For changesin 4
Serving The Front Range of Colorado benefitssee page
Enrollment in this Plan is limited see page 4 for requirements
Enrollment code
High Option
D61 Self Only
D62 Self and Family
Standard Option
D64 Self Only For CommercialMedicare
D65 Self and Family HMO and POS products
Visit the OPM website at http www opm gov insure
and
our website at http www pacificare com colorado
Table of Contents
Page
Introduction 3
Plain language 3
How to use this brochure 3
Section 1 Health Maintenance Organizations 3
Section 2 How we change for 2000 4
Section 3 How to get benefits 4
Section 4 What to do if we deny your claim or request for service 6
Section 5 Benefits 8
Section 6 General exclusions Things we dont cover 22
Section 7 Limitations Rules that affect your benefits 22
Section 8 FEHB facts 23
Inspector General Advisory Stop Healthcare Fraud 26
Summary of benefits Inside back cover
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Page 3
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Introduction
PacifiCare of Colorado
6455 South Yosemite Street Englewood CO 80111
This Brochure describes the benefits you can receive from PacifiCare of Colorado Inc under its contract CS 1761 with the Office of
Personnel Management OPM as authorized by the Federal Employees Heath Benefits FEHB law This brochure is the official
statement of benefits on which you can rely A person enrolled in this Plan is entitled to the benefits described in this brochure If you
are enrolled for Self and Family coverage each eligible family member is also entitled to these benefits
OPM negotiates benefits and premiums with each Plan annually Benefit changes are effective January 1 2000 and are shown on page
4 Premiums are listed at the end of this brochure
Plain Language
The President and Vice President are making the Government's communication more responsive accessible and understandable to the
public by requiring agencies to use plain language Health Plan representatives and Office of Personnel Management staff have
worked cooperatively to make portions of this brochure clearer In it you will find common everyday words except for necessary
technical terms you and other personal pronouns active voice and short sentences
We refer to PacifiCare of Colorado as this Plan throughout this brochure even though in other legal documents you will see a Plan
referred to as a carrier
These changes do not affect the benefits or services we provide We have rewritten this brochure only to make it more understandable
We have not rewritten the benefits section of this brochure You will find new benefits language next year
How To Use This Brochure
This brochure has eight sections Each section has important information you should read If you want to compare this Plan's benefits with
benefits from other FEHB plans you will find that the brochures have the same format and similar information to make comparisons easier
1 Health Maintenance Organizations HMO This Plan is an HMO Turn to this section for a brief description of HMOs and
how they work
2 How we change for 2000 If you are a current member and want to see how we have changed read this section
3 How to get benefits Make sure you read this section it tells you how to get services and how we operate
4 What to do if we deny your claim or request for service This section tells you what to do if you disagree with our decision
not to pay for your claim or to deny your request for a service
5 Benefits Look here to see the benefits we will provide as well as specific exclusions and limitations You will also find information
about non FEHB benefits
6 General exclusions Things we don't cover Look here to see benefits that we will not provide
7 Limitations Rules that affect your benefits This section describes limits that can affect your benefits
8 FEHB facts Read this information about the Federal Employees Health Benefits FEHB Program
Section 1 Health Maintenance Organizations
Health Maintenance organizations HMOs are Health Plans that require you to see Plan providers specific physicians hospitals and
other providers that contract with us These providers coordinate your health care services The care you receive includes preventive
care such as routine office visits physical exams well baby care and immunizations as well as treatment for illness and injury
When you receive services from our providers you will not have to submit claim forms or pay bills However you must pay copayments
and coinsurance listed in this brochure When you receive emergency services you may have to submit claim forms
You should join an HMO because you prefer the plan's benefits not because a particular provider is available You cannot change Plans
because a provider leaves our Plan We cannot guarantee that any one physician hospital or other provider will be available and or
remain under contract with us Our providers follow generally accepted medical practice when prescribing any course of treatment
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Section 2 How We Change For 2000
Program wide changes To keep your premiums as low as possible OPM has set a minimum copay of 10 for all primary care office visits
This year you have a right to more information about this Plan care management our networks
facilities and providers
If you have a chronic or disabling condition and your provider leaves the Plan at our request you may
continue to see your specialist for up to 90 days If your provider leaves the Plan and you are in the
second or third trimester of pregnancy you may be able to continue seeing your OB GYN until the end
of your postpartum care You have similar rights if this Plan leaves the FEHB Program See Section 3
How to get benefits for more information
You may review and obtain copies of your medical records on request If you want copies of your
medical records ask your health care provider for them You may ask that a physician amend a record
that is not accurate not relevant or incomplete If the physician does not amend your record you may
add a brief statement to it If they do not provide you your records call us and we will assist you
If you are over age 50 all FEHB plans will cover a screening sigmoidoscopy every five years This
screening is for colorectal cancer
Changes to this Plan The prescription drug benefit now has 3 levels of formulary non formulary copayments 5 10 20 for High Option and 10 20 30 for Standard Option Prior authorization is no longer required
Insulin pumps and insulin pump supplies are now covered under the durable medical equipment benefit
The entire dental copayment list is now shown
Your share of the standard option premium will increase by 10 for Self Only or 10 for Self and Family
Your share of the high option premium will increase by 12 for Self Only or 12 for Self and Family
Section 3 How to get benefits
What is this Plan's To enroll with us you must live in our service area This is where our providers practice Our service service area area is
The Colorado counties of Adams Arapahoe Bent Boulder Cheyenne Clear Creek Crowley Denver
Douglas Elbert El Paso Fremont Gilpin Grand Huerfano Jefferson Kiowa Kit Carson Lake La
Plata Larimer Lincoln Logan Morgan Otero Park Phillips Pueblo Sedgwick Summit Teller
Washington Weld and Yuma
Ordinarily you must get your care from providers who contract with us If you receive care outside our
service area we will pay only for emergency care We will not pay for any other health care services
If you or a covered family member move outside of our service area you can enroll in another Plan If
your dependents lives out of the area for example if your child goes to college in another state you
should consider enrolling in a fee for service plan or an HMO that has agreements with affiliates in
other areas If you or a family member move you do not have to wait until Open Season to change
plans Contact your employing or retirement office
How much do You must share the cost of some services This is called either a copayment a set dollar amount or I pay for services coinsurance a set percentage of charges Please remember you must pay this amount when you
receive services
After you pay 3,600 in copayments or coinsurance for one family member or 10,000 for two or more
family members you do not have to make any further payments for certain services for the rest of the
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Section 3 How to get benefits continued
How much do year This is called a catastrophic limit However copayments or coinsurance for your prescription I pay for services drugs dental services and non authorized non referred services do not count toward these limits and
continued you must continue to make these payments
Be sure to keep accurate records of your copayments and coinsurance since you are responsible for
informing us when you reach the limits
Do I have to You normally won't have to submit claims to us unless you receive emergency services from a submit claims provider who doesn't contract with us If you file a claim please send us all of the documents for your
claim as soon as possible You must submit claims by December 31 of the year after the year you
received the service Either OPM or we can extend this deadline if you show that circumstances
beyond your control prevented you from filing on time
Who provides my PacifiCare of Colorado Inc is a Mixed Model HMO which means that we contract both with physicians health care who are in private practice in their own offices throughout the 34 county service area as well as
participating medical groups practicing in conveniently located group practice centers There are
approximately 1,450 primary care physicians PCPs and over 2,600 referral specialists participating
with PacifiCare of Colorado Each member can select his or her own primary care doctor
Our participating physicians are organized into Integrated Care Teams groups of PCPs and specialists
who have joined together to contract with PacifiCare PCPs belong to just one Integrated Care Team
but many specialists belong to more than one team When you need specialty care your PCP will most
likely refer you to a specialist affiliated with the PCP's own Integrated Care Team However your
PCP does have the option to refer you to any participating PacifiCare specialist when he or she
determines it is appropriate
What do I do if my Call us We will help you select a new one
primary care physician
leaves the Plan
What do I do if I need Talk to your Plan physician If you need to be hospitalized your primary care physician or specialist
to go into the hospital will make the necessary hospital arrangements and supervise your care
What do I do if I'm in First call our customer service department at 800 877 9777 If you are new to the FEHB Program we the hospital when I will arrange for you to receive care If you are currently in the FEHB Program and are switching to us
