CALIFORNIA - Pacificare Health Systems

PART A
24
Your Medical Benefits
10. Cochlear Implant Device – An implantable
cochlear device for bilateral, profoundly hearing
impaired individuals who are not benefited
from conventional amplification (hearing aids)
is covered. Coverage is for Members at least
18 months of age who have profound bilateral
sensory hearing loss or for prelingual Members
with minimal speech perception under the best
hearing aided condition. Please also refer to
“Cochlear Implant Medical and Surgical Services.”
11. Cochlear Implant Medical and Surgical
Services – The implantation of a cochlear device
for bilateral, profoundly hearing impaired or
prelingual individuals who are not benefited
from conventional amplification (hearing aids) is
covered. This benefit includes services needed to
support the mapping and functional assessment of
the cochlear device at the authorized Participating
Provider. (For an explanation of speech therapy
benefits, please refer to “Outpatient Medical
Rehabilitation Therapy.”)
12. Dental Treatment Anesthesia – See “Oral
Surgery and Dental Services: Dental Treatment
Anesthesia.”
13. Diabetic Management and Treatment –
Coverage includes outpatient self-management
training, education and medical nutrition therapy
services. The diabetes outpatient self-management
training, education and medical nutrition therapy
services covered under this benefit will be
provided by appropriately licensed or registered
health care professionals. These services must be
provided under the direction of and prescribed by
a Participating Provider.
14. Diabetic Self-Management Items – Equipment
and supplies for the management and treatment
of Type 1, Type 2 and gestational diabetes are
covered, based upon the medical needs of the
Member, including, but not necessarily limited to:
blood glucose monitors; blood glucose monitors
designed to assist the visually impaired; strips;
lancets and lancet puncture devices; pen delivery
systems (for the administration of insulin); insulin
pumps and all related necessary supplies; ketone
urine testing strips; insulin syringes, podiatry
services and devices to prevent or treat diabetesrelated
complications. Members must have
coverage under the Outpatient Prescription Drug
Benefit for insulin, glucagon and other diabetic
medications to be covered. Visual aids are covered
for Members who have a visual impairment that
would prohibit the proper dosing of insulin.
Visual aids do not include eyeglasses (frames
and lenses) or contact lenses. The Member’s
Participating Provider will prescribe insulin
syringes, lancets, glucose test strips and ketone
urine test strips to be filled at a pharmacy that
contracts with PacifiCare.
15. Dialysis – Acute and chronic hemodialysis
services and supplies are covered. For chronic
hemodialysis, application for Medicare Part A and
Part B coverage must be made. Chronic dialysis
(peritoneal or hemodialysis) must be authorized
by the Member’s Participating Medical Group
or PacifiCare and provided within the Member’s
Participating Medical Group. The fact that the
Member is outside the geographic area served by
the Participating Medical Group will not entitle
the Member to coverage for maintenance of
chronic dialysis to facilitate travel.
16. Durable Medical Equipment (Rental, Purchase
or Repair) – Durable Medical Equipment is
covered when it is designed to assist in the
treatment of an injury or illness of the Member,
and the equipment is primarily for use in the
home. Durable Medical Equipment is medical
equipment that can exist for a reasonable
period of time without significant deterioration.
Examples of covered Durable Medical Equipment
include wheelchairs, hospital beds, standard
oxygen-delivery systems and equipment for the
treatment of asthma (nebulizers, masks, tubing
and peak flow meters, the equipment and
supplies must be prescribed by and are limited
to the amount requested by the Participating
Physician). Outpatient drugs, prescription
medications and inhaler spacers for the treatment
of asthma are available under the prescription
drug benefit if purchased as a supplemental
benefit. Please refer to the Pharmacy Schedule
of Benefits, “Medication Covered By Your
* The benefits described in Section Five will not be Covered Services unless they are determined to be Medically
Necessary by Member’s Participating Medical Group or PacifiCare and are provided by Member’s Primary Care
Physician or authorized by Member’s Participating Medical Group or PacifiCare.