CALIFORNIA - Pacificare Health Systems

PART A
30
Your Medical Benefits
promote normal development or function as a
consequence of PKU. Special food products do
not include food that is naturally low in protein
but may include a special low-protein formula
specifically approved for PKU and special food
products that are specially formulated to have less
than 1 gram of protein per serving.
37. Physician Care (Primary Care Physician
and Specialist) – Diagnostic, consultation and
treatment services provided by the Member’s
Primary Care Physician are covered. Services of a
specialist are covered upon referral by Member’s
Participating Medical Group or PacifiCare. A
specialist is a licensed health care professional
with advanced training in an area of medicine or
surgery.
38. Physician OB/GYN Care – The Member may
obtain obstetrical and gynecological Physician
services directly from an OB/GYN, Family Practice
Physician or surgeon (designated by the Member’s
Participating Medical Group as providing OB/GYN
services) affiliated with the Member’s Participating
Medical Group.
39. Prosthetics and Corrective Appliances –
Prosthetics and Corrective Appliances Prosthetics
(except for bionic or myoelectric as explained
below) are covered when Medically Necessary
as determined by the Member’s Participating
Medical Group or PacifiCare. Prosthetics are
durable, custom-made devices designed to
replace all or part of a permanently inoperative or
malfunctioning body part or organ. Examples of
covered prosthetics include initial contact lens in
an eye following a surgical cataract extraction and
removable, non-dental prosthetic devices such as
a limb that does not require surgical connection
to nerves, muscles or other tissue.
Custom-made or custom-fitted corrective
appliances are covered when Medically Necessary
as determined by the Member’s Participating
Medical Group or PacifiCare. Corrective
appliances are devices that are designed to
support a weakened body part. These appliances
are manufactured or custom-fitted to an individual
Member.
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Bionic and myoelectric prosthetics are not
covered. Bionic prosthetics are prosthetics that
require surgical connection to nerves, muscles
or other tissues. Myoelectric prosthetics are
prosthetics which have electric motors to
enhance motion.
Replacements, repairs and adjustments to
corrective appliances and prosthetics coverage
are limited to normal wear and tear or because
of a significant change in the Member’s physical
condition. Repair or replacement must be
authorized by the Member’s Participating
Medical Group or PacifiCare.
Refer to “Footwear” in Benefits Available on an
Outpatient Basis.
For a detailed listing of covered durable medical
equipment, including prosthetic and corrective
appliances, please contact the PacifiCare
Customer Service department at 1-800-624-8822.
40. Radiation Therapy (Standard and Complex) –
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Standard photon beam radiation therapy is
covered.
Complex radiation therapy is covered. This
therapy requires specialized equipment,
as well as specially trained or certified
personnel to perform the therapy. Examples
include, but are not limited to: brachytherapy
(radioactive implants) and conformal photon
beam radiation. (Gamma knife procedures
and stereotactic procedures are covered
as outpatient surgeries for the purpose of
determining Copayments. (Please refer to your
Schedule of Benefits for applicable Copayment,
if any.)
41. Reconstructive Surgery – Reconstructive surgery
is covered to correct or repair abnormal structures
of the body caused by congenital defects,
developmental abnormalities, trauma, infection,
tumors or disease. The purpose of reconstructive
surgery is to improve function or create a normal
* 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.