join this Plan your former plan will pay for the hospital stay until
You are discharged not merely moved to an alternative care center or
The day your benefits from your former plan run out or
The 92 nd day after you became a member of this Plan whichever happens first
These provisions apply only to the person who is hospitalized
How do I get Your primary care physician will arrange your referral to a specialist However you may see a specialty care participating primary care dentist without a referral access your mental health and substance abuse
benefits without a referral by contacting PacifiCare Behavioral Health at 888 777 2735 and access
participating OB GYNs without a referral for anything that is obstetrical or gynecological in nature A
member may also use their eye refraction benefit without a referral by contacting VSP at 888 426 4877
If you need to see a specialist frequently because of a chronic complex or serious medical condition
your primary care physician will develop a treatment plan that allows you to see your specialist for a
certain number of visits without additional referrals Your primary care physician will use our criteria when
creating your treatment plan the physician may have to get an authorization or approval beforehand
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Section 3 How to get benefits continued
What do I do if I am Your primary care physician will decide what treatment you need If he or she decides to refer you to a seeing a specialist specialist ask if you can see your current specialist If your current specialist does not participate with
when I enroll us or the physician medical group Integrated Care Team within which your PCP works you must receive treatment from a specialist who does Generally we will not pay for you to see a specialist
who does not participate with our Plan
What do I do if my Call your primary care physician who will arrange for you to see another specialist You may receive specialist leaves the Plan services from your current specialist until we can make arrangements for you to see someone else
But what if I have Please contact us if you believe your condition is chronic or disabling You may able to continue seeing a serious illness and your provider for up to 90 days after we notify you that we are terminating the contract with the
my provider leaves the provider unless the termination is for cause If you are in the second or third trimester of pregnancy Plan or this Plan leaves you may continue to see your OB GYN until the end of your postpartum care
the program You may also be able to continue seeing your provider if your Plan drops out of the FEHB Program
and you enroll in a new FEHB Plan Contact the new Plan and explain that you have a serious or
chronic condition or are in your second or third trimester Your new Plan will pay for or provide your
care for up to 90 days after you receive notice that your prior plan is leaving the FEHB Program If you
are in your second or third trimester your new plan will pay for the OB GYN care you receive from
your current provider until the end of your postpartum care
How do you authorize Your physician must get our approval before sending you to a hospital referring you to a specialist or medical services recommending follow up care Before giving approval we consider if the service is medically
necessary and if it follows generally accepted medical practice
How do you decide if a Our National and Regional Medical Committees determine whether or not treatments procedures and service is experimental drugs are no longer considered experimental or investigational Our determinations are based on the
or investigational safety and efficacy of new medical procedures technologies devices and drugs
Section 4 What to do if we deny your claim or request for service
If we deny your services or won't pay your claim you may ask us to reconsider our decision Your request must
1 Be in writing
2 Refer to specific brochure wording explaining why you believe our decision is wrong and
3 Be made within six months from the date of our initial denial or refusal We may extend this time limit if you show that you were
unable to make a timely request due to reasons beyond your control
We have 30 days from the date we receive your reconsideration request to
1 Maintain our denial in writing
2 Pay the claim
3 Arrange for a health care provider to give you the service or
4 Ask for more information
If we ask your medical provider for more information we will send you a copy of our request We must make a decision within 30
days after we receive the additional information If we do not receive the requested information within 60 days we will make our
decision based on the information we already have
When may I ask OPM You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal OPM to review a denial will determine if we correctly applied the terms of our contract when we denied your claim or request
for service
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Section 4 What to do if we deny your claim or request for service continued
What if I have a serious Call us at 800 877 9777 and we will expedite our review or life threatening
condition and you haven't responded to
my request for service
What if you have denied If we expedite your review due to a serious medical condition and deny your claim we will inform my request for care and OPM so that they can give your claim expedited treatment too
my condition is serious or life threatening Alternatively you can call OPM's health benefits Contract Division IV at 202 606 0737 between 8
a m and 5 p m Serious or life threatening conditions are ones that may cause permanent loss of
bodily functions or death if they are not treated as soon as possible
Are there other You must write to OPM and ask them to review our decision within 90 days after we uphold our initial time limits denial or refusal of service You may also ask OPM to review your claim if
1 We did not answer your question within 30 days In this case OPM must receive your request
within 120 days of the date you asked us to reconsider your claim
2 You provided us with additional information we asked for and we did not answer within 30 days In
this case OPM must receive your request within 120 days of the date we asked you for additional
information
What do I send to OPM Your request must be complete or OPM will return it to you You must send the following information
1 A statement about why you believe our decision is wrong based on specific benefit provisions in
this brochure
2 Copies of documents that support your claim such as physicians letters operative reports bills
medical records and explanation of benefits EOB forms
3 Copies of all letters you sent us about the claim
4 Copies of all letters we sent you about the claim and
5 Your daytime phone number and the best time to call
If you want OPM to review different claims you must clearly identify which documents apply to
which claim
Who can make Those who have a legal right to file a disputed claim with OPM are the request
1 Anyone enrolled in the Plan
2 The estate of a person once enrolled in the Plan and
3 Medical providers legal counsel and other interested parties who are acting as the enrolled person's
representative They must send a copy of the person's specific written consent with the review request
What address should I Send your request for review to Office of Personnel Management Office of Insurance Programs send my disputed claim to Contracts Division IV P O Box 436 Washington D C 20044
What if OPM upholds OPM's decision is final There are no other administrative appeals If OPM agrees with our decision the Plan's denial your only recourse is to sue
If you decide to sue you must file the suit against OPM in Federal court by December 31 of the third
year after the year in which you received the disputed services or supplies
What laws apply if I Federal law governs your lawsuit benefits and payment of benefits The Federal court will base its file a lawsuit review on the record that was before OPM when OPM made its decision on your claim You may
recover only the amount of benefits in dispute
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Section 4 What to do if we deny your claim or request for service continued
What laws apply if I You or a person acting on your behalf may not sue to recover benefits on a claim for treatment file a lawsuit services supplies or drugs covered by us until you have completed the OPM review procedure
continued described above
Your records and Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you and the Privacy Act us to determine if our denial of your claim is correct The information OPM collects during the review
process becomes a permanent part of your disputed claims file and is subject to the provisions of the
Freedom of Information Act and Privacy Act OPM may disclose this information to support the
disputed claim decision If you file a lawsuit this information will become part of the court record
Section 5 Medical and Surgical Benefits
What is covered A comprehensive range of preventive diagnostic and treatment services is provided by Plan doctors and other Plan providers This includes all necessary office visits
High Option You pay a 10 copay per office visit 10 copay for a doctor's house call no copay for
home visits by nurses and therapists
Standard Option You pay a 15 copay per office visit a 100 copay for outpatient surgery and 23 hour observation 15 copay for
a doctor's house call no copay for home visits by nurses and therapists
The following services are included
Preventive care including well baby well child care and periodic check ups
Mammograms are covered as follows for women age 35 through 39 one mammogram during
these five years for women age 40 through 49 one mammogram every one or two years for
women age 50 through 64 one mammogram every year and for women age 65 and above one
mammogram every two years In addition to routine screening mammograms are covered when
prescribed by the doctor as medically necessary to diagnose or treat your illness
Routine immunizations and boosters
Consultations by specialists
Diagnostic procedures such as laboratory tests and X rays
Complete obstetrical maternity care for all covered females including prenatal delivery and
postnatal care by a Plan doctor The mother at her option may remain in the hospital up to 48
hours after a regular delivery and 96 hours after a cesarean delivery Inpatient stays will be
extended if medically necessary If enrollment in the Plan is terminated during pregnancy benefits
will not be provided after coverage under the Plan has ended Ordinary nursery care of the newborn
child during the covered portion of the mother's hospital confinement for maternity will be covered
under either a Self Only or Self and Family enrollment other care of an infant who requires
