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					      EFFECTIVE JANUARY 1, 2002




Health Maintenance Organization

              Combined Evidence of Coverage
                  and Disclosure Form
                 for Basic Plan and the
              Managed Medicare Health Plan



                     NEVADA




         Contracted by the Board of Administration
  Under the Public Employees’ Medical & Hospital Care Act
BLANK INSIDE FRONT COVER
The booklet is divided into the following parts: Section One pertains to members enrolled in the
Basic Health Plan; Section Two pertains to members enrolled in the Managed Medicare Health Plan
(Medicare+Choice); Section Three provides information that is common for Basic and Managed
Medicare members. Each Section is clearly marked at the top of each page.

We have included a Summary of Benefits for Basic and Managed Medicare with a comprehensive
description following. It will be to your advantage to familiarize yourself with this booklet before you
need services.

Take time to review this booklet. The information contained will be useful throughout the year.




  This Combined Evidence of Coverage and Disclosure Form constitutes only a summary of the
  health plan. The health plan contract must be consulted to determine the exact terms and
  conditions of coverage. However, the statement of benefits, exclusions and limitations in this
  Evidence of Coverage is complete and is incorporated by reference into the contract.
  Federal law mandates that PacifiCare comply with Title VI of the Civil Rights Act of 1964, the
  Rehabilitation Act of 1973, the Age Discrimination Act of 1975, the Americans with Disabilities
  Act, and other laws applicable to recipients of federal funds, and other applicable laws and rules.
  Specifically, PacifiCare does not discriminate in the employment of staff or in the provision of
  health care services on the basis of race, disability, religion, sex, sexual orientation, health, creed,
  age or national origin.
  The contract is on file and available for review in the office of the CalPERS Health Program
  Development Division, 400 P Street, Sacramento, CA 95814, or P.O. Box 720724, Sacramento,
  CA 94229-0724. A copy of the contract may be purchased from the CalPERS Health Program
  Development Division for a reasonable duplication charge.
BLANK
W   E L C O M E          T O      P   A C I F I    C   A R E      O F      N   E V A D A

We have made arrangements with local private practice, individual physician associations and
hospitals to provide comprehensive medical care to our Members. As a result, when you choose
PacifiCare, you then choose your medical care provider from a host of Primary Care Physicians
and community hospitals.
Read this Evidence of Coverage booklet carefully, as it provides detailed information about how
to receive services and what is covered. Please feel free to call PacifiCare Customer Service at
1-800-347-8600 or telephone number for the hearing impaired (TTY) 1-800-360-1797,
Monday - Friday, 7 a.m. - 6 p.m. if you have any questions.
If you are retired, entitled to Medicare Part A and enrolled in Part B and live within the Managed
Medicare (PacifiCare’s Medicare+Choice Plan) Service Area, you must enroll in Managed Medicare
Plan but not in the PacifiCare Basic Plan. Please refer to the “Definitions” section of this Evidence
of Coverage booklet for a complete description of each Service Area.
Please remember that when you join any PacifiCare Plan you agree to receive all of your medical
services, except for Emergency Care or Out-of-Area Urgent Care through your PacifiCare Contracting
Medical Provider. Should you choose to use non-Contracting Medical Providers for non-Emergency
Care, you may be financially responsible for services received.
Please refer to the Definitions section of your booklet for descriptions of Emergency and Urgently
Needed Services.




                                                                                                        1
T    A B L E             O F          C     O N T E N T S


SECTION 1 – BASIC PLAN
    BENEFIT CHANGES FOR 2002 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
    ELIGIBILITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
    ENROLLMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
    HOW TO USE THE PLAN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
     Choice of Physicians and Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
     Selection of Different Primary Care Physicians by Family Members: . . . . . . . . . . . . . . . . . 7
     How to Receive Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
     Liability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
     Member Identification Card . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
     Customer Service. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
    RATES FOR BASIC PLAN. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
    CHART OF SUMMARY OF BENEFITS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
    BENEFIT DESCRIPTIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
      In-Patient Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
      Bone Marrow Transplants. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
      Skilled Nursing or Convalescent Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
      Surgeon and Anesthesiologist Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
      Additional Inpatient Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
      Physician Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
      Administration of Blood and Blood Plasma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
      Ambulance Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
      Emergency and Urgently Needed Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
      Diagnostic X-ray and Laboratory Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
      Durable Medical Equipment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
      Corrective Appliances, Artificial Aids, Prosthetics and Orthotics . . . . . . . . . . . . . . . . . . . 13
      Therapeutic Footwear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
      Urinary Catheters. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
      Health Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
      Home Health Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
      Hospice. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
      Immunizations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
      Hepatitis B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
      Outpatient Surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
      Short-Term Physical, Speech and Occupational Therapy . . . . . . . . . . . . . . . . . . . . . . . . . 14
      Prenatal and Postnatal Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
      Normal Delivery, Cesarean Section, Complications of Pregnancy . . . . . . . . . . . . . . . . . . 14
      Voluntary Interruption of Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
      Family Planning Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
      Prescription Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
      Mental Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
      Partial Hospitalization Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
      Substance Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
      Hearing Aid. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
      Chiropractic Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
      Diabetes Management and Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
      Digestive Disorders Coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

2
                                                                                        T    A B L E              O F          C     O N T E N T S
                                                                                                                                            C   O N T I N U E D

 EXCLUSIONS AND LIMITATIONS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
 PRESCRIPTION DRUG BENEFIT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
 BEHAVIORAL HEALTH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
 GENERAL PROVISIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
   Second Medical Opinions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
   Reimbursement Provisions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
   PacifiCare Grievance Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
   Basic Plan Appeals Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
   CalPERS Administrative Hearing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
   Arbitration Procedure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
   Alternate Arrangements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
   Member Rights and Responsibilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
   Confidentiality and Disclosure of Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
 TERMINATION OF GROUP MEMBERSHIP – CONTINUATION OF COVERAGE . . . . . . . . 36
   Termination of Benefits and Re-enrollment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
   COBRA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
   Individual Continuation of Benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
 PAYMENT BY THIRD PARTIES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
   Third Party Recovery Process and the Members’ Responsibilities . . . . . . . . . . . . . . . . . . . 39
   Coordination of Benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
   Workers’ Compensation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

SECTION 2 – MANAGED MEDICARE PLAN                                              . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

 BENEFIT CHANGES FOR 2002 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
 ELIGIBILITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
 ENROLLMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
 HOW TO USE THE PLAN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
  Choice of Physicians and Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
  Selection of Different Primary Care Physicians by Family Members . . . . . . . . . . . . . . . . . 46
  How to Receive Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
  Liability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
  Member Identification Card . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
  Customer Service. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
 RATES FOR MANAGED MEDICARE PLAN. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
 CHART OF SUMMARY OF BENEFITS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
 BENEFIT DESCRIPTIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
   Inpatient Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
   Hospitalization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
   Skilled Nursing Facility Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
   Outpatient Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
   Physician Services/Basic Health Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
   Annual Physical Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
   Preventive Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
   Health Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
   Hospital Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
   Blood and its Administration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
                                                                                                                                                             3
T   A B L E              O F         C     O N T E N T S
C   O N T I N U E D

       Home Health Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
       Immunizations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
       Laboratory Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
       X-ray Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
       Urgently Needed Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
       Emergency Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
       Emergency Admission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
       Ambulance Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
       Hearing Aid. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
       Mental Health and Substance Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
       Partial Hospitalization Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
       Durable Medical Equipment and Medical Supplies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
       Prosthetic Devices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
       Therapeutic Footwear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
       Prescription Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
       Immunosuppressive Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
       Injectable Drugs for Osteoporosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
       Self-Administered Erythropoietin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
       Self-Administered Chemo Drugs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
       Vision Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
       Chiropractic Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
       Podiatry Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
       Dental Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
    EXCLUSIONS AND LIMITATIONS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
    HEARING AID BENEFIT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
    PRESCRIPTION DRUG BENEFIT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
    BEHAVIORAL HEALTH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
    GENERAL PROVISIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
      Second Medical Opinions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
      PacifiCare Grievance Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
      Medicare Appeals Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
      CalPERS Administrative Hearing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
      Alternate Arrangements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
      Member Rights and Responsibilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
      Confidentiality and Disclosure of Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
      Advance Directives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
    TERMINATION OF GROUP MEMBERSHIP – CONTINUATION OF COVERAGE . . . . . . . . 74
      Termination of Benefits and Re-enrollment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
      COBRA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
      CMS Termination Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
    PAYMENT BY THIRD PARTIES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
      Third Party Recovery Process and the Member’s Responsibility . . . . . . . . . . . . . . . . . . . . 76
      Coordination of Benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76

SECTION 3 – GENERAL INFORMATION FOR ALL MEMBERS                                                                  . . . . . . . . . . . 77
       Definitions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
       PacifiCare of Nevada Service Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
       PacifiCare Addresses and Telephone Numbers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
4
                                           B   A S I C   P   L A N



BENEFIT CHANGES FOR 2002                                 ELIGIBILITY
This contract term is for one year, effective            Covering Your Family Members
January 1, 2002 through December 31, 2002.
Some of this plan’s benefits such as visit limits for    Individuals eligible for coverage under this
certain services are currently based on a calendar       Agreement include eligible CalPERS employees,
year. You should review this booklet carefully.          as defined by CalPERS, and the employee’s
                                                         Eligible Dependent(s).
Prescription Drug Copayments: Your prescription
drug Copayments have now changed to:                     Eligible Dependents shall include:
     $5 per Prescription unit for Formulary              1. a Subscriber’s lawful spouse; and
        generic medications;
                                                         2. the Subscriber’s unmarried children through
   $15 per Prescription unit for Formulary
                                                            birth, adoption or placement for adoption
        brand-name medications; and
                                                            under the age of 23.
   $30 per Prescription unit for non-Formulary
        medications.                                     Coverage may extend beyond age twenty-three
                                                         (23) when a Child:
For mail-order prescription drugs, your
Copayments have now changed to:                          1. can be certified as incapable of self-sustaining
   $10 per Prescription unit for generic                    employment by reason of mental retardation
        medications;                                        or physical handicap; and
   $25 per Prescription unit for brand-name              2. is dependent on the Subscriber.
        medications; and
   $45 per Prescription unit for non-Formulary           There will be no lapse in coverage if a full-time
        medications.                                     student becomes incapacitated prior to age
                                                         twenty-three (23).
There is a $1,000 out-of-pocket maximum for
covered for Prescription Drugs purchased through         All adult Members must continuously reside in
the mail-order program per member per year.              the State of Nevada. Members that either:
Office Visit Copayments: Your office visit               • visit or live outside the State of Nevada for
Copayment has now changed to $10.                          more than ninety (90) days; or
Chiropractic Visit Copayment: Your Copayment             • permanently relocate will lose coverage
for Chiropractic visits has changed to $10.                under this Agreement.
Norplant Device and Norplant Medications: are            Children may reside outside the State of Nevada,
now excluded from coverage.                              but are limited to coverage for Emergency and
                                                         Urgent Medical Services. To receive full benefits
BENEFITS OF THIS PLAN ARE AVAILABLE ONLY                 under this Agreement, Children must receive care
FOR SERVICES AND SUPPLIES FURNISHED                      from PacifiCare of Nevada Contracting Medical
DURING THE TERM THE PLAN IS IN EFFECT                    Providers.
AND WHILE THE BENEFITS YOU ARE CLAIMING
ARE ACTUALLY COVERED BY THIS PLAN.                       Information pertaining to eligibility, enrollment,
                                                         cancellation or termination of coverage,
IF BENEFITS ARE MODIFIED, THE REVISED                    conversion rights, etc. can be found in the
BENEFITS (INCLUDING ANY REDUCTION IN                     CalPERS open enrollment booklet – CalPERS
BENEFITS OR ELIMINATION OF BENEFITS)                     Health Program Handbook. The booklet is
APPLY TO SERVICES OR SUPPLIES FURNISHED                  prepared by CalPERS Health Benefit Services
ON OR AFTER THE EFFECTIVE DATE OF                        Division, in Sacramento. A copy of this booklet
MODIFICATION. THERE IS NO VESTED RIGHT                   will be distributed or sent to you. If you do not
TO RECEIVE THE BENEFITS OF THIS PLAN.


                                                                                                              5
                                         B   A S I C   P   L A N


receive a copy, contact your employing office,         Who Can Enroll Outside of Open Enrollment?
your Health Benefits Officer or write to:
                                                       Certain events may qualify a dependent for
    CalPERS, Health Benefit Services Division          enrollment with PacifiCare outside of CalPERS
    P.O. Box 942714                                    designated Open Enrollment Period.
    Sacramento, CA 94229-2714
                                                       Such qualifying events include (but are not
Remember, it is your responsibility to stay            limited to):
informed about your coverage. If you have any
                                                       • Marriage to the Subscriber;
questions, consult your Health Benefits Officer in
your agency or the retirement system from which        • Birth of a Child;
you receive your allowance, or write to CalPERS        • Adoption or placement for adoption of a
Health Benefit Services Division at the address in       Child;
the previous paragraph or telephone the
appropriate number shown below:                        • Legal obligation to cover a Spouse or Child;
CalPERS Health Benefit Services Division               • Loss of Coverage.
Toll free number 1-800-352-2238                        Note: For determinations of eligibility to enroll
FAX 916-326-3935                                       outside the Open Enrollment Period, PacifiCare
916-326-3240 (Telecommunications Device for            will follow the requirements imposed by CalPERS
              the Deaf-Interpreter)                    and Nevada law.
                                                       A completed enrollment form, with proof of a
ENROLLMENT                                             qualifying event, must be submitted for newly
                                                       Eligible Dependents within thirty-one (31) days
To enroll in PacifiCare, contact your agency health
                                                       of the qualifying event. Upon receipt and
benefits officer, or if you are retired, CalPERS.
                                                       processing of this documentation, a PacifiCare
Please refer to the CalPERS Health Program             Membership card will be issued in the
Handbook for information on:                           dependent’s name.
• When enrollment is permissible                       Newborns, adopted children or children placed
• Enrollment of new subscribers                        for adoption are automatically covered for the
                                                       first thirty-one (31) days of their eligibility.
• Addition of family dependents
                                                       Certain other events may qualify an employee or
If you are enrolled in PacifiCare and you retire,      dependent for enrollment with PacifiCare outside
become eligible for Medicare, and live within the      of CalPERS designated Open Enrollment Period.
Managed Medicare Service Area, you will be             If, at the time of Open Enrollment, the employee
required to transfer your enrollment to Managed        or dependent:
Medicare Plan if you wish to continue coverage
under the PacifiCare Plans.                            • was covered under any health insurance
                                                         policy or health benefits plan; and
Who Must Enroll During Open Enrollment?
                                                       • lost coverage due to the end of eligibility,
If you are:                                              termination of employment, or termination of
• an eligible employee; or                               the other plan’s coverage; then
• an Eligible Dependent;                               a completed enrollment form, along with proof
                                                       of prior coverage, must be submitted within
and you wish to enroll with PacifiCare, you must       thirty-one (31) days after the termination of such
submit a completed CalPERS enrollment form to          coverage. Upon receipt and processing of this
your Employer during the Open Enrollment Period.       documentation, each new Member will be issued
                                                       a PacifiCare Membership card.

6
                                          B   A S I C   P   L A N



HOW TO USE THE PLAN                                     Other contracting providers are paid on a
                                                        discounted fee-for-service or fixed case rate basis.
Choice of Physicians and Providers
                                                        • The monthly payment typically covers
PLEASE READ THE FOLLOWING INFORMATION                     professional services directly provided by the
SO YOU WILL KNOW FROM WHOM OR                             Medical Group or IPA, and may also cover
WHAT GROUP OF PROVIDERS HEALTH CARE                       hospital and certain referral services.
MAY BE OBTAINED.
                                                        • Some of PacifiCare’s contracting hospitals
Your relationship with your PacifiCare Primary            receive similar monthly payments in return
Care Physician is an important one. That is why           for arranging hospital services for Members.
PacifiCare strongly recommends you choose a               Other hospitals are paid on a discounted fee-
PacifiCare Primary Care Physician close to your           for-service or fixed charge per day of
home or work. Having your PacifiCare Primary              hospitalization. Most acute care, subacute
Care Physician nearby makes receiving medical             care, transitional inpatient care and skilled
care and developing a trusting and open                   nursing facilities are paid on a fixed charge
relationship that much easier. Each Member may            per day per inpatient care.
select their own PacifiCare Primary Care Physician.
                                                        • PacifiCare provides stop-loss protection to our
Once you have chosen your PacifiCare Primary              contracting Medical Groups, IPAs and
Care Physician, we recommend that you have all            hospitals that receive the monthly payments
your medical records transferred to his/her office.       described above. If any providers do not
This will give your PacifiCare Primary Care               obtain stop-loss protection from PacifiCare,
Physician access to your medical history, and             they must obtain stop-loss insurance from an
make him or her aware of any existing health              insurance carrier acceptable to PacifiCare.
conditions you may have.
                                                        Selection of Different Primary Care
Always ask to see your PacifiCare Primary Care
                                                        Physicians by Family Members:
Physician when you make an appointment. Your
PacifiCare Primary Care Physician is responsible        Please refer to the “Changing Primary Care
for all your routine health care services, so he or     Physician” section of this brochure for detailed
she should be the first one you call with any           information on changing your physician or
health concerns.                                        provider selections after your initial enrollment.
                                                        There are specific procedures to follow for
Please clearly write the name of the Primary
                                                        provider changes and transfers.
Care Physician you choose on your HBD-12
form in box “11”.                                       IT IS IMPORTANT TO KNOW THAT WHEN
                                                        YOU ENROLL IN THE BASIC PLAN, SERVICES
PacifiCare typically contracts with Medical
                                                        ARE PROVIDED THROUGH THE PLAN’S
Groups and Independent Practice Associations
                                                        DELIVERY SYSTEM, AND THE CONTINUED
(IPAs) to provide medical services to Members
                                                        PARTICIPATION OF ANY ONE DOCTOR,
and with hospitals to provide hospital services.
                                                        HOSPITAL OR OTHER PROVIDER CANNOT
The contracting Medical Groups and IPAs, in turn,
                                                        BE GUARANTEED.
employ or contract with individual physicians.
• Some of our contracting Medical Groups and            How to Receive Care
  IPAs receive an agreed upon monthly                   Scheduling Appointments
  payment from PacifiCare to provide services
                                                        It’s easy – simply call your PacifiCare Primary Care
  to Members. This monthly payment may be
                                                        Physician’s office and request an appointment.
  either a fixed dollar amount for each member
                                                        There are no special rules to follow. Appointments
  or a percentage of the monthly premium
                                                        are scheduled according to the type of medical
  received by PacifiCare.

                                                                                                             7
                                           B   A S I C   P   L A N


care you are requesting. Medical conditions              needs that require follow-up and receive training
requiring more immediate attention are scheduled         in self-care and other measures to promote their
sooner. The telephone number for your PacifiCare         own health.
Primary Care Physician is listed in the Provider
                                                         Changing Primary Care Physicians
Directory enclosed with this Combined Evidence
of Coverage and Disclosure Document.                     If you wish, you may request to change PacifiCare
                                                         Primary Care Physician at any time. The PCP
You may schedule an appointment with a
                                                         change will be effective the same day. Call
specialist in Behavioral Health, Optometry
                                                         PacifiCare Customer Service for assistance at
(ophthalmologists require a referral from your
                                                         1-800-347-8600 or telephone number for the
optometrist), or OB/GYN without a Referral.
                                                         hearing impaired (TTY) 1-800-360-1797,
Please refer to the Provider Directory for your
                                                         Monday - Friday, 7 a.m. - 6 p.m. You will receive
PacifiCare Specialists.
                                                         a new PacifiCare membership card that shows
Referrals to Specialists                                 this change.
Even though your PacifiCare Primary Care                 To help promote a smooth transition of your
Physician is trained to handle the majority of           health care when you change your Primary Care
common health needs, there may be a time                 Physician, please let us know if you are currently
when he or she feels you need more specialized           seeing a Specialist, receiving Home Health
treatment. You may receive a Referral to an              Agency services, or using Durable Medical
appropriate Specialist. In some cases, the request       Equipment. PacifiCare Customer Service can
for a Referral will need to have Prior Authorization.    assist with the transfer of your care or equipment.
PacifiCare may direct your Primary Care
                                                         However, we may deny your request to change
Physician and Specialist to deliver care at certain
                                                         your Primary Care Physician if you are:
contracted hospitals or other facilities. This
determination shall be made by PacifiCare’s                  -   hospitalized;
Medical Director within 24 hours for urgent                  -   confined in a Skilled Nursing Facility;
requests or within 48 hours for standard requests
once all documentation needed to review the                  -   an organ transplant candidate; or
request is received by PacifiCare.                           -   being treated for an unstable, acute
Once you receive a Referral from your PacifiCare                 medical condition for which you are
Primary Care Physician you may schedule an                       receiving active medical care.
appointment with the Specialist. Your Primary            If your request to change to a different PacifiCare
Care Physician may refer you to a contracted             Primary Care Physician is denied by PacifiCare,
Specialist. PacifiCare may designate the                 you have a right to file a grievance.
contracted Specialist, based upon factors, which
include the Specialists’ privileges at the Hospital      It is PacifiCare’s policy that each affected
designated by PacifiCare, the capabilities of the        Member receives timely and consistent notice
Specialists, and the outcomes. If for any reason         when his/her Primary Care Physician or
you receive a bill from a Specialist, simply             Specialist is no longer participating in PacifiCare.
forward it to PacifiCare for payment. See page 26        It is PacifiCare’s goal to make a good faith effort
for the address to send your claim.                      to notify you within 30 days of the termination of
                                                         any plan health care provider that affects you.
PacifiCare has approved procedures to identify,          We will assist you in selecting a new Primary
assess, and establish treatment plans (including         Care Physician or ensure you have access to all
direct access visits to Specialists) for members         Covered Services in the plan’s Benefit Plan.
with complex or serious medical conditions. In
addition, PacifiCare will maintain procedures to
ensure that members are informed of health care
8
                                          B   A S I C   P   L A N


Second Medical Opinion                                      -   How do I choose a doctor?
You, or your treating Primary Care Physician,               -   How do I change PCPs?
may request a Second Medical Opinion from a                 -   What happens if I move?
PacifiCare Contracting Medical Provider when                -   How do I add my new baby to the plan?
necessary.                                                  -   How do I obtain additional information
                                                                about my physician?
Non-Contracting Provider referrals will be
approved only when the services requested are           … Just call on us. Our Customer Service
not available from a PacifiCare Contracting             Associates are ready to answer.
Medical Provider as appropriate. For more               For PacifiCare call toll-free:
information, please contact PacifiCare’s Customer
                                                        1-800-347-8600 or
Service at 1-800-347-8600 or telephone number
                                                        Telephone Number for the Hearing Impaired
for the hearing impaired (TTY) 1-800-360-1797,
                                                        (TTY) 1-800-360-1797,
Monday - Friday, 7 a.m. - 6 p.m.
                                                         Monday - Friday, 7 a.m. - 6 p.m.
Liability
In the event PacifiCare fails to pay a Contracting      RATES FOR BASIC PLAN
Medical Provider for covered services, the              Subtract your employer’s contribution to
Member shall not be liable to the provider for          calculate your monthly out-of-pocket costs, if any.
any sums owed by the health plan to the
                                                        PacifiCare Monthly Rates
provider. However, the Member may be liable for
any sums owed to a non-contracting provider             Type of Enrollment                    Current Rate
unless the services provided were authorized by         Subscriber only                           $323.25
the Member’s Primary Care Physician or were
provided for in an emergency.                           Subscriber and one family member          $646.51

Member Identification Card                              Subscriber and two or
                                                        more family members                       $840.46
Once we have processed your application, you
and any enrolled dependent(s) will receive a            If your family unit includes both Managed
Member Identification Card. Present this ID card        Medicare Members and PacifiCare Basic Plan
whenever you receive medical services or                Members, see your Health Plan Decision
prescription drugs. Carry your PacifiCare               Guide for the appropriate plan codes and
Member Identification Card with you at all times.       prepayment charges.
If you move or lose your PacifiCare Member              Other Charges
Identification Card, please contact PacifiCare
                                                        In addition to the premiums described above,
Customer Service at 1-800-347-8600 or
                                                        you are responsible for the copayments set forth
telephone number for the hearing impaired (TTY)
                                                        in the benefit and copayment section.
1-800-360-1797, Monday - Friday, 7 a.m. - 6 p.m.
                                                        State Employees and Annuitants
Customer Service
                                                        The rate shown above will be effective January 1,
PacifiCare Customer Service is available to             2002, and will be reduced by the amount the
answer questions and provide assistance. We             State of California contributes toward the cost of
encourage you to call with any and all health           your health benefits plan. These contribution
plan questions or concerns. So if you have              amounts are subject to change by legislative
questions like…                                         action. Any such change resulting in a change in
   -   What do I do in an emergency?                    the amount of your contribution will be
   -   What’s covered if I’m traveling?                 accomplished automatically by the State
   -   What if I lose my ID card?                       Controller or affected retirement system without
                                                                                                           9
                                        B   A S I C   P   L A N


action on your part. For current contribution
information, contact your agency or retirement
system health benefits officer.
Public Agency Employees and Annuitants
The rate shown on this page will be effective
January 1 2002, and will be reduced by the
amount your public agency contributes toward
the cost of your health benefits plan. The amount
varies among public agencies; therefore, for
assistance in calculating your net cost, contact
your agency or retirement systems health
benefits officer.
Rate Change
The plan rates may be changed as of January 1,
2003. PacifiCare will provide at least a 60-day
written notice to the CalPERS Board prior to
January, 1 2003.




10
                                          B   A S I C   P   L A N


THIS IS ONLY A BRIEF SUMMARY. REFER TO THE BENEFIT DESCRIPTIONS IN THIS BOOK FOR
FURTHER INFORMATION.


                              CHART OF SUMMARY OF BENEFITS
  CATEGORY DESCRIPTION                                                 MEMBER COPAYMENT
                                                                         & LIMITATIONS
  HOSPITAL
   Inpatient visit                                                         Covered in full
   Outpatient visit                                                        Covered in full
  INPATIENT SERVICES
    Room and Board                                                         Covered   in   full
    Doctor Visits                                                          Covered   in   full
    Bone Marrow Transplants                                                Covered   in   full
    Skilled Nursing Care (up to 30 calendar days/year)                     Covered   in   full
    Surgeon and anesthesiologist services                                  Covered   in   full
  OUTPATIENT SERVICES
   Physician Services*
     Office Visits                                                            $10   copay
     Allergy Testing                                                          $10   copay
     Allergy Treatment                                                        $10   copay
     Vision Screening                                                         $10   copay
     Hearing Screening                                                        $10   copay
     Pap Smears                                                               $10   copay
     Annual Physical Evaluations                                              $10   copay
  AMBULANCE SERVICE (AS MEDICALLY NECESSARY)                               Covered in full
  BLOOD AND BLOOD PRODUCTS                                                 Covered in full
  (includes collection and storage of autologous blood)
  EMERGENCY AND URGENTLY NEEDED SERVICES                            $25 copay (waived if admitted)
  DIAGNOSTIC X-RAY/LAB PROCEDURES                                             $10 copay
  DURABLE MEDICAL EQUIPMENT                                                Covered in full
  (including orthotics and prosthetics)
  HOME HEALTH CARE                                                         Covered in full
  HOSPICE                                                                  Covered in full
  IMMUNIZATIONS                                                               $10 copay
  PHYSICAL/OCCUPATIONAL/SPEECH THERAPY                                Inpatient – Covered in full
                                                                       Outpatient – $10 copay



*Physician Office Visit Copayment applies.



