PacifiCare® Life Assurance
Company
Summary of Benefits |
PacifiCare Personal Select 80-60/5000
|
Self Directed Account Maximum per Calendar Year*
Individual
|
Not Applicable
|
Family
|
Not Applicable
|
Self Directed Account Rollover per Calendar Year*
Individual
|
Not Applicable
|
Family
|
Not Applicable
|
| Deductible & Policy Maximums |
Participating Provider
|
Non-Participating Provider
|
Calendar Year Deductible
Individual
|
$5,000
|
Family
|
$10,000
|
Additional Deductible (per occurance)
Inpatient Hospital Services
|
Not Applicable
|
$500
|
Outpatient Surgical Services
|
Not Applicable
|
$250
|
Emergency Room Services (waived if admitted)
|
$100
|
Failure to obtain Pre-Authorization of Services
|
Not Applicable
|
$500
|
Coinsurance Maximum
Individual
|
$5,000
|
$10,000
|
Family (2x indifidual)
|
$10,000
|
$20,000
|
| Policy Maximum While Insured (per individual) |
$2,000,000
|
| Inpatient Benefits |
Participating Provider
Services subject to the Deductible
|
Non-Participating Provider
Services subject to the Deductible
|
| Inpatient Hospital Services |
80%
|
60%
|
Organ Transplant Services (1)
Maximum benefit while Insured (24 month waiting period) |
80%
|
Not Covered
|
|
Covered under Policy Maximum up to $2,000,000
|
Inpatient Maternity & Newborn Care (1)
Labor, Delivery and Postnatal Hospital Services |
80%
|
60%
|
Inpatient Skilled Nursing Facilities
Maximum benefit Up to 90 days per Calendar Year |
80%
|
60%
|
Inpatient Hospice Care
Maximum benefit $10,000 combined for Inpatient/Outpatient benefits per Calendar
Year |
80%
|
60%
|
| Inpatient Rehabilitation Care |
80%
|
60%
|
Mental Illness & Mental Health Inpatient Treatment
Maximum benefit $10,000 combined for Inpatient/Outpatient benefits per
Calendar Year |
80%
|
60%
|
| Outpatient Benefits |
Participating Provider
Services subject to the Deductible
|
Non-Participating Provider
Services subject to the Deductible
|
| Physician Office Visits (1 & 2) |
80%
|
60%
|
Periodic Health Evaluations (age 19 and over)
(1)
Hearing and Vision Screening; Immunizations; Routine Laboratory tests; Weight
Evaluations; |
80%
|
60%
|
| Allergy Testing and Treatment |
80%
|
60%
|
| Outpatient Maternity Care (1) |
80%
|
60%
|
| Urgent Care Services |
80%
|
60%
|
Ambulance (emergency services and specified
transfers)
Maximum Benefit $3,000 per Calendar Year |
80%
|
| Durable Medical Equipment (DME), Prosthetics, and
Corrective Appliances Maximum Benefit $5,000 combined for DME, Prosthetics
and Corrective Appliances per Calendar Year |
80%
|
60%
|
Home Health Care
Maximum Benefit 130 visits combined per Calendar Year |
80%
|
60%
|
Outpatient Hospice Services
Maximum benefit $10,000 combined for Inpatient/Outpatient benefits per Calendar
Year |
80%
|
60%
|
Radiology & Laboratory Services (1)
(other than Physician Office visit) |
80%
|
60%
|
Specialized Scanning, Imaging and Laboratory Services
(1)
|
80%
|
60%
|
Outpatient Medical Rehabilitative Therapy (1)
Speech, Physical, Occupational therapy - Maximum Benefit $2,000 per Calendar
Year |
80%
|
60%
|
Mental Illness and Mental Health (1)
Maximum benefit $2,000 combined for Inpatient/Outpatient benefits per Calendar
Year |
80%
|
60%
|
Complementay and Alternative Medicine Chiropractor
and Acupuncture Services (1)
Maximum Benefit $500 per Calendar Year |
80%
|
60%
|
| Outpatient Surgery (1) |
80%
|
60%
|
| Outpatient Prescription Benefits |
Participating Pharmacy
|
Non-Participating Pharmacy
|
3-Tier Retail Pharmacy
Generic / Brand Name / Non-Formulary (per one Prescription Unit or up to
30 days supply) |
Not Covered
|
Not Covered
|
3-Tier Mail-Service Pharmacy
Generic / Brand Name / Non-Formulary (per one Prescription Unit or up to
90 days supply) |
Not Covered
|
Not Covered
|
| Maximum Benefit |
Not Covered
|
| Supplemental Benefit Rider |