definitive treatment will be covered only if the infant is covered under a Self and Family enrollment
Voluntary sterilization family planning services Norplant a surgically implanted contraceptive
Injectable contraceptive drugs and Intrauterine Devices IUDs
Diagnosis and treatment of diseases of the eye
The insertion of internal prosthetic devices such as pacemakers lenses following cataract removal
cochlear implants surgically implanted breast prostheses following mastectomy and artificial joints
Cornea heart heart lung kidney and liver transplants allogeneic donor bone marrow transplants
autologous bone marrow transplants autologous stem cell and peripheral stem cell support for
the following conditions acute lymphocytic or non lymphocytic leukemia advanced Hodgkin's
lymphoma advanced non Hodgkin's lymphoma advanced neuroblastoma testicular mediastinal
retroperitoneal and ovarian germ cell tumors breast cancer multiple myeloma and epithelial
ovarian cancer
8 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Section 5 Medical and Surgical Benefits continued
What is covered Treatment for breast cancer multiple myeloma and epithelial ovarian cancer may be provided in continued an NCI or NIH approved clinical trial at a Plan designated center of excellence and if approved
by the Plan's medical director in accordance with the Plan's protocols Related medical and
hospital expenses of the donor are covered
Women who undergo mastectomies may at their option have this procedure performed on an
inpatient basis and remain in the hospital up to 48 hours after the procedure
Dialysis
Blood and blood plasma
Chemotherapy radiation therapy and inhalation therapy
Surgical treatment of morbid obesity based on criteria established by the Plan
Home health services of nurses and therapists including intravenous fluids and medications
when prescribed by your Plan doctor who will periodically review the program for continuing
appropriateness and need Mothers with newborns released from the hospital in accordance with
PacifiCare of Colorado guidelines are entitled to one visit at home by a nurse as well as the
services of a homemaker for four hours on two days within 30 days following delivery
All necessary medical or surgical care in a hospital or extended care facility from Plan doctors and
other Plan providers
Limited benefits Allergy testing and treatment are provided You pay 10 copay High Option or 15 copay Standard Option for a comprehensive diagnostic allergy evaluation In addition you pay a 10 copay High
Option or 15 copay Standard Option for each doctor's office visit or you pay 5 per visit for an
injection when a physician is not seen
Durable medical equipment limited to apnea monitors bilirubin lights or blankets bone stimulators
continuous passive motion machines CPM feeding pumps hospital beds insulin pump supplies
including cartridges extension tubing batteries infusion sets and customary dressings provided by
the pump supplier to secure infusion sets lymphedema pumps nebulizers positive airway pressure
devices C PAP Bi PAP suction machines traction equipment ventilators external extremity
prosthetics or oxygen is covered up to 1,500 per member per calendar year when the use of the
equipment will permit care in other than an acute care or rehab facility Additionally surgical bras
including external prosthesis will be covered up to 250 per member per contract year Orthopedic
braces and podiatric shoe inserts meeting criteria are covered up to a combined maximum of 500 per
member per calendar year Coverage is provided for one peak flow meter per member per lifetime
and one glucometer per member per lifetime Coverage is also provided for insulin pumps meeting
criteria not subject to the 1,500 maximum described above You pay nothing
Oral and maxillofacial surgery is provided for nondental surgical and hospitalization procedures for
congenital defects such as cleft lip and cleft palate and for medical or surgical procedures occurring
within or adjacent to the oral cavity or sinuses including but not limited to treatment of fractures and
excision of tumors and cysts All other procedures involving the teeth or intra oral areas surrounding
the teeth are not covered including any dental care involved in treatment of temporomandibular joint
TMJ pain dysfunction syndrome
Reconstructive surgery will be provided to correct a condition that has resulted in a functional defect
or that has resulted from an injury or surgery that has produced a major effect on the member's appearance
and the condition can reasonably be expected to be corrected by such surgery A patient and her attending
physician may decide whether to have breast reconstruction surgery following a mastectomy and whether
surgery on the other breast is needed to produce symmetrical appearance
Short term rehabilitative therapy physical speech and occupational is provided on an inpatient or
outpatient basis outpatient therapy is limited to whichever is greater 20 visits or two months per condition
if significant improvement can be expected within two months You pay nothing for inpatient or home
therapy you pay a 10 copay High Option or a 15 copay Standard Option per outpatient
session Speech therapy is limited to care required immediately following an acute episode
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 9
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Section 5 Medical and Surgical Benefits continued
Limited benefits for stroke surgery to the larynx accidental brain injury not birth related and hearing loss in 3 5 year continued old children based on criteria Occupational therapy is limited to services that assist the member to
achieve and maintain self care and improved functioning in other activities of daily living
Diagnosis and treatment of infertility as well as artificial insemination are covered you pay a 50
copay cost of donor sperm is not covered The following types of artificial insemination are covered
intravaginal insemination IVI intracervical insemination ICI and intrauterine insemination IUI
Fertility drugs are not covered Other assisted reproductive technology ART procedures such as
in vitro fertilization and embryo transfer are not covered
Cardiac rehabilitation following a heart transplant bypass surgery or a myocardial infarction is
provided at an approved facility for short term follow up care up to 90 sessions you pay nothing
What is not covered Physical examinations that are not necessary for medical reasons such as those required for obtaining or continuing employment or insurance attending school or camp or travel
Reversal of voluntary surgically induced sterility
Surgery primarily for cosmetic purposes
Transplants not listed as covered
Blood derivatives not replaced by member
Hearing aids
Long term rehabilitative therapy
Chiropractic services
Homemaker services except for mothers with newborns and services of home health aides
Obesity treatment except for surgical treatment of morbid obesity
Premenstrual PMS lactation headache eating disorder and other educational clinics
Foot orthotics except as covered under Durable medical equipment
Total Parenteral Nutrition TPN
Section 5 HospitalExtended Care Benefits
What is covered
Hospital Care The Plan provides a comprehensive range of benefits with no dollar or day limit when you are hospitalized
under the care of a Plan doctor
High Option You pay nothing
Standard Option You pay a 300 deductible per person per year 500 maximum per family per year
All necessary services are covered including
Semiprivate room accommodations when a Plan doctor determines it is medically necessary the
doctor may prescribe private accommodations or private duty nursing care
Specialized care units such as intensive care or cardiac care units
Extended care The Plan provides a comprehensive range of benefits for up to 120 days per calendar year when full time
skilled nursing care is necessary and confinement in a skilled nursing facility is medically appropriate
as determined by a Plan doctor and approved by the Plan You pay nothing for up to 120 days per
year all charges thereafter All necessary services are covered including
10 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Section 5 HospitalExtended Care Benefits continued
Extended care Bed board and general nursing care
continued
Drugs biologicals supplies and equipment ordinarily provided or arranged by the skilled nursing
facility when prescribed by a Plan doctor
Subacute care facility services following hospitalization including accommodations meals general
nursing care medical supplies and equipment ordinarily furnished by the facility and prescribed drugs
and biologicals are covered up to sixty 60 days per contract year at an approved subacute care facility
Hospice Care Supportive and palliative care for a terminally ill member is covered in the home or hospice facility
when approved by the PacifiCare of Colorado Medical Director Services include inpatient and
outpatient care and family counseling these services are provided under the direction of a Plan doctor
who certifies that the patient is in the terminal stages of illness with a life expectancy of approximately
six months or less
Ambulance service Benefits are provided for air and ground ambulance transportation ordered or authorized by a Plan
doctor you pay a 25 copay per trip
Limited benefits
Acute inpatient Hospitalization for medical treatment of substance abuse is limited to emergency care diagnosis
detoxification treatment of medical conditions and medical management of withdrawal symptoms acute detoxification if
the Plan doctor determines that outpatient management or treatment in a Plan rehab facility either
inpatient or outpatient is not medically appropriate If treated in a Plan rehab facility for detoxification
you pay nothing High Option you pay 100 Standard Option See pages 13 and 14 for nonmedical
substance abuse benefits
What is not covered Personal comfort items such as telephone and television
Blood not replaced by member
Custodial care rest cures domiciliary or convalescent care
Hospitalization for any dental procedures
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
Section 5 Emergency Benefits
What is a medical A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe emergency endangers your life or could result in serious injury or disability and requires immediate medical or
surgical care Some problems are emergencies because if not treated promptly they might become
more serious examples include deep cuts and broken bones Others are emergencies because they are
potentially life threatening such as heart attacks strokes poisonings gunshot wounds or sudden
inability to breathe There are many other acute conditions that the Plan may determine are medical
emergencies what they all have in common is the need for quick action