                                                                                                     11
                                          B   A S I C   P    L A N

     CATEGORY DESCRIPTION                                              MEMBER COPAYMENT
                                                                         & LIMITATIONS
     PREGNANCY AND MATERNITY CARE
       Prenatal and Postnatal Care (office visits)                         $10 Copayment
       Normal delivery, cesarean section, complications                    Covered in full
       of pregnancy and medical services. Hospital stay
       of no less than 48 hours following a vaginal
       delivery and 96 hours following a cesarean section.
       Infertility Testing and Treatment                                  50% Copayment
     PRESCRIPTION DRUGS
       Retail:
         Generic Formulary                                       $5 Copayment per Prescription Unit
         Brand Formulary                                        $15 Copayment per Prescription Unit
         Non-Formulary                                          $30 Copayment per Prescription Unit
       Mail-order:
         Generic Formulary                                      $10 Copayment/3 Prescription Units*
         Brand Formulary                                        $25 Copayment/3 Prescription Units*
         Non-Formulary                                          $45 Copayment/3 Prescription Units*

     *$1,000 out-of-pocket maximum for covered for
      Prescription Drugs purchased through the mail-order
      program per member per year.
     MENTAL HEALTH
      Inpatient                                               Covered in full; 40 Days per Calendar Year
      Outpatient                                               $20 Copay; 40 Visits per Calendar Year
      Partial Hospitalization Services                                     Covered in Full
     SUBSTANCE ABUSE
       Inpatient                                                          Covered in full;
                                                                  up to $9,000 per Calendar Year
       Outpatient counseling on an individual, family, or                   $20 copay;
       group basis when not admitted to a facility, when       Covered up to $1,500 per Calendar Year
       authorized by a PacifiCare Plan Physician.
     CHIROPRACTIC
       Medically Necessary                                    $10 Copayment; upon referral by your PCP
     VISION CARE
       Eye Refraction – To determine need for lenses               $10 Copayment per Refraction;
                                                                      once per Calendar Year
       Eyeglasses                                             Not covered except after Cataract Surgery
     HEARING AID
       Audiological Exam                                                    Not Covered
       Hearing Aid Instrument                                               Not Covered




12
                                         B   A S I C   P   L A N



BENEFIT DESCRIPTIONS                                   • Periodic Physical Evaluations $10 copayment
                                                       • Well-Baby and
These services are covered as indicated when
                                                         Well-Child Care               $10 copayment
provided by or prescribed by your Primary Care
                                                       • Eye Refractions               $10 copayment
Physician.
                                                       Administration of Blood and
In-Patient Services
                                                       Blood Plasma                      Covered in full
Room and Board                    Covered in full
                                                       Including the processing and storage of
• Semi-private room (unlimited days)
                                                       autologous blood
• Intensive care unit (as medically necessary)
• Private room (as medically necessary)                Ambulance Service                 Covered in full
• Operating, recovery and special treatment            Land or air (as Medically Necessary)
    rooms                                              Emergency and Urgently
• Doctor’s services                                    Needed Services                   $25 copayment
Bone Marrow Transplants           Covered in full      (Waived if admitted as an inpatient)
Bone Marrow Transplants for the treatment of           Diagnostic X-ray and
aplastic anemia, leukemia, Wiskott-Aldrich             Laboratory Services               $10 copayment
syndrome, or severe combined immunodeficiency
disease are covered when determined by                 Durable Medical Equipment        Covered in full
PacifiCare to be Medically Necessary.                  Rental or purchase of durable medical equipment
                                                       (used in your home)
Skilled Nursing or
Convalescent Care                 Covered in full      Corrective Appliances, Artificial Aids,
(Up to 30 days per Calendar Year)                      Prosthetics and Orthotics          Covered in full
Surgeon and                                            Therapeutic Footwear                Covered in full
Anesthesiologist Services          Covered in full     Limited to severe diabetic foot disease
Additional Inpatient Services     Covered in full      Urinary Catheters                Covered in full
• Laboratory and X-ray                                 Covered for an individual who has permanent
• Drugs, anesthesia, medications and                   urinary incontinence or permanent urinary
  biologicals                                          retention
• Physical, speech, occupational and                   Health Education                Fees may apply
  respiratory therapy                                  • Counseling (Fees not to exceed Office Copay
• Hemodialysis and administration of blood               Amount)
• Blood and blood plasma, including the                • Educational materials          Fee may apply
  collection and storage of autologous blood           • Medical social services
• Nursing care, private-duty nursing (as
  medically necessary)                                 Home Health Care                   Covered in full
• All other medically necessary inpatient services     Home health visits (Nurses, physical,
                                                       occupational, speech, respiratory therapist)
Physician Services*
• Office Visits                   $10   copayment      Hospice                             Covered in full
• Specialist/Consultant Visits    $10   copayment      Hospice Services are covered when authorized
• Home Visits                     $10   copayment      through the Member’s Contracting Physician and
• Allergy Testing                 $10   copayment      the Member: a) has been judged to have 180
• Allergy Treatment                $0   copayment      days of life expectancy or less, b) has decided to
• Vision Screening                $10   copayment      no longer pursue aggressive medical treatment
• Hearing Screening               $10   copayment      and c) the goal of treatment is to provide
• Pap Smears                      $10   copayment      supportive nursing care and counseling to the

*Each office visit requires only a single copayment even if multiple outpatient services are performed.
                                                                                                          13
                                          B   A S I C   P   L A N


member during the terminal phase of illness, social     • Injectable Contraceptives    $10 copayment
services evaluation, and home health aid services.      • Depo-Provera medication is limited to one
Immunizations                     $10 Copayment           injection every 90 days.
PacifiCare will cover immunizations consistent          Prescription Drugs
with the following: American Academy of                   Retail
Pediatrics, the American Academy of Family                  Generic Formulary Prescription Drugs
Physicians, and the Center for Disease Control.             $5 Copayment per Prescription Unit
Immunizations for adults are covered, including             Brand-Name Formulary Prescription Drugs
those required for travel.                                  $15 Copayment per Prescription Unit
Hepatitis B                   $10 Copayment                 Non-Formulary Brand-Name
Covered when Medically Necessary, or for                    Prescription Drugs
“occupational risk”                                         $30 Copayment per Prescription Unit
                                                          Mail-Order
Outpatient Surgery                   Covered in full        Generic Formulary Prescription Drugs
(as a substitute for inpatient surgery)                     $10 Copayment/3 Prescription Units**
Short-Term Physical, Speech and                             Brand-Name Formulary Prescription Drugs
Occupational Therapy            $10 copayment               $25 Copayment/3 Prescription Units**
                                                            Non-Formulary Brand-Name
Prenatal and Postnatal Care       $10 copayment*            Prescription Drugs
(office visits)                                             $45 Copayment/3 Prescription Units**
Normal Delivery, Cesarean Section,                      Please see the Prescription Drug section of this
Complications of Pregnancy       Covered in full        booklet.
• Physician and Medical Services
• Hospital and other related services                   Mental Health
                                                        • Outpatient Care                  $20 copayment
Voluntary Interruption of Pregnancy                       Up to 40 sessions per Calendar Year with a
1st trimester                        Not Covered          psychiatrist, psychologist, or other duly-
2nd trimester                        Not Covered          licensed counselor for crisis intervention
After 20 weeks                       Not Covered          and evaluation.
Abortions are covered for Life-threatening              • Inpatient Care                    Covered in full
emergencies only. Prior authorization is required.        40 days hospitalization per calendar year.
Family Planning Services          50% Copayment         Partial Hospitalization Services Covered in full
(Included when authorized through                       Two visits for partial or respite care may be
your Primary Care Physician)                            substituted for each 1 day of hospitalization.
Infertility-procedures consistent with established      For more comprehensive mental health benefits,
medical practices in the treatment of infertility by    see the Behavioral Health section of this booklet.
Physicians including but not limited to, diagnosis,
diagnostic tests, medication and surgery.               Substance Abuse
• Physician visits for contraceptive                    Short-term treatment for acute alcohol or drug
    devices and oral contraceptives                     abuse (detoxification, crisis intervention and
    prescriptions                  $10 copayment        referral to a licensed community agency for
• Vasectomy                        $50 copayment        social services)
• Tubal ligation                  $250 copayment        • Outpatient Care                   $20 copayment
                                                            Up to $1500 per Calendar Year

 *Each office visit requires only a single copayment even if multiple outpatient services are performed.
**There is a $1,000 out-of-pocket maximum for covered for Prescription Drugs purchased through the
  mail-order program per member per year.
14
                                         B   A S I C   P   L A N


Hearing Aid                                            $2,500 per year for special food products which
• Audiological Exam                   Not Covered      are prescribed or ordered by a physician as
• Instrument                          Not Covered      medically necessary for the treatment of a person
Chiropractic Care               $10 copayment          described above is covered. This coverage is
Based upon medical necessity. PCP                      provided whether or not the condition existed
referral required.                                     when the policy was purchased. “Inherited
                                                       metabolic disease” means a disease caused by an
Diabetes Management and Treatment                      inherited abnormality of the body chemistry of a
    Copay is determined by the provider visited        person; and “special food product” means a food
       (i.e. $10 copay per Physician Visit Copay       product that is specially formulated to have less
according to Health Improvement Schedule, etc.)        than 1 gram of protein per serving and is
Medication, equipment, supplies and appliances         intended to be consumed under the direction of
that are medically necessary for the treatment of      a physician for the dietary treatment of an
diabetes. Coverage for the self-management and         inherited metabolic disease. The term special
treatment of diabetes includes:                        food product does not include a food that is
a. the training and education provided to an           naturally low in protein.
   insured after he/she is initially diagnosed with
   diabetes which is medically necessary for the       EXCLUSIONS AND LIMITATIONS
   care and management of diabetes, including          All services and benefits for care and conditions
   counseling in nutrition and the proper use of       as described below shall be excluded from
   equipment and supplies for the treatment of         coverage under this plan unless specifically
   diabetes.                                           included as a supplemental benefit rider.
b. training and education which is medically
   necessary as a result of a subsequent               General Exclusions
   diagnosis that indicates a significant change       The following services are not covered by
   in the symptoms or condition of the insured         PacifiCare.
   and which requires modification of his/her
   program of self-management of diabetes; and         A. (i) All services not specifically included in the
                                                          attached Benefit Descriptions, (ii) services
c. training and education which is medically              rendered without authorization from
   necessary because of the development of new            Member’s Primary Care Physician (except for
   techniques and treatment for diabetes.                 Emergency or Urgently Needed Services), and
“Diabetes” to include Type 1, Type II, and                (iii) services prior to Member’s start date of
gestational diabetes.                                     coverage or subsequent to the time coverage
                                                          ends.
Digestive Disorders Coverage         Covered up to
(Enteral formulas)      $2,500 per Calendar Year       B. PacifiCare is not responsible for the cost of
                          according to Guidelines         services rendered by Outside Providers when
Enteral formulas for use at home that are                 the Member has refused treatment provided
prescribed or ordered by a physician as                   or authorized through Member’s Primary Care
medically necessary for the treatment of inherited        Physician.
metabolic diseases characterized by deficient
                                                       C. PacifiCare is not responsible for the cost of
metabolism, or malabsorption originating from
                                                          services which, in the judgment of the Health
congenital defects or defects arising shortly after
                                                          Plan, are not Medically Necessary or not
birth, or amino acid, organic acid, carbohydrates,
                                                          required in accordance with professionally
or fat are covered according to Nevada State
                                                          recognized standards of medical practice.
mandated guidelines.


                                                                                                         15
                                        B    A S I C   P   L A N


D. PacifiCare is not responsible for the cost of       • Ambulance service (ground or air) to the
   services which are part of a plan of treatment        mortuary.
   for a non-covered services, including services      • Wheelchair transport – a vehicle which can
   and supplies to treat medical conditions              transport a wheelchair (e.g. a specially-
   which are recognized by the organized                 designed van or taxi).
   medical community in the State of Nevada, in        • Personal transportation costs such as gasoline
   conformance with professionally recognized            costs for private vehicle or taxi fare.
   standards of practice, to be direct and
                                                       Behavioral Health (Inpatient)
   predictable consequences of such non-
                                                       • Recreational or diversional activities.
   covered services; provided, however, that the
                                                       • Inpatient psychiatric services where the
   Health Plan shall not exclude coverage for
                                                          Member receives medical or surgical care,
   Medically Necessary services required to treat
                                                          but does not meet established criteria for
   medical conditions that may arise but are not
                                                          inpatient behavioral health stay.
   predictable in advance, such as unexpected
                                                       • Board and care, convalescent services, and/or
   complications of surgery.
                                                          custodial services provided in a psychiatric
Exclusions and Limitations                                hospital after treatment ends.
                                                       • Psychotherapy and behavioral treatment of
Abortions                                                 long-term and chronic behavioral health
• Covered for medical necessity only.                     disorders, such as bipolar disorder, autism,
Acupuncture                                               schizophrenia, and eating disorders are not
• Not covered.                                            covered unless Medically Necessary.
                                                       • Marriage counseling, independent living
Acupressure
                                                          training, biofeedback, hypnotherapy and co-
• Not covered.
                                                          dependency treatment are excluded.
Allergy Testing & Injections                           • Services that are primarily oriented towards
• Cytotoxicity testing/Bryan’s test                       treating a social, developmental or learning
• Urine autoinjection.                                    problem rather than a medical problem.
• Skin titration/Rinket method.
                                                       Behavioral Health (Outpatient)
• Provocative and neutralizing testing
                                                       • Meals and transportation.
    (subcutaneous) for food allergies.
                                                       • Activity therapies, group activities or other
• Sublingual provocative test.
                                                          services and programs which are solely
• Serum allergy/histamine release testing.
                                                          recreational or diversional activities.
Ambulance Service                                      • Day care.
(Non-Emergency)                                        • Outpatient hospital psychiatric programs
• Transportation to the Provider for routine care         consisting of only psychosocial activities.
   when transport by other means would not             • Outpatient prescription drugs.
   endanger the Member’s health.
                                                       Biofeedback
• Ambulance service when the Member is
                                                       • Not covered.
   unable to locate another form of transport
   and the Member’s health would not be                Birth Control
   compromised.                                        • Over-the-counter supplies and devices are not
• Ambulance service as a convenience to a                  covered.
   family Member rather than Medical                   Blood and Blood Products
   Necessity.                                          • A platelet-derived wound healing formula
• Air ambulance services when the time                    used in the repair of chronic, non-healing,
   required to transport the Member by ground             cutaneous ulcers or wounds.
   ambulance poses no medical threat, and the
   point of pick-up is accessible by land vehicle.
16
                                            B   A S I C   P   L A N


• Blood that is stored but not used when the                  studies, clinical literature, Medicare, and
  Member cancels or reschedules an elective                   Federal Drug Administration decisions. If the
  surgery.                                                    proven benefits of a new treatment outweighs
• Blood charges associated with non-authorized                the risks, the new treatment is added to the
  or non-covered procedures.                                  member’s benefits and coverage is adjusted
Chemotherapy                                                  accordingly.
• Alternative medicines are not covered.                  Family Planning/Infertility
Cosmetic Surgery                                          • Second generation fertility drugs such as
•   Not covered unless Medically Necessary or
                                                             Pergonal and injectable infertility drugs are
    following a mastectomy in order to maintain
                                                             not covered.
    symmetry.
                                                          • In-vitro fertilization, gamete and zygote
•   Coverage for newborns, adopted children, and
                                                             intrafallopian transfers, and other fertility
    children placed for adoption, who were covered
                                                             procedures and services related to such
    from birth, adoption, or adoption placement, shall
                                                             procedures are not covered.
    include treatment of medically diagnosed
                                                          • Reversal of sterilization is not covered.
    congenital or birth abnormalities.
                                                          • Infertility medical expenses of surrogate
                                                             mothers who are not Members are not
Dental Care                                                  covered.
• General dental services such as items or                • Genetic counseling not associated with an
  services in connection with care, treatment,               intrauterine pregnancy.
  filling, removal, replacement, or artificial
  restoration of the teeth or structures directly         Home Health Care
  supporting the teeth, treatment of dental               • Custodial care, domiciliary care and/or
  abscess, or other oral conditions (unless                 private nursing duty.
  Member has supplemental dental plan).                   • Skilled nursing care solely for the purpose of
• Physician services provided in connection                 drawing a Member’s blood for testing.
  with non-covered dental services.                       • Routine, custodial, and convalescent care.
                                                          • Homemaker services unrelated to Member
Durable Medical Equipment                                   care, home meal delivery services (e.g.
• Disposable supplies such as bandages, elastic             “Meals-on-Wheels”) or transportation services
  stockings, bath tub lifts, breast pumps and               (e.g. “Dial-a-Ride”).
  grab bars.
• Lightweight oxygen conversing device.                   Hospice Services
                                                          • Members who do not meet the definition of
Experimental/Investigational Medicine                       “terminally ill.”
• Experimental Procedures and Items are those             • Hospice services that are not reasonable and
   procedures, items, treatments, devices and               necessary for the management of a terminal
   drugs considered to be experimental. Any                 illness and include care provided in non-
   procedure, test, drug, or equipment as a part            certified hospice programs.
   of a research study or that is generally not
   accepted as standard practice in the medical           Inpatient Hospital Admissions and Services
   community is excluded.                                 • Experimental procedures and items.
• Technology Assessment is a regular review of            • Those services and items not considered
   new procedures, devices, and drugs to                     reasonable and medically necessary for the
   determine whether or not they are safe and                diagnosis, care and treatment of an illness or
   effective for members. The Technology                     injury suffered by the hospitalized Member.
   Assessment Group, consisting of staff, experts,        • Private rooms (unless Medically Necessary).
   Primary Care Physicians, pharmacists, and              • Personal or comfort items.
   specialists conducts careful reviews of case           • Private duty nurse or “sitter” (unless
                                                             Medically Necessary).
                                                                                                             17
                                        B   A S I C   P   L A N


• Early admission to perform pre-operative            • Procedures, services, medications and
  testing (unless preapproved), early admission         supplies related to sex transformations.
  for the Member, Member’s family or                  • Elective or voluntary enhancement
  Member’s physician’s convenience.                     procedures, services, supplies, and
• Take home medications and/or supplies                 medications including weight loss, hair
  (unless the Member has Supplemental                   growth, athletic performance, cosmetic
  Pharmacy Benefit).                                    purposes, anti-aging, and mental
• Elective, non-Medically Necessary surgery             performance.
  and procedures (e.g. cosmetic surgery).             • New procedures, services, supplies, and
Laboratory Services (Diagnostic)                        medications until they are reviewed for safety,
• Paternity testing services.                           efficacy, and cost effectiveness and approved
• Pre-marital blood testing.                            by PacifiCare.
• Laboratory services to determine blood              Obesity
   alcohol.                                           • Treatment for obesity unless Medically
• FAA testing requirements.                             Necessary
• Employer required drug testing.
                                                      Office Visits
• Testing required for school admissions.
                                                      • Treatment for any illness or injury when not
• Non-medically indicated, experimental, or
                                                         attended by a licensed physician, surgeon, or
   unnecessary diagnostic and/or routine
                                                         healthcare professional.
   laboratory services are not covered.
                                                      • Services that are oriented toward treating a
Massage Therapy                                          social, developmental or learning problem as
• Not covered.                                           opposed to a medical problem.
Maternity Care                                        • Completion of insurance forms.
• Medical and hospital costs resulting from a         • Clearance to return to work following an
  normal full-term delivery in a hospital outside        illness, or need for documentation of an
  of the PacifiCare of Nevada Service Area.              illness as requested by an employer as a
• Amniocentesis for sex determination.                   reason for being absent.
• Elective delivery at home.                          Outpatient Surgery and Procedures
Miscellaneous                                         • Non-Medically Necessary and/or non-
• Coverage of any injury or condition sustained         authorized outpatient surgery and/or
   in the intentional commission of an illegal act      procedures.
   by the Member.                                     • Outpatient surgery only for the purpose of
• Treatment for disabilities connected to               improving the Member’s appearance rather
   military service for which the Member is             than improving a physiological function (e.g.
   legally entitled to services through a Federal       cosmetic surgery).
   Governmental Agency, and to which Member           Pain Rehabilitation
   has reasonable accessibility.                      • Pain management programs are not covered.
• All services and items incident to the
                                                      Physicals – Health Assessments
   improvement of the functioning of a
                                                      • Routine physical examinations for insurance
   malformed portion of the body or system,
                                                         qualification, school attendance, and
   unless determined by a PacifiCare Medical
                                                         employment are not covered.
   Director or their designee to be Medically
                                                      • Services must be provided through the
   Necessary, consistent with professionally
                                                         Network unless it is an emergency or urgent
   accepted standards or practice.
                                                         situation.
• Care of conditions for which state or local
   law requires treatment in a public facility.

18
                                          B   A S I C   P   L A N


Podiatry                                                    United States pharmacopeial Convention, or
• Removal or reduction of corns and calluses,               in the American Hospital Formulary Services
   clipping of toenails, flat feet, fallen arches,          edition of Drug Information; medications
   and chronic foot strain except when                      limited to investigational use by law.
   Medically Necessary for diabetic or
                                                        Pulmonary Rehabilitation
   neurological involvement or peripheral
                                                        • Not covered.
   vascular disease.
• Foot orthotics not covered.                           Rehabilitative Therapy
                                                        (In/Outpatient Physical, Occupational
Prescription Drugs
                                                        & Speech Therapy)
• Elective or voluntary enhancement procedures,
                                                        • General exercises that are intended only to
   services, supplies and medications, including
                                                            promote overall fitness.
   weight loss, hair growth, athletic performance,
                                                        • Maintenance therapy.
   cosmetic purposes, anti-aging, and mental
                                                        • Long term therapy or rehabilitation for
   performance.
                                                            chronic conditions unless the Member
• New procedures, services, supplies, and
                                                            experiences an acute exacerbation, and a
   medications until they are reviewed for safety,
                                                            need for short-term therapeutic intervention is
   efficacy, and cost effectiveness and approved
                                                            documented.
   by PacifiCare.
• Cerezyme for Gauchers disease is limited to           Skilled Nursing Care Facility
   no greater than 30 c/kg per month given in           • Custodial care.
   divided doses.                                       • Respite services.
• Non-FDA labeled indications or uses of drugs.         • Services of a private duty nurse or private
                                                            duty attendant.
The following prescriptions are not covered
under this Agreement:                                   Specialist/Consultant
• Over-the-counter medications.                         (Referral to)
• Convenience dosage forms.                             • Services provided by a specialist and/or
• Combination products.                                    consultant without Referral or Pre-
• Slow release oral medications.                           Certification are not covered.
• Prescription medication for treatment of a            Supplies
   non-covered medical condition.                       • Parenteral and enteral nutritional supplies,
• Vitamins not included on the PacifiCare                  nutrients and nutritional supplements, unless
   Formulary.                                              defined as covered under medical foods.
• Nutritional supplements.                                 These supplies are covered when used in the
• Products used for cosmetic purposes.                     hospital, skilled nursing facility or under the
• Tobacco withdrawal medication.                           direction of home health.
• Unit dose pre-packaged medications.                   • Disposable supplies such as bandages, IV
• Experimental/Investigational drugs not FDA               tubing, elastic stockings (other than when
   approved.                                               used in the hospital, nursing facility or under
• Non-Formulary injectable drugs are not                   the direction of home health).
   covered unless specifically authorized by a
   PacifiCare Medical Director or their designee.       TMJ – Temporomandibular Joint Dysfunction
• Penlac used for treating mild to moderate             Treatment
   onychomycasis (nail fungus) is excluded.             • TMJ of dental origin is not covered.
• Medications prescribed for experimental or            • Treatment methods which are recognized as
   non-FDA approved indications unless                     dental procedures such as:
   prescribed in a manner consistent with a             • Extraction of teeth.
   specific indication in Drug Information for the      • Treatment of malocclusion or any abnormality
   Health Care Professional, published by the              resulting from malocclusion.
                                                                                                         19
                                        B   A S I C   P   L A N


Termination of Pregnancy                              PRESCRIPTION DRUG BENEFIT
• Elective (planned) abortion is not covered.
                                                      What is the Formulary?
Transplants                                           The Formulary is a list of outpatient prescription
• Organ transplants are limited to non-               drugs that are covered by PacifiCare when
   experimental procedures that are proven to         prescribed by a PacifiCare Contracting Medical
   be effective for a specific diagnosis and          Provider and filled at a PacifiCare Contracting
   determined to be medically necessary by            Pharmacy. The Formulary was created and is
   established criteria.                              regularly updated by a Pharmacy and
• Artificial organs including but not limited to,     Therapeutics Committee that consists of
   heart and pancreas are excluded.                   practicing physicians and pharmacists. The
• Unauthorized or not pre-certified organ             committee decides which prescription drugs
   procurement and transplant services.               provide quality treatment for the best value. Your
• All non-Medically Necessary donor and/or            physician has a copy of the Formulary and will
   recipient expenses including: transportation       use it as a reference when prescribing
   expenses, lodging expenses, meals.                 medications or you can refer to our web site at
• Transplantation provided in a non-certified         www.pacificare.com.
   transplant facility.
                                                      How to Use the Program
• Recipient or donor transportation costs to the
                                                      • Present your PacifiCare ID card at any
   transplantation center are not covered.
                                                        PacifiCare Contracting Pharmacy.
Vision Care & Services
                                                      • Pay your copayment for each prescription
• Corrective lenses and frames, contact lenses
                                                        unit of medication or the retail cost of the
    (except post-cataract extraction), low vision
                                                        prescription, whichever is less.
    aides, and contact lens fitting and
    measurements, except when provided as a           • If your prescription costs more than your
    supplemental benefit.                               copayment, your prescription may be for a
• Radial keratotomy or other surgical treatments        non-Formulary drug. Your may ask your
    for refractive errors.                              pharmacist to contact your physician for a
• Eye exam/corrective eyewear required by an            Formulary alternative form of the medication.
    employer.                                         What is Covered?
• Conditions covered by Workers’ Compensation.        All medications listed in the Formulary are
X-Ray – Diagnostic & Therapeutic                      covered, when ordered by a PacifiCare
• Non-medically indicated or unnecessary              Contracting Medical Provider and filled at a
   X-ray services.                                    PacifiCare Contracting Pharmacy. The Formulary
• Experimental or unproved radiological tests or      includes a broad range of FDA approved generic
   treatments.                                        and brand-name medications. The Formulary
• Thermography.                                       does not include all prescription medications.
                                                      Please contact PacifiCare Customer Service at
                                                      1-800-347-8600 if you would like more
                                                      information about the Formulary.
                                                      What Does “Generic” Mean?
                                                      A generic drug is a medication that has met the
                                                      standards set by the Food & Drug Administration
                                                      (FDA) to assure its bioequivalency to the original
                                                      patented brand-name mediation. Once a generic
                                                      drug is approved by the FDA as being
                                                      bioequivalent, its level of safety, purity, strength
20
                                        B   A S I C   P   L A N


and effectiveness is the same as the brand-name       Prescription Drug Benefit Limitations
product. When new generic drugs are approved          and Exclusions
by the FDA and added to the Formulary,
                                                      The Prescription Drug Benefit will not be
PacifiCare will cover the generic version in place
                                                      provided for any of the following:
of the brand-name drug. By using these
equivalent medications, you can maintain quality      • Medications available without a prescription
while realizing substantial savings.                    (over-the-counter), unless listed on the
                                                        Formulary.
If there is no generic equivalent available for a
specific brand-name drug, your contracted             • Medications prescribed by Non-Contracting
physician may prescribe a “therapeutic                  Medical Providers.
substitute” instead. Unlike a generic, which has      • Non-Formulary injectable drugs are not
the identical active ingredient as the brand-name       covered unless specifically authorized by a
version, a therapeutic substitute has a chemical        PacifiCare Medical Director or their designee.
composition so close to its brand-name
counterpart that it has the same clinical – or        • Drugs or medicines purchased before you
therapeutic – effect.                                   started or after you terminated your
                                                        PacifiCare membership.
How Much Medication Can I Obtain for a
Copayment?                                            • Dental related prescriptions (i.e. Gel-Kam,
Covered medications are dispensed in a                  Peridex, fluoride preparations, etc.)
predetermined amount called a prescription unit.      • Therapeutic devices or appliances, including
A prescription unit is the maximum quantity that        hypodermic needles, syringes, support
may be dispensed for a single copayment.                garments, and other non-medicinal
Typically the quantity will range from 30 to 100        substances (except insulin syringes).
tablets or capsules. Some medications may
provide more or less, depending on how they are       • Cosmetic, dietary supplements, diet pills, or
typically dosed. Medications such as inhalers,          health and beauty aids.
tubes of ointment or cream or insulin vials will      • Medications for which the cost is recovered
be covered at a copayment per unit (inhaler,            under any Workers’ Compensation,
tube, vial).                                            Occupational Disease Law, or from any state
How Much Medication Can I Obtain at                     or government agency, or medication
One Time?                                               furnished by any other drug or medical
A maximum of one month’s (30-day supply) fill           services for which there is Covered in full to
of any medication generally can be obtained at          the patient.
one time. The only exceptions are:                    • Medications prescribed for experimental or
• Birth control pills, which can be purchased in        non-FDA approved indications unless
  three-month fills at a participating pharmacy         prescribed in a manner consistent with a
  or through the PacifiCare mail order                  specific indication in Drug Information for the
  pharmacy for the appropriate mail order               Health Care Professional, published by the
  copayment.                                            United States Pharmacopeia Convention or in
                                                        the American Hospital Formulary Services
• A 90-day supply of maintenance medications            edition of Drug Information or any other
  can be obtained through the Mail Service.             source which reflects community practice
  Refer to the section on Mail Services on the          standards; medications limited to
  following pages.                                      investigational use by law.