Participating Provider
|
Non-Participating Provider
|
ALCOHOLISM TREATMENT
Inpatient and Outpatient Treatment
- Maximum Benefit: Combined maximum of $4,500 in any 24-consecutive months. |
80%
|
* The Self Directed Account Maximum and
Rollover Per Calendar Quarter is subject to increase due to the Covered
Person’s participation in designated PacifiCare Wellness Programs
(1) SDA Non-Covered Services: Covered Expenses not eligible
for reimbursement under the SDA include, but are not limited to the following:
Allergy Testing/Serum and Treatment, Ambulance, Colonoscopy or flexible
sigmoidoscopy, except for qualified individuals as part of Colorectal Cancer
Screening, Durable medical equipment, Emergency room, Family Planning Services,
Genetic Testing and Counseling, Hearing Aids and Hearing Devices, Hospice
Services, Infusion Therapy, Infertility treatment, Injectable or Intravenous
drugs (other than antibiotics and immunization injections, Inpatient and
Outpatient Alcohol, Drug or Other Substance Abuse, Inpatient and Outpatient
Hospital Services, Inpatient and Outpatient Maternity and Newborn Care (Labor,
Delivery and Postnatal Hospital Services),Inpatient and outpatient Rehabilitation
Care, Inpatient Hospice Care, Inpatient Skilled Nursing Facilities, Laboratory
Services (other than those under Physician Office Visits), Mental Illness
services, Neuromuscular Skeletal Services, Organ Transplantation Services
(Bone Marrow, Stem Cell and Organ Transplants), Outpatient or Physician
office based surgery Physician services (other than physician office visits),
Prescription drugs, Prosthetic devices, Prosthetics and Corrective Appliances,
Radiology Services (other than standard x-rays), Specialized scanning, imaging,
and diagnostic procedures such as Computed Tomography (CT), Single Photon
Emission Computerized Tomography radionuclide Scanning (SPECT), Positron
Emission Tomography (PET), Magnetic Resonance Angiography (MRA) and Magnetic
Resonance Imaging (MRI) (with or without oral, rectal, injected or infused
contrast media), Electrocardiogram (EKG), Electro-encephalography (EEG),
Electromyograph (EMG) and nuclear medicine studies, Sterilization, Therapeutic
services, Transplants, Ultrasound, and Urgent Care facility services. Any
service shown as not applicable or not covered, Nontraditional or non-Covered
Services are also not eligible for reimbursement under the SDA . Please
refer to the Certificate for additional plan information, including exclusions
and imitations.
Reimbursements under the Self Directed Account (SDA) are limited to Covered
Services indicated in this Comparison as SDA -eligible expenses and
are subject to the conditions and limitations of the Policy. In all cases,
reimbursements will be limited to substantiated qualified medical expenses.
SDA Covered Services: The following is a summary of SDA covered services.
Please note that this is not a complete list. Refer to the Certificate for
additional plan information, including exclusions and limitations. Covered
Expenses reimbursable under the SDA include the following: Physician Office
Visits, Preventive Screenings -- Breast Cancer Screening including Mammography
screening, Pelvic Cancer Screening, Detection of Osteoporosis, Colorectal
Cancer Screening, Prostate Cancer Screening, Covered diagnostic laboratory
services, Radiology services limited to standard plain x-ray films, Periodic
Health Evaluations.
(2) Physician Office Visit Schedule: The detection
and treatment of an injury or sickness durine a Physician Office Visit
including associated coverd diagnostic X-ray and labroatory services;
Breast, Pelvic Cancer and Mammography screening; Detection of Osteoporosis;
Prostate Cancer Screening; Periodic health evaluation for children (through
age 18); Diabetic Education
|
Plan Updates 