Emergencies within If you are in an emergency situation please call your primary care doctor If you cannot reach your primary the service area care doctor or his her coverage call PacifiCare at 800 877 6685 for assistance In extreme emergencies
if you are unable to contact your doctor contact the local emergency system e g the 911 telephone system
or go to the nearest hospital emergency room Be sure to tell the emergency room personnel that you are a
Plan member so they can notify the Plan You or a family member must notify the Plan within 48 hours unless
it was not reasonably possible to do so It is your responsibility to ensure that the Plan has been timely notified
If you need to be hospitalized the Plan must be notified within 48 hours or on the first working day
following your admission unless it was not reasonably possible to notify the Plan within that time If you
are hospitalized in non Plan facilities and Plan doctors believe care can be better provided in a Plan
hospital you will be transferred when medically feasible with any ambulance charges covered in full
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Section 5 Emergency Benefits continued
Emergencies within Benefits are available for care from non Plan providers in a medical emergency only if delay in the service area reaching a Plan provider would result in death disability or significant jeopardy to your condition
To be covered by this Plan any follow up care recommended by non Plan providers must be approved
by the Plan or provided by Plan providers
Plan pays Reasonable charges for emergency services to the extent the services would have been covered if
received from Plan providers or per urgent care center visit where a facility charge is made
You pay A 25 copay per physician office visit or per urgent care center visit where no facility charge is made
or a 50 copay per hospital emergency room visit or per urgent care center visit where a facility charge
is made for emergency care services that are covered benefits of this Plan If the emergency results in
an admission to a hospital the copay is waived Standard Option members also pay a 300 deductible
per person per contract year up to a maximum of 500 per family per year
Emergencies outside Benefits are available for any medically necessary health service that is immediately required because the service area of injury or unforeseen illness
If you need to be hospitalized the Plan must be notified within 48 hours or on the first working day
following your admission unless it was not reasonably possible to notify the Plan within that time If a
Plan doctor believes care can be better provided in a Plan hospital you will be transferred when
medically feasible with any ambulance charges covered in full
To be covered by this Plan any follow up care recommended by non Plan providers must be approved
by the Plan or provided by the Plan providers
Plan pays Reasonable charges for emergency care services to the extent the services would have been covered if
received from Plan providers In addition to coverage of emergency services follow up care to
emergency services received outside the service area or urgently needed services are covered up to a
maximum PacifiCare of Colorado payment of 400 per person per calendar year
You pay A 25 copay per physician office visit or per urgent care center visit where no facility charge is made
or a 50 copay per hospital emergency room visit or per urgent care center visit where a facility charge
is made for emergency care services that are covered benefits of this Plan If the emergency results in
an admission to a hospital the emergency care copay is waived Standard Option members also pay
a 300 deductible per person per contract year up to a maximum of 500 per family per year for any
inpatient services
What is covered Emergency or urgent care at a doctor's office or at an urgent care center including follow up care to emergency services received outside the service area
Emergency care as an outpatient or inpatient at a hospital including doctors services
Ground or air ambulance service approved by the Plan you pay a 25 copayment
What is not covered Elective care or nonemergency care
Emergency care provided outside the service area if the need for care could have been foreseen
before leaving the service area
Medical and hospital costs resulting from a normal full term delivery of a baby outside the service area
Filing claims for With your authorization the Plan will pay benefits directly to the providers of your emergency care non Plan providers upon receipt of their claims Physician claims should be submitted on the HCFA 1500 claim form If
you are required to pay for the services submit itemized bills and your receipts to the Plan along with
an explanation of the services and the identification information from your ID card
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Section 5 Emergency Benefits continued
Filing claims for Payment will be sent to you or the provider if you did not pay the bill unless the claim is denied If non Plan providers it is denied you will receive notice of the decision including the reasons for the denial and the provisions
continued of the contract on which denial was based If you disagree with the Plan's decision you may request
reconsideration in accordance with the disputed claims procedure described on pages 6 7 and 8
Section 5 Mental ConditionsSubstance Abuse Benefits
Mental conditions
What is covered To the extent shown below the Plan provides the following services necessary for the diagnosis and treatment of acute psychiatric conditions including the treatment of mental illness or disorders
Diagnostic evaluation
Psychological testing
Psychiatric treatment including individual and group therapy
Hospitalization including inpatient professional services
No primary care physician referral is necessary to access mental health and substance abuse services
To access these benefits call PacifiCare Behavioral Health at 888 777 2735
The following six conditions will be covered as medical rather than mental health schizophrenia
schizoaffective disorder bipolar affective disorder major depressive disorder specific obsessivecompulsive
disorder and panic disorder
Outpatient care Visits are based on medical necessity with no pre determined limit on the number of visits allowed
You pay a 25 copayment per visit
Inpatient care Coverage of inpatient days will be based on medical necessity with no pre determined limit on the
number of days allowed
High Option You pay nothing
Standard Option You pay a 300 deductible per person per year up to a maximum of 500 per family per year for any inpatient
services
What is not covered Care for psychiatric conditions that in the professional judgment of Plan providers are not subject to significant improvement through relatively short term treatment
Psychiatric evaluation or therapy on court order or as a condition of parole or probation unless
determined by a Plan provider to be necessary and appropriate
Psychological testing when not medically necessary to determine the appropriate treatment of a
short term psychiatric condition
Substance abuse
What is covered This Plan provides medical and hospital services such as acute detoxification services for the medical non psychiatric aspects of substance abuse including alcoholism and drug addiction the same as for
any other illness or condition and to the extent shown below the services necessary for diagnosis and
treatment
Outpatient care Up to 90 outpatient visits each calendar year for treatment at a rehab center approved by the Plan you
pay nothing for up to 90 visits all charges thereafter
The substance abuse benefit may be combined with the outpatient mental conditions benefit shown
above provided such treatment is necessary as a mental health service and is approved by the Plan to
permit additional outpatient visits subject to the applicable mental conditions benefit copayments
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 13
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Section 5 Mental ConditionsSubstance Abuse Benefits continued
Substance abuse continued
Inpatient care Up to 45 days of substance abuse rehabilitation intermediate care programs each calendar year in a
rehab center approved by the Plan you pay nothing during the benefit period all charges thereafter
Rehabilitation services are limited to one course of treatment either inpatient or outpatient per
member per calendar year There is a combined inpatient and outpatient lifetime maximum of two
courses of treatment
What is not covered Treatment that is not authorized by a Plan provider
All charges if the member does not complete the treatment program
Substance abuse treatment on court order or as a condition of parole or probation unless determined
by a Plan provider to be necessary and appropriate
Section 5 Prescription Drug Benefits
What is covered Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan pharmacy will be dispensed for up to a 30 day supply or the manufacturer's standard trade package size not to exceed
one pint 16 oz of liquid 60 grams of ointment creams or topical preparation or one commercially
prepared unit i e one inhaler one vial Drugs are prescribed by Plan doctors and dispensed in
accordance with the Plan's drug formulary Non formulary drugs will be covered when prescribed by
a Plan doctor Prior authorization is no longer needed as there are now different copayments for
formulary and non formulary medications Quantity limitations and benefit plan exclusions still apply
The PacifiCare Formulary is a list of over 1600 prescription drugs that physicians use as a guide when
prescribing medications for patients The Formulary plays an important role in providing safe
effective and affordable prescription drugs to PacifiCare members It also allows us to work together
with physicians and pharmacies to ensure that our members are getting the drug therapy they need A
Pharmacy and Therapeutics Committee consisting of physicians and pharmacists evaluate prescription
drugs based on safety effectiveness quality treatment and overall value The committee considers first
and foremost the safety and effectiveness of a medication before reviewing the cost
Please Note PacifiCare of Colorado does not coordinate benefits for outpatient prescription drugs
High Option You pay a 5 copayment for a generic prescription on the formulary a 10 copayment
for a brand name prescription on the formulary or a 20 copayment for a covered prescription that is
not on the formulary
Standard Option You pay a 10 copayment for a generic prescription on the formulary a 20 copayment for a brand name
prescription on the formulary or a 30 copayment for a covered prescription that is not on the formulary
Maintenance medications requiring a 90 day supply or more can be filled through a mail order
prescription drug program You pay the copay that applies to your enrollment option for each 30 day
