CALIFORNIA - Pacificare Health Systems

Introducing PacifiCare’s HMO Plan
Since 1978, we’ve been providing health care coverage in the state. This publication will help you
become more familiar with your health care benefits. It will also introduce you to our health care
community.
PacifiCare ® provides health care coverage to Members who have properly enrolled in our plan and
meet our eligibility requirements. To learn more about these requirements, see Section 8. Member
Eligibility.
What is this publication?
This publication is called a Combined Evidence of Coverage and Disclosure Form. It is a legal
document that explains your health care plan and should answer many important questions about
your benefits. Many of the words and terms are capitalized because they have special meanings. To
better understand these terms, please see Section 11. Definitions.
Whether you are the Subscriber of this coverage or enrolled as a Family Member, your Combined
Evidence of Coverage and Disclosure Form is key to making the most of your membership. You’ll
learn about important topics like how to select a Primary Care Physician and what to do if you need
hospitalization.
What else should I read to understand my benefits?
Along with reading this publication, be sure to review your Schedule of Benefits and any benefit
materials. Your Schedule of Benefits provides the details of your particular Health Plan, including any
Copayments that you may have to pay when using a health care service. Together, these documents
explain your coverage.
What if I still need help?
After you become familiar with your benefits, you may still need assistance. Please don’t hesitate to
call our Customer Service department at 1-800-624-8822 or 1-800-442-8833 (TDHI). NOTE: Your
Combined Evidence of Coverage and Disclosure Form and Schedule of Benefits provides the terms and
conditions of your coverage with PacifiCare, and all applicants have a right to view these documents
prior to enrollment. The Combined Evidence of Coverage and Disclosure Form should be read
completely and carefully. Individuals with special health needs should pay special attention to those
sections that apply to them.
You may correspond with PacifiCare at the following address:
PacifiCare of California
5701 Katella Avenue
P.O. Box 6006
Cypress, California 90630
www.pacificare.com
Note: This Combined Evidence of Coverage and Disclosure Form discloses the terms and conditions
of coverage with PacifiCare and all applicants have a right to view this document prior to enrollment.
This Form should be read completely and carefully. Individuals with special health needs should
carefully read those sections that apply to them. You may receive additional information about the
benefits of the PacifiCare Health Plan by calling 1-800-624-8822 or 1-800-442-8833 (TDHI).
PLEASE READ THE FOLLOWING INFORMATION SO YOU WILL KNOW FROM WHOM OR WHAT
GROUP OF PROVIDERS HEALTH CARE COVERAGE MAY BE OBTAINED.
Questions? Call the Customer Service Department at 1-800-624-8822.