CALIFORNIA - Pacificare Health Systems

approved transplant center. (See “National
Preferred Transplant Network” in Section 11.
Definitions.)
11. Chiropractic Care – Care and treatment provided
by a chiropractor are not covered.
12. Communication Devices – Computers, personal
digital assistants and any speech-generating
devices are not covered. Please also refer to
“Durable Medical Equipment” and “Prosthetic
and Corrective Appliances.” 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.
13. Complementary and Alternative Medicine –
Complementary and Alternative Medicine is not
covered. (See the definition for “Complementary
and Alternative Medicine.”)
14. Cosmetic Services and Surgery – Cosmetic
surgery and cosmetic services are not covered.
Cosmetic surgery and cosmetic services are
defined as surgery and services performed to
alter or reshape normal structures of the body
in order to improve appearance. Drugs, devices
and procedures related to cosmetic surgery or
cosmetic services are not covered. Cosmetic
surgeries or cosmetic services do not become
reconstructive surgery because of a Member’s
psychological or psychiatric condition. PacifiCare
covers certain transgender surgery and services
related to the surgery to change a Member’s
physical characteristics to those of the opposite
gender. Inpatient and Outpatient Services for
transgender surgery and services related to the
surgery require prior authorization by PacifiCare
and are subject to a combined Inpatient and
Outpatient lifetime benefit maximum of $75,000
for each Member.
No benefits are provided for:
a. Liposuction to reshape waist, hips, thighs
and buttocks;
b. Cosmetic chest reconstruction or
augmentation mammoplasty;
c. Electrolysis and laser hair removal,
except when required as part of covered
transgender genital reconstruction surgery;
Your Medical Benefits
d. Drugs for hair loss or growth;
e. Voice therapy or voice modification surgery;
f. Sperm or gamete procurement for future
infertility or storage of sperm, gametes, or
embryos;
g. Penile implant devices, penile device
implantation, and penile implant revision or
reinsertion;
h. Intersex surgery (transsexual operations)
except as specifically provided under the
“Limited Transgender Benefit” or treatment
of any resulting complications, unless that
treatment is determined to be Medically
Necessary.
15. Custodial Care – Custodial Care is not
covered except for those services provided by
an appropriately licensed Hospice agency or
appropriately licensed Hospice facility incident
to a Member’s terminal illness as described in the
explanation of “Hospice Services” in Section 5.
Medical Benefits of this Combined Evidence of
Coverage and Disclosure Form.
16. Dental Care, Dental Appliances and
Orthodontics – Except as otherwise provided
under the outpatient benefit captioned, “Oral
Surgery and Dental Services,” dental care,
dental appliances and orthodontics are not
covered. Dental Care means all services required
for prevention and treatment of diseases and
disorders of the teeth, including, but not limited
to: oral exams, X-rays, routine fluoride treatment;
plaque removal, tooth decay, routine tooth
extraction, dental embryonal tissue disorders,
periodontal disease, crowns, fillings, dental
implants, caps, dentures, braces and orthodontic
procedures. (Coverage for Dental Care may
be available if purchased by the University of
California as a separate benefit. If your Health
Plan includes a separate Dental Care benefit, a
brochure describing it will be enclosed with these
materials.)
17. Dental Treatment Anesthesia – Dental treatment
anesthesia provided or administered in a dentist’s
office is not covered. Charges for the dental
procedure(s) itself, including, but not limited to,
professional fees of the dentist or oral surgeon,
Questions? Call the Customer Service Department at 1-800-624-8822. 33
PART A