supply You pay 2 formulary copays per 90 day supply or up to 4 pre packaged units for a formulary
medication You pay 3 non formulary copays minus 15 for a 90 day supply or up to 4 pre packaged
units for a non formulary medication Contact PacifiCare of Colorado's Customer Service Department
at 800 877 9777 for more information and to receive a mail order form
Covered medications and accessories include
Drugs for which a prescription is required by law
Oral contraceptive drugs contraceptive diaphragms and cervical caps subject to name brand drug
copayments
Implanted time release medications such as Norplant and injectable contraceptive drugs are
covered Please see Medical and Surgical Benefits What is covered on page 8
14 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Section 5 Prescription Drug Benefits continued
What is covered Insulin with a copay charge applied to every two vials You can receive up to six vials of insulin continued through the mail order program You pay two copays for formulary insulin or 3 non formulary
copays minus 15 for a non formulary insulin
Injectable drugs except insulin when preauthorized you pay a 10 copay per prescription unit
or refill under both options
Disposable needles and syringes needed to inject covered prescribed medication needles and syringes
dispensed in the manufacturer's standard trade package will be subject to the name brand copayment
Intravenous fluids and medication for home use are covered under Medical and Surgical Benefits
covered under Home Health Services see page 9
Commercially prepared progesterone and estrogen products that meet prior authorization requirements
Limited Benefits Diabetic glucose and ketone test strips and lancets are covered and dispensed in the
manufacturer's standard trade size package You pay the applicable copay per manufacturer's
standard trade size package unit up to 100 test strips or 200 lancets per 30 day supply
Drugs to treat sexual dysfunction are covered when plan criteria is met Contact the plan for dose
limits You pay 50 of the cost of the medication per prescription unit or refill up to the dosage
limits and all charges above that
What is not covered Drugs available without a prescription or for which there is a nonprescription equivalent available
Drugs obtained at a non Plan pharmacy except for out of area emergencies
Vitamins and nutritional substances that can be purchased without a prescription
Medical supplies such as dressings and antiseptics
Contraceptive devices except injectables diaphragms intrauterine devices IUDs and cervical caps
Smoking cessation drugs and medication including nicotine patches except through the
StopSmoking program
Drugs for weight reduction
Lifestyle enhancement drugs including but not limited to drugs to enhance hair growth anti aging
and mental performance
Fertility drugs
Drugs for cosmetic purposes
Drugs to enhance athletic performance
Convenience packaged medications including but not limited to Insulin penfil and Questran
individual packages
Section 5 Other Benefits
Dental Care This plan provides the following comprehensive program of dental coverage through participating Plan dentists This listing represents a description of the benefits and exclusions For more detailed
information regarding covered services and claims related concerns call PacifiCare Dental Customer
Services at 800 228 3384
Choosing your dentist Please select a dentist from the list of Dental Providers available in your area for each member of
your family Your dental benefits and services are available only through the participating dentist you
selected except for out of area emergencies However you may change dentists by calling PacifiCare
Dental Customer Services
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 15
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Section 5 Other Benefits continued
Dental Care continued
Receiving care Member fees are due at the time of service
NOTE Your dentist may prescribe certain procedures not covered under your Plan benefit Nonmember
fees will be charged for such services Where UCR is shown the procedure is not a covered
benefit and you pay the dentist's usual customary and reasonable fee for that service
Specialty care If you receive care from a specialist you pay a 50 member payment High Option and a 60 member payment Standard Option of the PacifiCare contracted specialists fee schedule
PacifiCare Dental maintains a panel of qualified Dental Specialists to provide you with the treatment
that is beyond the scope of the General Dentist Once PacifiCare has reviewed and approved the
recommended specialty referral PacifiCare will coordinate the referral to the closest specialist in your area
What is covered The copayments due at your PacifiCare primary care dentists office are
High Option Standard Option
You Pay You Pay
Visits Office Visit per visit charge in addition to procedure 5 5
may be referred to as a sterilization charge in some offices After hours visit in addition to service provided 30 30
Missed appointment without 24 hours notice copay per each 30 minutes of appointment time 20 20
Preventive Emergency treatment palliative 10 10
Routine teeth cleaning once every 6 months 0 10 Topical application to age 14 0 7
Oral Hygiene Instructions 0 0 Diagnostic film allowance includes exam and diagnosis
Single film 0 4 Additional up to 12 films 0 3
Full mouth series including bitewings if necessary 0 17 Intraoral occlusal view 0 4
Bitewing films 2 films 0 5 Bitewing films 4 films 0 9
Panographictype film 0 20 Restorative Dentistry fillings
Amalgam Restorations Primary teeth 1 surface 5 16
Primary teeth 2 surfaces 8 20 Primary teeth 3 surfaces 11 25
Primary teeth 4 or more surfaces 13 28 Permanent teeth 1 surface 6 18
Permanent teeth 2 surfaces 9 22 Permanent teeth 3 surfaces 12 26
Permanent teeth 4 or more surfaces 14 30 Composite Resins tooth colored fillings fee includes acid etching andor bonding
1 Surface anterior 12 20 2 Surfaces anterior 17 28
3 Surfaces anterior 22 36 4 Surfaces anterior 25 42
Pin retention per tooth not including restoration 15 UCR Sealants per tooth 10 10
Sedative base 0 10 Oral Surgery
Extractions fee includes local anesthesia and routine postoperative visits Uncomplicated single extraction 7 18
Each additional uncomplicated extraction 7 18
16 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Section 5 Other Benefits continued
Dental Care continued
Oral Surgery continued Surgical removal of an erupted tooth 12 28
Removal of impacted tooth soft tissue 50 60 Removal of impacted tooth partially bony 70 85
Removal of impacted tooth completely bony 90 110 Other Procedures
Postoperative visit complications ie osteitis 0 0 Biopsy and microscopic examination 20 UCR
Alveoloplasty edentulous per quadrant 70 85 Alveoloectomy per quadrant 50 65
Intraoral incision and drainage of abscess soft tissue 30 UCR Frenectomy 30 45
Removal of exostosis tori 50 UCR Anesthesia
Additional charges for general anesthetics nitrous oxide anesthetists or anesthesiologists are the responsibility of the patient
Local anesthesia 0 0 Periodontics
Periodontal maintenance procedures following active surgical and adjunctive periodontal therapies 40 50
Scaling and root planing per quadrant 40 50 Full mouth debridement 40 50
Correction of occlusion per quadrant minor spot grinding equilibration not a covered benefit 18 26
Gingivectomy per quadrant includes postsurgical visits 150 175 Osseous or mucogingival surgery per quadrant
includes postsurgical visits 275 300 Gingivectomy treatment per tooth 30 35
Gingival flap procedures includes RP Quad 135 UCR Endodontics
Direct pulp capping 6 12 Therapeutic pulpotomy in addition to restoration per
treatment 6 20 Indirect pulp capping recalcification including temporary
restoration 10 15 Root Canal Therapy
Anterior RCT 85 110 Bicuspid RCT 12 canals 110 160
Molar RCT 1 canal 85 110 Molar RCT 2 canals 110 160
Molar RCT 3 canals 165 220 Molar RCT 4 canals 185 250
Apicoectomy andor retrograde therapyper tooth 160 180 Apicoectomy separate procedure per tooth 100 120
Hemisection root amputation 60 UCR Crown and Bridge
Crowns Plastic permanent processed 80 120
Porcelain jacket 200 260 Porcelain with metal 200 260
Full cast metal 190 240 34 metal 190 240
Crown build up extensive amalgamcomposite including pins 45 UCR Stainless steel primary 40 50
Stainless steel permanent 40 50 Preformed post and build up 45 UCR
Cast post with core or coping 75 UCR Crown recementation or inlay 10 15
Bridge recementation 15 20 Pontics artificial tooth on a fixed bridge
Cast metal 190 240 Porcelain with metal 200 260
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 17
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Section 5 Other Benefits continued
Dental Care continued
What is covered Prosthetics removable continued Dentures
Dentures partial dentures and reline allowances include adjustments for a 90day period following installation Fees for specialized techniques involving precision dentures personalization or characterization
are in addition to those listed Complete upper or lower denture 240 300
Immediate upper or lower denture 260 320 Partial acrylic upper or lower base teethclasps extra 80 100
Partial upper or lower with chrome cobalt alloy palatal or lingual bar and acrylic saddles teethclasps extra 295 350
Unilateral partial base 80 100 Anterior stayplate basetemporary 60 75
Teeth and clasps extra per unit for partials stayplates etc 10 15 Denturepartial adjustment 10 15
Office reline cold cure acrylic 45 85 Denture reline laboratory 75 110
Tissue conditioning per denture 15 UCR Denture duplication jump case per denture 80 110
Simple stress breakers 25 30 Repairs
Denturepartial resin base no teeth involved 30 40 Replace missing or broken teeth each 20 25
Replace missing or broken clasp each 30 35 Space Maintainers
Removable plastic 40 50 Fixed unilateral band type 40 50
Fixed stainless steel crown type 40 50 Fixed lingual palatal bar type or bilateral 40 50
Where precious metal is used additional copayment will be required Additional fees will be required for laboratory services for removable prosthetics not to exceed 80
Emergency benefit Coverage is limited to palliative treatment of infection and pain Definitive treatment is not covered outside the service area The out of area coverage reimburses the usual and customary fee up to a maximum of 50 per occurrence
PacifiCare must be notified within 30 days
In Area emergency In emergency situations PacifiCare Dental primary care dentists shall furnish such care as needed immediately or if appropriate not more than 24 hours after the request Dental emergencies are
defined as conditions where hemorrhage acute pain or infection of dental origin exists
During Normal Business Hours Contact your primary care dental office If you are unable to
contact your primary care dental office please call PacifiCare Dental at 800 228 3384 and a Dental
