CALIFORNIA - Pacificare Health Systems

PART A
UNIvERSITY OF CALIFORNIA
Behavioral Health
Preauthorization is required for all Mental Health Services, Chemical Dependency Services and Severe Mental Illness
(SMI) Benefits. You do not need to go through your Primary Care Physician, but you must obtain prior authorization
through PacifiCare Behavioral Health of California (PBHC), an affiliate of PacifiCare that specializes in mental health and
chemical dependency benefits. PBHC is available to you toll-free, 24 hours a day, 7 days a week, at 1-800-999-9585.
Mental Health Services
Inpatient Deductible None
Inpatient per Admittance $250 per admission
Inpatient, Residential and Day Treatment
Unlimited days (based upon Medical Necessity)
$250 per admission
Outpatient Treatment
Unlimited visits (based upon Medical Necessity)
$15 Copayment per visit
Emergency and Urgently Needed Services1 Same as medical plan Copayment for
(Copayment waived if admitted as inpatient)
Emergency and Urgently Needed Services1 Chemical Dependency Health Services
Inpatient Deductible None
Inpatient Treatment $250 per admission
Outpatient Treatment $15 Copayment per visit
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Emergency and Urgently Needed Services 1
(Copayment waived if admitted as inpatient)
Serious Mental Illness Benefit 2
Same as medical plan Copayment for
Emergency and Urgently Needed Services 1
Inpatient Deductible None
Inpatient per Admittance $250 per admission
Inpatient, Residential and Day Treatment
Unlimited days (based upon Medical Necessity)
$250 per admission
Outpatient Treatment
Unlimited visits (based upon Medical Necessity)
$15 Copayment per visit
Emergency and Urgently Needed Services1 Same as medical plan Copayment for
(Copayment waived if admitted as inpatient)
Emergency and Urgently Needed Services1 1 Urgently Needed Services are Medically Necessary Services required outside the Service Area to prevent serious deterioration of a
Member’s health resulting from an unforeseen illness or injury manifesting itself by acute symptoms of sufficient severity, including
severe pain, such that treatment cannot be delayed until the Member returns to the Service Area.
2 Severe Mental Illness Diagnoses include: schizophrenia, schizoaffective disorder, bipolar disorder, major depressive disorder, panic
disorder, obsessive-compulsive disorder, pervasive developmental disorders (autism), anorexia and bulimia nervosa. In addition, the
Severe Mental Illness Benefit includes coverage of Serious Emotional Disturbance of Children (SED).
You do not need to go through your Primary Care Physician, but you must obtain prior authorization through PacifiCare
Behavioral Health of California (PBHC), an affiliate of PacifiCare that specializes in Mental Health and Chemical
Dependency Benefits. PBHC is available to you toll-free, 24 hours a day, 7 days a week, at 1-800-999-9585.