CALIFORNIA - Pacificare Health Systems

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by the Intravenous route. Infusion therapy is
covered when furnished as part of a treatment
plan authorized by the Member’s Primary
Care Physician, Participating Medical Group or
PacifiCare. The infusions must be administered
in the Member’s home, Participating Physician’s
office or in an institution, such as a board and
care, Custodial Care, or assisted living facility,
that is not a hospital or institution primarily
engaged in providing Skilled Nursing Services
or Rehabilitation Services.
Outpatient Injectable Medications
– Outpatient injectable medications (except
insulin) include those drugs or preparations
which are not usually self-administered and
which are given by the Intramuscular or
Subcutaneous route. Outpatient injectable
medications (except insulin) are covered
when administered as a customary component
of a Physician’s office visit, and when not
otherwise limited or excluded (e.g., insulin,
certain immunizations, infertility drugs,
birth control, or off-label use of covered
injectable medications). Outpatient injectable
medications must be obtained through
a Participating Provider, the Member’s
Participating Medical Group or PacifiCare
Designated Pharmacy, and may require
Preauthorization by PacifiCare.
Self-Injectable Medications – Self-injectable
medications (except insulin) are defined as
those drugs which are either generally selfadministered
by Intramuscular injection at
a frequency of one or more times per week,
or which are generally self-administered
by the Subcutaneous route. Self-injectable
medications (except insulin) are covered
when prescribed by a Participating Provider,
as authorized by the Member’s Participating
Medical Group or by PacifiCare. Self-injectable
medications must be obtained through a
Participating Provider, through the Member’s
Participating Medical Group or PacifiCaredesignated
pharmacy/specialty injectable
vendor, and may require Preauthorization by
PacifiCare. A separate Copayment applies to all
self-injectable medications for a 30-day supply
(or for the prescribed course of treatment if
shorter), whether self-administered or injected
Your Medical Benefits
in the Physician’s office, and is applied in
addition to any office visit Copayment.
25. Laboratory Services – Medically Necessary
diagnostic and therapeutic laboratory services are
covered.
26. Maternity Care, Tests and Procedures
– Physician visits, laboratory services (including
the California Department of Health Services’
expanded alpha fetoprotein (AFP) program)
and radiology services are covered for prenatal
and postpartum maternity care. Nurse midwife
services are covered when available within
and authorized by the Member’s Participating
Medical Group. Genetic testing and counseling
are covered when authorized by the Member’s
Participating Medical Group as part of an
amniocentesis or chorionic villus sampling
procedure.
27. Medical Supplies and Materials – Medical
supplies and materials necessary to treat an illness
or injury are covered when used or furnished
while the Member is treated in the Participating
Provider’s office, during the course of an illness
or injury, or stabilization of an injury or illness,
under the direct supervision of the Participating
Provider. Examples of items commonly furnished
in the Participating Provider’s office to treat the
Member’s illness or injury are gauzes, ointments,
bandages, slings and casts.
28. Mental Health Services – Only services to treat
Severe Mental Illness for adults and children, and
Serious Emotional Disturbances of a Child are
covered. (See your Supplement to this Combined
Evidence of Coverage and Disclosure Form
for a description of this coverage.) Refer to the
Schedule of Benefits for additional coverage of
Mental Health Services, if any.
29. OB/GYN Physician Care – See “Physician OB/
GYN Care.”
30. Oral Surgery and Dental Services – Emergency
Services for stabilizing an acute injury to sound
natural teeth, the jawbone or the surrounding
structures and tissues are covered. Coverage is
limited to treatment provided within 48 hours
of injury or as soon as the member is medically
stable. Other covered oral surgery and dental
services include:
Questions? Call the Customer Service Department at 1-800-624-8822. 27
PART A