Customer Services Representative will assist you
After Normal Business Hours Contact your primary care dental office If you are unable to contact
your primary care dental office you may seek emergency care only at any licensed dental office
PacifiCare Dental will reimburse you up to 50
For emergency care requiring an after hours appointment you may be assessed a 30 visit charge in
addition to any copayment
Out of Area emergency Out of area emergencies are covered as follows if the member develops a condition or sustains an injury while temporarily outside of the PacifiCare of Colorado service area the need for such care was
not reasonably foreseeable and it is not feasible for the member to call PacifiCare and present him
herself to a PacifiCare dentist
Reimbursement Claims for emergency benefits should be filed with PacifiCare Dental Services P O Box 483 Tustin CA for emergencies 92781 within 30 days after the emergency care and must provide sufficient information to verify
entitlement to payment Include
covered member's name and ID number
dentist's name
18 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Section 5 Other Benefits continued
Dental Care continued
Reimbursement nature of problem for emergencies
continued date of treatment
treatment given
itemized charges
copy of receipt
What is not covered Care by non Plan dentists except for authorized referrals or emergencies
Cosmetic dental care
Hospital and medical charges of any kind including dental services rendered in a hospital
General anesthesia including intravenous or inhalation sedation except when medically necessary
for extractions only
Loss or theft of dentures appliances or bridgework
Dental treatment started prior to the member's eligibility to receive benefits under this Plan or
started after the member's termination
Other dental services not shown as covered
Orthodontics Through a PacifiCare panel Orthodontist plan members are eligible to receive up to a 2 year orthodontic treatment provided by a PacifiCare contracted provider You pay orthodontic charges of 1950 for
members under 19 years of age and 2200 for members 19 years or older plus 300 start up fees
250 retention fees and X ray costs
What is covered Comprehensive orthodontic care at a panel orthodontic office for a usual and customary 24 month treatment plan
The start up services shall include initial examination study models diagnosis consultation and
placement of orthodontic appliances braces
The retention services may include impressions for post treatment retainers placement of
retainers retainer adjustments and post treatment supervision as needed The normal retention fee
is 250 and shall not exceed this amount This amount is limited to the customary 24 month
retention phase
The orthodontist has agreed that any course of orthodontic treatment initiated under this plan shall
be completed at the election of the member under the terms conditions and fees provided herein
should the member become ineligible as a Plan member prior to completion of orthodontic treatment
A qualified member with cleft lip palate is not subject to the limits of this Plan and the benefit for
the services of a specialist shall apply as stated at the beginning of the dental benefit description
Administrative Fee If you do not keep an appointment and fail to notify the provider office of
cancellation 24 hours in advance you may be assessed a service charge
Limitations Orthodontic treatment must be provided by a member of the PacifiCare orthodontic panel
Cases that are other than basic and usual may require additional charges
If a member does not require treatment or elects not to have treatment after the doctor has
completed a diagnosis and consultation the patient may be charged a consultation fee of 85
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 19
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Section 5 Other Benefits continued
Orthodontics continued
What is not covered X ray fees orthodontic
Start up and retention as described under Orthodontic Benefits
Lost stolen or broken appliances
Procedures not listed or procedures required in addition to basic usual and customary orthodontic
services including palatal expansion devices functional appliances and myofunctional therapy
Work in progress i e cases banded prior to inception of eligibility
Orthodontic emergencies or changes in treatment necessitated by accidents of any kind adverse
growth patterns or poor patient cooperation
Orthodontic treatment and or surgical procedures for skeletal abnormalities such as micrognathia
facial asymmetrical and facial deformities
Treatment related to temporomandibular joint disorders
Any procedures considered within the field of general dentistry and those not usually performed in
the orthodontic office
Severe or mutilated malocclusions that are not amiable to ideal orthodontic therapy
Orthodontic treatment of impacted teeth requiring surgical exposure
Cosmetic braces plastic ceramic sapphire lingual etc
Vision Care
What is covered In addition to the medical and surgical benefits provided for diagnosis and treatment of diseases of the eye eye refractions to provide a written lens prescription may be obtained every 24 months from
Plan providers You may go directly to a participating VSP case manager without a PCP referral or
authorization from VSP For a list of participating providers call VSP at 888 426 4877 You pay a 10
copay High Option or a 15 copay Standard Option per refraction
What is not covered Corrective lenses or frames
Eye exercises
Radial keratotomy and Excimer Laser Surgery
Smoking Cessation Clinics
What is covered PacifiCare of Colorado is pleased to offer StopSmoking a one year self directed self paced smoking cessation program to our members The StopSmoking program includes regularly scheduled
motivational phone calls with a trained smoking cessation specialist and a StopSmoking kit complete
with video and audio tapes and brochures to guide smokers to quit There is a one time charge of 20
for enrollment in the StopSmoking program
After enrollment in the program a letter is sent to your PCP to inform him or her of your participation
Additionally with a prescription from your PCP Federal members in the StopSmoking program have
coverage for two smoking cessation aid products Habitrol a transdermal patch used in nicotine
replacement therapy or Zyban a prescription drug that has been shown effective in reducing the urge
to smoke Up to a 30 day supply of any dosage will be covered for a 20 copayment Coverage of
these aids is available for up to 90 days per year limited to 3 years per lifetime
To enroll in the StopSmoking program or for more information please call 800 513 5131
20 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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NonFEHB Benefits Available to Plan Members The benefits described on this page are neither offered nor guaranteed under the contract with the FEHB Program
but are made available to all enrollees and family members who are members of this Plan The cost of the benefits
described on this page is not included in the FEHB premium any charges for these services do not count toward any
FEHB deductibles out of pocket maximum copay charges etc These benefits are not subject to the FEHB disputed
claims procedures
Medicare prepaid plan enrollment This Plan offers Medicare recipients the opportunity to enroll in the Plan through Medicare As indicated on page 22 annuitants and former spouses with FEHB coverage and Medicare Part B
may elect to drop their FEHB coverage and enroll in a Medicare prepaid plan when one is available in their area
They may then later reenroll in the FEHB Program Most Federal annuitants have Medicare Part A Those without
Medicare Part A may join this Medicare prepaid plan but will probably have to pay for hospital coverage in addition
to the Part B premium Before you join the plan ask whether the plan covers hospital benefits and if so what you
will have to pay Contact your retirement system for information on dropping your FEHB enrollment and changing
to a Medicare prepaid plan
If you are Medicare eligible and are interested in enrolling in a Medicare HMO sponsored by this Plan without
dropping your enrollment in this Plan's FEHB plan call 800 771 4347 for information on the benefits available
under the Medicare HMO
Secure Horizons offered by PacifiCare is a health care management program for Medicare eligible enrollees In
the State of Colorado over 70,000 seniors are currently covered These enrollees live within our approved Medicare
Service area which includes the counties of Adams Arapahoe Boulder Crowley Denver Douglas El Paso
Fremont Huerfano Jefferson Larimer Otero Pueblo Teller and Weld
For individuals with Medicare Parts A and B the Secure Horizons product ranges from no premium to 35 per
member per month These low premiums are possible because we are administering Medicare benefits in a defined
service area with a select group of physicians hospitals and ancillary providers The range in your actual cost is
dependent upon the county in which you reside
Outside of the low monthly premium some of the other Secure Horizons highlights are
No deductibles
Coverage for preventive care eye exams hearing exams mammograms and physical examinations
Hospitalization covered in full
Low predictable copayments
Coverage for outpatient prescription medications
Coverage for basic dental procedures
Health education and risk appraisals
No paperwork
Coverage for eyewear prescription glasses or contacts
Contact us at 800 771 4347 for information on the Medicare prepaid plan and the cost of that enrollment
Benefits on this page are not part of the FEHB contract
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Section 6 General Exclusions Things we dont cover
The exclusions in this section apply to all benefits Although we may list a specific service as a benefit we will not cover it unless
your Plan doctor determines it is medically necessary to prevent diagnose or treat your illness or condition
We do not cover Services drugs or supplies that are not medically necessary the following
Services not required according to accepted standards of medical dental or psychiatric practice
Care by non Plan providers except for authorized referrals or emergencies see Emergency
Benefits
Experimental or investigational procedures treatments drugs or devices
Procedures services drugs and supplies related to abortions except when the life of the mother
would be endangered if the fetus were carried to term or when the pregnancy is the result of an act
of rape or incest
Procedures services drugs and supplies related to sex transformations
Services or supplies you receive from a provider or facility barred from the FEHB Program and
Expenses you incurred while you were not enrolled in this Plan
Section 7 Limitations Rules that affect your benefits