                                                                                                        21
                                         B   A S I C   P   L A N


• PacifiCare reserves the right to require prior       •   Smith’s Pharmacy
  authorization on certain pharmaceuticals             •   Summit Pharmacy
  prior to dispensing.                                 •   Sun United Drugs
• Elective or voluntary enhancement                    •   Sunrise Medical Plaza Pharmacy
  procedures, services and medication                  •   Sunrise OP Pharmacy
  including but not limited to: weight loss, hair      •   Target Pharmacy
  growth, athletic performance, cosmetic               •   University Drug
  purposes, anti-aging and mental performance          •   Uptown United Drug
  are excluded.                                        •   Vencor Pharmacy
                                                       •   Village East Drugs
• New procedure services, supplies and                 •   Von’s Pharmacy
  medications until they are reviewed for safety,      •   Wal-Mart Pharmacy
  efficacy, cost effectiveness and approved by         •   Walgreen’s Pharmacy
  PacifiCare.                                          •   White Cross United Drugs
Where to Get Your Prescriptions Filled                 Filling Prescriptions in an Emergency
Covered medications must be obtained at one of         Please use a PacifiCare Contracting Pharmacy to
the following PacifiCare Contracting Pharmacies.       have your prescriptions filled. If you should have
•    Albertsons                                        to pay for your prescription at a non-contracted
•    Campus Pharmacy                                   pharmacy following an urgent or emergency
•    Craig Rancho Pharmacy                             visit, you may request reimbursement by sending
•    Elliott’s Drug Mart                               your prescription receipts to:
•    Green Valley Drugs                                    PacifiCare Claims Department
•    Henderson Drugs                                       P.O. Box 52078
•    Kmart Pharmacies                                      Phoenix, Arizona 85072-2078
•    Lam’s
•    Landmark                                          Should you have questions regarding your
•    Lied Ambulatory Care Center                       Prescription Drug Benefit or PacifiCare’s
•    Lin’s Marketplace                                 Formulary, please call Customer Service at
•    Long’s                                            1-800-347-8600 or telephone number for the
•    McCarren Quick Care Pharmacy                      hearing impaired (TTY) 1-800-360-1797,
•    Medicine Shoppe                                   Monday – Friday, 7 am to 6 pm for assistance.
•    Network Pharmacy                                  Having Your Prescriptions Delivered by Mail is
•    Nevada Care Pharmacy                              Easy, Just Follow These Steps:
•    Nevada RX Drug
                                                       1. Obtain a written prescription from your
•    Park Flamingo Pharmacy
                                                          physician for each medication you would like
•    Partell
                                                          to have filled. NOTE: WE MUST HAVE A
•    Pharmerica
                                                          NEW PRESCRIPTION in order to fill a mail-
•    Prescription Solutions Mail Order
                                                          order request. Please ask your physician if
•    Raley’s Drug’s
                                                          you can obtain a 90-day supply with
•    Rancho Quick Care
                                                          additional refills for any maintenance
•    Rite-Aid
                                                          medication. If you use the Prescriptions by
•    Red Rock
                                                          Mail Program, you may receive up to three
•    Resources Pharmaceuticals
                                                          (3) prescription units for $10 Formulary
•    Safeway
                                                          generic or $25 brand-name or $45 non-
•    Sav-On Pharmacy
                                                          Formulary.
•    Seniorcare Pharmacy
•    Silver Pharmacy & Supply
22
                                         B   A S I C   P   L A N


2. Fill out the prescription mail-order form. A        health. First, because of Harmony Healthcare’s
   new order form will be mailed back along            strict Provider credentialing process and
   with your prescription for your next order.         continuous oversight of quality of care, you can
3. Send the prescription mail-order form with          trust that you are seeing qualified practitioners.
   your written prescription(s) and insert the         Also, Harmony Healthcare takes the guesswork
   applicable copayment to:                            out of finding a behavioral health Provider and
                                                       can match your specific needs with the
       Prescription Solutions®                         appropriate Provider. And since you can call
       P.O. Box 9040                                   Harmony Healthcare’s toll-free number at any
       Carlsbad, CA 92018-9040                         time, you can receive a confidential Referral
4. Before filling your prescription(s), one of our     directly. Additionally, your Primary Care
   Registered Pharmacists will check your              Physician can request a Referral on your behalf
   prescription(s) for possible drug interactions.     by calling Harmony Healthcare directly.
   Once your prescription is filled, the               How to Access Your Benefits
   pharmacist will check the order again to
   make sure the correct medication and dosage         To access your behavioral health benefits, call
   is shipped to you. Your prescription will           Harmony Healthcare directly at 702-251-8000
   arrive in 10-14 working days.                       Monday through Friday from 8 a.m. to 7 p.m.
                                                       and Saturday between 8 a.m. and 11 a.m. After-
I Have Additional Questions:                           hours Monday through Friday from 7 p.m. to 8
If you have additional questions regarding your        a.m., Saturday after 11 a.m. or all day Sunday
prescription benefit call Customer Service at          call 1-800-363-4874. When you call, you’ll
1-800-347-8600 or telephone number for the             speak with a coordinator who’ll check your
hearing impaired (TTY) 1-800-360-1797,                 eligibility, gather basic information about you
Monday - Friday, 7 a.m. - 6 p.m.                       and your situation. Depending on the help you
                                                       need, a clinician may then talk with you about
                                                       the problem you’re experiencing and assess what
BEHAVIORAL HEALTH                                      Provider and treatment would be best for your
Mental Health Services and Chemical                    situation.
Dependency                                             If you would like to receive information about
Harmony Healthcare Behavioral Health Services          Harmony HealthCare’s Contracting Medical
                                                       Providers, obtain Referrals for specialty care or to
There’s Help When You Need It                          obtain care after normal office hours, please call
There may be times in your life when you find          Harmony Healthcare directly at 702-251-8000
yourself feeling overwhelmed and needing help.         Monday through Friday from 8 a.m. to 7 p.m.
Maybe it’s a mental health problem. Or perhaps         and Saturday between 8 a.m. and 11 a.m. After-
you could be struggling with an alcohol                hours Monday through Friday from 7 p.m. to 8
addiction. Whatever the problem, you don’t need        a.m., Saturday after 11 a.m. or all day Sunday
to handle it alone. We can help. Your health care      call 1-800-363-4874.
partners, PacifiCare and Harmony Healthcare            Harmony Healthcare Maintains Confidentiality
Behavioral Health Services can provide you with
the support you need for mental health and             With Harmony Healthcare, you can be assured
chemical dependency benefits.                          that what you discuss with its staff is kept strictly
                                                       confidential. Harmony Healthcare provides
Harmony Healthcare Behavioral Health Services          information only to the professionals delivering
specializes in providing behavioral health care.       your treatment. Confidentiality is built into the
You benefit in several ways by receiving your          operations of Harmony Healthcare through a
mental health and chemical dependency benefits         system of control and security that protects both
through a company specializing in behavioral           written and computer-based information.
                                                                                                          23
                                        B   A S I C   P   L A N



Questions and Answers                                 would not create an unreasonable risk to your
                                                      health.
Is Prior- Authorization always necessary to start
a treatment program?                                  What do I do if I receive a claim?
To start a treatment program just call Harmony        All authorized services prescribed by Harmony
Healthcare. A coordinator will assist you to get      Healthcare should be billed directly to Harmony
connected to the right provider. In an Emergency      Healthcare by the provider. However, if you get
or urgent care, out-of-area care and urgent care      Emergency treatment from a Non-Contracting
in unusual circumstances, you should first do         Medical Provider, you may receive a bill. Send
everything possible to ensure your physical           Harmony Healthcare a copy of the bill or claim
safety, then call Harmony Healthcare within 48        within 90 days of the date of service, or as soon
hours of admission or visit to a provider, or as      as possible. Harmony Healthcare will not pay for
soon as reasonably possible.                          bills or claims given to us that are more than one
                                                      year old. Mail bills to:
What happens in an Emergency?
In an Emergency, Harmony Healthcare’s first               Physicians IPA
concern is for your health and well being. If             P.O. Box 95638
faced with an Emergency, do everything possible           Las Vegas, Nevada 89193-5638
to ensure your physical safety, which may             If your plan includes a Copayment, you are
include calling 911. Get to a treatment center        responsible to pay these directly to the Provider.
first, then, as soon as reasonably possible, call
Harmony Healthcare at 702-251-8000 Monday             How are new treatments and technologies
through Friday from 8 a.m. to 7 p.m. and              evaluated?
Saturday between 8 a.m. and 11 a.m. After-hours       Harmony Healthcare is committed to evaluating
Monday through Friday from 7 p.m. to 8 a.m.,          new treatments and technologies in behavioral
Saturday after 11 a.m. or all day Sunday call         health care. A committee composed of Harmony
1-800-363-4874.                                       Healthcare’s Medical Director and people with
                                                      research and academic backgrounds meet at
Please see the Emergency Services section in your     least once per year to assess new advances and
member materials for more specific information.       programs.
Harmony Healthcare will coordinate all follow-
up behavioral health services to Emergency            Emergency Services
treatment on your behalf. This may include a          Medically Necessary Emergency Services means
transfer to a Contracting Medical Provider            health care services that are provided to an
designated by Harmony Healthcare when you             insured by a provider of healthcare after the
are stable and the transfer would not create an       sudden onset of a medical condition that
unreasonable risk to your health.                     manifests itself by symptoms of sufficient severity
Can I receive care outside the Service Area?          that a prudent person would believe that the
For behavioral health services outside the Service    absence of immediate medical attention could
Area, you will be covered for Emergency               result in:
Services and Urgently Needed Services only.           a) serious jeopardy to the health of an insured;
Please see the Emergency Services question
above and in your member materials for more           b) serious jeopardy to the health of an unborn
specific information. Harmony Healthcare will            child;
coordinate all follow-up behavioral health            c) serious impairment of a bodily function; or
services to Emergency treatment on your behalf.
This may include a transfer to a Contracting          d) serious dysfunction of a bodily organ or part.
Medical Provider designated by Harmony                Examples of emergencies include heart attacks,
Healthcare when you are stable and the transfer       strokes, poisonings, and sudden inability to breathe.

24
                                         B   A S I C   P   L A N


If you find yourself in an Emergency situation:        Urgently Needed Services
1. Immediately call 911 or go to the nearest           Urgently needed services are services that are
   emergency room and present your PacifiCare          provided outside the Service Area by Non-
   membership card.                                    Contracting Medical Providers or facilities. They
                                                       are covered services that appear to be required
2. Within forty-eight (48) hours, or as soon as
                                                       in order to prevent serious deterioration of your
   reasonably possible, notify PacifiCare of
                                                       health resulting from an illness or injury if:
   emergency treatment so that your PacifiCare
   Primary Care Provider can supervise your            • you are outside of or temporarily absent*
   treatment and arrange for transfer to your            from the Service Area, and
   chosen PacifiCare Network, when your                • receipt of the health care service cannot be
   condition permits.                                    delayed until you return to the Service Area.
3. Should you receive any bills related to your        What to Do When You Require Emergency or
   emergency care, please send the bills to            Urgently Needed Services
   PacifiCare Claims Department:
                                                       Wherever you are, if you believe that you
       PacifiCare of Nevada, Inc.                      require emergency services or urgently needed
       Desert Regional Service Center                  services, you should:
       P. O. Box 52078
       Phoenix, AZ 85072-2078                          1. If possible, call, or have someone on your
                                                          behalf call, your Primary Care Physician or
PacifiCare will pay for Emergency Services as long        call the number on the back of your
as the condition continues to be an Emergency.            PacifiCare ID card. You may call your PCP’s
Once your condition is stabilized, your Primary           office24-hours a day, 7 days a week.
Care Provider must coordinate your care or the
                                                       2. If you are unable to reach your PCP’s office,
cost of such care may be your responsibility.             go to your Contracting Hospital or Urgent
It is important to notify PacifiCare in an                Care Center.
Emergency so that we can be involved in the            3. If you cannot reach your Contracting Hospital
management of your health care and transfer can           or Urgent Care Center, proceed to the nearest
be arranged when your medical condition is                emergency room and present your PacifiCare
stable (depending on the distance involved).              member card.
If you have an Emergency while out of the              What to Do if You Receive Bills for Emergency
PacifiCare Service Area, we prefer that you return     or Urgently Needed Services
to the PacifiCare Service Area to receive follow-
up care through your PacifiCare Contracting            If you receive any bills related to your
Medical Provider. However, follow-up care will         emergency or urgent care, you should send
be covered out-of-area as long as the care             them to:
required continues to meet the definition for              Customer Service
either Emergency Services or Out-of-Area                   c/o PacifiCare of Nevada Claims
Urgently Needed Services.                                  P.O. Box 52093
                                                           Phoenix, AZ 85072-2093
If you have an Emergency within the PacifiCare
Network, you must receive any follow-up care           Or, call Customer Service at 1-800-347-8600 or
through your PacifiCare Contracting Medical            1-800-367-8939 Telecommunications Device for
Provider. You are responsible for a $25                the Deaf (TDD), Monday through Friday 7:00
emergency room copayment if you are not                a.m. to 6:00 p.m.
admitted to the hospital.

*A temporary absence is an absence from the geographic service area lasting less than ninety (90) days.
                                                                                                       25
                                         B   A S I C   P   L A N



Follow-Up Care                                         If you believe you have surpassed your annual
                                                       copayment maximum, please submit all receipts
If you require additional services following
                                                       and a letter of explanation to:
stabilization of an emergency condition, you
should obtain these services from or with the              PacifiCare of Nevada, Inc.
authorization of your Primary Care Physician.              Customer Service
Follow-up care provided in an emergency room               P.O. Box 52078
is not a covered benefit.                                  Phoenix, AZ 85072-2078
Out-of-Area follow-up care includes, but is not        Any payments you have made beyond your
limited to: Routine follow-up care to Emergency        Annual Copayment Maximum will be
or Urgently Needed Services, such as treatments,       reimbursed.
procedures, x-rays, lab work and doctor’s visits,
as well a Rehabilitation Services, Skilled Nursing     GENERAL PROVISIONS
Care, Custodial Care, or Home Care.
                                                       Second Medical Opinions
Non-Qualifying Services
                                                       You, or your treating Primary Care Physician,
Medical or hospital services which do not qualify      may request a Second Medical Opinion by
as emergency or urgently needed services               submitting a request for a Second Medical
received without prior authorization from your         Opinion to PacifiCare. The request will be
Primary Care Physician are not covered. Thus,          evaluated by a PacifiCare Medical Director
for example, medical care provided outside the         based on the nature of the recommended
Service Area will not be covered if the need for       procedure or disease progression and the
care is for a known or chronic condition that is       Member’s signs and symptoms.
not manifesting itself by acute symptoms as set
forth in this section.                                 Reimbursement Provisions
Annual Copayment Maximum –                             PacifiCare is designed to eliminate claim forms
$1,200 Individual\$2,700 family                        and expenses other than required copayments. In
                                                       some circumstances, you may have expenses for
To protect you from large expenses, a limit,           covered services. If this happens, PacifiCare will
called your Annual Copayment Maximum, is               reimburse you for those expenses minus any
placed on the dollar amount of certain                 applicable copayment amounts.
copayments you might have to pay during a
calendar year. When the copayments you make            If you receive a bill for covered services, please
during any calendar year exceed the annual             provide us a copy of the bill within 120 days of
copayment maximum, then no further                     the date the service was rendered. Please submit
copayments will be required for services               the bill to:
received during the remainder of the calendar              PacifiCare Claims Department
year. Your annual copayment maximum is                     P.O. Box 52078
$1,200 for individuals and $2,700 for families.            Phoenix, AZ 85072-2078
• It is important to retain receipts of all            Occasionally, we are compelled to deny such
  copayments made, in order to submit proof of         claims. In that event, you may resubmit within
  reaching the copayment maximum.                      one year of the initial denial, explaining in
• The Annual Copayment Maximum does not                writing why you believe your claims should be
  apply to any other supplemental benefits such        approved. Your request will be considered a
  as outpatient prescription drugs, chiropractic       formal appeal and handled under the Appeals
  care, vision care and other supplemental             procedure described in the booklet.
  benefits.

26
                                         B   A S I C   P   L A N


Any questions about claims procedures should           needed, PacifiCare will notify you in writing of
be directed to the Customer Service.                   the reason for the delay and the anticipated time
Subscriber Liability for Payment                       needed to resolve your grievance.

In the event PacifiCare fails to pay a Contracting     Quality Improvement Department
Medical Provider for covered services, the             Complaints that involve potential quality of care
Member shall not be liable to the provider for         issues are referred to PacifiCare’s Quality
any sums owed by the health plan to the                Improvement Department for review. These
provider. However, the Member may be liable for        reviews are performed to assure that care is
any sums owed to a Non-Contracting provider            accessible, provided in a timely manner and
unless the services provided were authorized by        meets current community standards.
PacifiCare or were provided for an emergency.
                                                       Once Quality Improvement’s assessment is
Informal Complaints                                    complete, a determination will be made as to
PacifiCare will attempt to resolve any complaint       whether or not the medical care provided meets
that you might have. We encourage the informal         medically recognized standards. If it is
resolution of complaints (i.e. over the telephone),    determined that these standards have not been
especially if such complaints result from              met, PacifiCare will arrange for the appropriate
misinformation, misunderstanding or lack of            corrective action to be taken.
information. However, if your complaint cannot         Peer Review Organization Quality of Care
be resolved in this manner, a more formal              Complaint Process
Member grievance procedure is available.
                                                       If you are concerned about the quality of care
PacifiCare Grievance Procedure                         you have received, you may file a complaint
                                                       with the Peer Review Organization (PRO) in your
You have a right to file a complaint – also called     local area. (The name, address and telephone
a grievance – about problems you observe or            number of your local PRO are referenced in the
experience, including:                                 Appeals section below.)
• Complaints about the quality of services that
  you receive.
                                                       Basic Plan Appeals Procedure
                                                       As a Member of PacifiCare, you have the right to
• Complaints regarding such issues as office
                                                       appeal. You may appeal any decision regarding
  waiting times, physician’s behavior, adequacy
                                                       PacifiCare’s payment for or PacifiCare’s failure to
  of facilities, or other similar concerns.
                                                       provide what you believe are covered services
PacifiCare will attempt to resolve any complaint       on this plan. These include:
and encourages the informal resolution of
                                                       • The reimbursement for emergency services
complaints. However, if a grievance cannot be
                                                         anywhere in the world or out-of-area urgently
resolved in this manner, a more formal grievance
                                                         needed services.
procedure is available.
                                                       • A denied claim for any other health service
To use the Formal Grievance Procedure, you
                                                         furnished by a Non-Contracted Medical
must submit a grievance in writing to PacifiCare
                                                         Provider that you believe should have been
Customer Service. The grievance will be
                                                         arranged for, or reimbursed by PacifiCare.
acknowledged within five (5) business days of
receipt by PacifiCare.                                 • Those services you have not received, but
                                                         which you feel are the responsibility of
PacifiCare will advise you of PacifiCare’s
                                                         PacifiCare to pay for or arrange.
resolution of the grievance within thirty (30) days
of its receipt, unless good cause exists that          • The discontinuation of services which you
precludes PacifiCare from resolving the issue            believe are medically necessary covered
within this time frame. If additional time is            services.
                                                                                                        27
                                          B   A S I C   P   L A N


PacifiCare has a standard Appeals procedure and                ATTN: Appeal and Grievance Department
an expedited 72-hour Appeals procedure.                        PacifiCare of Nevada
Who May File an Appeal?                                        700 East Warm Springs Road
                                                               Las Vegas, Nevada 89119
You may file an Appeal or someone else may file
the Appeal on your behalf if you appoint them,              You must send your request within twenty-
in writing, as your representative.                         four (24) months of the initial decision.

Support For Your Appeal                                 2. The twenty-four (24) month limit may be
                                                           increased for good cause. You should include
You are not required to file more information to           in your request the reason why you could not
support your request for 1) service 2) payment for         file within that time frame.
services already received; or 3) your request for
reconsideration (Appeal). PacifiCare will gather        3. Within thirty (30) days of receipt of the
all necessary information. However, it may be              reconsideration (Appeal) request, PacifiCare
helpful if you include more information to clarify         will 1) conduct an investigation; 2) reconsider
or support your request. For example, in support           the issue; and 3) notify you in writing of the
of your request you may want to include                    decision. During the reconsideration, you or
information such as medical records or physician           your representative may present or give
opinions. To get medical records, you may send             relevant facts and/or more evidence for
a written request to your Primary Care Physician.          review either 1) in person; 2) via telephone 3)
Another Contracting Provider’s medical records             or in writing.
may not be included in your medical records             B. Expedited 72-Hour Initial Determination
received from your Primary Care Physician. You
                                                        You have the right to request and receive
will then need to separately ask the Contracting
                                                        expedited decisions affecting your medical
Provider who provided medical services to you.
                                                        treatment in “Time-Sensitive” situations. A Time-
This may include a Contracting Specialist as well
                                                        Sensitive situation is one where waiting for a
as a Contracting Hospital.
                                                        decision to be made within the standard decision
You have the ability to give more information in        time frame could seriously jeopardize your 1) life
person or in writing. In the case of an expedited       or health; or 2) your ability to regain maximum
decision or Appeal, you or your authorized              function. PacifiCare will determine if your
representative may provide evidence 1) in               situation is Time-Sensitive based on medical
person; 2) via telephone; or 3) in writing.             criteria or if your physician calls or writes in
A. Standard Appeals Procedure                           support of your request. If PacifiCare (or your
                                                        physician) decides that your situation is Time-
Requests for payment or provision of services are       Sensitive, a decision will be issued within
submitted to PacifiCare. As this occurs, you will       seventy-two (72) hours from the time the request
be notified in writing of the decision. If the          was received.
decision is a denial (partial or complete), the
notice will state the reasons for the denial as well    C. Expedited 72-Hour Review
as inform you of your rights to reconsideration         How to ask for an Expedited 72-Hour Review
(Appeal).
                                                        To ask for an expedited 72-hour review, you or
1. If you decide to appeal the decision you             your authorized representative may 1) call; 2)
   receive in the notice, you should send a             write; 3) fax; or 4) visit PacifiCare. Be sure to ask
   written request for reconsideration (Appeal).        for an expedited 72-hour review when you make
   Please mail your written request to:                 your request.




28
                                        B   A S I C   P   L A N


   Call:     1-800-347-8600                           an independent external review of 1) PacifiCare’s
             7:00 a.m. to 6:00 p.m.                   denial of the requested service or procedure; or
   Write:    PacifiCare of Nevada, Inc.               2) PacifiCare’s denial of payment for the service
             Expedited 72-Hour Review Unit            or procedure. If you request an external review,
             700 East Warm Springs Road               an independent physician or provider who is not
             Las Vegas, Nevada 89119                  affiliated with PacifiCare of Nevada will review
                                                      the denial. As with a Standard Appeal, you may
   Fax:      1-800-269-2688                           submit whatever information you believe is
             Attention: Expedited 72-Hour             relevant in support of your request. However,
             Review Unit                              neither you nor PacifiCare will have an
             8:00 a.m. to 5:00 p.m.                   opportunity to meet with the reviewer or
   Walk-in: PacifiCare of Nevada, Inc.                participate in the reviewer’s decision.
            700 East Warm Springs Road                All requests for an independent external review
            Las Vegas, Nevada 89119                   must be made within sixty (60) calendar days of
            8:00 a.m. to 5:00 p.m.                    the date that you receive PacifiCare’s denial. You,
D. Independent External Review                        your physician, or your designated representative
                                                      may request an external review. To do so, please
PacifiCare offers a independent external review       call PacifiCare’s Customer Service Department at
process to review the denial of a requested           1-800-347-8600 or send in your request in
service or procedure or the denial of payment for     writing to:
a service or procedure, based upon a lack of
Medical Necessity, or based upon the                      PacifiCare of Nevada
determination that the service or procedure is            Appeal and Grievance Department
Experimental or Investigational. The process is           700 East Warm Springs Road
available at no charge to Members who meet all            Las Vegas, Nevada 89119-4323
of the following criteria:                            The independent external review will be
1. The Member has received an initial denial for      performed by an independent physician or
   the service or procedure from PacifiCare of        provider who is qualified to decide whether the
   Nevada;                                            requested service or procedure 1) is or is not
                                                      Medically Necessary; or 2) is or is not
2. The denial is based on a lack of Medical           Experimental or Investigational. The reviewer will
   Necessity, as defined in this Evidence of          not have material affiliation or interest with
   Coverage and Disclosure or based on the            PacifiCare. The reviewer will be selected by an
   determination that the service or procedure is     external independent review organization that
   Experimental or Investigational as defined in      contracts with PacifiCare. Neither you nor
   this Evidence of Coverage and Disclosure;          PacifiCare will choose or control the choice of
3. The Member has appealed the denial to              reviewer. In certain cases, a panel of physicians
   PacifiCare of Nevada as described in this          or providers, as deemed appropriate by the
   Evidence of Coverage and Disclosure;               external independent review organization, will
                                                      perform the independent external review.
4. PacifiCare has upheld the denial at the plan
   level; and                                         PacifiCare will forward your request to the
                                                      independent external review organization within
5. The cost of the service or procedure
                                                      five business days of receipt of your request.
   requested is more than five hundred dollars
                                                      PacifiCare will include with your request the
   ($500.00).
                                                      following:
If you meet all of the criteria listed above, you
                                                      1. All relevant medical records pertaining to
may request an external review. You may request
                                                         your case;
                                                                                                      29
                                          B   A S I C   P   L A N


2. All other documents PacifiCare used in               Investigational, as defined in this Evidence of
   determining that the service or procedure is         Coverage and Disclosure. The reviewer will not
   not Medically Necessary or Experimental or           decide whether the service or procedure is
   Investigational; and                                 covered under your health plan with PacifiCare
                                                        of Nevada. The independent external review
3. All other information or evidence that you or
                                                        organization will provide you and PacifiCare
   your physician have submitted to PacifiCare.
                                                        with 1) the reviewer’s decision; 2) a description
As stated above you or your physician may wish          of the qualifications of the reviewer, and 3) any
to submit additional information in support of          other information deemed appropriate by the
your request. Please submit all pertinent               organization.
information you wish to be included with your
                                                        Requesting Reconsideration of the External
request. PacifiCare will include this information       Review Decision
along with all other documents forwarded to the
independent external review organization.               If either you or PacifiCare disagrees with the
PacifiCare will also include with your request all      reviewer’s decision, either you or PacifiCare may
previous information you have submitted. The            request that the reviewer’s decision be
external review decision will be made within            reconsidered on the following grounds:
thirty (30) calendar days of PacifiCare’s receipt of    1. Error on the face of the information or
your request for review. However, this timeframe           evidence submitted;
may be extended if the reviewer needs additional
information to make a decision.                         2. Fraud; or

Expediting your Independent External Review             3. New information or evidence which was not
                                                           available at the time the reviewer made his or
The independent external review process will be            her decision.
expedited if you meet all of the criteria for
                                                        Requests for reconsideration must be submitted
independent external review as noted above. You
                                                        within fifteen (15) calendar days of your receipt
must also have previously completed an
                                                        of the reviewer’s decision. Your reconsideration
expedited 72 hour review as described in the
                                                        request must be submitted to the independent
previous section. The independent external
                                                        external review organization. The independent
review process will also be expedited if your
                                                        external review organization will determine
physician certifies that the requested service or
                                                        whether the reviewer’s decision will be
procedure would be significantly less effective if
                                                        reconsidered. If neither you nor PacifiCare
not promptly initiated. The review decision will
                                                        requests reconsideration within such fifteen (15)
be made within ten (10) business days of the            calendar days, the reviewer’s decision shall be
request for expedited review. However, this             considered final.
timeframe may be extended if the reviewer needs
additional information to make a decision.              If either you or PacifiCare requests reconsideration,
                                                        the independent external review organization
Independent External Review Decision                    will promptly review the request. You as well as
The reviewer’s decision will be in writing within       PacifiCare will be notified in writing as to
the applicable timeframes as noted above. The           whether or not the reviewer’s decision will be
reviewer’s decision will include the reasons why        reconsidered. A final decision shall be provided
the service or procedure 1) is or is not Medically      to you and PacifiCare within the following
Necessary; or 2) is or is not Experimental or           timeframes:
Investigational where applicable. The reviewer          1. Standard Independent External Review (Not
will decide only whether the service or                    expedited) – within thirty (30) calendar days
procedure 1) is or is not Medically Necessary, as          following the organization’s receipt of the
defined in this Evidence of Coverage and                   request for reconsideration. Expedited
Disclosure; or 2) is or is not Experimental or             Independent.
30
                                          B   A S I C   P   L A N


2. External Review – within ten (10) calendar           Eligibility Issues:
   days following the organization’s receipt of         Must be referred directly to CalPERS. Contact the
   the request for reconsideration.                     CalPERS Health Benefits Services Division at P.O.
However, either of the above noted timeframes           Box 942714, Sacramento, CA 94229-2714 or
may be extended if the reviewer should require          telephone 1-800-352-2238.
additional information to make a decision.              Malpractice:
If the final independent external review decision       You must proceed directly to court on issues of
is that the service or procedure is Medically           malpractice
Necessary or is not Experimental or Investigational,    Bad Faith:
PacifiCare will accept the decision and provide         You must proceed directly to court on issues of
coverage for such service or procedure in               bad faith
accordance with the terms and conditions of
                                                        Coverage Issues:
your Evidence of Coverage and Disclosure.
                                                        A coverage issue concerns the denial or approval
If the final independent external review decision       of health care services substantially based on a
is that the service or procedure is not Medically       finding that the provision of a particular service
Necessary or is Experimental or Investigational,        is included or excluded as a covered benefit
PacifiCare will not be obligated to provide             under this Evidence of Coverage Booklet. It does
coverage for the service or procedure and you will      not include a plan or contracting provider
be deemed to have exhausted the Appeals process.        decision regarding a disputed health care service.
To obtain further information regarding PacifiCare’s    If you are dissatisfied with the outcome of
independent external review process, please call        PacifiCare’s internal grievance process or if you
PacifiCare’s Customer Service Department.               have been in the process for 30 days or more,
                                                        you may request an Administrative Hearing
Nevada Division of Insurance                            before CalPERS Board of Administration. As an
The Nevada Department of Business and                   alternative to the hearing process you may
Industry, Division of Insurance has established         submit the matter to binding arbitration.
a toll-free telephone service to receive inquiries      However you must choose between the CalPERS
and complaints from consumers of healthcare             administrative Hearing and arbitration. You may
in Nevada.                                              not take the issue through both procedures. Or,
                                                        you may choose Small Claims Court, if your
The toll-free number is 888-872-3234. The hours         coverage dispute is within the jurisdictional
of operation of the Division are: Monday through        limits of Small Claims Court.
Friday from 8:00 a.m. until 5:00 p.m. Pacific
Standard Time. If you have local telephone              Disputed Health Care Service Issues
access to the Carson City and Las Vegas offices         A disputed health care service issue concerns any
of the Division of Insurance, you should call:          health care service eligible for coverage and
Carson City – 702-687-4270; Las Vegas –                 payment under this Evident of Coverage booklet
702-486-4009.                                           that has been denied, modified, or delayed in
We suggest that Members first provide the HMO           whole or in part due to a finding that the service
with the opportunity to resolve member issues           is not medically necessary. A decision regarding
through the grievance and appeals procedures            a disputed health care service relates to the
afforded to members by the HMO before                   practice of medicine and is not a coverage issue,
contacting the Division of Insurance.                   and includes decisions as to whether a particular
                                                        service is experimental or investigational.
If you do not achieve resolution of your complaint
through the internal grievance process described        If you are dissatisfied with the outcome of
above you have several options depending on             PacifiCare’s internal grievance process or if you
the nature of the complaint.                            have been in the process for 30 days or more,
                                                                                                            31
                                          B   A S I C   P   L A N


you may request an independent medical review           benefits, or contract interpretation (except
from the Department of Managed Health Care.             disputes concerning eligibility for enrollment,
                                                        effective date of coverage, and malpractice or
If you are dissatisfied with the outcome of the
                                                        bad faith).
independent medical review process, you may
request an Administrative Hearing before the            Arbitration resolves differences pertaining to any
CalPERS Board of Administration, or you may             personal liability, tort claims, or contract disputes
submit the matter to binding arbitration.               (excluding claims for professional malpractice or
                                                        bad faith) originating from this agreement.
CalPERS Administrative Hearing
                                                        PLEASE NOTE: Arbitration is an option, but not
Only issues of eligibility and coverage issues          an obligation. For issues of eligibility and
which concern the denial or approval of health          coverage, as you may choose to refer such issues
care services substantially based on a finding that     to CalPERS.
the provision of a particular service is included
or excluded as a covered benefit under this             PacifiCare of Nevada does not have an internal
Evidence of Coverage Booklet may be appealed            arbitration process. Please contact the Nevada
to CalPERS.                                             Department of Business and Industry, Division
                                                        of Insurance at 1-888-872-3234 for more
The CalPERS Board of Administration will                information concerning your arbitration rights.
conduct an Administrative Hearing upon your
appeal from PacifiCare’s denial of coverage             BY ENROLLING IN THIS PLAN YOU ARE
issues. However, your written appeal must be            AGREEING TO HAVE CERTAIN DISPUTES
submitted to CalPERS within 30 days of the              (mentioned above) DECIDED BY NEUTRAL
postmark date of PacifiCare’s letter of denial.         BINDING ARBITRATION. BOTH PACIFICARE
                                                        AND PLAN MEMBERS WAIVE THEIR RIGHT TO
During the Administrative Hearing, evidence and         A JURY OR COURT TRIAL FOR THESE DISPUTES.
testimony will be presented to an Administrative
Law Judge. As an alternative to this hearing you        Alternate Arrangements
have recourse to arbitration. However you must          In the event a Contracting Provider is unable or
choose between the Administrative Hearing and           unwilling to provide care to any Member,
arbitration. You may not take the same issue            PacifiCare agrees to make a reasonable effort to
through both procedures. You may withdraw your          secure alternate arrangements for the provision of
appeal to the CalPERS Board of administration at        care without additional expense to the Member.
any time, and proceed with arbitration.                 If such alternate arrangements are not made
To receive an informational brochure or to file         available, or are not deemed satisfactory to the
for appeal, please contact:                             Board and PacifiCare due to problems of access
    CalPERS Health Benefit Services Division            or quality of care, then PacifiCare agrees to
    P.O. Box 942714                                     provide services and/or benefits through non-
    Sacramento, CA 94229-2714                           contracting providers, if necessary. In such an
                                                        event, PacifiCare will reimburse Member for
To file for an Administrative Hearing, please
                                                        such fees, less any deductible or copayment
contact:
                                                        specified in this Agreement, and the limitation
    CalPERS Health Benefit Services Division
                                                        contained herein.
    P.O. Box 942714
    Sacramento, CA 94229-2714                           This provision shall not apply in the event of:
    1-800-352-2238.                                     • A major disaster or epidemic;
Arbitration Procedure                                   • Circumstances beyond PacifiCare’s control;
Arbitration is an option for the resolution of any      • Failure to obtain prior approval of PacifiCare.
disputes concerning the health care services or
32
                                         B   A S I C   P   L A N



