CALIFORNIA - Pacificare Health Systems

PART B
Benefits Available on an Outpatient Basis (continued)
Health Education Services Paid in full
Hearing Screening $15 Copayment
Hemodialysis $15 Copayment
Home Care Paid in full
Hospice Care – Outpatient Basis and In-Home Visits Paid in full as covered by Medicare
Immunizations $15 Copayment
Laboratory and Radiology Paid in full
Medical Social Services Paid in full
Mental Health Services
For additional benefits, See Behavioral Health Benefits.
Up to twenty (20) visits for crisis intervention during each
Calendar Year following your initial date of eligibility.
A Copayment may be charged for missed scheduled
appointments.
$15 Copayment per visit
Oral Surgery
(when Medically Necessary)
Paid in full
Outpatient Rehabilitation Therapy $15 Copayment
Outpatient Surgery Paid in full
Periodic Health Evaluations $15 Copayment
Phenylketonuria (PKU) Testing and Treatment $15 Copayment
Surgery Paid in full
Vision Refractions/Screening $15 Copayment
Vision Hardware $20 Copayment every 24 months
Well-Woman Care
Includes Pap smear (by your Primary Care Physician or
an OB/GYN in your Contracting Medical Group) and
referral by the Contracting Medical Group for screening
mammography when Medicare criteria is met.
$15 Copayment
If you receive services without Prior Authorization from Non-Contracting Providers,
except for Emergency Services, Urgently Needed Services, out-of-area renal dialysis
and routine travel dialysis, or services for which PacifiCare allows you to self-refer to
Contracting Providers, neither PacifiCare nor Medicare will pay for those services.
This is a brief summary of your benefits. Please refer to your Retiree Benefits Summary
and Retiree Benefits Summary Insert for a complete explanation of your benefits including
copayments and coinsurance amounts, and a listing of limitations and exclusions.
Transgender Benefits
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Inpatient Benefits:
Inpatient Transgender Surgery – Inpatient
Transgender surgery requires prior
authorization from PacifiCare. Transgender
surgery and services related to the surgery that
are authorized by PacifiCare are subject to a
combined Inpatient and Outpatient lifetime
benefit maximum of $75,000 for each Member.
PacifiCare covers certain transgender surgery
and services related to the surgery to change
a Member’s physical characteristics to those of
the opposite gender.
Travel expense reimbursement is limited
to reasonable expenses for transportation,
meals, and lodging for the Member to obtain
authorized surgical consultation, transgender
reassignment surgical procedure(s) and
follow-up care, when the authorized surgeon
and facility are located more than 200 miles
from the Member’s Primary Residence. The
transportation and lodging arrangements must
be arranged by or approved in advance by
PacifiCare. Reimbursement excludes coverage
for alcohol and tobacco. Food and lodging
expenses are not covered for any day a Member
is not receiving authorized transgender