Medicare Tell us if you or a family member is enrolled in Medicare Part A or B Medicare will determine who is responsible for paying for the medical services and we will coordinate the payments On occasion you
may need to file a Medicare claim form
If you are eligible for Medicare you may enroll in a Medicare Choice plan and also remain enrolled
with us
If you are an annuitant or former spouse you can suspend your FEHB coverage and enroll in a
Medicare Choice plan when one is available in your area For information on suspending your FEHB
enrollment and changing to a Medicare Choice plan contact your retirement office If you later want
to re enroll in the FEHB Program generally you may do so only at the next Open Season
If you involuntarily lose coverage or move out of the Medicare Choice service area you may re enroll
in the FEHB Program at any time
If you do not have Medicare Part A or B you can still be covered under the FEHB Program and your
benefits will not be reduced We cannot require you to enroll in Medicare
For information on Medicare Choice plans contact your local Social Security Administration SSA
office or request it from SSA at 800 638 6833 For information on the Medicare Choice plan offered
by this Plan see page 21
Other group When anyone has coverage with us and with another group health plan it is called double coverage insurance coverage You must tell us if you or a family member has double coverage You must also send us documents
about other insurance if we ask for them
When you have double coverage one plan is the primary payer it pays benefits first The other plan is
secondary it pays benefits next We decide which insurance is primary according to the National
Association of Insurance Commissioners Guidelines
If we pay second we will determine what the reasonable charge for the benefit should be After the
first plan pays we will pay either what is left of the reasonable charge or our regular benefit whichever is
less We will not pay more than the reasonable charge If we are the secondary payer we may be
entitled to receive payment from your primary plan
We will always provide you with the benefits described in this brochure Remember even if you do
not file a claim with your other plan you must still tell us that you have double coverage
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Section 7 Limitations Rules that affect your benefits continued
Circumstances beyond Under certain extraordinary circumstances we may have to delay your services or be unable to provide our control them In that case we will make all reasonable efforts to provide you with necessary care
When others are When you receive money to compensate you for medical or hospital care for injuries or illness that responsible for injuries another person caused you must reimburse us for whatever services we paid for We will cover the
cost of treatment that exceeds the amount you received in the settlement If you do not seek damages
you must agree to let us try This is called subrogation If you need more information contact us for
our subrogation procedures
TRICARE TRICARE is the health care program for members eligible dependents and retirees of the military TRICARE includes the CHAMPUS program If both TRICARE and this Plan cover you we are the primary
payer See your TRICARE Health Benefits Advisor if you have questions about TRICARE coverage
Workers compensation
We do not cover You need because of a workplace related disease or injury that the Office of Workers Compensation services that Programs OWCP or a similar Federal or State agency determine they must provide
OWCP or a similar agency pays for through a third party injury settlement or other similar
proceeding that is based on a claim you filed under OWCP or similar laws
Once the OWCP or similar agency has paid its maximum benefits for your treatment we will provide
your benefits
Medicaid We pay first if both Medicaid and this Plan cover you
Other Government We do not cover services and supplies that a local State or Federal Government agency directly or Agencies indirectly pays for
Section 8 FEHB Facts
You have a right to OPM requires that all FEHB Plans comply with the Patients Bill of Rights which gives you the right information about to information about your health plan its networks providers and facilities You can also find out
your HMO about care management which includes medical practice guidelines disease management programs and how we determine if procedures are experimental or investigational OPM's website
www opm gov lists the specific types of information that we must make available to you
If you want specific information about us call 800 877 9777 or write to 6455 South Yosemite Street
Englewood Colorado 80111 You may also contact us by fax at 303 714 3977 or visit our website at
www pacificare com colorado
Where do I get Your employing or retirement office can answer your questions and give you a Guide to Federal information about Employees Health Benefits Plans brochures for other plans and other materials you need to make an
enrolling in the informed decision about FEHB Program
When you may change your enrollment
How you can cover your family members
What happens when you transfer to another Federal agency go on leave without pay enter
military service or retire
When your enrollment ends and
The next Open Season for enrollment
We don't determine who is eligible for coverage and in most cases cannot change your enrollment
status without information from your employing or retirement office
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Section 8 FEHB Facts continued
When are my benefits The benefits in this brochure are effective on January 1 If you are new to this plan your coverage and and premiums effective premiums begin on the first day of your first pay period that starts on or after January 1 Annuitants
premiums begin on January 1
What happens When you retire you can usually stay in the FEHB Program Generally you must have been enrolled when I retire in the FEHB Program for the last five years of your Federal service If you do not meet this requirement
you may be eligible for other forms of coverage such as Temporary Continuation of Coverage which
is described later in this section
What types of coverage Self Only coverage is for you alone Self and Family coverage is for you your spouse and your are available for unmarried dependent children under age 22 including any foster or step children your employing or
my family and me retirement office authorizes coverage for Under certain circumstances you may also get coverage for a disabled child 22 years of age or older who is incapable of self support
If you have a Self Only enrollment you may change to a Self and Family enrollment if you marry give
birth or add a child to your family You may change your enrollment 31 days before to 60 days after you
give birth or add the child to your family The benefits and premiums for your Self and Family enrollment
begin on the first day of the pay period in which the child is born or becomes an eligible family member
Your employing or retirement office will not notify you when a family member is no longer eligible to
receive health benefits nor will we Please tell us immediately when you add or remove family
members from your coverage for any reason including divorce
If you or one of your family members is enrolled in one FEHB plan that person may not be enrolled in
another FEHB plan
Are my medical We will keep your medical and claims information confidential Only the following will have access to it and claims records
confidential OPM this plan and subcontractors when they administer this contract
This Plan and appropriate third parties such as other insurance plans and the Office of Workers
Compensation Programs OWCP when coordinating benefit payments and subrogating claims
Law enforcement officials when investigating and or prosecuting alleged civil or criminal actions
OPM and the General Accounting Office when conducting audits
Individuals involved in bona fide medical research or education that does not disclose your
identity or
OPM when reviewing a disputed claim or defending litigation about a claim
Information for new members
Identification cards We will send you an identification ID card Use your copy of the Health Benefits Election Form SF2809 or the OPM annuitant confirmation letter until you receive your ID card You can also use an
Employee Express confirmation letter
What if I paid a Your old plan's deductible continues until our coverage begins deductible under
my old plan
Pre existing conditions We will not refuse to cover the treatment of a condition that you or a family member had before you enrolled in this Plan solely because you had the condition before you enrolled
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Section 8 FEHB Facts continued
When you lose benefits
What happens if my You will receive an additional 31 days of coverage for no additional premium when enrollment in this
Plan ends Your enrollment ends unless you cancel your enrollment or
You are a family member no longer eligible for coverage
You may be eligible for former spouse coverage or Temporary Continuation of Coverage
What is former If you are divorced from a Federal employee or annuitant you may not continue to get benefits under spouse coverage your former spouse's enrollment But you may be eligible for your own FEHB coverage under the
spouse equity law If you are recently divorced or are anticipating a divorce contact your ex spouse's
employing or retirement office to get more information about your coverage choices
What is TCC Temporary Continuation of Coverage TCC If you leave Federal service or if you lose coverage because you no longer qualify as a family member you may be eligible for TCC For example you can
receive TCC if you are not able to continue your FEHB enrollment after you retire You may not elect
TCC if you are fired from your Federal job due to gross misconduct
Get the RI 79 27 which describes TCC and the RI 70 5 the Guide to Federal Employees Health
Benefits Plans for Temporary Continuation of Coverage and Former Spouse Enrollees from your
employing or retirement office
Key points about TCC
You can pick a new plan
If you leave Federal service you can receive TCC for up to 18 months after you separate
If you no longer qualify as a family member you can receive TCC for up to 36 months
Your TCC enrollment starts after regular coverage ends
If you or your employing office delay processing your request you still have to pay premiums
from the 32 nd day after your regular coverage ends even if several months have passed
You pay the total premium and generally a 2 percent administrative charge The Government does
not share your costs
You receive another 31 day extension of coverage when your TCC enrollment ends unless you
cancel your TCC or stop paying the premium
