHI) 1-800-685-9355, Monday through Friday, 7:00 a.m. to 9:00 p.m.<br />
225<br />
PART B
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