CALIFORNIA - Pacificare Health Systems

eassignment services. Travel expenses are
included in the $75,000 lifetime benefit
maximum.
Reconstructive Surgery – Reconstructive
surgery is covered to correct or repair
abnormal structures of the body caused
by congenital defects, developmental
abnormalities, trauma, infection, tumors
or disease. The purpose of reconstructive
surgery is to correct abnormal structures
of the body to improve function or
create a normal appearance to the extent
possible. Reconstructive procedures require
Preauthorization by the Member’s Contracting
Medical Group/IPA or PacifiCare in accordance
with standards of care as practiced by
Physicians specializing in reconstructive
surgery. PacifiCare covers certain transgender
surgery and services related to the surgery to
change a Member’s physical characteristics
to those of the opposite gender. Inpatient
and Outpatient Services for transgender
surgery and services related to the surgery
require prior authorization by PacifiCare
and are subject to a combined Inpatient
and Outpatient lifetime benefit maximum of
$75,000 for each Member.
Outpatient Benefits:
Outpatient Transgender Services –
Outpatient Services including outpatient
surgery services for transgender surgery,
services related to the surgery, outpatient
office visit, and related services, require prior
authorization by PacifiCare and 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.
Exclusions and Limitations
Cosmetic Services and Surgery – Cosmetic
surgery and cosmetic services are not covered.
Cosmetic surgery and cosmetic services are
defined as surgery and services performed
to alter or reshape normal structures of
the body in order to improve appearance.
Drugs, devices and procedures related to
cosmetic surgery or cosmetic services are
not covered. Cosmetic surgeries or cosmetic
services do not become reconstructive surgery
because of a Member’s psychological or
psychiatric condition. PacifiCare covers certain
transgender surgery and services related to
the surgery to change a Member’s physical
characteristics to those of the opposite
gender. Inpatient and Outpatient Services
for transgender surgery and services related
to the surgery require prior authorization
by PacifiCare and are subject to a combined
Inpatient and Outpatient lifetime benefit
maximum of $75,000 for each Member.
No benefits are provided for:
1. Liposuction to reshape waist, hips, thighs
and buttocks;
2. Cosmetic chest reconstruction or
augmentation mammoplasty;
3. Electrolysis and laser hair removal,
except when required as part of covered
transgender genital reconstruction surgery;
4. Drugs for hair loss or growth;
5. Voice therapy or voice modification surgery;
6. Sperm or gamete procurement for future
infertility or storage of sperm, gametes, or
embryos;
7. Penile implant devices, penile device
implantation, and penile implant revision
or reinsertion;
8. Intersex surgery (transsexual operations)
except as specifically provided under the
“Limited Transgender Benefit” or treatment
of any resulting complications, unless that
treatment is determined to be Medically
Necessary
Questions? Call the Customer Service Department at 1-800-228-2144,
(TDHI) 1-800-685-9355, Monday through Friday, 7:00 a.m. to 9:00 p.m.
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PART B