You are not eligible for TCC if you can receive regular FEHB Program benefits
How do I enroll If you leave Federal service your employing office will notify you of your right to enroll under TCC in TCC You must enroll within 60 days of leaving or receiving this notice whichever is later
Children You must notify your employing or retirement office within 60 days after your child is no
longer an eligible family member That office will send you information about enrolling in TCC You
must enroll your child within 60 days after they become eligible for TCC or receive this notice
whichever is later
Former spouses You or your former spouse must notify your employing or retirement office within
60 days of one of these qualifying events
Divorce
Loss of spouse equity coverage within 36 months after the divorce
Your employing or retirement office will then send your former spouse information about enrolling in
TCC Your former spouse must enroll within 60 days after the event which qualifies them for coverage
or receiving the information whichever is later
Note Your child or former spouse loses TCC eligibility unless you or your former spouse notify your
employing or retirement office within the 60 day deadline
25
25
25
Page 26
27
Section 8 FEHB Facts continued
How can I convert You may convert to an individual policy if to individual coverage
Your coverage under TCC or the spouse equity law ends If you canceled your coverage or did not
pay your premium you cannot convert
You decided not to receive coverage under TCC or the spouse equity law or
You are not eligible for coverage under TCC or the spouse equity law
If you leave Federal service your employing office will notify you if individual coverage is available
You must apply in writing to us within 31 days after you receive this notice However if you are a
family member who is losing coverage the employing or retirement office will not notify you You
must apply in writing to us within 31 days after you are no longer eligible for coverage
Your benefits and rates will differ from those under the FEHB Program however you will not have to
answer questions about your health and we will not impose a waiting period or limit your coverage
due to pre existing conditions
How can I get a If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage that Certificate of Group indicates how long you have been enrolled with us You can use this certificate when getting health
Health Plan Coverage insurance or other health care coverage You must arrange for the other coverage within 63 days of leaving this Plan Your new plan must reduce or eliminate waiting periods limitations or exclusions
for health related conditions based on the information in the certificate
If you have been enrolled with us for less than 12 months but were previously enrolled in other FEHB
plans you may request a certificate from them as well
Inspector General Advisory Stop Health Care Fraud
Fraud increases the cost of health care for everyone If you suspect that a physician pharmacy or hospital has charged you for services
you did not receive billed you twice for the same service or misrepresented any information do the following
Call the provider and ask for an explanation There may be an error
If the provider does not resolve the matter call us at 800 877 9777 and explain the situation
If we do not resolve the issue call or write
THE HEALTH CARE FRAUD HOTLINE
202 418 3300
U S Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street NW Room 6400
Washington DC 20415
Penalties for Fraud
Anyone who falsifies a claim to obtain FEHB Program benefits can be prosecuted for fraud Also the Inspector General may investigate
anyone who uses an ID card if they
Try to obtain services for a person who is not an eligible family member or
Are no longer enrolled in the Plan and try to obtain benefits
Your agency may also take administrative action against you
26
26
26
Page 27
28
Colorado
27 27
Summary
of
Benefits
for
PacifiCare
of
2000
Do
not
rely
on
this
chart
alone
All
benefits
are
provided
in
full
unless
otherwise
indicated
subject
to
the
limitations
and
exclusions
set
forth
in
the
brochure
This
chart
merely
summarizes
certain
important
expenses
covered
by
the
Plan
If
you
wish
to
enroll
or
change
your
enrollment
in
this
Plan
be
sure
to
indicate
the
correct
enrollment
code
on
your
enrollment
form
codes
appear
on
the
cover
of
this
brochure
ALL
SERVICES
COVERED
UNDER
THIS
PLAN
WITH
THE
EXCEPTION
OF
EMERGENCY
CARE
ARE
COVERED
ONLY
WHEN
PROVIDED
OR
ARRANGED
BY
PLAN
DOCTORS
Benefits
High
Option
pays provides
Page
Standard
Option
pays provides
Page
Inpatient
care Hospital
Comprehensive
range
of
medical
and
surgical
services
without
dollar
or
day
Comprehensive
range
of
medical
and
surgical
services
without
dollar
or
day
limit
Includes
inhospital
doctor
care
room
and
board
general
nursing
care
limit
Includes
inhospital
doctor
care
room
and
board
general
nursing
care
private
room
and
private
nursing
care
if
medically
necessary
diagnostic
tests
private
room
and
private
nursing
care
if
medically
necessary
diagnostic
tests
drugs
and
medical
supplies
use
of
operating
room
intensive
care
and
drugs
and
medical
supplies
use
of
operating
room
intensive
care
and
complete
maternity
care
You
pay
nothing
10
complete
maternity
care
You
pay
a
300
deductible
per
member
a
maximum
of
500
per
family
per
year
10
Extended
Care
All
necessary
services
for
up
to
120
days
per
year
You
pay
nothing
10
All
necessary
services
for
up
to
120
days
per
year
You
pay
nothing
10
Mental
Conditions
Diagnosis
and
treatment
of
acute
psychiatric
conditions
You
pay
nothing
13
Diagnosis
and
treatment
of
acute
psychiatric
conditions
You
pay
a
300
deductible
per
member
maximum
of
500
per
family
per
year
13
Substance
Abuse
Up
to
45
days
per
year
in
a
substance
abuse
treatment
program
You
pay
nothing
14
Up
to
45
days
per
year
in
a
substance
abuse
treatment
program
You
pay
nothing
14
Outpatient
care
Comprehensive
range
of
services
such
as
diagnosis
and
treatment
of
illness
Comprehensive
range
of
services
such
as
diagnosis
and
treatment
of
illness
or
or
injury
including
specialists
care
preventive
care
including
wellbaby
injury
including
specialists
care
preventive
care
including
wellbabywell
wellchild
care
periodic
checkups
and
routine
immunizations
laboratory
child
care
periodic
checkups
and
routine
immunizations
laboratory
tests
and
tests
and
Xrays
complete
maternity
care
You
pay
a
10
copay
per
office
Xrays
complete
maternity
care
You
pay
a
15
copay
per
office
visit
and
for
visit
and
for
house
calls
by
a
doctor
8
house
calls
by
a
doctor
a
100
copay
for
outpatient
surgery
and
23hour
observation
8
Home
Health
Care
All
necessary
visits
by
nurses
and
therapists
You
pay
nothing
9
All
necessary
visits
by
nurses
and
therapists
You
pay
nothing
9
Mental
Conditions
Number
of
visits
is
based
on
medical
necessity
You
pay
a
25
copay
per
visit
13
Number
of
visits
is
based
on
medical
necessity
You
pay
a
25
copay
per
visit
13
Substance
Abuse
Up
to
90
outpatient
visits
per
year
You
pay
nothing
13
Up
to
90
outpatient
visits
per
year
You
pay
nothing
13
Emergency
care
Reasonable
charges
for
services
and
supplies
required
because
of
a
medical
Reasonable
charges
for
services
and
supplies
required
because
of
a
medical
emergency
You
pay
a
50
copay
to
the
hospital
for
each
emergency
room
emergency
You
pay
a
50
copay
to
the
hospital
for
each
emergency
room
visit
and
any
charges
for
services
which
are
not
covered
by
this
Plan
11
visit
and
any
charges
for
services
which
are
not
covered
by
this
Plan
11
Prescription
drugs
Drugs
prescribed
by
a
Plan
doctor
and
obtained
at
a
Plan
pharmacy
You
pay
Drugs
prescribed
by
a
Plan
doctor
and
obtained
at
a
Plan
pharmacy
You
pay
up
to
a
5
copay
per
prescription
unit
or
refill
for
generic
drugs
on
the
formulary
up
to
a
10
copay
per
prescription
unit
or
refill
for
generic
drugs
on
the
formulary
a
10
copay
for
name
brand
drugs
on
the
formulary
and
a
20
copay
for
a
20
copay
for
name
brand
drugs
on
the
formulary
and
a
30
copay
for
covered
nonformulary
drugs
a
10
copayment
for
injectables
except
covered
nonformulary
drugs
a
10
copayment
for
injectables
except
insulin
insulin
Maintenance
medications
can
be
filled
through
mailorder
program
14
Maintenance
medications
can
be
filled
through
mailorder
program
14
Dental
care
Preventive
dental
care
and
comprehensive
range
of
restorative
orthodontic
Preventive
dental
care
and
comprehensive
range
of
restorative
orthodontic
and
other
services
You
pay
copays
for
most
services
15
and
other
services
You
pay
copays
for
most
services
15
Vision
care
One
refraction
every
24
months
You
pay
a
10
copay
per
refraction
20
One
refraction
every
24
months
You
pay
a
15
copay
per
refraction
20
Outofpocket
maximum
Copayments
are
required
for
a
few
benefits
however
after
your
outofpocket
Copayments
are
required
for
a
few
benefits
however
after
your
outofpocket
expenses
reach
a
maximum
of
3600
per
Self
Only
or
10000
per
Self
and
expenses
reach
a
maximum
of
3600
per
Self
Only
or
10000
per
Self
and
Family
enrollment
per
calendar
year
covered
benefits
will
be
provided
at
Family
enrollment
per
calendar
year
covered
benefits
will
be
provided
at
100
This
copay
maximum
does
not
include
prescription
drugs
or
dental
100
This
copay
maximum
does
not
include
prescription
drugs
or
dental
services
4
services
4
27
27
Page 28
2000 Rate Information for
PacifiCare of Colorado Inc
Non Postal rates apply to most non Postal enrollees If you are in a special enrollment category refer to the
FEHB Guide for that category or contact the agency that maintains your health benefits enrollment
Postal rates apply to most career U S Postal Service employees In 2000 two categories of contribution rates
referred to as Category A rates and Category B rates will apply for certain career employees If you are a career
postal employee but not a member of a special postal employment class refer to the category definitions in
The Guide to Federal Employees Health Benefits Plans for United States Postal Service Employees RI 70 2
to determine which rate applies to you
Postal rates do not apply to non career postal employees postal retirees certain special postal employment
classes or associate members of any postal employee organization Such persons not subject to postal rates must
refer to the applicable Guide to Federal Employees Health Benefits Plans
NonPostal Premium Postal Premium A Postal Premium B
Biweekly Monthly Biweekly Biweekly
Type of Code Govt Your Govt Your USPS Your USPS Your
Enrollment Share Share Share Share Share Share Share Share
DenverPuebloColSpringsFtCollinsLaPlata
High Option D61 6565 2188 14224 4741 7768 985 7768 985 Self Only
High Option D62 16986 5662 36803 12268 20100 2548 20100 2548 Self and Family
DenverPuebloColSpringsFtCollinsLaPlata
Standard Option D64 5132 1711 11120 3707 6073 770 6073 770 Self Only
Standard Option D65 13300 4433 28817 9605 15738 1995 15738 1995 Self and Family 28