Member Rights and Responsibilities                     • Exercise these rights regardless of your race,
                                                         physical or mental disability, ethnicity,
PacifiCare is committed to the treatment of
                                                         gender, sexual orientation, creed, age,
PacifiCare Members in a manner that respects
                                                         religion or your national origin, cultural or
your personal rights and responsibilities
                                                         educational background, economic or health
regarding the health care you receive. As a
                                                         status, English proficiency, reading skills, or
PacifiCare member, you have the right to receive
                                                         source of payment for your health care.
the following information about your rights and
                                                         Expect these rights to be upheld by PacifiCare
responsibilities:
                                                         and contracting providers.
Timely, Quality Care
                                                       • Have confidential treatment of all
• Choice of a qualified Contracting Primary              communications and records pertaining to
  Care Physician and Contracting Hospital.               your care. PacifiCare adopts and implements
  PacifiCare can let you know if a specific              written policies and procedures to protect the
  contracting Primary Care Physician is not              confidentiality of member information used
  accepting new patients at a particular time.           for any purpose. These policies include the
  Your Contracting Primary Care Physician will           protection of any information that can be
  discuss with you the Contracting Hospital that         used to identify a member, employee access
  best fits your needs in the event you need             to private information, routine and special
  Hospital services.                                     consent. Routine consent covers the use of
• Candid discussion of appropriate or                    identifiable information that is needed for
  Medically Necessary treatment options for              treatment, coordination of care, quality
  your condition, regardless of cost or benefit          measurement and improvement (including
  coverage.                                              surveys), utilization review, billing or fraud
                                                         detection. Your routine consent is given to
• Timely access to your Contracting Primary              PacifiCare when you sign your
  Care Physician and Referrals to Specialists            application/Individual Election Form. Unless
  when Medically Necessary.                              required by law, special consent or written
• Receive Emergency Services without prior               permission from you shall be obtained before
  authorization when you, as a prudent                   medical records or individual member data
  layperson acting reasonably, believed that an          can be made available to any person who is
  Emergency Medical Condition existed.                   not directly concerned with your health care
  Payment will not be withheld in cases where            or responsible for making payments for the
  you have acted as a prudent layperson with             cost of such care. This includes release to
  an average knowledge of health and                     employers. In the event you are unable to
  medicine in seeking Emergency Services.                give consent, PacifiCare will follow
                                                         applicable State and Federal laws.
• Actively participate in decisions regarding
  your own health and treatment options.               • Extend your rights to any person who may
                                                         have legal responsibility to make decisions on
• Receive Urgently Needed Services when                  your behalf regarding your medical care.
  traveling outside the Plan’s Service Area or in
  the Plan’s service area when unusual or              • Refuse treatment or leave a medical facility,
  extenuating circumstances prevent you from             even against the advice of a physician,
  obtaining care from your Contracting Primary           (provided you accept the responsibility and
  Care Physician.                                        consequences of the decision). However,
                                                         your refusal in no way limits or otherwise
Treatment with Dignity and Respect                       precludes you from receiving other medically
• Be treated with dignity and respect and to have        necessary covered services for which you
  your right to privacy recognized in all settings.      consent.
                                                                                                      33
                                         B   A S I C   P   L A N


• Complete an Advance Directive, Living Will               appointment as well as the physician
  or other directive and give it to your                   providing care.
  Contracting Primary Care Physician or
                                                       • Be advised if a physician proposes to engage
  Medical Provider to include in your medical
                                                         in experimental or investigational procedures
  record.
                                                         affecting your care or treatment. You have the
• Receive timely access to your medical                  right to refuse to participate in such research
  records and any information that pertains to           projects.
  them by contacting your Contracted Primary
                                                       • Be informed of continuing health care
  Care Physician.
                                                         requirements following discharge from
PacifiCare Information                                   inpatient or outpatient facilities.
• Receive information about PacifiCare and             • Examine and receive an explanation of any
  Covered Services.                                      bills for non-covered services, regardless of
• Receive information about and know the                 payment source.
  names and qualifications of contracted               • Request information about PacifiCare Quality
  physicians, health care professionals, and             Improvement Program, its goals, processes
  providers involved in your medical treatment.          and/or outcomes.
• Receive information about an illness, the full       Timely Problem Resolution
  course of treatment options, and prospects for
                                                       • Make complaints and request appeals about
  recovery in terms you can understand,
                                                         PacifiCare or care provided without
  including how medical treatment decisions
                                                         discrimination and expect problems to be
  are made by the Contracting Primary Care
                                                         fairly examined and appropriately addressed
  Physician.
                                                         within the timeframes set by the plan to
• Receive information regarding how medical              adhere to accrediting and regulatory bodies.
  treatment decisions are made by your                   In keeping with the requirements of
  Contracting Primary Care Physician or                  accrediting and regulatory bodies, you may
  PacifiCare, including payment structure.               choose to have a service or treatment
• Receive information about your medications             decision, if it meets certain criteria, reviewed
  – what they are, how to take them and                  by a physician or panel of physicians who are
  possible side effects.                                 not affiliated with the health plan. This process
                                                         is called an independent external review.
• Receive as much information about any
  proposed treatment or procedure as you may           As a Member of PacifiCare Your Responsibility
  need in order to give an informed consent or         is to:
  to refuse a course of treatment. Except in           • Provide PacifiCare, your physicians other
  emergencies, this information shall include a          health care professionals and contracting
  description of the procedure or treatment, the         providers, to the degree possible, the
  medically significant risks involved, any              information needed in order to care for you.
  alternate course of treatment or non-treatment
                                                       • Participate in understanding and do your part
  and the risks involved in each, and the name
                                                         to improve your own health condition,
  of the person who will carry out the
                                                         medical and behavioral, by following
  procedure or treatment.
                                                         treatment plans, instructions and care that
• Receive reasonable continuity of care,                 you have agreed on with your physician(s).
  including information about continuing
                                                       • Behave in a manner that supports the care
  health care requirements following discharge
                                                         provided to other patients and the general
  from inpatient or outpatient facilities. Also to
                                                         functioning of the facility.
  know in advance, the time and location of an
34
                                          B   A S I C    P   L A N



• Accept the financial responsibility for any           Your Medical Record
  copayment or coinsurance associated with
                                                        Your personal and confidential health care
  services received while under the care of a
                                                        information is maintained at your contracting
  physician or while a patient at a facility.
                                                        doctor’s office in the form of a medical record.
• Review information regarding covered                  These records include general information about
  services, policies and procedures as stated in        you and documentation of the medical care you
  your member materials or Evidence of                  have received. Each time you see your contracting
  Coverage Information.                                 doctor, information about that visit is included in
• Ask questions regarding your care of your             your medical record.
  Primary Care Physician or PacifiCare. If you          Your medical record plays a critical role in
  have a suggestion, concern, complaint or              ensuring you receive quality medical care. First, it
  payment issue, we recommend you call the              provides the doctor treating you with your
  PacifiCare Customer Service department at             medical history. It also provides valuable
  1-800-347-8600 or for the hearing impaired            information used by PacifiCare to ensure quality
  TTY 1-800-360-1797. Our Customer Service              care. As a member, you may access, inspect,
  Representatives are available Monday through          amend and copy your medical records at your
  Friday 7 a.m. to 6 p.m.                               contracting doctor’s office. There may be a
Updating Your Membership Records                        nominal charge for copying your medical records.

Your membership record contains personal                Protected by Law
information from your enrollment application            Federal and State Law protects the confidentiality
including your address and telephone number, as         and privacy of members’ medical records and
well as your specific Health Plan coverage, and         personal information. PacifiCare does not
the Primary Care Physician whom you selected            jeopardize employee-employer relationships by
upon enrollment. These records are very                 releasing to employers information that is either
important because they identify you as an eligible      explicitly or implicitly member-identifiable.
Member and determine where you can receive              PacifiCare takes measure to remove all identifiers
services.                                               when reporting medical and other data to
Please report any changes in name, address,             employers, regardless of the level of risk assumed
phone number, marital status, or status of your         by the employer or PacifiCare.
dependents, please call or write PacifiCare             Routine Consent
Customer Service at 1-800-347-8600 and CalPERS
                                                        When you joined PacifiCare, you signed a
at 1-800-352-2238. You should also report any
                                                        statement that gives your routine consent for the
liability claims (such as claims against another
                                                        release of protected information needed for your
driver in an auto accident) eligibility under
                                                        treatment, coordination of care, payment of
Workers’ Compensation and Medicaid eligibility.
                                                        claims, or administration of benefits. This consent
Confidentiality and Disclosure of                       also allows PacifiCare to do research and measure
Information                                             quality using aggregated or unidentifiable data
                                                        wherever possible. PacifiCare collects and uses
As new technologies give us a greater ability to        members’ medical information for the purpose of
share and access information, there is also             conducting quality assessments, utilization
increasing concern over the unauthorized use of         reviews, fraud detection and oversight reviews.
confidential information. This is particularly true     However, your personal medical information
in health care, where patients’ medical                 cannot be released without your special consent,
information is often sensitive. You’ll be glad to       unless required by law. If you transfer to a new
know PacifiCare is dedicated to protecting your         Primary Care Physician, for example, you will
confidential health care information.
                                                                                                          35
                                         B   A S I C   P   L A N


need to sign a medical release to transfer your        If you have questions or concerns about the
records to the new doctor.                             privacy of your health information, contact
Ensuring Privacy                                       PacifiCare Customer Service at 1-800-347-8600
                                                       (TTY 1-800-360-1797), Monday through Friday
PacifiCare is doing several things to ensure the       7:00 am through 6:00 pm.
privacy of your personal health information. We
have developed organization-wide confidentiality       TERMINATION OF GROUP
policies and procedures that cover all areas of        MEMBERSHIP – CONTINUATION
our business and are meeting national standards        OF COVERAGE
on confidentiality issues. PacifiCare has an
internal review committee that ensures members’        Termination of Benefits and
rights for privacy are being protected. This           Re-enrollment
committee is responsible for reviewing policies
                                                       Coverage may be terminated for individual
and practices regarding the collection, use and
                                                       Members if any of the following events occur:
disclosure of medical information.
                                                       • The agreement between the Board and
We are also working to protect confidentiality in
                                                         PacifiCare is terminated. (PacifiCare may
settings outside PacifiCare by requiring medical
                                                         terminate its agreement with CalPERS by
groups and other providers with whom we
                                                         providing CalPERS with 10 days prior written
contract to have confidentiality policies and
                                                         notice in the event CalPERS fails to make
procedures that meet state and federal
                                                         premium payments within 60 days of the
requirements. This would include physicians
                                                         due date.)
being prohibited from giving information to
employers. Additionally, PacifiCare performs           • The voluntary cancellation by the Employee,
annual assessments to ensure they are complying          Annuitant or Dependent in accordance with
with those requirements.                                 State of Nevada Regulations. In the event of
                                                         such voluntary cancellation, the Member
Special Consent
                                                         shall cease to be covered hereunder without
Requests for confidential information from any           notice from the Employer or PacifiCare at
party(ies) regarding mental illness, substance           midnight of the day on which such
abuse, genetic testing, HIV and AIDS cannot be           cancellation becomes effective in accordance
released/re-released without a written consent           with State of Nevada Regulations.
from the member. This special consent must
                                                       • If an Employee, Annuitant or Dependent
specify the information at issue and permit the
                                                         ceases to be eligible for coverage.
patient to revoke the consent at any time.
                                                       All rights to coverage and care stop on the date
In addition, in the event that a member lacks the
                                                       your group coverage stops. Any Member whose
ability to give informed consent for specific
                                                       enrollment terminates other than by voluntary
treatments, PacifiCare works to obtain special
                                                       cancellation or termination of the group
consent. This is done in three ways: First, by
                                                       agreement and who is hospitalized on the day of
obtaining a copy of the member’s completed
                                                       termination shall be granted a continuation of
Advance Directive, if available. Second, the
                                                       benefits with respect to medical conditions that
member’s legal guardian, power of attorney,
                                                       were present or pre-existing at the time of
and/or next of kin is identified and contacted for
                                                       hospitalization or occurred during the
consent. Third, lacking an individual authorized
                                                       hospitalization and which require continued
to give consent on behalf of the member, an
                                                       hospitalization. This continued coverage shall
application for guardianship is submitted to the
                                                       not extend beyond the 91st day following the
State Public Administrator.
                                                       termination.


36
                                            B   A S I C   P   L A N


If for any reason either CalPERS or PacifiCare            the health plan and the Board, re-application is
terminates the group agreement, your coverage             not necessary.
will end on the day the group agreement
terminates. You will have no right to enroll in the       COBRA
Individual Conversion Plan or to elect group              As a result of the Consolidated Omnibus
continuation coverage.                                    Reconciliation Act of 1985, as amended (COBRA),
However, if the Group Agreement terminates                you and your covered dependents may be entitled
while you or an enrolled dependent are totally            to continuation of coverage under CalPERS group
disabled and under treatment of a Physician, the          health care plan. You may qualify for continuation
services and benefits of this plan will continue          of coverage if you lose coverage for one of the
for the treatment of the disability until the earliest    following reasons:
of the following, (1) the total disability ceases; or     18 month events:
(2) for a maximum period of twelve (12) months
                                                          1. Termination or separation from employment
after the date of termination, or (3) until this
                                                             for reasons other than gross misconduct.
agreement is replaced by another group, hospital
or medical plan without limitations as to the             2. Reduction of work hours.
disabling condition. Coverage is for the disabling        36 Month events:
condition only and is subject to all limitations
and exclusions of the applicable plan.                    1. Your spouse ceases to be eligible due to
                                                             divorce or legal separation.
If you permanently move to a geographical area
outside the PacifiCare Service Area, we encourage         2. A dependent child ceases to be an eligible
you to provide us with written notice at least one           dependent.
month prior to your move. You will no longer be           3. Subscriber’s death.
eligible to continue membership in PacifiCare
and you must contact your employing agency or             4. Primary COBRA subscriber becomes entitled
CalPERS to enroll in another health benefit plan.            to Medicare.
Until such new coverage begins, PacifiCare will           Events for extension of coverage:
cover for out-of-area emergencies only. A
                                                          1. An 18-month enrollment may be extended by
permanent move means an uninterrupted absence
                                                             11 months subject to determination of
of more than 90 days from the Service Area.
                                                             disability by Social Security. The premium
In the event any Member believes that his or her             rate is 150% of the group gross premium rate
benefits under this Agreement have been                      for coverage months 19 through 29.
terminated because of his or her health status or
                                                          2. An 18 month enrollment may be extended for
health requirements, the Member may seek from
                                                             up to 42 months for a former employee who
the Nevada Commissioner of Insurance review of
                                                             was at least age 60 upon termination of
the termination.
                                                             employment and employed with the
Reinstatement and Renewal Provisions                         employer for a minimum of 5 years upon
Your coverage will remain in effect for each                 termination. The premium is 213% of the
month for which prepayment fees have been                    group gross premium rate as of coverage
received. If a Member’s coverage is terminated,              month 19 forward.
the Member must submit a new application in                   • Termination of extended coverage.
order to be reinstated or they must re-enroll
                                                              • Individual reaches age 65.
during an Open Enrollment Period. If a Member’s
coverage has not been terminated and the                      • Individual becomes covered through
Member seeks to renew coverage under an                         another group health plan regardless of
agreement subsequent to this agreement between                  level of benefit.
                                                                                                             37
                                        B   A S I C   P   L A N


• Individual becomes entitled to Medicare*.           conversion plan if you lost coverage because of a
• Employer maintained group health plan               termination of the agreement between PacifiCare
  coverage is terminated.                             and the Board. Written applications for conversion
                                                      must be received by PacifiCare within 31 days of
• Note: The continuation may be extended to           the loss of group coverage. There are some
  the employee’s spouse or former spouse. The         restrictions on eligibility, please contact the
  extended coverage terminates five years from        PacifiCare Customer Service for details.
  the original end date of the 18-month COBRA
  enrollment.                                         Creditable Coverage

Premiums                                              Under new federal and state law effective July 1,
                                                      1997, individuals may receive credit for coverage
• The COBRA premium rate is 102% of the               under most major medical plans. Employer
  gross premium amount and no employer                health plans (for two or more employees) must
  contribution is provided.                           recognize this credit for previous coverage when
• The initial premium payment must be made            applying pre-existing condition exclusions.
  within 45 days of the COBRA election.               Once an individual has accumulated twelve (12)
  Payment must include premium for all retro          months of coverage credit, an Employer health
  months of the coverage.                             plan may no longer apply a pre-existing
• There is a 30-day grace period for premium          condition exclusion. Employer health plans must
  payments. The payments must be submitted            also recognize and apply credit to any pre-
  to the health plan by the date that is 30 days      existing condition exclusion for coverage totaling
  after the first day of that period. For example     less than twelve (12) months. This way, no
  if the January premium is due on January 1st,       individual may be subject to more than twelve
  the 30-day grace period ends on January 31st.       (12) total months under a pre-existing condition
                                                      exclusion, except for the following reasons:
Election/Notification:
                                                      1. The individual is a Late Enrollee. Late Enrollees
• Election of COBRA continuation must be                 may be subject to eighteen (18) months under
  made within 60 calendar days of the notice             a pre-existing condition exclusion.
  of eligibility.
                                                      2. The individual experiences a lapse in
• Employees, annuitants, and dependents have             coverage of sixty-three (63) days or longer
  a responsibility to notify their employer or           after the most recent period of coverage and
  CalPERS of an event that has occurred. They            before the enrollment date in a Employer
  are not responsible for knowing to request             health plan.
  COBRA information.
                                                      Employer group waiting periods and HMO
• Notice of termination of COBRA continuation         affiliation periods will not count towards the
  coverage must be directed to the enrolled           sixty-three (63) day break in coverage or the
  spouse as well as the former employee. This         twelve/eighteen (12/18) months of creditable
  notice is generated by the health plan.             coverage.
Individual Continuation of Benefits                   This is meant as a brief overview only; for more
If you or any covered family members lose             information on recent health care reform
coverage because of a loss of eligibility you may     legislation and your rights under the law, please
be able to convert to PacifiCare’s Individual         contact CalPERS.
Conversion Plan. You are not eligible for the

*Members who are entitled to Medicare Part A and enrolled in Part B and who have enrolled in the
 Managed Medicare Plan.
38
                                           B   A S I C   P   L A N


Certificates of Creditable Coverage                          documents. Failure to cooperate with
To document credit for previous health care                  PacifiCare in this regard could result in
coverage, health plans are required to                       membership termination.
automatically forward Certificates of Creditable         Coordination of Benefits
Coverage to all Employer health plan Subscribers
upon cessation of coverage.                              If you or a family member is covered by
                                                         PacifiCare and another Employer health plan
Creditable coverage information for Eligible             (including Medicare), PacifiCare will coordinate
Dependents will be included on the Subscriber’s          its benefits with those of the other plan. The goal
Certificate, unless the dependent’s address of           of this coordination is to maximize coverage for
record or coverage information is substantially          allowable expenses, minimize out-of-pocket
different from that of the Subscriber’s.                 costs and to prevent any payment duplication.
Certificates of Creditable Coverage can be               PacifiCare coordinates benefits in accordance
obtained upon request by calling Customer                with the guidelines set forth in Nevada
Service at 1-800-347-8600 or telephone number            Administrative Code. According to the guidelines,
for the hearing impaired at 1-800-360-1797,              benefits will be coordinated as follows:
Monday - Friday, 7 a.m. - 6 p.m.
                                                         • If the person who received care is covered as
Your first Certificate will be issued free of charge;      an employee under one contract and as a
follow-up requests for the same Certificate may            dependent under another, the employee’s
involve a fee.                                             coverage pays first.
                                                         • If the person who receives care is a
PAYMENT BY THIRD PARTIES                                   dependent child, then the plan benefits of the
Third-Party Recovery Process and the                       parent whose birthday occurs earlier in the
Members’ Responsibilities                                  calendar year shall cover the child first.
If you are ever injured through the actions of           • If both parents have the same birthday, the
another (a third party) and receive compensation           benefits of the plan that covered a parent
for your medical care, you will be required to             longer shall cover a dependent child first.
reimburse PacifiCare, or its nominee, for the            • If the dependent child’s parents are legally
reasonable value of medical services and benefits          separated or divorced, then:
provided. The amount of reimbursement shall
not exceed the amount of compensation you                    -   The coverage of the parent with custody
receive from the third party.                                    pays first. If the parent with custody has
                                                                 remarried, the step-parent’s coverage pays
• You must obtain PacifiCare’s written consent                   second. The coverage of the parent who
  prior to settling any claim or releasing any                   does not have custody pays last.
  third-party from liability, if such a release
  would limit PacifiCare’s right of reimbursement.           -   Regardless of which parent has custody,
                                                                 whenever a court decree specifies the
• Should you settle your claim against a third                   parent who is financially responsible for
  party and compromise PacifiCare’s                              the child’s health care expenses, the
  reimbursement rights, PacifiCare reserves the                  coverage of that parent pays first.
  right to initiate legal action. Attorney fees will
  be awarded to the prevailing party.                        -   If the person who received care is covered
                                                                 as an active employee under one contract
• You are required to cooperate in protecting                    and as an inactive employee under
  the interest of PacifiCare by providing                        another, the coverage through active
  PacifiCare with all liens, assignments or other                employment pays first.

                                                                                                             39
                                            B   A S I C   P   L A N


     -   If one of the plans determines the order of      If you or a family member is covered by
         benefits based upon the gender of a              PacifiCare and another Employer health plan,
         parent, and, as a result, the plans do not       PacifiCare will coordinate its benefits with those
         agree on the order of benefit                    of the other plan. The goal of this coordination is
         determination, the plan with the gender          to maximize coverage for allowable expenses,
         rule shall determine the order of benefits.      minimize out-of-pocket costs and to prevent
     -   A plan with an order of benefit                  payment duplication.
         determination provision which complies           Workers’ Compensation
         with this rule, herein call a “complying
         plan,” may coordinate its benefits with a        If you are receiving benefits as a result of
         plan which is “excess” or “always                Workers’ Compensation, PacifiCare will not
         secondary” or which uses an order of             duplicate those benefits.
         benefit determination which is                   • It is your responsibility to take whatever
         inconsistent with those contained in this          action is necessary to receive payment under
         rule, herein called a “non-complying               Workers’ Compensation laws, when such
         plan.” If the complying plan is the primary        payments can reasonably be expected.
         plan, it shall pay or provide its benefits on
                                                          • If PacifiCare happens, for whatever reason, to
         a primary basis. If this occurs, see your
                                                            duplicate benefits to which you are entitled
         Benefits Manager to review the terms of
                                                            under Workers’ Compensation law, you are
         the Agreement.
                                                            required to reimburse PacifiCare, at prevailing
     -   If both parents of a dependent child are           rates, immediately after receiving monetary
         covered under separate PacifiCare                  award, whether by settlement or judgment.
         coverage, only one parent may cover the
                                                          • In the event of a dispute arising between you
         child as a dependent.
                                                            and your Workers’ Compensation laws,
     -   When none of the above applies, the                PacifiCare will provide the benefits described
         coverage you have had for the longest              in this agreement until the dispute is resolved.
         continuous period of time pays first.
                                                          • If you receive a settlement of Workers’
• In order to ensure proper coordination, you               Compensation that includes payment of
  must inform PacifiCare of any other health                future medical costs, you may be liable to
  coverage for which you or your Dependents                 reimburse PacifiCare for those costs.
  may be enrolled.
• If PacifiCare pays out more benefits than
  appropriate, PacifiCare may choose to
  recover excess benefit payments from you,
  the plan with primary responsibility, or any
  other person or entity that benefited from the
  overpayment.
For the purpose of implementing coordination of
benefits, PacifiCare may, without consent of any
person, release to or obtain from an insurance
company, organization, or person information
that PacifiCare deems to be necessary. Any
person seeking benefits under this plan shall
furnish to PacifiCare such information as may be
necessary to implement coordination of benefits.

40
SECTION 2 – MANAGED MEDICARE PLAN
          (Medicare+Choice)




                                    41
42
                          M   A N A G E D       M   E D I C A R E      P   L A N



WE     L C O M E          TO PACIFICARE’S
MA     N A G E D          MEDICARE HEALTH                                   P   L A N

PacifiCare of Nevada offers a Managed Medicare Plan (Medicare+Choice) to retired employees and
their dependents who are entitled for Part A and enrolled in Part B of Medicare. Additionally, you must
not currently have end-stage renal disease or receive routine kidney dialysis treatments. This does not
apply if you are currently a non-Medicare Member of PacifiCare. If you develop end-stage renal disease
while a member this Plan, you cannot be Disenrolled. PacifiCare is under contract with the Centers for
Medicare and Medicaid Services (CMS), the federal agency which administers Medicare, to provide
health care to eligible Medicare beneficiaries. PacifiCare currently provides health care coverage to
approximately 1,000,000 members nationwide.

If you are retired, and are entitled to Medicare Part A and enrolled in Part B, and live within the
Managed Medicare Service Area you must enroll in PacifiCare Managed Medicare Plan, but not in
the PacifiCare Basic Plan.

The benefits, limitations and exclusions for the Managed Medicare Plan are contained in this booklet.

Please read this Evidence of Coverage brochure carefully. It provides detailed information about how
to receive services, and what is covered. Please feel free to call PacifiCare if you have any questions at
1-800-347-8600 or telephone number for the hearing impaired (TTY) 1-800-360-1797, Monday -
Friday, 7 a.m. - 6 p.m.

Please remember that when you join PacifiCare you agree to receive all of your medical services,
except for Emergency care or Out-of-Area Urgent Care, through your PacifiCare Contracting Primary
Care Physician. Should you choose to use non-contracting providers for non-emergency care,
PacifiCare will not be financially responsible for these services.

Please refer to the “Definitions” section of this booklet for descriptions of Emergency and Urgent care.

This policy does not cover custodial care in a skilled nursing facility or in any other facility or
situation.




