CALIFORNIA - Pacificare Health Systems

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
reassignment services. Travel expenses are
included in the $75,000 lifetime benefit
maximum.
11. Mastectomy, Breast Reconstruction After
Mastectomy and Complications From
Mastectomy – Medically Necessary mastectomy
and lymph node dissection are covered, including
prosthetic devices and/or reconstructive surgery
to restore and achieve symmetry for the Member
incident to the mastectomy. The length of a
Hospital stay is determined by the attending
Physician and surgeon in consultation with
the Member, consistent with sound clinical
principles and processes. Coverage includes any
initial and subsequent reconstructive surgeries
or prosthetic devices for the diseased breast on
which the mastectomy was performed. Coverage
is provided for surgery and reconstruction of the
other breast if, in the opinion of the attending
surgeon, this surgery is necessary to achieve
symmetrical appearance. Medical treatment for
any complications from a mastectomy, including
lymphedema, is covered.
12. Maternity Care – Prenatal and maternity
care services are covered, including labor,
delivery and recovery room charges, delivery by
cesarean section, treatment of miscarriage and
complications of pregnancy or childbirth.
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Educational courses on lactation, childcare and/
or prepared childbirth classes are not covered.
Alternative birthing center services are covered
when provided or arranged by a Participating
Hospital affiliated with the Member’s
Your Medical Benefits
Participating Medical Group.
Licensed/Certificated nurse midwife services
are covered only when available within the
Member’s Participating Medical Group.
Elective home deliveries are not covered.
A minimum 48-hour inpatient stay for normal
vaginal delivery and a minimum 96-hour inpatient
stay following delivery by cesarean section are
covered. Coverage for inpatient Hospital care
may be for a time period less than the minimum
hours if the decision for an earlier discharge of
the mother and newborn is made by the treating
Physician in consultation with the mother.
In addition, if the mother and newborn are
discharged prior to the 48- or 96-hour minimum
time periods, a post-discharge follow-up visit for
the mother and newborn will be provided within
48 hours of discharge, when prescribed by the
treating Physician.
13. Morbid Obesity (Surgical Treatment)
– PacifiCare covers Roux-en-Y gastric bypass or
vertical banded gastroplasty surgical procedures
when Medically Necessary and Preauthorized;
PacifiCare utilized the National Institutes of Health
(NIH) Consensus Report criteria as a factor for
determining the Medical Necessity of requests for
surgical treatment for morbid obesity. Please refer
to your Schedule of Benefits under the inpatient
hospitalization benefit for your Copayment
information, if any.
14. Newborn Care – Postnatal Hospital Services
are covered, including circumcision (if desired
and performed in the Hospital) and special
care nursery. A newborn Copayment applies
in addition to the Copayment for maternity
care, unless the newborn is discharged with the
mother within 48 hours of the baby’s normal
vaginal delivery or within 96 hours of the baby’s
cesarean delivery. Circumcision is covered for
male newborns prior to hospital discharge. See
“Circumcision” under “Outpatient Benefits” for an
explanation of coverage after hospital discharge.
15. Organ Transplant and Transplant Services
– Non-experimental and non-investigational organ
transplants and transplant services are covered
when the recipient is a Member and the transplant
is performed at a National Preferred Transplant
Questions? Call the Customer Service Department at 1-800-624-8822. 21
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PART A