CALIFORNIA - Pacificare Health Systems

Benefit” under “Miscellaneous Prescription Drug
Coverage” for coverage.
n
Replacements, repairs and adjustments to
Durable Medical Equipment are limited
to normal wear and tear or because of a
significant change in the Member’s physical
condition. The Member’s Participating
Medical Group or PacifiCare has the option
to repair or replace Durable Medical
Equipment items. Replacement of lost
or stolen Durable Medical Equipment is
not covered. The following equipment
and accessories are not covered: Non-
Medically Necessary optional attachments
and modifications to Durable Medical
Equipment for the comfort or convenience
of the Member, accessories for portability
or travel, a second piece of equipment with
or without additional accessories that is
for the same or similar medical purpose as
existing equipment, and home and/or car
modifications to accommodate the Member’s
condition.
For a detailed listing of covered Durable Medical
Equipment, please contact the PacifiCare
Customer Service department at
1-800-624-8822.
17. Family Planning – Refer to the Schedule of
Benefits for the specific terms of coverage under
your Health Plan.
18. Footwear – Specialized footwear, including foot
orthotics, custom-made or standard orthopedic
shoes, are covered for a Member with diabetic
foot disease or when an orthopedic shoe is
permanently attached to a Medically Necessary
orthopedic brace.
19. Health Education Services – Includes wellness
programs such as a stop smoking program
available to enrolled Members. PacifiCare also
makes health and wellness information available
to Members. For more information about the stop
smoking program or any other wellness program,
call the PacifiCare Customer Service department at
1-800-624-8822, or visit the PacifiCare Web site.
The Member’s Participating Medical Group may
offer additional community health programs.
These programs are independent of health
Your Medical Benefits
improvement programs offered by PacifiCare and
are not covered. Fees charged will not apply to
the Member’s Copayment maximum.
20. Home Health Care – A Member is eligible to
receive Home Health Care Visits if the Member:
(i) is confined to the home (home is wherever
the Member makes his or her home but does
not include acute care, rehabilitation or Skilled
Nursing Facilities); (ii) needs Medically Necessary
skilled nursing visits or needs physical, speech or
occupational therapy; and (iii) the Home Health
Care Visits are provided under a plan of care
established and periodically reviewed and ordered
by a PacifiCare Participating Provider. “Skilled
Nursing Services” means the services provided
directly by or under the direct supervision
of licensed nursing personnel, including the
supportive care of a Home Health Aide. Skilled
nursing visits may be provided by a registered
nurse or licensed vocational nurse.
If a Member is eligible for Home Health Care Visits
in accordance with the authorized treatment plan,
the following Medically Necessary Home Health
Care Visits may be included but are not limited to:
a. Skilled nursing visits;
b. Home Health Aide Services visits that
provide supportive care in the home
which are reasonable and necessary to the
Member’s illness or injury;
c. Physical, occupational, or speech therapy
that is provided on a per visit basis;
d. Medical supplies, durable medical
equipment; and
e. Infusion therapy medications and supplies
and laboratory services as prescribed by a
Participating Provider to the extent such
services would be covered by PacifiCare
had the Member remained in the hospital,
rehabilitation or Skilled Nursing Facility.
f. Drugs, medications and related
pharmaceutical services are covered for
those Members enrolled in PacifiCare’s
Outpatient Prescription Benefit. Outpatient
prescription drugs may be available as a
supplemental benefit. Please refer to your
Schedule of Benefits.
Questions? Call the Customer Service Department at 1-800-624-8822. 25
PART A