CALIFORNIA - Pacificare Health Systems

treatment of allergies. Allergy serum, needles and
syringes must be obtained through a PacifiCare
Participating Physician.
3. Allergy Treatment – Services and supplies are
covered, including provocative antigen testing, to
determine appropriate allergy treatment. Services
and supplies for the treatment of allergies,
including allergen/antigen immunotherapy and
serum, are covered according to an established
treatment plan.
4. Ambulance – The use of an ambulance (land or
air) is covered without Preauthorization, when
the Member, as a Prudent Layperson, reasonably
believes that the medical or psychiatric condition
requires Emergency Services, and an ambulance
transport is necessary to receive these services.
Such coverage includes, but is not limited to,
ambulance or ambulance transport services
provided through the 911 emergency response
system. Ambulance transportation is limited to
the nearest available emergency facility having the
expertise to stabilize the Member’s Emergency
Medical Condition. Use of an ambulance for
a non-Emergency Service is covered only
when specifically authorized by the Member’s
Participating Medical Group or PacifiCare.
5. Attention Deficit/Hyperactivity Disorder –
The medical management of Attention Deficit/
Hyperactivity Disorder (ADHD) is covered,
including the diagnostic evaluation and laboratory
monitoring of prescribed drugs. Coverage for
outpatient prescribed drugs is covered as a
supplemental benefit (please see “Outpatient
Prescription Drug Program” section of this
Combined Evidence of Coverage and Disclosure
Form. This benefit does not include non-crisis
mental health counseling or behavior modification
programs.
6. 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.
7. Bloodless Surgery – Please refer to the benefit
described under “Inpatient Benefits for Bloodless
Surgery.” Outpatient services Copayments and/or
Your Medical Benefits
deductibles apply for any services received on an
outpatient basis.
8. Cancer Clinical Trials – Please refer to the
benefit described under “Inpatient Cancer
Clinical Trials.” Outpatient services Copayments
and/or deductibles apply for any Cancer Clinical
Trials services received on an outpatient basis
according to the Copayments for that specific
outpatient service. PacifiCare is required to
pay for the services covered under this benefit
at the rate agreed upon by PacifiCare and a
Participating Provider, minus any applicable
Copayment, coinsurance or deductibles. In the
event the Member participates in a clinical trial
provided by a Non-Participating Provider that does
not agree to perform these services at the rate
PacifiCare negotiates with Participating Providers,
the Member will be responsible for payment of
the difference between the Non-Participating
Provider’s billed charges and the rate negotiated
by PacifiCare with Participating Providers,
in addition to any applicable Copayment,
coinsurance or deductibles. Any additional
expenses the Member may have to pay beyond
PacifiCare’s negotiated rate as a result of using
a Non-Participating Provider do not apply to the
Member’s annual Copayment maximum.
9. Circumcision – Circumcision is covered for
male newborns prior to hospital discharge.
Circumcision is covered after hospital discharge
only when:
Circumcision was delayed by the Participating
Provider during initial hospitalization. Unless
the delay was for medical reasons, the
circumcision is covered after discharge only
through the 28-day neonatal period, or
Circumcision was determined to be medically
inappropriate during initial hospitalization due
to medical reasons (for example, prematurity,
congenital deformity, etc.). The circumcision
is covered when the Participating Provider
determines it is medically safe and only up to a
maximum age of six months.
Circumcision other than noted under the
outpatient “Circumcision” benefit will be reviewed
for Medical Necessity by the Participating Medical
Group or PacifiCare Medical Director.
Questions? Call the Customer Service Department at 1-800-624-8822. 23
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PART A