CALIFORNIA - Pacificare Health Systems

filling, removal or replacement of teeth, or
structures directly supporting the teeth, are not
covered except for services covered by PacifiCare
under the outpatient benefit, “Oral Surgery and
Dental Services.”
32. Outpatient Medical Rehabilitation Therapy –
Services provided by a registered physical, speech
or occupational therapist for the treatment of an
illness, disease or injury are covered.
33. Outpatient Surgery – Short-stay, same-day
or other similar outpatient surgery facilities
are covered when provided as a substitute for
inpatient care.
34. Outpatient Transgender Services – Outpatient
Services including outpatient surgery services
for transgender surgery, services related to the
surgery, outpatient office visit, and related services
require prior authorization by PacifiCare and are
subject to a combined Inpatient and Outpatient
lifetime benefit maximum of $75,000 for each
Member. PacifiCare covers certain transgender
surgery and services related to the surgery to
change a Member’s physical characteristics to
those of the opposite gender.
35. Periodic Health Evaluation – Periodic Health
Evaluations are covered as recommended by
PacifiCare’s Preventive Health Guidelines and
the Member’s Primary Care Physician. This may
include, but is not limited to, the following
screenings:
n
n
Breast Cancer Screening and Diagnosis
– Services are covered for the screening
and diagnosis of breast cancer. Screening
and diagnosis will be covered consistent
with generally accepted medical practice
and scientific evidence, upon referral by
the Member’s Primary Care Physician.
Mammography for screening or diagnostic
purposes is covered as authorized by the
Member’s participating nurse practitioner,
participating certified nurse midwife or
Participating Provider.
Hearing Screening – Routine hearing screening
by a participating health professional is covered
to determine the need for hearing correction.
Hearing aids are not covered, nor is their
Your Medical Benefits
testing or adjustment. (Hearing Screenings are
limited to Dependents under age 19.)
Prostate Screening – Evaluations for the
screening and diagnosis of prostate cancer is
covered (including, but not limited to, prostatespecific
antigen testing and digital rectal
examination). These evaluations are provided
when consistent with good professional
practice.
Vision Screening – Annual routine eye health
assessment and screening by a Participating
Provider are covered to determine the health
of the Member’s eyes and the possible need
for vision correction. An annual retinal
examination is covered for Members with
diabetes.
Well-Baby Care – Up to the age of 2, preventive
health services are covered (including
immunizations) when provided by the
child’s Participating Medical Group. An office
Copayment applies when infants are ill at the
time services are provided.
Well-Woman Care – Medically Necessary
services, including a Pap smear (cytology), are
covered. The Member may receive obstetrical
and gynecological Physician services directly
from an OB/GYN or Family Practice Physician
or surgeon (designated by the Member’s
Participating Medical Group as providing
OB/GYN services) affiliated with Member’s
Participating Medical Group.
36. Phenylketonuria (PKU) Testing and Treatment
– Testing for Phenylketonuria (PKU) is covered
to prevent the development of serious physical
or mental disabilities or to promote normal
development or function as a consequence of
PKU enzyme deficiency. PKU includes those
formulas and special food products that are
part of a diet prescribed by a Participating
Physician and managed by a health care
professional in consultation with a Physician
who specializes in the treatment of metabolic
disease and who participates in or is authorized
by PacifiCare, provided that the diet is deemed
Medically Necessary to avert the development
of serious physical or mental disabilities or to
Questions? Call the Customer Service Department at 1-800-624-8822. 29
n
n
n
n
PART A