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                           M   A N A G E D        M     E D I C A R E     P   L A N



BENEFIT CHANGES FOR 2002                                   ELIGIBILITY
This contract term is for one year, effective              You and your dependents are eligible to enroll if
                                                           you meet the eligibility requirements specified in
January 1, 2002 through December 31, 2002.
                                                           the Act and Regulations.
Some of this plan’s benefits such as visit limits for
certain services are currently based on a calendar         To enroll in the Managed Medicare Plan
year. You should review this booklet carefully.            (Medicare+Choice) you must: (1) be entitled to
                                                           Medicare Part A and enrolled in Part B; (2) not
Prescription Drug Copayments: Your prescription            be an active employee; and (3) live within the
drug Copayments have now changed to:                       Managed Medicare Service Area. The Managed
    $5 per Prescription unit for Formulary                 Medicare Service Area is included on last page of
       generic medications;                                this brochure. If you have End Stage Renal
   $15 per Prescription unit for Formulary                 Disease you are not eligible for the Managed
        brand-name medications; and                        Medicare Plan, unless you are currently enrolled
   $30 per Prescription unit for non-Formulary             as a non-Medicare member of PacifiCare. Persons
        medications.                                       currently receiving Medicare certified hospice
For mail-order prescription drugs, your                    care are eligible to enroll in the Managed
Copayments have now changed to:                            Medicare Plan. As a member, hospice related
   $10 per Prescription unit for generic                   care will be paid directly by Medicare, and all
        medications;                                       other non-hospice related services will be paid
   $25 per Prescription unit for brand-name                directly by PacifiCare.
        medications; and                                   Information pertaining to eligibility, enrollment,
   $45 per Prescription unit for non-Formulary             cancellation or termination of coverage,
        medications.                                       conversion rights, etc., can be found in the
There is a $1,000 out-of-pocket maximum for                CalPERS open enrollment booklet – CalPERS
covered for Prescription Drugs purchased through           Health Program Handbook and Understanding
the mail-order program per member per year.                Medicare and Your CalPERS Health Benefits. The
                                                           booklets are prepared by CalPERS Health Benefit
Office Visit Copayments: Your office visit                 Services Division, in Sacramento. A copy of this
Copayment has now changed to $10.                          booklet will be distributed or sent to you. If you
Chiropractic Visits: Your copayment has changed            do not receive a copy, contact your employing
to $10 per visit.                                          office, your Health Benefits Officer or write to
                                                           CalPERS, Health Benefit Services Division at
Norplant Device and Norplant Medications: are              P.O. Box 942714, Sacramento, CA 94229-2714.
now excluded from coverage.
                                                           For additional information concerning covered
BENEFITS OF THIS PLAN ARE AVAILABLE ONLY                   benefits, contact CalPERS.
FOR SERVICES AND SUPPLIES FURNISHED
                                                           Remember, it is your responsibility to stay
DURING THE TERM THE PLAN IS IN EFFECT
                                                           informed about your coverage. If you have any
AND WHILE THE BENEFITS YOU ARE CLAIMING
                                                           questions, consult the retirement system from
ARE ACTUALLY COVERED BY THIS PLAN.
                                                           which you receive your allowance, or write to
IF BENEFITS ARE MODIFIED, THE REVISED                      CalPERS Health Benefit Services Division at the
BENEFITS (INCLUDING ANY REDUCTION IN                       address in the previous paragraph or telephone
BENEFITS OR ELIMINATION OF BENEFITS)                       the appropriate number shown below:
APPLY TO SERVICES OR SUPPLIES FURNISHED                    CalPERS Health Benefit Services Division
ON OR AFTER THE EFFECTIVE DATE OF                          Toll free number 800-352-2238
MODIFICATION. THERE IS NO VESTED RIGHT                     FAX 916-326-3935
TO RECEIVE THE BENEFITS OF THIS PLAN.                      916-326-3240 (Telecommunications Device for
                                                                         the Deaf-Interpreter)
44
                          M   A N A G E D       M     E D I C A R E    P   L A N



ENROLLMENT                                                  their affiliated OB/GYNs, Hospitals, and
                                                            Specialists.
To enroll in the Managed Medicare Plan, submit
a written request or open enrollment Change              When selecting your Primary Care Physician,
Request for Retirees – HBD 30 – to the CalPERS           please keep in mind that each family member
Health Benefit Services Division.                        may choose a different Primary Care Physician.
Please refer to the CalPERS Health Program               Please clearly write the name of the Primary
Handbook informational pamphlets for                     Care Physician you choose on your HBD-12
information on:                                          form in box “11”.
• When enrollment is permissible                         PacifiCare typically contracts with Medical
                                                         groups and Independent Practice Associations
• Enrollment of new subscribers
                                                         (IPAs) to provide medical services to Members
• Addition of family dependents                          and with hospitals to provide hospital services.
To enroll in the Managed Medicare Plan, simply           The contracting Medical Groups and IPAs, in turn,
select a Primary Care Physician from the Provider        employ or contract with individual physicians.
Directory                                                • Most of our contracting Medical Groups and
Also, please clearly indicate the name of the              IPAs receive an agreed upon monthly payment
Primary Care Physician you choose in your written          from PacifiCare to provide services to
request or HBD 30.                                         Members. This monthly payment may be
                                                           either a fixed dollar amount for each member
When PacifiCare receives notification from                 or a percentage of the monthly premium
CalPERS, we will send you a Group Retiree                  received by PacifiCare.
Election Form and Statement of Understanding.
You must sign this form and return it to PacifiCare      • The monthly payment typically covers
for processing. After this form has been processed,        professional services directly provided by the
you will receive an Identification Card. This ID           Primary Care Physician, and may also cover
card should be presented whenever you receive              hospital and certain referral services.
medical services or prescription drugs.                  • Some of PacifiCare’s contracting hospitals
                                                           receive similar monthly payments in return
HOW TO USE THE PLAN                                        for arranging hospital services for Members.
                                                           Other hospitals are paid on a discounted fee-
Choice of Physicians and Providers                         for-service or fixed charge per day of
PLEASE READ THE FOLLOWING SO YOU WILL                      hospitalization. Most acute care, subacute
KNOW FROM WHOM OR WHAT GROUP OF                            care, transitional inpatient care and skilled
PROVIDERS HEALTH CARE MAY BE OBTAINED.                     nursing facilities are paid on a fixed charge
                                                           per day per inpatient care.
Here’s how to select your Primary Care Physician:
                                                         • PacifiCare provides stop-loss protection to our
• Each family member may choose a Family                   contracting Medical Groups, IPAs and
  Practice, General Practice, Internal Medicine,           hospitals that receive the monthly payments
  or Pediatric Physician to be their Primary               described above. If any providers do not
  Care Physician.                                          obtain stop-loss protection from PacifiCare,
• Women may self-refer themselves to an                    they must obtain stop-loss insurance from an
  OB/GYN that is affiliated with their Primary             insurance carrier acceptable to PacifiCare.
  Care Physician.
• Choose your Primary Care Physician from the
  PacifiCare Provider Directory. The Provider
  Directory includes a listing of all PCPs, and
                                                                                                          45
                           M   A N A G E D        M     E D I C A R E     P   L A N



Selection of Different Primary Care                        determination shall be made by PacifiCare’s
Physicians by Family Members                               Medical Director within 24 hours for urgent
                                                           requests or within 48 hours for standard requests
Please refer to the “Changing Primary Care
                                                           once all documentation needed to review the
Physicians” section of this brochure for detailed
                                                           request is received by PacifiCare.
information on changing your physician or
provider selections after your initial enrollment.         Once you receive a Referral from your PacifiCare
There are specific procedures to follow for                Primary Care Physician you may schedule an
provider changes and transfers.                            appointment with the Specialist. Your Primary
                                                           Care Physician may refer you to a contracted
IT IS IMPORTANT TO KNOW THAT WHEN
                                                           Specialist. PacifiCare may designate the
YOU ENROLL IN THE MANAGED MEDICARE
                                                           contracted Specialist, based upon factors, which
PLAN, SERVICES ARE PROVIDED THROUGH
                                                           include the Specialists’ privileges at the Hospital
THE PLAN’S DELIVERY SYSTEM, AND THE
                                                           designated by PacifiCare, the capabilities of the
CONTINUED PARTICIPATION OF ANY ONE
                                                           Specialists, and the outcomes. If for any reason
DOCTOR, HOSPITAL OR OTHER PROVIDER
                                                           you receive a bill from a Specialist, simply
CANNOT BE GUARANTEED.
                                                           forward it to PacifiCare for payment. See page 26
How to Receive Care                                        for the address to send your claim.
Scheduling Appointments                                    Your Primary Care Physician may refer you to
                                                           any of the contracted Specialists provided the
It’s easy – simply call your PacifiCare Primary            specialist has privileges at the hospital designated
Care Physician’s office and request an                     by PacifiCare of Nevada and your Primary Care
appointment. There are no special rules to                 Physician.
follow. Appointments are scheduled according to
the type of medical care you are requesting.               PacifiCare has approved procedures to identify,
Medical conditions requiring more immediate                assess, and establish treatment plans (including
attention are scheduled sooner. The telephone              direct access visits to Specialists) for members
number for your PacifiCare Primary Care                    with complex or serious medical conditions. In
Physician is listed in the Provider Directory              addition, PacifiCare will maintain procedures to
enclosed with this Combined Evidence of                    ensure that members are informed of health care
Coverage and Disclosure Document.                          needs that require follow-up and receive training
                                                           in self-care and other measures to promote their
You may schedule an appointment with a                     own health.
specialist in Behavioral Health, Optometry
(ophthalmologists require a referral from your             Changing Primary Care Physicians
optometrist), or OB/GYN without a Referral.                If you wish, you may request to change
Please refer to the Provider Directory for your            PacifiCare Primary Care Physician at any time.
PacifiCare Specialists.                                    The PCP change will be effective the same day.
Referrals to Specialists                                   Call PacifiCare Customer Service for assistance at
                                                           1-800-347-8600 or telephone number for the
Even though your PacifiCare Primary Care                   hearing impaired (TTY) 1-800-360-1797,
Physician is trained to handle the majority of             Monday - Friday, 7 a.m. - 6 p.m. You will receive
common health needs, there may be a time                   a new PacifiCare membership card that shows
when he or she feels you need more specialized             this change.
treatment. You may receive a Referral to an
appropriate Specialist. In some cases, the request         To help promote a smooth transition of your
for a Referral will need to have Prior Authorization.      health care when you change your Primary Care
PacifiCare may direct your Primary Care                    Physician, please let us know if you are currently
Physician and Specialist to deliver care at certain        seeing a Specialist, receiving Home Health
contracted hospitals or other facilities. This             Agency services, or using Durable Medical
46
                            M   A N A G E D        M     E D I C A R E     P   L A N



Equipment. PacifiCare Customer Service can                  by the health plan to the provider. However, the
assist with the transfer of your care or equipment.         Member may be liable for any sums owed to a
However, we may deny your request to change                 non-contracting provider unless the services
your Primary Care Physician if you are:                     provided were authorized PacifiCare or were
                                                            provided for an emergency.
   -   hospitalized;
                                                            Member Identification Card
   -   confined in a Skilled Nursing Facility,
                                                            Once we have processed your application, you
   -   an organ transplant candidate; or                    and any enrolled dependent(s) will receive a
   -   being treated for an unstable, acute                 Member Identification Card. Present this ID card
       medical condition for which you are                  whenever you receive medical services or
       receiving active medical care.                       prescription drugs. Carry your PacifiCare Member
                                                            Identification Card with you at all times. If you
If your request to change to a different PacifiCare
                                                            move or lose your PacifiCare Member Identification
Primary Care Physician is denied by PacifiCare,
                                                            Card, please contact PacifiCare Customer Service
you have a right to file a grievance.
                                                            at 1-800-347-8600 or telephone number for the
It is PacifiCare’s policy that each affected Member         hearing impaired (TTY) 1-800-360-1797,
receives timely and consistent notice when                  Monday - Friday, 7 a.m. - 6 p.m.
his/her Primary Care Physician or Specialist is no
longer participating in PacifiCare. It is PacifiCare’s      Customer Service
goal to make a good faith effort to notify you              PacifiCare Customer Service is available to
within 30 days of the termination of any plan               answer questions and provide assistance. We
health care provider that affects you. We will              encourage you to call with any and all health
assist you in selecting a new Primary Care                  plan questions or concerns. If you have questions
Physician or ensure you have access to all                  such as…
Covered Services in the plan’s Benefit Plan.
                                                               -   What do I do in an emergency?
Second Medical Opinion                                         -   What’s covered if I’m traveling?
You, or your treating Primary Care Physician,                  -   What if I lose my ID card?
may request a Second Medical Opinion from a                    -   How do I choose a doctor?
PacifiCare Contracting Medical Provider when                   -   How do I change Primary Care
necessary.                                                         Physicians?
                                                               -   What happens if I move?
Non-Contracting Provider referrals will be                     -   How do I add my dependents to the plan?
approved only when the services requested are                  -   How do I obtain additional information
not available from a PacifiCare Contracting                        about my physician?
Medical Provider as appropriate. For more
information, please contact PacifiCare’s Customer           …Just call on us. Our Customer Service
Service at 1-800-347-8600 or telephone number               representatives are ready to answer.
for the hearing impaired (TTY) 1-800-360-1797,              For PacifiCare call toll-free:
Monday - Friday, 7 a.m. - 6 p.m.
                                                            1-800-347-8600 or
Liability                                                   Telephone Number for the Hearing Impaired
                                                            (TTY) 1-800-360-1797
In the event PacifiCare fails to pay a contracting
                                                            Monday - Friday, 7 a.m. - 6 p.m.
provider for covered services, the Member shall
hot be liable to the provider for any sums owed




                                                                                                            47
                          M   A N A G E D       M    E D I C A R E   P   L A N



RATES FOR MANAGED MEDICARE PLAN
Managed Medicare* Monthly Rates
Type of Enrollment                   Current Rate
Subscriber only                          $167.20
Subscriber and one family member         $334.40
Subscriber and two family members        $434.72
If your family unit includes both Managed
Medicare Plan Members and PacifiCare Basic
Plan Members, see your CalPERS Health Plan
Decision Guide for the appropriate plan codes
and prepayment charges.
Other Charges. In addition to the premiums
described above, you are responsible for the
copayments set forth in the “Benefit and
Copayment” section.
State Annuitants. The rates shown above are
effective January 1, 2002, and will be reduced by
the amount the State of California contributes
toward the cost of your health benefit plan. These
contribution amounts are subject to change as a
result of legislative action. Any such change will
be accomplished by the affected retirement
system without any action on your part. For
current contribution information, contact your
retirement system health benefits officer.
Public Agency Annuitants. The rates shown
above are effective January 1, 2002 and will be
reduced by the amount your public agency
contributes toward the cost of your health benefit
plan. This amount varies among public agencies.
For assistance on calculating your net
contribution, contact your agency or retirement
system health benefits officer.
Rate Change. The plan rates may be changed as
of January 2003, following at least 60 days’
written notice to the Board prior to such change.




*Members who are entitled to Medicare Part A and enrolled in Part B and who have enrolled in the
 Managed Medicare Plan.
48
                          M   A N A G E D      M   E D I C A R E      P   L A N



THIS IS ONLY A BRIEF SUMMARY. REFER TO THE BENEFIT DESCRIPTIONS IN THIS BOOK FOR
FURTHER INFORMATION.


                              CHART OF SUMMARY OF BENEFITS
  CATEGORY DESCRIPTION                                               MEMBER COPAYMENT
                                                                       & LIMITATIONS
  HOSPITAL
   Inpatient visit                                                        Covered in full
   Outpatient visit                                                       Covered in full
  PHYSICIAN SERVICES*
    Office/Home                                                           $10 Copayment
    Allergy Testing                                                       $10 Copayment
    Allergy Treatment                                                     Covered in full
    Hearing Exam/Testing                                                  $10 Copayment
      Gynecological Exam                                                  $10 Copayment
      (Including Pap Smear/Breast Exam)
    Periodic Health Exam                                                  $10 Copayment
    Eye Exam                                                              $10 Copayment
  PREVENTIVE CARE
    Routine Physical Examinations                                         Covered   in   full
    Mammography Screening                                                 Covered   in   full
    Pap Smears                                                            Covered   in   full
    Colorectal Screening                                                  Covered   in   full
    Bone Density Screening                                                Covered   in   full
  IMMUNIZATIONS                                                           $10 Copayment
  DIAGNOSTIC X-RAY/LAB                                                    Covered in full
  DURABLE MEDICAL EQUIPMENT
  (INCLUDING ORTHOTICS AND PROSTHETICS)                                   Covered in full
  AMBULANCE                                                               Covered in full
  EMERGENCY CARE/SERVICES                                                 Covered in full
  HOME HEALTH SERVICES                                                    Covered in full
  PHYSICAL/OCCUPATIONAL/SPEECH THERAPY                                    $10 Copayment
  SKILLED NURSING CARE                                                    Covered in full
    Up to 100 days per
    Medicare Benefit Period
  HOSPICE                                                    Covered in full (as covered by Medicare)
  BIOFEEDBACK                                                           Covered in full
                                                            when approved under Medicare Guidelines
  BLOOD & BLOOD PRODUCTS                                                  Covered in full
    (Includes collection and storage of autologous blood)
    Donor Directed                                                        Processing Fee

*Physician Office Visit Copayment applies.

                                                                                                        49
                                M   A N A G E D     M   E D I C A R E   P   L A N

     CATEGORY DESCRIPTION                                               MEMBER COPAYMENT
                                                                          & LIMITATIONS
     PRESCRIPTION DRUGS
       Retail:
         Generic Formulary                                       $5 Copayment per Prescription Unit
         Brand Formulary                                         $15 Copayment per Prescription Unit
         Non-Formulary                                           $30 Copayment per Prescription Unit
       Mail-order:
         Generic Formulary                                       $10 Copayment/3 Prescription Units*
         Brand Formulary                                         $25 Copayment/3 Prescription Units*
         Non-Formulary                                           $45 Copayment/3 Prescription Units*
     *$1,000 out-of-pocket maximum for covered
      Prescription Drugs purchased through the mail-order
      program per member per year.
     MENTAL HEALTH CARE AND SUBSTANCE ABUSE
       Inpatient                                               Covered in full; 190 Day Lifetime Limit
       Outpatient                                                          Covered in full;
                                                              Unlimited visits as long as prior-authorized
       Partial Hospitalization Services available                           Covered in full
     CHIROPRACTIC
       Medically Necessary                                     Covered in full upon referral by your PCP
       Routine, Self-referred                                           $10 per visit for up to
                                                                     20 visits per Calendar Year
     PODIATRY CARE
       Medically Necessary                                     Covered in full upon referral by your PCP
       Routine Self-referred                                    $10 copay; 3 visits per Calendar Year
     VISION CARE
       Eye Refraction - To determine need for lenses                        Covered in full
       Eye Glasses                                               One refractive visit per Calendar Year
                                                                 20% discount at contracting providers
     HEARING AID
       Audiological Exam                                                  Covered in full
       Hearing Aid Instrument                                 $1,000 per Member once every 36 months
     OTHER SERVICES & SUPPLIES
      Medical Supplies                                                      Covered   in   full
      Hemophilia clotting factors                                           Covered   in   full
      Antigens                                                              Covered   in   full
      Therapeutic shoes for those suffering from                            Covered   in   full
      diabetic foot disease
     DENTAL CARE
       Limited, Medically Necessary Care per Medicare                       Covered in full

       Guidelines Only
     HEALTH IMPROVEMENT SERVICES
       Diabetes Management                                                  Covered in full
       Chronic Disease Management                                           Fees may apply
       Healthy Lifestyle Courses                                            Fees may apply
       Smoking Cessation                                                    Fees may apply


50
                            M   A N A G E D        M   E D I C A R E     P   L A N



BENEFIT DESCRIPTIONS                                      • Physical therapy, occupational therapy
                                                            and speech pathology services, including
This policy does not cover custodial care in a
                                                            services provided in a Comprehensive
skilled nursing facility or in any other facility or
                                                            Outpatient Rehabilitation Facility (CORF)
situation.
                                                                                          $10 Copayment
Inpatient Services                                        • Medical supplies including casts,
                                                            dressings and splints           Covered in full
Hospitalization                     Covered in full
                                for unlimited days        Annual Physical Examination      $10 Copayment
•   Semi-private room (private if medically               Preventive Care
    necessary)                                            • Mammography Screening           Covered   in   full
•   Regular Nursing services                              • Pap Smears                      Covered   in   full
•   Inpatient physician and surgical services             • Colorectal Screening            Covered   in   full
•   All meals including special diets                     • Bone density screening          Covered   in   full
•   Drugs and medication
•   Laboratory tests                                      Health Education                 $10 Copayment
•   X-rays and other radiology services                   Hospital Services                 Covered in full
•   Necessary medical supplies and appliances             Outpatient surgical services
•   Inpatient alcohol/drug rehabilitation
                                                          Blood and its Administration      Covered in full
•   Blood and its administration (including
                                                          (including autologous blood,
    autologous blood, processing and storage)
                                                          processing and storage)
•   Special care units
•   Rehabilitation services (medical)                     Home Health Care                   Covered in full
                                                          • Intermittent skilled nursing care
Skilled Nursing Facility Care
                                                          • Part-time home health aide
Covered in full up to 100 days of skilled nursing
                                                          • Physical, speech, and occupational therapy
facility care per benefit period* after a 3-day
                                                          • Medical social services
hospital stay. Primary Care Physician may waive
                                                          • Medical supplies and equipment provided by
the hospital stay.
                                                            the agency
• Semi-private room
                                                          • Home I.V. drug therapy
• Regular nursing services
• All meals including special diets                       Immunizations                      Covered in full
• Physical, occupational, and speech therapy              Influenza virus vaccine once a year. Pneumonia
• Drugs furnished by the facility                         vaccination as prescribed by doctor. Hepatitis B
• Necessary medical supplies                              vaccine if at medium or high risk.
• Use of appliances such as a wheelchair                  • All other immunizations
Outpatient Services                                         including for travel           $10 Copayment
Physician Services/Basic Health Services**                Laboratory Services               Covered in full
• Office Visits                  $10 Copayment            X-ray Services                    Covered in full
• Consultation, Diagnosis, and                            Including annual mammography when authorized
   Treatment by specialist       $10 Copayment            by your PacifiCare contracting physician.
• Medical and surgical Care      $10 Copayment
• Allergy tests and Treatment $10 Copayment
• Allergy Serum                   Covered in full

 *A benefit period starts the first time you enter a hospital, and ends when you have been out of a
  hospital or other facility providing skilled nursing or rehabilitation services for 60 consecutive days.
**Each office visit requires only a single copayment even if multiple outpatient services are performed.
                                                                                                            51
                          M   A N A G E D       M     E D I C A R E     P   L A N



Urgently Needed Services                                 Hearing Aid
• In-Area                         Covered in full        • Audiological Exam               Covered in full
   at your physician’s office                            • Hearing Aid Instrument       $1,000 allowance
• Out-of-Area          Covered in full worldwide                                    once every 36 months
Urgently Needed Services mean covered services           Mental Health and Substance Abuse
provided when you are temporarily absent from            • Inpatient                       Covered in full
the Managed Medicare Service Area (or, under               In a Medicare approved Psychiatric
unusual and extraordinary circumstances,                   Hospital; 190-day lifetime limit
provided when you are in the Service Area but            • Outpatient                      Covered in full
                                                           Unlimited visits; per year as
your PacifiCare Primary Care Physician is
                                                           long as prior-authorized
temporarily unavailable or inaccessible) when
such services are Medically Necessary and                Partial Hospitalization Services Covered in full
immediately required: 1) as a result of an               Partial hospitalization is used to shorten an
unforeseen illness, injury, or condition; and 2) it      inpatient stay and transition the member to a less
is not reasonable given the circumstances to             intense level of care. There must be evidence of
obtain the services through your PacifiCare              the need for the acute, intense, structured
Primary Care Physician.                                  combination of services provided by a partial
                                                         hospitalization program or that in the absence of
Emergency Services*                Covered in full       partial hospitalization, there would be reasonable
Covered world-wide                                       risk of requiring hospitalization.
Emergency Admission*               Covered in full       Durable Medical Equipment
world-wide for unlimited days                            and Medical Supplies               Covered in full
Emergency Services means covered inpatient and           Prosthetic Devices                 Covered in full
outpatient services that are: 1) Furnished by a
                                                         Therapeutic Footwear                Covered in full
provider qualified to furnish emergency services;        Limited to severe diabetic foot disease
and 2) Needed to evaluate or stabilize an
emergency medical condition.                             Prescription Drugs
                                                           Retail
The definition of an emergency medical                       Generic Formulary Prescription Drugs
condition is: A condition manifesting itself by              $5 Copayment per Prescription Unit
acute symptoms of sufficient severity (including             Brand-Name Formulary Prescription Drugs
severe pain) such that a prudent layperson, with             $15 Copayment per Prescription Unit
an average knowledge of health and medicine,                 Non-Formulary Brand-Name
could reasonably expect the absence of                       Prescription Drugs
immediate medical attention to result in – 1)                $30 Copayment per Prescription Unit
Serious jeopardy to the health of the individual           Mail Order
or, in the case of a pregnant woman, the health              Generic Formulary Prescription Drugs
of the woman or her unborn child; 2) Serious                 $10 Copayment/3 Prescription Units**
impairment to bodily functions; or 3) serious                Brand-Name Formulary Prescription Drugs
dysfunction of any bodily organ or part.                     $25 Copayment/3 Prescription Units**
                                                             Non-Formulary Brand-Name
Ambulance Services                 Covered in full           Prescription Drugs
world-wide                                                   $45 Copayment/3 Prescription Units**
                                                         Please see the Prescription Drug section of this
                                                         booklet.

 *A member should notify his/her Primary Care Physician or PacifiCare of emergency services within
  48 hours or as soon as reasonably possible.
**There is a $1,000 out-of-pocket maximum for covered for Prescription Drugs purchased through the
  mail-order program per member per year.
52
                          M   A N A G E D       M     E D I C A R E     P   L A N



Immunosuppressive Drugs        Covered in full           Dental Care
                          following Medicare-            • Extraction of teeth to prepare the
                          approved transplant              jaw for radiation treatment of
Includes Imuran, Sandimmune and any other                  neoplastic disease               Covered in full
FDA approved outpatient immunosuppressive
                                                         • Surgery of the jaw or related
agent.
                                                           structures, setting fractures of
Injectable Drugs for Osteoporosis       $5                 jaw or facial bones              Covered in full
for post-menopausal homebound women under
                                                         • Surgical removal of a tumor      Covered in full
a doctor’s supervision
Self-Administered                                        EXCLUSIONS AND LIMITATIONS
Erythropoietin Drug for
Dialysis Patients                  Covered in full       All services and benefits for care and conditions
                           when self-administered        within each of the following classifications shall
                      at home for dialysis patients      be excluded from coverage under this plan except
                                                         such services as may be specifically provided.
Self-Administered
Chemo Drugs                      Covered in full         Limited Benefits
                when prescribed by your Secure           1.   Biofeedback, covered only when Medicare
               Horizons Physician as anti-cancer              approved under Medicare Guidelines.
                        chemo-therapeutic agent
Includes Melphalan (Alkeran), Cyclophoshamide            2.   Chiropractic care Medically Necessary
(Cytoxin), Methotrexate (Rheumatrex) and                      care, limited to manual manipulation of the
Etoposide (Vepesid).                                          spine to correct a subluxation that can be
                                                              demonstrated by x-ray. You must receive a
Vision Care                                                   referral from your PCP.
• Examination for glasses
    (Refractive)                    $10 copayment        For routine care, you may self-refer yourself to a
• Eyeglasses                         20% discount        contracting Chiropractor. You will pay $10 per
                       with contracting providers        visit for up to 20 visits per Calendar Year.
                 (Lenses covered every two years)        3.   Religious non-medical health care
             Covered in full after cataract surgery           practitioner’s services.
Chiropractic Care                                        4.   Cosmetic surgery, covered only when
• Medically Necessary as                                      needed because of accidental injury or to
   covered by Medicare        $10 Copayment,                  improve the functioning of a malformed part
                    upon referral by your PCP                 of the body. Breast reconstruction is covered
• Self-referral for                                           following a mastectomy for breast cancer.
   routine care                $10 Copayment
                       per visit; up to 20 visits        5.   Dental care, covered only for medically
                            per Calendar Year.                necessary surgery of the jaw and related
                                                              structures, according to Medicare guidelines.
Podiatry Care
• Medically Necessary        $10 Copayment,              6.   Personal or comfort items and private
                  (upon referral by your PCP)                 rooms, covered only when medically
                                                              necessary during inpatient hospitalization.
• Self-referral for
  routine care                     $10 Copayment         7.   Podiatry, covered only when Medicare
                        3 visits per Calendar Year            approved and upon referral by your PCP.



