CALIFORNIA - Pacificare Health Systems

Section 1. Getting Started: Your Primary
Care Physician 4
Introduction 4
What is a Primary Care Physician? 4
What is the difference between a Subscriber
and an enrolled Family Member? 4
Choosing a Primary Care Physician 4
What is a Participating Medical Group? 5
Your Provider Directory – Choice of Physicians
and Hospitals (Facilities) 5
Choosing a Primary Care Physician for Each
Enrolled Family Member 5
Continuity of Care for New Members at the
Time of Enrollment 5
If You Are Pregnant 6
Does your group or Hospital restrict any
reproductive services? 7
Section 2. Seeing the Doctor 8
Seeing the Doctor: Scheduling Appointments 8
Referrals to Specialists and Non-Physician
Health Care Practitioners 8
PacifiCare Express Referrals® 8
Standing Referrals to Specialists 9
Extended Referral for Care by a Specialist 9
OB/GYN: Getting Care Without a Referral 9
Second Medical Opinions 9
What is PacifiCare’s Case Management
program? 11
Prearranging Hospital Stays 11
Section 3. Emergency and Urgently
Needed Services 12
What are Emergency Medical Services? 12
What is an Emergency Medical Condition? 12
What To Do When You Require Emergency
Services 12
Post-Stabilization and Follow-up Care 12
Out-of-Area Services 13
What To Do When You Require Urgently Needed
Services 13
Out-of-Area Urgently Needed Services 13
Table of Contents
International Emergency and Urgently Needed
Services 14
Section 4. Changing Your Doctor or
Medical Group 15
Changing Your Primary Care Physician 15
When We Change Your Participating Medical
Group 16
Continuing Care With a Terminated Physician 16
Section 5. Your Medical Benefits 18
Inpatient Benefits 18
Outpatient Benefits 22
Exclusions and Limitations of Benefits 31
General Exclusions 31
Other Exclusions and Limitations 31
Outpatient Prescription Drug Program
Schedule of Benefits 42
Hearing Aid Benefits 48
HMO Schedule of Benefits 49
Infertility Basic Diagnosis and Treatment
Supplement 54
Section 6. How Your Behavioral Health
Care Benefits Work 57
Understanding Behavioral Health: Your
Benefits 57
Getting Started: Your Participating Provider 58
Emergency Services and Urgently Needed
Services 61
Covered Behavioral Health Services 63
Overseeing Your Behavioral Health Services 67
General Information 76
Definitions 78
Section 7. Payment Responsibility 84
What are Premiums? (Prepayment Fees) 84
What are Copayments? (Other Charges) 84
Annual Copayment Maximum 84
If You Get a Bill (Reimbursement Provisions) 84
What is a Schedule of Benefits? 85
Bills From Non-Participating Providers 85
How to Avoid Unnecessary Bills 85