CALIFORNIA - Pacificare Health Systems

a. Members who do not meet the definition of
terminally ill. Terminal illness is defined as
a medical condition resulting in a prognosis
of life expectancy of one year if the disease
follows its natural course.
b. Hospice services that are not reasonable and
necessary for the management of a terminal
illness (e.g., care provided in a noncertified
Hospice program).
Note: Hospice services provided by a Non-
Participating Hospice Agency are not covered
except in certain circumstances in counties in
California in which there are no Participating
Hospice Agencies and only when prior authorized
and arranged by PacifiCare or the Member’s
Participating Medical Group.
35. Immunizations – Immunization and vaccines for
travel and/or required work-related, insurance,
school, marriage, adoption, immigration, camp,
volunteer work, licensure, certification or
registration, sports or recreational activities are
not covered.
36. Infertility Reversal – Reversals of sterilization
procedures are not covered.
37. Infertility Services – Infertility Services are not
covered unless purchased by the Subscriber’s
Employer Group. Please refer to your Schedule
of Benefits. The following services are excluded
under the PacifiCare Health Plan: Ovum
transplants, ovum or ovum bank charges,
sperm or sperm bank charges and the medical
or Hospital Services incurred by surrogate
mothers who are not PacifiCare Members are not
covered. Medical and Hospital Infertility Services
for a Member whose fertility is impaired due
to an elective sterilization, including surgery,
medications and supplies, are not covered.
38. Institutional Services and Supplies – Except
for Skilled Nursing Services provided in a
Skilled Nursing Facility, any services or supplies
furnished by a facility that is primarily a place
of rest, a place for the aged, a nursing home or
any similar institution, regardless of affiliation
or denomination, are not covered. (Skilled
Nursing Services are covered as described in this
Combined Evidence of Coverage and Disclosure
Form in the sections titled, “Inpatient Benefits”
Your Medical Benefits
and “Outpatient Benefits.”) Members residing in
these facilities are eligible for Covered Services
that 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.
39. Maternity Care, Tests, and Procedures –
Elective home deliveries are not covered.
Educational courses on lactation, child care and/
or prepared childbirth classes are not covered.
40. Medicare Benefits for Medicare Eligible
Members – The amount payable by Medicare
for Medicare Covered Services is not covered by
PacifiCare for Medicare Eligible Members, whether
or not a Medicare Eligible Member has enrolled in
Medicare Part A and Medicare Part B.
41. Mental Health and Nervous Disorders – Mental
Health Services are not covered except for
diagnosis and treatment of Severe Mental Illness
for adults and children, and for diagnosis and
treatment of Serious Emotional Disturbances of
Children. Please refer to the behavioral health
supplement to this Combined Evidence of
Coverage and Disclosure Form for a description
of this coverage. Academic or educational testing,
as well as educational counseling or remediation
are not covered. Coverage for Crisis Intervention
may also be available as an additional benefit.
Please refer to the Schedule of Benefits for
coverage, if any.
42. Non-Physician Health Care Practitioners –
This Plan may not cover services of all Non-
Physician Health Care Practitioners. Treatment
by Non-Physician Health Care Practitioners such
as acupuncturists, chiropractors, licensed clinical
social workers, marriage and family therapists
are not covered. Psychologists or licensed clinical
social workers may be covered as a supplemental
benefit (please see the “How Your PacifiCare
Behavioral Health Benefits Work” section of this
Combined Evidence of Coverage and Disclosure
Form). For coverage of Severe Mental Illnesses
(SMI) of adults and children, and for children,
the treatment of Serious Emotional Disturbances
(SED), refer to “Outpatient Benefits, Mental
Health Services.”
Questions? Call the Customer Service Department at 1-800-624-8822. 37
PART A