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     Routine podiatry limited to 3 visits per              14. Medical and surgical treatment of the jaw
     Calendar Year. You may self-refer yourself, to            and supportive structures covered only when
     a contracted Podiatrist.                                  Medicare approved.
8.   Drugs for inpatient hospital and skilled nursing      Exclusions
     stays are covered (e.g. immunosuppressive
                                                           1.   Acupuncture.
     drugs). Drugs and biologicals that cannot be
     self-administered and are furnished on an             2.   All items and services which are not
     outpatient basis are also covered, subject to              medically necessary for the diagnosis and
     applicable copayments.                                     treatment of illness or injury.
9.   Services rendered outside the Managed                 3.   All services not specifically included in the
     Medicare Service Area, covered only for                    description of benefits and copayments,
     emergency or urgently needed services.                     services rendered without authorization from
     Follow-up care out-of-area will be covered                 a member’s PacifiCare Primary Care
     as long as care required continues to meet                 Physician (except for emergency or urgently
     the definition for either emergent or urgently             needed care), services prior to member’s
                                                                start date of coverage or subsequent to the
     needed care.
                                                                time coverage ends.
10. Elective or Voluntary Enhancement
                                                           4.   Any benefits not covered by Medicare
    procedures, services, supplies, and medication
                                                                unless otherwise specified in this Evidence
    including but not limited to: weight loss,                  of Coverage.
    hair growth, sexual performance, athletic
    performance, cosmetic purposes, anti-aging,            5.   Custodial or domiciliary care.
    and mental performance.                                6.   Medical and hospital services of a donor
11. Experimental medicine, surgery, or other                    when the recipient of an organ transplant is
    experimental health care procedures                         not a member.
    covered only when approved as a basic                  7.   Physical examinations for the purpose of
    health care service by PacifiCare.                          maintaining or obtaining employment,
12. Chronic Renal Disease (CRD) or End Stage                    licenses, insurance, or for premarital
                                                                purposes.
    Renal Disease (ESRD). If you currently have
    End Stage Renal Disease, that is permanent             8.   Non-Medicare covered organ transplants.
    kidney failure which requires regular kidney           9.   Drugs prescribed by a dentist.
    dialysis or a transplant to maintain life, or had
    a kidney transplant in the past 36 months,             10. Meals delivered to your home.
    the Centers for Medicare and Medicaid                  11. Naturopath’s services.
    Services (the Federal government agency
                                                           12. Orthopedic shoes, unless they are part of a
    that administers Medicare) prohibits you
                                                               leg brace and are included in the
    from enrolling in the Managed Medicare
                                                               orthopedist’s charge or therapeutic shoes for
    Plan. This does not apply if you are                       those suffering from diabetic foot disease as
    currently a non-Medicare member of                         outlined in the table for “Other Services and
    PacifiCare. If you develop End Stage Renal                 Supplies.”
    Disease while you are a member of the
    Managed Medicare Plan, you cannot be                   13. Supportive devices for the feet, except
    disenrolled from the plan.                                 orthopedic or therapeutic shoes as described
                                                               above.
13. Medically related vision care covered only
    when Medicare criteria is met. Refractions             14. Personal convenience items, such as a
    and glasses are covered, under your vision                 telephone or television in your room at a
    benefit.                                                   hospital or skilled nursing facility.
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15. Private duty nurse.                                HEARING AID BENEFIT
16. Private room in a hospital, unless Medically       An audiological evaluation to measure the extent
    Necessary.                                         of hearing loss and hearing aid evaluation to
17. Services performed by immediate relatives          determine the most appropriate make and model
    or members of your household.                      of hearing aid. The evaluations will be provided
                                                       at no cost to the member.
18. Services which are not reasonable and
    necessary under Medicare Program                   To access your hearing aid benefit, you must first
    standards.                                         go through your Primary Care Physician. If your
                                                       Primary Care Physician determines a hearing aid
19. Long-term services beyond that which
    Medicare would cover, including but not            is needed, and PacifiCare authorizes the referral,
    limited to skilled nursing and respite care,       you may make an appointment with a
    except when determined by PacifiCare to be         Contracting audiologist.
    less costly than the basic minimum                 Up to a maximum dollar amount of $1,000 per
    benefits.Routine foreseeable care provided         member once every thirty-six months for hearing
    outside of the Service Area (e.g. routine lab      aid (monaural or binaural) including, ear mold(s),
    draws or check ups for chronic conditions).        the hearing aid instrument, the initial battery,
20. Reversal of sterilization procedures, sex          cords and other ancillary equipment. Includes
    change operations, conception by artificial        visits for fitting, counseling, adjustments, repairs,
    means, such as in vitro fertilization, zygote      etc. at Covered in full for a one year period
    intrafallopian transfers and gamete                following the provision of a covered hearing aid.
    intrafallopian transfers (unless defined as        Clinical Trials
    covered), and non-prescription contraceptive
    supplies and devices.                              Original Medicare now covers routine costs of
                                                       qualifying clinical trials. If you join a clinical
21. Emergency facility services for non-
                                                       trial, you will be responsible for any coinsurance
    authorized routine conditions.
                                                       under Original Medicare.
22. Surgical treatment of morbid obesity unless
    determined Medically Necessary by a                When you enroll in a clinical trial, the providers
    PacifiCare Medical Director or designee.           are paid directly by Original Medicare for all the
                                                       covered services you receive. The clinical trial
23. Dental splints, dental prosthesis or any           providers do not have to be PacifiCare
    dental treatment for the teeth, gums, jaw or       Contracting Medical Providers.
    dental treatment related to
    temporomandibular joint syndrome (TMJ).            This means that you do not need to get a Referral
                                                       to join a clinical trial. However, you should tell
24. Radial keratotomy, low vision aids and             us before you start a clinical trial. That way, we
    services.
                                                       can still keep track of your health care services.
25. Experimental or investigational medical and        You may remain enrolled in the Group Retiree
    surgical procedures, equipment and                 Plan even if you elect to participate in a clinical
    medications are not covered.                       trial. Your routine care unrelated to the clinical
26. Dental care is excluded, except as covered         trial must still be arranged by PacifiCare.
    under Medicare.




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PRESCRIPTION DRUG BENEFIT                               bioequivalent, its level of safety, purity, strength
                                                        and effectiveness is the same as the brand-name
What is the Formulary?
                                                        product. When new generic drugs are approved
The Formulary is a list of outpatient prescription      by the FDA and added to the Formulary,
drugs that are covered by PacifiCare when               PacifiCare will cover the generic version in place
prescribed by a PacifiCare Contracting Medical          of the brand-name drug. By using these
Provider and filled at a PacifiCare Contracting         equivalent medications, you can maintain quality
Pharmacy. The Formulary was created and is              while realizing substantial savings.
regularly updated by a Pharmacy and
                                                        If there is no generic equivalent available for a
Therapeutics Committee that consists of
                                                        specific brand-name drug, your contracted
practicing physicians and pharmacists. The
                                                        physician may prescribe a “therapeutic
committee decides which prescription drugs
                                                        substitute” instead. Unlike a generic, which has
provide quality treatment for the best value. Your
                                                        the identical active ingredient as the brand-name
physician has a copy of the Formulary and will
                                                        version, a therapeutic substitute has a chemical
use it as a reference when prescribing
                                                        composition so close to its brand-name
medications or you can refer to our web site at
                                                        counterpart that it has the same clinical – or
www.pacificare.com.
                                                        therapeutic – effect.
How to Use the Program
                                                        How Much Medication Can I Obtain for a
• Present your PacifiCare ID card at any                Copayment?
  PacifiCare Contracting Pharmacy.
                                                        Covered medications are dispensed in a
• Pay your copayment for each prescription              predetermined amount called a prescription unit.
  unit of medication or the retail cost of the          A prescription unit is the maximum quantity that
  prescription, whichever is less.                      may be dispensed for a single copayment.
• If your prescription costs more than your             Typically the quantity will range from 30 to 100
  copayment, your prescription may be for a             tablets or capsules. Some medications may
  non-Formulary drug. Your may ask your                 provide more or less, depending on how they are
  pharmacist to contact your physician for a            typically dosed. Medications such as inhalers,
  Formulary alternative form of the medication.         tubes of ointment or cream or insulin vials will
                                                        be covered at a copayment per unit (inhaler,
What is Covered?                                        tube, vial).
All medications listed in the Formulary are             How Much Medication Can I Obtain at
covered, when ordered by a PacifiCare                   One Time?
Contracting Medical Provider and filled at a
PacifiCare Contracting Pharmacy. The Formulary          A maximum of one month’s (30-day supply) fill
includes a broad range of FDA approved generic          of any medication generally can be obtained at
and brand-name medications. The Formulary               one time. The only exceptions are:
does not include all prescription medications.          • Birth control pills, which can be purchased in
Please contact PacifiCare Customer Service at             three-month fills at a participating pharmacy
1-800-347-8600 if you would like more                     or through the PacifiCare mail order
information about the Formulary.                          pharmacy for the appropriate mail order
                                                          copayment.
What Does “Generic” Mean?
                                                        • A 90-day supply of maintenance medications
A generic drug is a medication that has met the           can be obtained through the Mail Service.
standards set by the Food & Drug Administration           Refer to the section on Mail Services on the
(FDA) to assure its bioequivalency to the original        following pages.
patented brand-name mediation. Once a generic
drug is approved by the FDA as being
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Prescription Drug Benefit Limitations and              • Elective or voluntary enhancement
Exclusions                                               procedures, services and medication
                                                         including but not limited to: weight loss, hair
The Prescription Drug Benefit will not be
                                                         growth, athletic performance, cosmetic
provided for any of the following:
                                                         purposes, anti-aging and mental performance
• Medications available without a prescription           are excluded.
  (over-the-counter), unless listed on the
                                                       • New procedure services, supplies and
  Formulary.
                                                         medications until they are reviewed for safety,
• Medications prescribed by Non-Contracting              efficacy, cost effectiveness and approved by
  Medical Providers.                                     PacifiCare.
• Non-Formulary injectable drugs are not               Where to Get Your Prescriptions Filled
  covered unless specifically authorized by a
                                                       Covered medications must be obtained at one of
  PacifiCare Medical Director or their designee.
                                                       the following PacifiCare Contracting Pharmacies.
• Drugs or medicines purchased before you
                                                       •   Albertsons
  started or after you terminated your
                                                       •   Campus Pharmacy
  PacifiCare membership.
                                                       •   Craig Rancho Pharmacy
• Dental related prescriptions (i.e. Gel-Kam,          •   Elliott’s Drug Mart
  Peridex, fluoride preparations, etc.)                •   Green Valley Drugs
• Therapeutic devices or appliances, including         •   Henderson Drugs
  hypodermic needles, syringes, support                •   Kmart Pharmacies
  garments, and other non-medicinal                    •   Lam’s
  substances (except insulin syringes).                •   Landmark
                                                       •   Lied Ambulatory Care Center
• Cosmetic, dietary supplements, diet pills, or        •   Lin’s Marketplace
  health and beauty aids.                              •   Long’s
• Medications for which the cost is recovered          •   McCarren Quick Care Pharmacy
  under any Workers’ Compensation,                     •   Medicine Shoppe
  Occupational Disease Law, or from any state          •   Network Pharmacy
  or government agency, or medication                  •   Nevada Care Pharmacy
  furnished by any other drug or medical               •   Nevada RX Drug
  services for which there is Covered in full to       •   Park Flamingo Pharmacy
  the patient.                                         •   Partell
                                                       •   Pharmerica
• Medications prescribed for experimental or           •   Prescription Solutions Mail Order
  non-FDA approved indications unless                  •   Raley’s Drug’s
  prescribed in a manner consistent with a             •   Rancho Quick Care
  specific indication in Drug Information for the      •   Rite-Aid
  Health Care Professional, published by the           •   Red Rock
  United States Pharmacopeia Convention or in          •   Resources Pharmaceuticals
  the American Hospital Formulary Services             •   Safeway
  edition of Drug Information or any other             •   Sav-On Pharmacy
  source which reflects community practice             •   Seniorcare Pharmacy
  standards; medications limited to                    •   Silver Pharmacy & Supply
  investigational use by law.                          •   Smith’s Pharmacy
• PacifiCare reserves the right to require prior       •   Summit Pharmacy
  authorization on certain pharmaceuticals             •   Sun United Drugs
  prior to dispensing.                                 •   Sunrise Medical Plaza Pharmacy
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•    Sunrise OP Pharmacy                                 3. Send the prescription mail-order form with
•    Target Pharmacy                                        your written prescription(s) and applicable
•    University Drug                                        copayment to:
•    Uptown United Drug
                                                                Prescription Solutions®
•    Vencor Pharmacy                                            PO Box 9040
•    Village East Drugs                                         Carlsbad, CA 92018-9040
•    Von’s Pharmacy
•    Wal-Mart Pharmacy                                   4. Before filling your prescription(s), one of our
•    Walgreen’s Pharmacy                                    Registered Pharmacists will check your
•    White Cross United Drugs                               prescription(s) for possible drug interactions.
                                                            Once your prescription is filled, the
Filling Prescriptions in an Emergency                       pharmacist will check the order again to
Please use a PacifiCare Contracting Pharmacy to             make sure the correct medication and dosage
have your prescriptions filled. If you should have          is shipped to you. Your prescription will
to pay for your prescription at a non-contracted            arrive in 10-14 working days.
pharmacy following an urgent or emergency                I Have Additional Questions:
visit, you may request reimbursement by sending
your prescription receipts to:                           If you have additional questions regarding your
                                                         prescription benefit call Customer Service at
     PacifiCare Claims Department                        1-800-347-8600 or telephone number for the
     P.O. Box 52078                                      hearing impaired (TTY) 1-800-360-1797,
     Phoenix, Arizona 85072-2078                         Monday - Friday, 7 a.m. - 6 p.m.
Should you have questions regarding your
Prescription Drug Benefit or PacifiCare’s                BEHAVIORAL HEALTH
Formulary, please call Customer Service at
1-800-347-8600 or telephone number for the               Mental Health Services And Chemical
hearing impaired (TTY) 1-800-360-1797,                   Dependency
Monday – Friday, 7 am to 6 pm for assistance.            Harmony Healthcare Behavioral Health Services
Having Your Prescriptions Delivered by Mail is
Easy, Just Follow These Steps:
                                                         There’s Help When You Need It
                                                         There may be times in your life when you find
1. Obtain a written prescription from your
                                                         yourself feeling overwhelmed and needing help.
   physician for each medication you would like
                                                         Maybe it’s a mental health problem. Or perhaps
   to have filled. NOTE: WE MUST HAVE A
                                                         you could be struggling with an alcohol
   NEW PRESCRIPTION in order to fill a mail-
                                                         addiction. Whatever the problem, you don’t need
   order request. Please ask your physician if
                                                         to handle it alone. We can help. Your health care
   you can obtain a 90-day supply with
                                                         partners, PacifiCare and Harmony Healthcare
   additional refills for any maintenance
                                                         Behavioral Health Services can provide you with
   medication. If you use the Prescriptions by
                                                         the support you need for mental health and
   Mail Program, you may receive up to three
                                                         chemical dependency benefits.
   (3) prescription units for $10 Formulary
   generic or $25 brand-name or $45 non-                 Harmony Healthcare Behavioral Health Services
   Formulary.                                            specializes in providing behavioral health care.
                                                         You benefit in several ways by receiving your
2. Fill out the prescription mail-order form. A
                                                         mental health and chemical dependency benefits
   new order form will be mailed back along
                                                         through a company specializing in behavioral
   with your prescription for your next order.
                                                         health. First, because of Harmony Healthcare’s
                                                         strict Provider credentialing process and

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continuous oversight of quality of care, you can           Questions and Answers
trust that you are seeing qualified practitioners.
                                                           Is Prior-Authorization always necessary to start
Also, Harmony Healthcare takes the guesswork
                                                           a treatment program?
out of finding a behavioral health Provider and
can match your specific needs with the                     To start a treatment program just call Harmony
appropriate Provider. And since you can call               Healthcare. A coordinator will assist you to get
Harmony Healthcare’s toll-free number at any               connected to the right provider. In an Emergency
time, you can receive a confidential Referral              or urgent care, out-of-area care and urgent care
directly. Additionally, your Primary Care                  in unusual circumstances, you should first do
Physician can request a Referral on your behalf            everything possible to ensure your physical
by calling Harmony Healthcare directly.                    safety, then call Harmony Healthcare within 48
                                                           hours of admission or visit to a provider, or as
How to Access Your Benefits
                                                           soon as reasonably possible.
To access your behavioral health benefits, call
                                                           What happens in an Emergency?
Harmony Healthcare directly at 702-251-8000
Monday through Friday from 8 a.m. to 7 p.m.                In an Emergency, Harmony Healthcare’s first
and Saturday between 8 a.m. and 11 a.m. After-             concern is for your health and well being. If
hours Monday through Friday from 7 p.m. to 8               faced with an Emergency, do everything possible
a.m., Saturday after 11 a.m. or all day Sunday             to ensure your physical safety, which may
call 1-800-363-4874. When you call, you’ll                 include calling 911. Get to a treatment center
speak with a coordinator who’ll check your                 first, then, as soon as reasonably possible, call
eligibility, gather basic information about you            Harmony Healthcare at 702-251-8000 Monday
and your situation. Depending on the help you              through Friday from 8 a.m. to 7 p.m. and
need, a clinician may then talk with you about             Saturday between 8 a.m. and 11 a.m. After-hours
the problem you’re experiencing and assess what            Monday through Friday from 7 p.m. to 8 a.m.,
Provider and treatment would be best for your              Saturday after 11 a.m. or all day Sunday call
situation.                                                 1-800-363-4874.
If you would like to receive information about             Please see the Emergency Services section in
Harmony HealthCare’s Contracting Medical                   your member materials for more specific
Providers, obtain Referrals for specialty care or to       information. Harmony Healthcare will coordinate
obtain care after normal office hours, please call         all follow-up behavioral health services to
Harmony Healthcare directly at 702-251-8000                Emergency treatment on your behalf. This may
Monday through Friday from 8 a.m. to 7 p.m.                include a transfer to a Contracting Medical
and Saturday between 8 a.m. and 11 a.m. After-             Provider designated by Harmony Healthcare
hours Monday through Friday from 7 p.m. to 8               when you are stable and the transfer would not
a.m., Saturday after 11 a.m. or all day Sunday             create an unreasonable risk to your health.
call 1-800-363-4874.                                       Can I receive care outside the Service Area?
Harmony Healthcare Maintains Confidentiality               For behavioral health services outside the Service
With Harmony Healthcare, you can be assured                Area, you will be covered for Emergency
that what you discuss with its staff is kept strictly      Services and Urgently Needed Services only.
confidential. Harmony Healthcare provides                  Please see the Emergency Services question
information only to the professionals delivering           above and in your member materials for more
your treatment. Confidentiality is built into the          specific information. Harmony Healthcare will
operations of Harmony Healthcare through a                 coordinate all follow-up behavioral health
system of control and security that protects both          services to Emergency treatment on your behalf.
written and computer-based information.                    This may include a transfer to a Contracting
                                                           Medical Provider designated by Harmony
                                                                                                           59
                           M   A N A G E D        M     E D I C A R E     P   L A N



Healthcare when you are stable and the transfer            Urgently Needed Services
would not create an unreasonable risk to your
                                                           Urgently Needed Services are covered services
health.
                                                           provided when an enrollee is temporarily absent
What do I do if I receive a claim?                         from the Plan’s Service (or, if applicable,
All authorized services prescribed by Harmony              continuation) Area (or, under unusual and
Healthcare should be billed directly to Harmony            extraordinary circumstances, proved when
Healthcare by the provider. However, if you get            enrollee is in the Service or continuation area but
Emergency treatment from a Non-Contracting                 the Plan’s Provider Network is temporarily
Medical Provider, you may receive a bill. Send             unavailable or inaccessible) when such services
Harmony Healthcare a copy of the bill or claim             are Medically Necessary and immediately
within 90 days of the date of service, or as soon          required – 1) As a result of an unforeseen illness,
as possible. Harmony Healthcare will not pay for           injury, or condition; and 2) It was not reasonable
bills or claims given to us that are more than one         given the circumstances to obtain the services
year old. Mail bills to:                                   through the health plan.

     Physicians IPA                                        Urgent situations refer to less serious Medical
     P.O. Box 95638                                        Conditions than emergency situations. Examples
     Las Vegas, Nevada 89193-5638                          include:

If your plan includes a Copayment, you are                 • non life-threatening cuts which nevertheless
responsible to pay these directly to the Provider.           require immediate suturing to ensure proper
                                                             healing
How are new treatments and technologies
evaluated?                                                 • acute illnesses when you are outside the
                                                             PacifiCare Service Area and the delay
Harmony Healthcare is committed to evaluating                necessary to return to the Service Area or to
new treatments and technologies in behavioral                contact your Participating Medical Group
health care. A committee composed of Harmony                 would result in a serious deterioration in your
Healthcare’s Medical Director and people with                health.
research and academic backgrounds meet at
least once per year to assess new advances and             What to Do When You Require
programs.                                                  Emergency or Urgently Needed Services
Emergency Services                                         Wherever you are, if you believe that you
                                                           require emergency services or urgently needed
The definition of an emergency medical                     services, you should:
condition is: A condition manifesting itself by
acute symptoms of sufficient severity (including           • If possible, call, or have someone on your
severe pain) such that a prudent layperson, with             behalf call, your Primary Care Physician or
an average knowledge of health and medicine,                 the number on the back of your ID Card.
could reasonably expect the absence of                       Assistance should be available 24-hours a
immediate medical attention to result in:                    day seven days a week.
1) Serious jeopardy to the health of the                   • Identify yourself as a PacifiCare Member and
individual or, in the case of a pregnant woman,              ask to speak to a physician. If you are calling
the health of the woman or her unborn child;                 during non-business hours and a physician is
2) Serious impairment to bodily functions; or 3)             not immediately available, ask to have the
serious dysfunction of any bodily organ or part.             physician-on-call paged. A physician should
Examples of emergencies include heart attacks,               call you back shortly.
strokes, poisonings, and sudden inability to breathe.      • Explain your situation and follow the
                                                             instructions provided.
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If you are unable to contact your Primary Care             Occasionally, we are compelled to deny such
Physician or if the severity of the injury or illness      claims. In that event, you may resubmit within
is such that the time required to make the call            one year of the initial denial, explaining in
would reasonably result in a serious deterioration         writing why you believe your claims should be
in your health or place your life or health in             approved. Your request will be considered a
serious jeopardy, then you should:                         formal grievance and handled under the
• Call 911 or go directly to the nearest                   Grievance and Appeals procedure described in
  medical facility for treatment.                          the booklet. Any questions about claims
                                                           procedures should be directed to the Customer
You must still notify PacifiCare or your                   Service at 1 1-800-228-2144.
Contracting Medical Provider within forty-eight
(48) hours or as soon as reasonably possible after         Subscriber Liability for Payment
the initial receipt of services to inform them of          In the event PacifiCare fails to pay a Contracting
the location, duration and nature of the services          Medical Provider for covered services, the
provided.                                                  Member shall not be liable to the provider for
PLEASE NOTE: It is important that you follow the           any sums owed by the health plan to the
steps outlined above. If you do not, you may be            provider. However, the Member may be liable for
financially responsible for services received.             any sums owed to a Non-Contracting provider
                                                           unless the services provided were authorized by
                                                           PacifiCare or were provided for an emergency.
GENERAL PROVISIONS
                                                           Informal Complaints
Second Medical Opinions
                                                           PacifiCare will attempt to resolve any complaint
You, or your treating Primary Care Physician,              that you might have. We encourage the informal
may request a Second Medical Opinion by                    resolution of complaints (i.e. over the telephone),
submitting a request for a Second Medical                  especially if such complaints result from
Opinion to PacifiCare. The request will be                 misinformation, misunderstanding or lack of
evaluated by a PacifiCare Medical Director                 information. However, if your complaint cannot
based on the nature of the recommended                     be resolved in this manner, a more formal
procedure or disease progression and the                   Member grievance procedure is available.
Member’s signs and symptoms.
                                                           PacifiCare Grievance Procedure
Reimbursement Provisions
                                                           You have a right to file a complaint – also called
PacifiCare is designed to eliminate claim forms            a grievance – about problems you observe or
and expenses other than required copayments. In            experience, including:
some circumstances, you may have expenses for
covered services. If this happens, PacifiCare will         • Complaints about the quality of services that
reimburse you for those expenses minus any                   you receive.
applicable copayment amounts.                              • Complaints regarding such issues as office
If you receive a bill for covered services, please           waiting times, physician’s behavior, adequacy
send us a copy of the bill within 120 days of the            of facilities, or other similar concerns.
date the service was rendered. Please submit the           PacifiCare will attempt to resolve any complaint
bill to:                                                   and encourages the informal resolution of
   PacifiCare Claims                                       complaints. However, if a grievance cannot be
   P.O. Box 52093                                          resolved in this manner, a more formal grievance
   Phoenix, AZ 85072-2093                                  procedure is available.



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To use the Formal Grievance Procedure, you               • Payment for out-of-area renal dialysis
must submit a grievance in writing to PacifiCare           services, Emergency Services, Post-
Customer Service. PacifiCare will acknowledge              Stabilization Care, or Urgently Needed
the grievance within five (5) business days of             Services;
receipt.
                                                         • Payment for any other health services
PacifiCare will advise you of PacifiCare’s                 furnished by a Non-Contracting Medical
resolution of the grievance within thirty (30) days        Provider or Facility that you believe are
of its receipt, unless good cause exists that              covered under Original Medicare or should
preclude PacifiCare from resolving the issue               have been arranged for, or reimbursed by
within this time frame. If additional time is              PacifiCare;
needed, PacifiCare will notify you in writing of
                                                         • Services you have not received, but that you
the reason for the delay and the anticipated time
                                                           believe are the responsibility of PacifiCare to
needed to resolve your grievance.
                                                           pay for or arrange; or,
Quality Improvement Department
                                                         • Discontinuation of services that you believe
Complaints that involve potential quality of care          are Medically Necessary Covered Services.
issues are referred to PacifiCare’s Quality
                                                         • Failure of PacifiCare to approve, arrange for
Improvement Department for review. These
                                                           or provide payment for health care service in
reviews are performed to assure that care is
                                                           a timely manner or to provide you with a
accessible, provided in a timely manner and
                                                           timely notice of an adverse determination
meets current community standards.
                                                           such that a delay would adversely affect your
Once Quality Improvement’s assessment is                   health.
complete, a determination will be made as to
                                                         Use the PacifiCare Grievance Procedure for
whether or not the medical care provided meets
                                                         complaints that are not denied claims or denied
medically recognized standards. If it is
                                                         services (see above). If you have a question about
determined that these standards have not been
                                                         which complaint process to use, please call
met, PacifiCare will arrange for the appropriate
                                                         PacifiCare Customer Service at 1-800-347-8600
corrective action to be taken.
                                                         or telephone number for the hearing impaired
Peer Review Organization Quality of Care                 (TTY) 1-800-360-1797, Monday - Friday,
Complaint Process                                        7 a.m. - 6 p.m.
If you are concerned about the quality of care           PacifiCare has a standard Appeal procedure and
you have received, you may file a complaint              an expedited Appeal procedure.
with the Peer Review Organization (PRO) in your
                                                         Who May File an Appeal
local area. (The name, address and telephone
number of your local PRO are referenced in the           1. You may file an Appeal.
Appeals section below.)                                  2. Someone else may file the Appeal for you on
General Information on Medicare Appeals                     your behalf. You may appoint an individual to
Process                                                     act as your representative to file the Appeal
                                                            for you by following the steps below:
As a Group Retiree Plan Member, you have the
right to Appeal any Organization Determination              a. Give us your name, your Medicare
about our payment for, or failure to arrange or                number and a statement, which appoints
continue to arrange for, what you believe are                  an individual as your representative.
Covered Services under your M+C Plan. These                    (Note: you may appoint a physician or a
include:                                                       Provider.) For example: “ I __[your
                                                               name]__ appoint __[name of
                                                               representative]__ to act as my
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      representative in requesting an Appeal            Medicare Appeals Procedure
      from PacifiCare and/or the Centers for
                                                        If you decide to proceed with the Medicare
      Medicare and Medicaid Services
                                                        Standard Appeals Procedure, the following steps
      regarding the denial or discontinuation
                                                        will occur:
      of medical services.
                                                        1.   You must submit a written request for a
   b. You must sign and date the statement.
                                                             reconsideration to:
   c. Your representative must also sign and
                                                               PacifiCare Appeals and Grievance Unit
      date this statement unless he/she is an
                                                               700 E. Warm Springs Rd.
      attorney.
                                                               Las Vegas, NV 89119
   d. You must include this signed statement
                                                             You may also request a reconsideration
      with your Appeal.
                                                             through the Social Security office (or, if you
3. A Non-Contracting Medical Provider may file               are a railroad retirement beneficiary, through
   a standard Appeal of a denied claim if he/she             a Railroad Retirement Benefits Office). You
   completes a waiver of payment statement,                  must submit your written request within
   which says he/she will not bill you regardless            sixty (60) calendar days of the date of the
   of the outcome of the Appeal.                             notice of the initial organization
Support for Your Appeal                                      determination.

You are not required to submit additional                    Note: The sixty (60)-day limit may be
information to support your request for                      extended for good cause. Include in your
reconsideration (Appeal). PacifiCare is                      written request the reason why you could
responsible for gathering all necessary medical              not file within the sixty (60)-day timeframe.
information. However, it may be helpful to              2.   PacifiCare will conduct reconsideration and
include additional information to clarify or                 notify you in writing of the decision within
support your request. For example, you may                   30 days if the Appeal is for a denied service.
want to include in your Appeal request                       Note that PacifiCare must notify you of the
information such as medical records or physician             reconsideration decision as expeditiously as
opinions in support of your request. To obtain               possible, but no later than thirty (30)
medical records, you may send a written request              calendar days from receipt of your request.
to your Primary Care Physician. If your medical              PacifiCare may extend this timeframe by up
records from a Specialist are not included in your           to fourteen (14) calendar days if you request
medical records from your Primary Care                       the extension or if PacifiCare finds that
Physician, you may need to make a separate                   additional information is needed and the
request to the Specialist who provided medical               extension of time benefits you; for example,
services to you.                                             if PacifiCare needs additional medical
Assistance With Appeals                                      records from Non-Contracting Medical
                                                             Providers that could change a denial
Regardless whether you request a standard or                 decision.
expedited Appeal, you can have a friend, lawyer
or someone else help you. There are lawyers                  If the Appeal is for a denied claim,
who do not charge unless you win your Appeal.                PacifiCare must notify you of the
Groups such as lawyer referral services can help             reconsideration determination no later than
you find a lawyer. There are also groups, such as            sixty (60) days after receiving your request
legal aid services, who will give you free legal             for a reconsideration determination.
services if you qualify.                                     PacifiCare’s reconsideration decision will be
                                                             made by a person(s) not involved in the
                                                             initial decision. All reconsiderations of
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     adverse Organization Determinations based                requires, but no later than 14 calendar days
     on Medical Necessity must be made by a                   from date of CHDR’s notice.
     physician with expertise in the field of
                                                              Request for Payment: If CHDR decides in
     medicine that is appropriate for the service
                                                              your favor, we must pay for the service no
     at issue. However, that physician need not
                                                              later than 30 calendar days from the date of
     be of the same specialty or subspecialty as
                                                              CHDR’s notice.
     the treating physician.
                                                         6.   You may request a hearing before an
3.   If PacifiCare decides to reverse the original
                                                              Administrative Law Judge (ALJ) by submitting
     adverse decision, we must authorize or
                                                              a written request with PacifiCare, CMS or
     provide your service as expeditiously as
                                                              the Social Security Administration within
     your health requires, but no later than thirty
                                                              sixty (60) days of the date of CHDR’s notice
     (30) calendar days from the date we
                                                              that the reconsideration decision was not in
     received your request for an Appeal; or we
                                                              your favor. This sixty (60) day notice may be
     will pay your claim within sixty (60)
                                                              extended for good cause. A hearing can be
     calendar days of your request for an Appeal.
                                                              held only if the amount in controversy is
4.   If PacifiCare decides to uphold the original             one hundred dollars ($100) or more as
     adverse decision, either in whole or in part,            determined by the Administrative Law Judge.
     or if we fail to provide you with a decision             All hearing requests will be forwarded to
     on your reconsideration within the relevant              CHDR. CHDR will then forward your
     time frame, we will automatically forward                request and your reconsideration file to the
     the case to the Center for Health Dispute                hearing office. PacifiCare will also be made
     Resolution (CHDR) for a new and impartial                a party to the Appeal at the ALJ level.
     review and you will be notified. CHDR is
                                                         7.   If the Administrative Law Judge’s decision is
     CMS’s independent contractor for Appeal
                                                              adverse, either you or PacifiCare may
     reviews involving Medicare+Choice
                                                              request a review by the Departmental
     managed care plans, like Secure Horizons.
                                                              Appeals Board of the Social Security
     We must send CHDR the file within thirty
                                                              Administration, which may either review the
     (30) days of a request for services and within
                                                              decision or decline review.
     sixty (60) days of a request for payment.
     CHDR will either uphold PacifiCare’s                8.   If the amount involved is $1000 or more,
     decision or issue a new decision. If we                  either you or PacifiCare may request that a
     forward the case to CHDR, we still must                  decision made by the Departmental Appeals
     notify you of our decision within the                    Board (DAB) or the Administrative Law
     relevant time frame discussed above.                     Judge if the DAB has declined review, be
                                                              reviewed by a Federal district court.
5.   For cases submitted to CHDR for review,
     CHDR will make a reconsideration decision           9.   Any initial or reconsidered decision made
     and notify you in writing of their decision              by PacifiCare, CHDR, the Administrative
     and the reasons for the decision. If CHDR                Law Judge or the Departmental Appeals
     decides in your favor and reverses our                   Board can be reopened (a) within twelve
     decision the following must occur:                       months, (b) within four (4) years for just
                                                              cause, or (c) at any time for clerical
     Request for Service: If CHDR decides in
                                                              correction or in cases of fraud.
     your favor, we must authorize the service
     under dispute within 72 hours from the time         10. The reconsidered determination is final and
     of CHDR’s notice reversing our decision, or             binding upon PacifiCare. The binding
     provide the service under dispute as                    arbitration clause in your Group Retiree
     expeditiously as your health condition                  Election Form does not apply to disputes
                                                             subject to CMS’s Appeals process.
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Medicare Expedited/72 -Hour Determination                   Covered Service and you believe it is a Time-
and Appeal Procedures                                       Sensitive situation, you or your authorized
You have the right to request and receive expedited         representative may request that the
decisions affecting your medical treatment in               reconsideration (Appeal) be expedited. If a
“Time-Sensitive” situations. A Time-Sensitive               physician wishes to file an expedited Appeal
situation is a situation where waiting for a                for you, you must give him or her
decision to be made within the time frame of the            authorization to act on your behalf. If
standard decision-making process could seriously            PacifiCare decides that it is a Time-Sensitive
jeopardize your life or health, or your ability to          situation or if any physician states that it is
regain maximum function. If PacifiCare decides,             one, PacifiCare will make a decision on your
based on medical criteria, that your situation is           Appeal on an expedited/72-hour basis.
Time-Sensitive or if any physician calls or writes          Examples of service decisions which you may
in support of your request for an expedited                 appeal on an expedited basis, when you
review, PacifiCare will issue a decision as                 believe it is a Time-Sensitive situation,
expeditiously as possible, but no later than                include the following:
seventy-two (72) hours after receiving the                  • If you received a denial of a service you
request. We may extend this time frame by up to               requested;
fourteen (14) days if you request the extension or
                                                            • If you think you are being discharged from
if we need additional information, and the
                                                              a Skilled Nursing Facility too soon;
extension of time benefits you; for example, if we
need additional medical records from Non-                   • If you think your Home Health care is
Contracting Medical Providers that could change               being discontinued too soon;
a denial decision. If the time frame is extended,           • If you think you are being discharged from
you will be notified of the reasons for the delay             a Hospital too soon and you have missed
and informed of your right to file a Grievance                the deadline for a Peer Review
should you disagree with an extension. You will               Organization (PRO) review.
be notified promptly of our determination, but no
later than upon expiration of the extension.             The procedures for requesting and receiving an
                                                         expedited decision or an expedited Appeal are
Types of Decisions Subject to Expedited/72-Hour          described in the following sections.
Review:
                                                         How to Request an Expedited/72-Hour
1. Expedited Organization Determinations. If             Organization Determination or Reconsideration
   you believe you need a service and you
   believe it is a Time-Sensitive situation, you or      To request an expedited/72-hour review, you or
   any physician, including a physician with no          your authorized representative may call, write,
   connection to PacifiCare, may request that            fax or visit PacifiCare. Be sure to ask for an
   the decision be expedited. If PacifiCare              expedited/72-hour review when you make your
   decides that it is a Time-Sensitive situation or      request.
   if any physician states that it is one,               Call:               1-800-347-8600
   PacifiCare will make a decision on your
                                                         Business Hours:     Monday through Friday,
   request for a service on an expedited/72-hour
                                                                             7:00 a.m. - 6:00 p.m.
   basis (subject to extension as discussed
                                                                             PacifiCare will document
   below).
                                                                             your request in writing.
2. Expedited Appeals. If you want to request a
   reconsideration (Appeal) of a decision by             TTY:                1-800-360-1797
   PacifiCare to deny a service you requested or
   to discontinue a service you are receiving that
   you believe is a Medically Necessary
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Business Hours:      Monday through Friday,                • An extension up to fourteen (14) calendar
                     7:00 a.m. - 6:00 p.m.                   days is permitted for a 72-hour Appeal, if
                     PacifiCare will document                the extension of time benefits you, for
                     your request in writing.                example, if you need time to provide
Write:               PacifiCare Appeals &                    PacifiCare with additional information or
                     Grievance Unit                          if PacifiCare needs to have additional
                     700 East Warm Springs Road              diagnostic testing completed. PacifiCare
                     Las Vegas, Nevada 89119                 will make a decision as expeditiously as
                                                             your health requires, but no later than the
Fax:                 702-269-2737                            end of any extension period. If the
Attention:           Appeals and Grievance Unit              timeframe is extended, you will be
                                                             notified of the reasons for the delay and
Business Hours:      Monday through Friday,                  informed of your right to file a Grievance
                     8:00 a.m. - 5:00 p.m.                   should you disagree with an extension.
Walk-in:             PacifiCare of Nevada               2. Your request must be processed within
                     Administrative Offices                seventy-two (72) hours if any physician calls
                     700 East Warm Springs Road            or writes in support of your request for an
                     Las Vegas, Nevada 89119               expedited/72-hour review, and the physician
Business Hours:      Monday through Friday,                indicates that applying the standard review
                     8:00 a.m. - 5:00 p.m.                 timeframe could seriously jeopardize your life
                                                           or health or your ability to regain maximum
How Your Expedited/72-Hour Review Request
                                                           function.
Will Be Processed
                                                           • If a Non-Contracting Medical Provider
1. Upon receiving your reconsideration request,
                                                             supports your request, PacifiCare will
   PacifiCare will determine if your request
                                                             have seventy-two (72) hours from the time
   meets the definition of Time-Sensitive.
                                                             all the necessary medical information is
     • If your request does not meet the                     received from that Provider to make a
       definition, it will be handled within the             decision.
       standard review timeframes (14 days for
                                                        3. PacifiCare will make a decision on Appeal
       initial determinations or 30 days for
                                                           and notify you of it within 72-hours of receipt
       Appeals). You will be informed by
                                                           of your request. If PacifiCare decides to
       telephone whether your request will be
                                                           uphold the original adverse determination,
       processed through the expedited seventy-
                                                           either in whole or in part, the entire file will
       two (72) hour review or the standard
                                                           be forwarded by PacifiCare to CHDR for
       timeframes. You will also receive a written
                                                           review no later than 24 hours after our
       confirmation within three (3) calendar
                                                           decision. CHDR will send you a letter with
       days of the phone call. If you disagree
                                                           their decision within seventy-two (72) hours
       with PacifiCare’s decision to process your
                                                           of receipt of your case from PacifiCare, or at
       request within the standard timeframe,
                                                           the end of the 14 day extension.
       you may file a Grievance with PacifiCare.
       The written confirmation letter will             Standard and expedited Appeals received for
       include instructions on how to file a            denials due to “lack of Medical Necessity” will
       Grievance. If your request is Time-              be reconsidered by a physician with expertise in
       Sensitive, you will be notified of our           the medical field appropriate to the services
       decision within seventy-two (72) hours.          under appeal.
       You will also receive a follow-up letter
       within 3 calendar days of the phone call.

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There are four possible dispositions to a request       All CHDR determinations advise the parties of
for expedited organization determination and            the standards for reopening of the case by
Appeal. They are:                                       CHDR. A reopening may be requested by any
• Your request to expedite our                          party to the determination if the party believes
  determination/Appeal decision is accepted,            one of the following grounds for reopening is
  we make a decision in seventy-two (72) hours          applicable:
  and notify you that we will provide or                1. Error on the face of the evidence by CHDR in
  continue the service.                                    its review;
• Your request to expedite our                          2. Fraud; or,
  determination/Appeal decision is accepted,
                                                        3. New and additional information that was not
  we make a decision in seventy-two (72) hours
                                                           available at the time CHDR made its initial
  and notify you that we will not provide or
                                                           determination in the case.
  continue the service, and the case will be
  sent to CHDR for determination within 24              Peer Review Organization (PRO) Immediate
  hours.                                                Review of Hospital Discharges
• Your request to expedite our                          When you are being discharged from the
  determination/Appeal decision is not                  Hospital, you will receive a written notice of
  accepted, and we tell you that your request           explanation called a “Notice of Discharge and
  will be handled under the standard                    Medicare Appeal Rights.” If you think you are
  determination/Appeal process.                         being asked to leave the Hospital too soon, you
                                                        have the right to request a review by the PRO.
• Your request to expedite our
                                                        Such a request must be made by noon of the first
  determination/Appeal decision cannot be
                                                        workday after you receive the Notice of
  made in seventy-two (72) hours, and we let
                                                        Discharge and Medicare Appeal Rights. This
  you know that we will need up to an
                                                        document outlines your rights; you do not have
  additional fourteen (14) days to process your
                                                        to disagree with the non-coverage determination
  request.
                                                        order to receive it. Either PacifiCare or the
When you request an expedited determination, if         hospital is required to issue this notice. You
you do not hear from us within seventy-two (72)         cannot be made to pay for your Hospital care
hours of your request, you can assume that your         until the PRO makes its decision. You have the
request has been denied. Our failure to notify          right to receive all the Hospital care that is
you in a timely manner – within seventy-two (72)        necessary for the proper diagnosis and treatment
hours – constitutes a denial which you may              of your illness or injury. According to Federal
appeal.                                                 law, your discharge date must be determined
If you have questions regarding these rights,           solely by your medical need.
please call PacifiCare Customer Service at              You have the right to request a review by a Peer
1-800-347-8600/telephone number for the                 Review Organization (PRO) of any written Notice
hearing impaired (TTY) 1-800-360-1797,                  of Discharge and Medicare Appeal Rights that
Monday - Friday, 7 a.m. - 6 p.m.                        you receive. PROs are groups of doctors who are
CHDR Reopening                                          paid by the Federal Government to review
                                                        Medical Necessity, appropriateness, and quality
A reopening is not an Appeal right. Any of the          of Hospital treatment furnished to Medicare
parties to a reconsideration determination may          patients, including those enrolled in a managed
request a reopening, however, granting a                care plan (like PacifiCare). The phone number
reopening is solely at CHDR’s discretion. The           and address of the PRO for your area is:
party requesting a reopening must clearly state in
writing the basis on which the request is made.
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     HEALTH INSIGHT                                        Eligibility Issues:
     901 South Rancho Lane, Suite 200                      Must be referred directly to CalPERS. Contact the
     Las Vegas, Nevada 89106                               CalPERS Health Benefits Services Division at
     702-385-9933                                          P.O. Box 942714, Sacramento, CA 94229-2714
     Monday through Friday                                 or telephone 1-800-352-2238.
     8:00 a.m. – 5:00 p.m.
                                                           Malpractice:
If you ask for immediate review by the PRO, you            You must proceed directly to court on issues of
will be entitled to this process instead of                malpractice
PacifiCare’s Standard Appeals process (described
                                                           Bad Faith:
in this section). The advantage of the PRO review
                                                           You must proceed directly to court on issues of
is that you will get the results within three days if
                                                           bad faith.
you request the review on time. Also, you are not
financially liable for hospital charges during the         Coverage Issues:
PRO review.                                                A coverage issue concerns the denial or approval
                                                           of health care services substantially based on a
You may file an oral or written request for an
                                                           finding that the provision of a particular service
expedited/72-hour Appeal with PacifiCare only if
                                                           is included or excluded as a covered benefit
you have missed the deadline for requesting the
                                                           under this Evidence of Coverage Booklet. It does
PRO review. Specifically state that you want an
                                                           not include a plan or contracting provider
expedited Appeal or 72-hour Appeal or that you
                                                           decision regarding a disputed health care service.
believe your health could be seriously harmed by
                                                           If you are dissatisfied with the outcome of
waiting for a standard Appeal.
                                                           PacifiCare’s internal grievance process or if you
Nevada Division of Insurance                               have been in the process for 30 days or more,
The Nevada Department of Business and                      you may request an Administrative Hearing
Industry, Division of Insurance has established a          before CalPERS Board of Administration. As an
toll-free telephone service to receive inquiries           alternative to the hearing process you may
and complaints from consumers of healthcare in             submit the matter to binding arbitration.
Nevada.                                                    However you must choose between the CalPERS
                                                           administrative Hearing and arbitration. You may
The toll-free number is 888-872-3234. The hours            not take the issue through both procedures. Or,
of operation of the Division are: Monday through           you may choose Small Claims Court, if your
Friday from 8:00 a.m. until 5:00 p.m. Pacific              coverage dispute is within the jurisdictional
Standard Time. If you have local telephone                 limits of Small Claims Court.
access to the Carson City and Las Vegas offices
of the Division of Insurance, you should call:             Disputed Health Care Service Issues
Carson City – 702-687-4270; Las Vegas –                    A disputed health care service issue concerns any
702-486-4009.                                              health care service eligible for coverage and
We suggest that Members first provide the HMO              payment under this Evident of Coverage booklet
with the opportunity to resolve member issues              that has been denied, modified, or delayed in
through the grievance and appeals procedures               whole or in part due to a finding that the service
afforded to members by the HMO before                      is not medically necessary. A decision regarding
contacting the Division of Insurance.                      a disputed health care service relates to the
                                                           practice of medicine and is not a coverage issue,
If you do not achieve resolution of your                   and includes decisions as to whether a particular
complaint through the internal grievance process           service is experimental or investigational.
described above you have several options
depending on the nature of the complaint.                  If you are dissatisfied with the outcome of
                                                           PacifiCare’s internal grievance process or if you
                                                           have been in the process for 30 days or more,
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you may request an independent medical review            To file for an Administrative Hearing, please
from the Department of Managed Health Care.              contact:
If you are dissatisfied with the outcome of the             CalPERS Health Benefit Services Division
independent medical review process, you may                 P.O. Box 942714
request an Administrative Hearing before the                Sacramento, CA 94229-2714
CalPERS Board of Administration, or you may                 1-800-352-2238.
submit the matter to binding arbitration,
                                                         Arbitration Procedure
CalPERS Administrative Hearing                           Arbitration is an option for the resolution of any
Only issues of eligibility, and coverage and             disputes concerning the health care services or
disputed health care service issues that are not         benefits, or contract interpretation (except
covered by Medicare, but covered by                      disputes concerning eligibility for enrollment,
PacifiCare/Secure Horizons may be appealed to            effective date of coverage, and malpractice or
CalPERS.                                                 bad faith).
Coverage and disputed health care service issues         Arbitration resolves differences pertaining to any
for services covered by Medicare may be                  personal liability, tort claims, or contract disputes
appealed through the Medicare appeal process.            (excluding claims for professional malpractice or
You may proceed directly to court for issues of          bad faith) originating from this agreement.
malpractice and bad faith.                               PLEASE NOTE: Arbitration is an option, but not
Only issues of eligibility and coverage issues           an obligation. For issues of eligibility and
which concern the denial or approval of health           coverage, as you may choose to refer such issues
care services substantially based on a finding that      to CalPERS.
the provision of a particular service is included        PacifiCare of Nevada does not have an internal
or excluded as a covered benefit under this              arbitration process. Please contact the Nevada
Evidence of Coverage Booklet may be appealed             Department of Business and Industry, Division of
to CalPERS. The CalPERS Board of Administration          Insurance at 1-888-872-3234 for more
will conduct an Administrative Hearing upon              information concerning your arbitration rights.
your appeal from PacifiCare’s denial of coverage
issues. However, your written appeal must be             BY ENROLLING IN THIS PLAN YOU ARE
submitted to CalPERS within 30 days of the               AGREEING TO HAVE CERTAIN DISPUTES
postmark date of PacifiCare’s letter of denial.          (mentioned above) DECIDED BY NEUTRAL
                                                         BINDING ARBITRATION. BOTH PACIFICARE
During the Administrative Hearing, evidence and          AND PLAN MEMBERS WAIVE THEIR RIGHT TO
testimony will be presented to an Administrative         A JURY OR COURT TRIAL FOR THESE DISPUTES.
Law Judge. As an alternative to this hearing you
have recourse to arbitration. However you must           Alternate Arrangements
choose between the Administrative Hearing and            In the event a Contracting Provider is unable or
arbitration. You may not take the same issue             unwilling to provide care to any Member,
through both procedures. You may withdraw                PacifiCare agrees to make a reasonable effort to
your appeal to the CalPERS Board of                      secure alternate arrangements for the provision of
administration at any time, and proceed with             care without additional expense to the Member.
arbitration.                                             If such alternate arrangements are not made
To receive an informational brochure or to file          available, or are not deemed satisfactory to the
for appeal, please contact CalPERS Health                Board and PacifiCare due to problems of access
Benefit Services Division, P.O. Box 942714,              or quality of care, then PacifiCare agrees to
Sacramento, CA 94229-2714.                               provide services and/or benefits through non-
                                                         contracting providers, if necessary. In such an
                                                                                                            69
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event, PacifiCare will reimburse Member for              • Receive Urgently Needed Services when
such fees, less any deductible or copayment                traveling outside the Plan’s Service Area or in
specified in this Agreement, and the limitation            the Plan’s service area when unusual or
contained herein.                                          extenuating circumstances prevent you from
This provision shall not apply in the event of:            obtaining care from your Contracting Primary
                                                           Care Physician.
• A major disaster or epidemic;
                                                         Treatment with Dignity and Respect
• Circumstances beyond PacifiCare’s control;
                                                         • Be treated with dignity and respect and to
• Failure to obtain prior approval of PacifiCare.          have your right to privacy recognized in all
                                                           settings.
Member Rights and Responsibilities
                                                         • Exercise these rights regardless of your race,
PacifiCare is committed to the treatment of
                                                           physical or mental disability, ethnicity,
PacifiCare Members in a manner that respects
                                                           gender, sexual orientation, creed, age,
your personal rights and responsibilities
                                                           religion or your national origin, cultural or
regarding the health care you receive. As a
                                                           educational background, economic or health
PacifiCare member, you have the right to receive
                                                           status, English proficiency, reading skills, or
the following information about your rights and
                                                           source of payment for your health care.
responsibilities:
                                                           Expect these rights to be upheld by PacifiCare
Timely, Quality Care                                       and contracting providers.
• Choice of a qualified Contracting Primary              • Have confidential treatment of all
  Care Physician and Contracting Hospital.                 communications and records pertaining to
  PacifiCare can let you know if a specific                your care. PacifiCare adopts and implements
  contracting Primary Care Physician is not                written policies and procedures to protect the
  accepting new patients at a particular time.             confidentiality of member information used
  Your Contracting Primary Care Physician will             for any purpose. These policies include the
  discuss with you the Contracting Hospital that           protection of any information that can be
  best fits your needs in the event you need               used to identify a member, employee access
  Hospital services.                                       to private information, routine and special
• Candid discussion of appropriate or                      consent. Routine consent covers the use of
  Medically Necessary treatment options for                identifiable information that is needed for
  your condition, regardless of cost or benefit            treatment, coordination of care, quality
  coverage.                                                measurement and improvement (including
                                                           surveys), utilization review, billing or fraud
• Timely access to your Contracting Primary                detection. Your routine consent is given to
  Care Physician and Referrals to Specialists              PacifiCare when you sign your
  when Medically Necessary.                                application/Individual Election Form. Unless
• Receive Emergency Services without prior                 required by law, special consent or written
  authorization when you, as a prudent                     permission from you shall be obtained before
  layperson acting reasonably, believed that an            medical records or individual member data
  Emergency Medical Condition existed.                     can be made available to any person who is
  Payment will not be withheld in cases where              not directly concerned with your health care
  you have acted as a prudent layperson with               or responsible for making payments for the
  an average knowledge of health and                       cost of such care. This includes release to
  medicine in seeking Emergency Services.                  employers. In the event you are unable to
                                                           give consent, PacifiCare will follow
• Actively participate in decisions regarding              applicable State and Federal laws.
  your own health and treatment options.
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• Extend your rights to any person who may                description of the procedure or treatment, the
  have legal responsibility to make decisions on          medically significant risks involved, any
  your behalf regarding your medical care.                alternate course of treatment or non-treatment
• Refuse treatment or leave a medical facility,           and the risks involved in each, and the name
  even against the advice of a physician,                 of the person who will carry out the
  (provided you accept the responsibility and             procedure or treatment.
  consequences of the decision). However,              • Receive reasonable continuity of care,
  your refusal in no way limits or otherwise             including information about continuing
  precludes you from receiving other medically           health care requirements following discharge
  necessary covered services for which you               from inpatient or outpatient facilities. Also to
  consent.                                               know in advance, the time and location of an
• Complete an Advance Directive, Living Will or          appointment as well as the physician
  other directive and give it to your Contracting        providing care.
  Primary Care Physician or Medical Provider           • Be advised if a physician proposes to engage
  to include in your medical record.                     in experimental or investigational procedures
• Receive timely access to your medical                  affecting your care or treatment. You have the
  records and any information that pertains to           right to refuse to participate in such research
  them by contacting your Contracted Primary             projects.
  Care Physician.                                      • Be informed of continuing health care
PacifiCare Information                                   requirements following discharge from
                                                         inpatient or outpatient facilities.
• Receive information about PacifiCare and
  Covered Services.                                    • Examine and receive an explanation of any
                                                         bills for non-covered services, regardless of
• Receive information about and know the                 payment source.
  names and qualifications of contracted
  physicians, health care professionals, and           • Request information about PacifiCare Quality
  providers involved in your medical treatment.          Improvement Program, its goals, processes
                                                         and/or outcomes.
• Receive information about an illness, the full
  course of treatment options, and prospects for       Timely Problem Resolution
  recovery in terms you can understand,                • Make complaints and request appeals about
  including how medical treatment decisions              PacifiCare or care provided without
  are made by the Contracting Primary Care               discrimination and expect problems to be
  Physician.                                             fairly examined and appropriately addressed
• Receive information regarding how medical              within the timeframes set by the plan to
  treatment decisions are made by your                   adhere to accrediting and regulatory bodies.
  Contracting Primary Care Physician or                  In keeping with the requirements of
  PacifiCare, including payment structure.               accrediting and regulatory bodies, you may
                                                         choose to have a service or treatment
• Receive information about your medications –           decision, if it meets certain criteria, reviewed
  what they are, how to take them and possible           by a physician or panel of physicians who are
  side effects.                                          not affiliated with the health plan. This
• Receive as much information about any                  process is called an independent external
  proposed treatment or procedure as you may             review.
  need in order to give an informed consent or
  to refuse a course of treatment. Except in
  emergencies, this information shall include a
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As a Member of PacifiCare Your Responsibility            CalPERS at 1-800-352-2238. You should also
is to:                                                   report any liability claims (such as claims against
• Provide PacifiCare, your physicians other              another driver in an auto accident) eligibility
  health care professionals and contracting              under Workers’ Compensation and Medicaid
  providers, to the degree possible, the                 eligibility.
  information needed in order to care for you.           Confidentiality and Disclosure of
• Participate in understanding and do your part          Information
  to improve your own health condition,                  As new technologies give us a greater ability to
  medical and behavioral, by following                   share and access information, there is also
  treatment plans, instructions and care that            increasing concern over the unauthorized use of
  you have agreed on with your physician(s).             confidential information. This is particularly true
• Behave in a manner that supports the care              in health care, where patients’ medical
  provided to other patients and the general             information is often sensitive. You’ll be glad to
  functioning of the facility.                           know PacifiCare is dedicated to protecting your
                                                         confidential health care information.
• Accept the financial responsibility for any
  copayment or coinsurance associated with               Your Medical Record
  services received while under the care of a            Your personal and confidential health care
  physician or while a patient at a facility.            information is maintained at your contracting
• Review information regarding covered                   doctor’s office in the form of a medical record.
  services, policies and procedures as stated in         These records include general information about
  your member materials or Evidence of                   you and documentation of the medical care you
  Coverage Information.                                  have received. Each time you see your
                                                         contracting doctor, information about that visit is
• Ask questions regarding your care of your              included in your medical record.
  Primary Care Physician or PacifiCare. If you
  have a suggestion, concern, complaint or               Your medical record plays a critical role in
  payment issue, we recommend you call the               ensuring you receive quality medical care. First,
  PacifiCare Customer Service department at              it provides the doctor treating you with your
  1-800-347-8600 or for the hearing impaired             medical history. It also provides valuable
  TTY 1-800-360-1797. Our Customer Service               information used by PacifiCare to ensure quality
  Representatives are available Monday                   care. As a member, you may access, inspect,
  through Friday 7 a.m. to 6 p.m.                        amend and copy your medical records at your
                                                         contracting doctor’s office. There may be a
Updating Your Membership Records                         nominal charge for copying your medical
Your membership record contains personal                 records.
information from your enrollment application             Protected by Law
including your address and telephone number, as
well as your specific Health Plan coverage, and          Federal and State Law protects the confidentiality
the Primary Care Physician whom you selected             and privacy of members’ medical records and
upon enrollment. These records are very                  personal information. PacifiCare does not
important because they identify you as an                jeopardize employee-employer relationships by
eligible Member and determine where you can              releasing to employers information that is either
receive services.                                        explicitly or implicitly member-identifiable.
                                                         PacifiCare takes measure to remove all identifiers
Please report any changes in name, address,              when reporting medical and other data to
phone number, marital status, or status of your          employers, regardless of the level of risk assumed
dependents, please call or write PacifiCare              by the employer or PacifiCare.
Customer Service at 1-800-347-8600 and
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Routine Consent                                        specify the information at issue and permit the
When you joined PacifiCare, you signed a               patient to revoke the consent at any time.
statement that gives your routine consent for the      In addition, in the event that a member lacks the
release of protected information needed for your       ability to give informed consent for specific
treatment, coordination of care, payment of            treatments, PacifiCare works to obtain special
claims, or administration of benefits. This            consent. This is done in three ways: First, by
consent also allows PacifiCare to do research          obtaining a copy of the member’s completed
and measure quality using aggregated or                Advance Directive, if available. Second, the
unidentifiable data wherever possible. PacifiCare      member’s legal guardian, power of attorney,
collects and uses members’ medical information         and/or next of kin is identified and contacted for
for the purpose of conducting quality                  consent. Third, lacking an individual authorized
assessments, utilization reviews, fraud detection      to give consent on behalf of the member, an
and oversight reviews. However, your personal          application for guardianship is submitted to the
medical information cannot be released without         State Public Administrator.
your special consent, unless required by law. If
                                                       If you have questions or concerns about the
you transfer to a new Primary Care Physician, for
                                                       privacy of your health information, contact
example, you will need to sign a medical release
                                                       PacifiCare Customer Service at 1-800-347-8600
to transfer your records to the new doctor.
                                                       (TTY 1-800-360-1797), Monday through Friday
Ensuring Privacy                                       7:00 am through 6:00 pm.
PacifiCare is doing several things to ensure the       Advance Directives
privacy of your personal health information. We
have developed organization-wide confidentiality       PacifiCare is required by law to inform you of
policies and procedures that cover all areas of        your right to make health care decisions and to
our business and are meeting national standards        execute advance directives. An advance directive
on confidentiality issues. PacifiCare has an           is a formal document, written by you in advance
internal review committee that ensures members’        of an incapacitating illness or injury. As long as
rights for privacy are being protected. This           you can speak for yourself, PacifiCare Network
committee is responsible for reviewing policies        Providers will honor your wishes. But, if you
and practices regarding the collection, use and        become so sick that you cannot speak for
disclosure of medical information.                     yourself, then this directive will guide your
                                                       health care Providers in treating you and will
We are also working to protect confidentiality in      save your family, friends and physicians from
settings outside PacifiCare by requiring medical       having to guess what you would have wanted.
groups and other providers with whom we
contract to have confidentiality policies and          There may be several types of advance directives
procedures that meet state and federal                 you can choose from, depending on state law.
requirements. This would include physicians            Most states recognize:
being prohibited from giving information to            1. DPAHC (Durable Power of Attorney for
employers. Additionally, PacifiCare performs              Health Care);
annual assessments to ensure they are complying
                                                       2. Living Wills; and
with those requirements.
                                                       3. Natural Death Act Declarations.
Special Consent
                                                       It is necessary that you provide copies of your
Requests for confidential information from any
                                                       completed directive to:
party(ies) regarding mental illness, substance
abuse, genetic testing, HIV and AIDS cannot be         1. your Primary Care Physician;
released/re-released without a written consent         2. your agent; and
from the member. This special consent must
                                                       3. your family.                                   73
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Be sure to keep a copy with you and take a copy        However, if the Group Agreement terminates
to the Hospital when you are hospitalized for          while you or an enrolled dependent are totally
medical care.                                          disabled and under treatment of a Contracting
You are not required to initiate an advance            Physician, the services and benefits of this plan
directive, and you will not be denied care if you      will continue for the treatment of the disability
do not have an advance directive.                      until the earliest of the following: (1) the total
                                                       disability ceases; or (2) for a maximum period of
If you have questions regarding your health care       twelve (12) months after the date of termination,
choices, please contact PacifiCare Customer            or (3) until this agreement is replaced by another
Service at 1-800-347-8600 or telephone number          group, hospital or medical plan without
for the hearing impaired at 1-800-360-1797,            limitations as to the disabling condition.
Monday - Friday, 7 a.m. - 6 p.m.                       Coverage is for the disabling condition only and
                                                       is subject to all limitations and exclusions of the
TERMINATION OF GROUP                                   applicable plan.
MEMBERSHIP – CONTINUATION                              In addition, in the event a Member permits the
OF COVERAGE                                            use of a PacifiCare identification card by any
Termination of Benefits and                            other person, PacifiCare may refer the Member to
Re-enrollment                                          CalPERS for possible action in accordance with
                                                       Section 22813 of the Act.
Coverage may be terminated for individual
Members if any of the following events occur:          If you permanently move to a geographical area
                                                       outside the Managed Medicare Service Area, we
• The agreement between the Board and                  encourage you to provide us with written notice
  PacifiCare is terminated. (PacifiCare may            at least one month prior to your move. You will
  terminate its agreement with CalPERS by              no longer be eligible to continue membership in
  providing CalPERS with 10 days prior written         PacifiCare and you must contact CalPERS to
  notice in the event CalPERS fails to make            enroll in another health benefit plan. Until such
  premium payments within 60 days of the due           new coverage begins, PacifiCare will cover you
  date.)                                               for out-of-area emergencies only. A permanent
• The voluntary cancellation by the Employee,          move means an uninterrupted absence of more
  Annuitant or Dependent in accordance with            than 12 months from the Managed Medicare
  regulations.                                         Service Area.
• If an Employee, Annuitant or Dependent               In the event any Member believes that his or her
  ceases to be eligible for coverage.                  benefits under this Agreement have been
                                                       terminated because of his or her health status or
All rights to coverage and care stop on the date       health requirements, the Member may seek from
your group coverage stops. Any Member whose            the Nevada Commissioner of Corporations
enrollment terminates other than by voluntary          review of the termination.
cancellation or termination of the group
agreement and who is hospitalized on the day of        The effective date of the disenrollment will be
termination shall be granted a continuation of         the first of the month following the month in
benefits with respect to medical conditions that       which PacifiCare receives your written request.
were present or pre-existing at the time of            We will notify you in writing regarding the
hospitalization or occurred during the                 effective date of your disenrollment. Until the
hospitalization and which require continued            effective date of your disenrollment, you will be
hospitalization. The continued coverage shall not      covered by PacifiCare and your PacifiCare
extend beyond the 91st day following the               Primary Care Physician will provide your
termination.                                           medical care.

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COBRA                                                     • Employer maintained group health plan
                                                            coverage is terminated
As a result of the Consolidated Omnibus
Reconciliation Act of 1985, as amended                 Note: The continuation may be extended to the
(COBRA), you and your covered dependents may           employee’s spouse or former spouse. The
be entitled to continuation of coverage under          extended coverage terminates five years from the
CalPERS group health care plan. You may qualify        original end date of the 18-month COBRA
for continuation of coverage if you lose coverage      enrollment.
for one of the following reasons:                      Premiums
18 month events:                                       • The COBRA premium rate is 102% of the
1. Termination or separation from employment             gross premium amount and no employer
   for reasons other than gross misconduct.              contribution is provided.
2. Reduction of work hours.                            • The initial premium payment must be made
                                                         within 45 days of the COBRA election.
36 Month events:                                         Payment must include premium for all retro
1. Your spouse ceases to be eligible due to              months of the coverage.
   divorce or legal separation.                        • There is a 30-day grace period for premium
2. A dependent child ceases to be an eligible            payments. The payments must be submitted
   dependent.                                            to the health plan by the date that is 30 days
                                                         after the first day of that period. For example
3. Subscriber’s death.
                                                         if the January premium is due on January 1st,
4. Primary COBRA subscriber becomes entitled             the 30-day grace period ends on January 31st.
   to Medicare.
                                                       Election/Notification:
Events for extension of coverage:
                                                       • Election of COBRA continuation must be
1. An 18-month enrollment may be extended by             made within 60 calendar days of the notice
   11 months subject to determination of                 of eligibility.
   disability by Social Security. The premium
                                                       • Employees, annuitants, and dependents have
   rate is 150% of the group gross premium rate
                                                         a responsibility to notify their employer or
   for coverage months 19 through 29.
                                                         CalPERS of an event that has occurred. They
2. An 18 month enrollment may be extended for            are not responsible for knowing to request
   up to 42 months for a former employee who             COBRA information.
   was at least age 60 upon termination of
                                                       • Notice of termination of COBRA continuation
   employment and employed with the
                                                         coverage must be directed to the enrolled
   employer for a minimum of 5 years upon
                                                         spouse as well as the former employee. This
   termination. The premium is 213% of the
                                                         notice is generated by the health plan.
   group gross premium rate as of coverage
   month 19 forward.                                   CMS Termination Procedures
   • Termination of extended coverage:                 CMS permits member to voluntarily disenroll
   • Individual reaches age 65                         from Medicare+Choice plans at any time by
                                                       giving written notice to the health plan or by
   • Individual becomes covered through                disenrolling through any Social Security office.
     another group health plan regardless of           You should be aware that disenrolling at any
     level of benefit                                  time other than CalPERS Open Enrollment Period
   • Individual becomes entitled to Medicare*          may result in a loss of CalPERS sponsored health

*Members who are entitled to Medicare Part A and enrolled in Part B and who have enrolled in the
 Managed Medicare Plan.
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coverage. Contact the CalPERS Health Benefit at          about other insurance you may have. If you have
1-800-352-2238 for further information on                other insurance, you can help us obtain payment
disenrollment.                                           from the other insurer by promptly providing the
                                                         information we request.
Your coverage will remain in effect for each
month for which prepayment fees have been                1. If you are age sixty-five (65) or older and
received. If a Member’s coverage is terminated,             have coverage under an employer group
the Member must submit a new application in                 health plan, either through your current
order to be reinstated or they must re-enroll               employer or the employment of a spouse, you
during an Open Enrollment Period. If a Member’s             must utilize those plan benefits first. (This rule
coverage has not been terminated and the                    applies to the health plans of employers with
Member seeks to renew coverage under an                     twenty (20) or more employees.)
agreement subsequent to this agreement between           2. If you are under sixty-five (65) and entitled
the health plan and the Board, re-application is            to Medicare due to a disability (other than
not necessary.                                              end-stage renal disease) and have coverage
PAYMENT BY THIRD PARTIES                                    under a large employer group health plan of
                                                            one hundred (100) or more employees (or a
Third Party Recovery Process and the                        multiple employer plan that includes an
Member’s Responsibility                                     employer of one hundred or more
If you are injured by the actions or omissions of           employees), through a spouse’s employer
another (third) party and receive compensation              group coverage, you must utilize the benefits
for your medical care, you will be required to              under that plan prior to using your Group
reimburse PacifiCare or its nominee for the                 Retiree benefits.
reasonable value of medical services provided.           3. If automobile or no fault or liability
The amount of reimbursement shall not exceed                insurance is available to you, then benefits
the amount of compensation you receive from                 under that plan must be used first. Where a
the third-party.                                            judgment or settlement is made with a
You must obtain PacifiCare’s written consent                liability insurer, PacifiCare’s reimbursement
prior to settling any claim or releasing any third-         may be reduced by a pro-rata share of
party from liability if such a release would limit          procurement costs (e.g. attorney fees and costs).
PacifiCare’s right to reimbursement. Should you          4. If you have or develop end-stage renal
settle your claim against a third-party and                 disease (ESRD) and are covered under an
compromise these reimbursement rights,                      employer group health plan, you must use the
PacifiCare reserves the right to initiate legal             benefits of that plan for the first thirty (30)
action. Attorney fees will be awarded to the                months after becoming eligible for Medicare
prevailing party.                                           based on ESRD. Medicare is the primary payer
For purposes of this subsection, reasonable value           after this coordination period. (However, if
shall be determined to be the usual, customary              your Employer Group plan coverage was
or reasonable charge for services in the                    secondary to Medicare when you developed
geographic area where the services are rendered.            ESRD because it was not based on current
                                                            employment as described above, Medicare
Coordination of Benefits                                    continues to be primary payer).
You are always entitled to receive services              5. Workers’ compensation for treatment of a
through PacifiCare. However, Medicare law gives             work-related illness or injury will be primary.
PacifiCare the right to recover payments from
                                                         Coordination of benefits protects you from higher
certain “third party” insurance companies or
                                                         premiums; the end result is more affordable
from you if you were paid by a “third party.”
Because of this, we may ask you for information          health care for everyone.


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          SECTION 3 – GENERAL INFORMATION
                  FOR ALL MEMBERS




                                                                              77
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DEFINITIONS                                         Contract Year – The twelve (12) month period
                                                    that begins on the first day of the month the
Act – The Public Employees’ Medical and
                                                    Group Service Agreement between your
Hospital Care Act (Part 5, Division 5, Title 2 of
                                                    Employer and PacifiCare becomes effective.
the Government Code of the State of California.)
                                                    Copayment – The fee you pay at the time of
Anniversary Date – The first day of each contract
                                                    medical services in accordance with this plan.
term as defined in the Group Agreement.
                                                    Covered Services – Those Medically Necessary
Annuitant – A person who qualifies under the
                                                    benefits, services and supplies appropriately
provisions of the Act and Regulations.
                                                    accessed for which PacifiCare must pay while
Appeal – Any of the procedures that deal with       you are a Member which are:
the review of adverse Organization Determinations
                                                    • Services provided or furnished by Contracting
on the health care services a Member is entitled
                                                      Providers or authorized by PacifiCare or its’
to receive or any amounts that the Member must
                                                      Contracting Providers
pay for a service. These procedures include
reconsiderations by the Medicare+Choice             • Emergency Services and Urgently Needed
Organization, an independent review entity,           Services, for which you do not need Pre-
hearings before Administrative Law Judges (of the     Certification and which may be provided by
Social Security Administration), review by the        Non-Contracting Providers. Please refer to the
CalPERS Board, and judicial review.                   Emergency Services and Urgently Needed
                                                      Services section of this handbook
Benefits Manager – The individual so designated
by the Employer to perform the Employer’s           • Post-Stabilization services furnished by Non-
administration of this Agreement.                     Contracting Providers or Facilities that are
                                                      authorized by us or were not pre-approved
Board – The Board of Administration of Public
                                                      because PacifiCare did not respond to a
Employees’ Retirement System, State of
                                                      request for Pre-Certification for such services
California.
                                                      within 1 hour of the request or because we
Calendar Year – A twelve (12) month period that       could not be contacted for Pre-Certification
begins on January 1 and ends twelve (12)
                                                    • Renal Dialysis services provided while you
consecutive months later on December 31.
                                                      are temporarily outside of the Service Area
Center for Health Dispute Resolution
                                                    • Any services for which we provide Pre-
(CHDR/The Center) – An independent review
                                                      Certification for pre-approval. Those benefits,
entity under contract with CMS that reviews
                                                      services and supplies which we must furnish
Appeals by members of Medicare managed care
                                                      or pay for under PacifiCare for Plan members
plans, including PacifiCare.
                                                    Creditable Coverage – Coverage solely for an
Centers for Medicare and Medicaid Services
                                                    individual, other than limited benefits coverage,
(CMS) – The Federal Agency responsible for
                                                    under any of the following:
administering Medicare and Federal participation
in Medicaid.                                        1.   A retiree welfare benefit plan that provides
                                                         medical care to retirees of the retiree’s
Consolidated Omnibus Budget Reconciliation
                                                         dependents directly or through insurance,
Act (COBRA) – The Federal law requiring that
                                                         reimbursement or otherwise pursuant to the
certain group health plans give employees and
                                                         Employee Retirement Income Security Act of
qualified family members the opportunity to
                                                         1974.
continue their health care coverage at group
rates in specific instances where coverage would    2.   A church plan as defined in the Employee
otherwise end.                                           Retirement Income Security Act of 1974;

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3.   A health benefits plan issued by an              Durable Medical Equipment – Equipment that
     accountable health plan as defined by            can withstand repeated use, is primarily and
     Arizona Revised Statute 20-2301;                 usually used to serve a medical purpose, is
4.   Part A and Part B of Title XVIII of the Social   generally not useful to a person in the absence of
     Security Act (Medicare);                         illness or injury, and is appropriate for use in the
                                                      home. To be covered, Durable Medical
5.   Title XIX of the Social Security Act             Equipment must be Medically Necessary and
     (Medicaid) other than coverage consisting        prescribed by a PacifiCare Contracting Medical
     solely of benefits under Section 1928;           Provider for use in your home. Durable Medical
6.   Title 10, Chapter 55 of the United States        Equipment may be oxygen equipment,
     Code;                                            wheelchairs, hospital beds and other items that
                                                      are determined Medically Necessary, in
7.   A medical care program of the Indian Health      accordance with Medicare law, regulations and
     Services or of a tribal association;             guidelines.
8.   A health benefits risk pool operated by any      Effective Date – The date your PacifiCare
     state of the United States;                      coverage begins.
9.   A health plan offered pursuant to Title 5,       Eligible Dependents – Any member of a
     Chapter 89 of the United States Code;            subscriber’s family who is enrolled and meets all
10. A public health plan as defined by Federal        the eligibility requirements of the Employer and
    law;                                              PacifiCare, and for whom applicable health plan
                                                      premiums have been received by PacifiCare.
11. A health benefit plan offered through the
    Peace Corps;                                      Emergency Care – Covered inpatient and
                                                      outpatient services that are:
12. A policy or contract, including short term
    limited duration insurance, issued on an          1. Furnished by a provider qualified to furnish
    individual basis by an insurer, a health care        emergency services; and
    services organization, a medical service          2. Needed to evaluate or stabilize an emergency
    corporation or a hospital, medical, dental, or       medical condition.
    optometric service corporation or made
    available to persons defined as eligible          Emergency Medical Condition – A medical
    under section 36-2901, paragraph 4,               condition manifesting itself by acute symptoms of
    subdivisions (d), (e), (f), and (g).              sufficient severity (including severe pain) such
                                                      that a prudent layperson, with an average
13. A policy or contract issued by a health care      knowledge of health and medicine, could
    insurer or an accountable health plan to a        reasonably expect the absence of immediate
    member of a bona fide association.                medical attention to result in:
Custodial Care – Care furnished for the purpose       1. Serious jeopardy to the health of the
of meeting non-Medically Necessary personal              individual or, in the case of a pregnant
needs which could be provided by persons                 woman, the health of the woman or her
without professional skills or training, such as         unborn child;
assistance in mobility, dressing, bathing, eating,
preparation of special diets, and taking              2. Serious impairment to bodily functions; or
medication. Custodial Care is not covered by          3. Serious dysfunction of any bodily organ or
PacifiCare or Medicare unless provided in                part.
conjunction with Skilled Nursing Care and/or
skilled rehabilitation services.                      Employer – Your Employer, who has entered into
                                                      the Group Service Agreement with PacifiCare.

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Exclusions – Items or services that are not         providing pain relief, symptom management, and
covered under this Evidence of Coverage. A          supportive services to terminally ill people and
Summary of Exclusions and Limitations is            their families.
included in this Evidence of Coverage and
                                                    Hospital Services – A Medicare-certified
Disclosure Document.
                                                    institution licensed by the State, which provides
Experimental Procedures and Items – Items and       inpatient, outpatient, emergency, diagnostic and
procedures determined by PacifiCare and             therapeutic services. The term “Hospital” does
Original Medicare not to be generally accepted      not include a convalescent nursing home, rest
by the medical community. When making a             facility or facility for the aged which furnishes
determination as to whether a service or item is    primarily Custodial Care, including training in
experimental, PacifiCare will follow CMS            routines of daily living.
guidance (via the Medicare Carriers Manual and
                                                    Late Enrollee – An employee or eligible
Coverage Issues Manual) if applicable or rely
                                                    dependent who attempts to enroll in an employer
upon determinations already made by Medicare.
                                                    group health plan outside of the designated
Experimental Procedures and Items are not
                                                    Open Enrollment period or specified Open
covered under this Evidence of Coverage.
                                                    Enrollment period triggered by a qualifying
Formulary – A continually updated list of           event.
prescription medications, that represents the
                                                    Medically Necessary – An intervention will be
current covered drugs, decided upon by the
                                                    covered under the PacifiCare Health Plan if it is
clinical judgment of the members of the
                                                    an otherwise covered category of service, not
PacifiCare Pharmacy and Therapeutics
                                                    specifically excluded, and medically necessary.
Committee. This Committee is comprised of
                                                    An intervention may be medically indicated yet
physicians and pharmacists, many of which are
                                                    not be a covered benefit or meet the definition of
Providers and experts in the diagnosis and
                                                    medical necessity. An intervention is medically
treatment of disease. The Drug Formulary
                                                    necessary if, as recommended by the treating
contains both brand-name drugs and generic
                                                    physician and determined by the medical
drugs, all of which have FDA (Food and Drug
                                                    director of PacifiCare, it is (all of the following):
Administration) approval.
                                                    (a) A health intervention for the purpose of
Group –The association, trust, employer, or other
                                                        treating a medical condition;
group that has entered into this Agreement with
PacifiCare.                                         (b) The most appropriate supply or level of
                                                        service, considering potential benefits and
Group Service Agreement – The agreement
                                                        harms to the Member;
entered into by PacifiCare and your Employer
under which you receive the benefits and            (c) Known to be effective in treating the medical
services summarized in this Evidence of                 condition. For existing interventions,
Coverage and Disclosure Document.                       effectiveness is determined first by scientific
                                                        evidence, then by professional standards,
Home Health Agency – A Medicare-certified
                                                        then by expert opinion. For new
agency which provides intermittent Skilled
                                                        interventions, effectiveness is determined by
Nursing Care and other therapeutic services in
                                                        scientific evidence; and
your home when Medically Necessary, when you
are confined to your home and when authorized       (d) If more than one health intervention meets
by your Primary Care Physician.                         the requirements of (a) through (c) above,
                                                        furnished in the most cost-effective manner
Hospice – An organization or agency, certified by
                                                        which may be provided safely and effectively
Medicare, which is primarily engaged in
                                                        to the Member.


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In applying the above definition of medical                   interventions should be denied in the absence
necessity, the following terms shall have the                 of conclusive scientific evidence. Existing
following meanings:                                           interventions can meet the definition of
(i) A health intervention is an item or service               medical necessity in the absence of scientific
    delivered or undertaken primarily to treat                evidence if there is a strong conviction of
    (that is, prevent, diagnose, detect, treat, or            effectiveness and benefit expressed through
    palliate a medical condition or to maintain or            up-to-date and consistent professional
    restore functional ability. A medical condition           standards of care or, in the absence of such
    is a disease, illness, injury, genetic or                 standards, convincing expert opinion.
    congenital defect, pregnancy, or a biological          (iv) A new intervention is one which is not yet in
    condition that lies outside the range of                    widespread use for the medical condition and
    normal, age-appropriate human variation. A                  patient indications being considered. New
    health intervention is defined by the                       interventions for which clinical trials have not
    intervention itself, the medical condition and              been conducted because of epidemiological
    the patient indications for which it is being               reasons (i.e. rare or new diseases or orphan
    applied.                                                    populations) shall be evaluated on the basis
(ii) Effective means that the intervention can                  of professional standards of care. If
     reasonably be expected to produce the                      professional standards of care do not exist, or
     intended results and to have expected                      are outdated or contradictory, decisions about
     benefits that outweigh potential harmful                   such new interventions should be based on
     effects.                                                   convincing expert opinion.

(iii) Scientific evidence consists primarily of            (v) An intervention is considered cost effective if
      controlled clinical trials that either directly or       the benefits and harms relative to costs
      indirectly demonstrate the effect of the                 represent an economically efficient use of
      intervention on health outcomes. If controlled           resources for patients with this condition.
      clinical trials are not available, observational     Medicare (Original Medicare) – The Federal
      studies that suggest a causal relationship           Government health insurance program
      between the intervention and health                  established by Title XVIII of the Social Security
      outcomes can be used. Such studies do not            Act for people 65 years of age, or older, certain
      by themselves demonstrate a causal                   younger people with disabilities and people with
      relationship unless the magnitude of the effect      end stage renal disease (ESRD).
      observed exceeds anything that could be
                                                           Medicare+Choice (M+C) Organization – A
      explained either by the natural history of the
                                                           public or private entity organized and licensed
      medical condition or potential experimental
                                                           by the State as a risk-bearing entity that is
      biases. For existing interventions, the
                                                           certified by CMS as meeting M+C requirements.
      scientific evidence should be considered first
                                                           M+C Organizations can offer one or more M+C
      and, to the greatest extent possible, should be
                                                           Plans. PacifiCare Arizona, Inc. is an M+C
      the basis for determinations of medical
                                                           Organization.
      necessity. If no scientific evidence is
      available, professional standards of care            Member – Any Subscriber or Eligible Dependent
      should be considered. If professional                who is enrolled under this Agreement. Also, the
      standards of care do not exist, or are outdated      Medicare beneficiary entitled to receive Covered
      or contradictory, decisions about existing           Services, who has voluntarily elected to enroll in
      interventions should be based on expert              the this Plan and whose enrollment has been
      opinion. Giving priority to scientific evidence      confirmed by CMS.
      does not mean that coverage of existing

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Non-Contracting Medical Provider – Any                PacifiCare Contracting Pharmacy – A pharmacy
professional person, organization, health facility,   that has a contract to provide you with
hospital, or other person or institution licensed     medication(s) prescribed by your PacifiCare
and/or certified by the State to deliver or furnish   Contracting Medical Providers in accordance
health care services; and who is not employed,        with the terms and conditions of the Health Plan.
owned, operated by, or under contract with
                                                      PacifiCare Contracting Medical Provider – A
PacifiCare to deliver Covered Services to you.
                                                      PacifiCare Contracting Hospital or other health
Office Visit – A visit to your Primary Care           professional, supplier of health items, or Health
Physician, Specialist, other PacifiCare               Care Facility that has a contract to provide
Contracting Medical Provider or Non-Contracting       Covered Services to PacifiCare members.
Medical Provider upon Referral.                       Contracting Medical Providers are independent
Open Enrollment Period – A period set forth by        contractors and are not the employees or agents
CalPERS during which eligible employees,              of PacifiCare.
annuitants and their eligible dependents may          Peer Review Organization (PRO) – An
enroll.                                               independent contractor paid by CMS to review
Out-of-Pocket Maximum – The maximum dollar            Medical Necessity, appropriateness and quality
amount of Copayments or coinsurance you must          of medical care and services provided to
pay during the Contract Year for specified            Medicare beneficiaries. Upon request, the PRO
Covered Services. Once the Out-of-Pocket              also reviews Hospital discharges for
Maximum is met, you are not obligated to make         appropriateness, and quality of care complaints.
further copayments during the contract year for       Premium – The money paid to PacifiCare by the
the specified Covered Services. The Schedule of       retiree, employer or both, in order for a
Benefits, Limitations and Exclusions sets forth any   Member’s coverage to remain in force under this
Out-of-Pocket Maximum.                                Agreement.
PacifiCare – PacifiCare of Nevada, Inc. – A           Prior Authorization – A system whereby a
Nevada corporation that is organized and licensed     Provider must receive approval from PacifiCare
by the State as a risk-bearing entity that is         before you, the Member, receive certain Covered
certified by CMS as meeting Medicare+Choice           Services.
requirements. PacifiCare is a Medicare+Choice
                                                      Prescription Unit – The maximum amount
Organization.
                                                      (quantity) of medication that may be dispensed
PacifiCare Customer Service – A department of         per prescription for a single copayment. For most
PacifiCare dedicated to answering your questions      oral medications, the Prescription Unit represents
concerning your membership, benefits, grievances      a thirty (30) day supply of medication. The
and appeals. A Customer Service Representative        Prescription Unit for other medications will
is available to assist you during regular business    represent a single container, inhaler unit, package
hours, Monday through Friday, 7:00 a.m. to            or course of therapy. For drugs that could be
6:00 p.m. by calling 1-800-347-8600 or                habit forming, the Prescription Unit is set at a
telephone number for the hearing impaired (TTY)       smaller quantity for your protection and safety.
at 1-800-360-1797 or by writing to 4601 East
                                                      Primary Care Physician (PCP) – The Contracting
Hilton Avenue, Phoenix, AZ 85034.
                                                      Medical Provider you choose who is responsible
PacifiCare Contracting Hospital – A Hospital that     for providing or authorizing Covered Services
has a contract to provide Covered Services to you.    while you are a Member. Primary Care
                                                      Physicians may be physicians of Internal



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Medicine, Family Practice or General Practice.       Spouse – Your (the Subscriber’s) legally
However, they may also be other provider types,      recognized husband or wife under the laws of
based on your preference and health care needs.      the State of Nevada.
Provider Directory – A listing of Primary Care       State – The State of Nevada, responsible for
Providers, Contracting Medical Providers,            licensing and regulating PacifiCare of Nevada.
Contracting Hospitals, and Contracting
                                                     Subscriber – The person whose employment or
Pharmacies. PacifiCare Customer Service
                                                     other status, except for family dependency, is the
maintains updated provider directories available
                                                     basis for eligibility for membership in PacifiCare.
upon request.
                                                     A subscriber must meet the applicable eligibility
Qualifying Event – A situation that enables an       requirements of the Group Agreement and
individual to enroll outside of a designated Open    applicable health plan premiums must have been
Enrollment period or to obtain COBRA coverage.       received by PacifiCare on behalf of subscriber.
Referral – A recommendation by your PacifiCare       Technology Assessment – New procedures and
Primary Care Provider that you receive care from     technology must be proven medically effective
a Specialist, PacifiCare Contracting Medical         and cost competitive before they are eligible to
Provider, or Non-Contracting Medical Provider.       become a covered benefit. PacifiCare has a
Regulations – The Public Employees’ Medical          formal committee process involving multiple
and Hospital Care Act Regulations as adopted by      physicians at both the national and Arizona level
the Board and set forth in Subchapter 3, Chapter     to review and approve new procedures and
2, Division 1, Title 2 of the California Code of     technologies. When clinical necessity requires
Regulations.                                         rapid determination, a PacifiCare medical
                                                     director will make that determination using as
Service Area – The geographic areas located in       appropriate, scientifically based medical
the State of Nevada within which PacifiCare is       literature and independent external expert
licensed to operate by the Nevada Commissioner       opinion.
of Corporations and the Centers for Medicare
and Medicaid Services.                               Urgently Needed Services – Covered Services
                                                     provided when you are temporarily absent from
Skilled Nursing Care – Services that can only be     the Service Area (or, under unusual and
performed by, or under the supervision of            extraordinary circumstances, provided when you
licensed nursing personnel that are Medically        are in the Service Area but your Primary Care
Necessary and ordered by the Primary Care            Physician is temporarily unavailable or
Provider.                                            inaccessible) when such services are Medically
Skilled Nursing Facility – A facility which          Necessary and immediately required 1) as a
provides inpatient Skilled Nursing Care,             result of an unforeseen illness, injury, or
rehabilitation services or other related health      condition; and 2) it is not reasonable given the
services and is State licensed and/or certified by   circumstances to obtain the services through your
Medicare. The term “Skilled Nursing Facility”        Primary Care Physician.
does NOT include a convalescent nursing home,        Utilization Management – Utilization
rest facility or facility for the aged which         Management decision making is based only on
furnishes primarily Custodial Care, including        appropriateness of care and service. PacifiCare of
training in routines of daily living.                Nevada does not compensate practitioners or
Specialist – Any duly licensed physician,            other individuals conducting utilization review
osteopath, psychologist or other practitioner that   for denials of coverage or service. Financial
your PacifiCare Primary Care Provider/PacifiCare     incentives for utilization management decision-
Contracting Medical Provider may refer you to.       makers do not encourage denials of coverage or
                                                     service.
                                                                                                      83
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• Continuity of Care – PacifiCare is committed       • Concurrent Review – Provides on-site review
  to ensuring the continuity and coordination of       of all patients receiving care in an acute
  care that members receive. Efforts are made          hospital or skilled nursing facility for
  to ensure that members receive seamless,             appropriateness of care and medical necessity
  continuous and appropriate care among                and uses nationally recognized tools to help
  PCP’s and specialists treating the same              the doctor find the right care and facility for
  patient. Special attention is given to address       the members condition.
  continuity problems caused when a doctor
                                                     • Retrospective Review – Assists in gathering
  leaves a Network and has patients in active
                                                       and obtaining medical records and
  treatment. Efforts are made to either assist
                                                       information on unauthorized claims and
  with transferring care to another provider or
                                                       determines from records if the services were
  continue treatment with the current doctor for
                                                       appropriate and part of the members benefits.
  a limited amount of time to be determined by
  the patient’s individual needs. Care with          • Health Improvement – PacifiCare’s Health
  current doctors will be extended in instances        Improvement programs assist members in
  where interruption in the course of treatment        developing confidence and control over their
  can pose a significant risk to the member.           health or illness. The programs provide the
  PacifiCare will also make every effort to assist     tools and support members need to make the
  with finding alternative resources when a            daily decisions that affect their health and
  member’s benefits are exhausted.                     well being. These programs provide
                                                       physicians with information they need to
• Pre-Certification – Verifies that the
                                                       support our members’ efforts. The programs
  recommended treatment is medically
                                                       are fully integrated with PacifiCare’s quality
  appropriate and is covered under the policy
                                                       initiatives. Confidentiality is always
  and directs the care to the members chosen
                                                       maintained and preserved for all program
  Network maintaining member
                                                       participants. All Health Improvement
  communication with their doctor.
                                                       programs and services are offered at no
• Case Management – Provides the member                additional charge to PacifiCare members
  with information, training and self-help tools,      unless otherwise noted.
  looks for proven treatment to align members
  to correct treatment plans, helps patients deal
  with their medical condition and helps in
  reducing hospitalizations. Case management
  also assists to increase a member’s ability to
  self-advocate and access the healthcare
  system and provides increased knowledge
  about end of life planning and resources.




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PacifiCare of Nevada Service Area
You are eligible for enrollment and continued
coverage in PacifiCare as long as you reside in
the listed below:
88901        89031         89116         89146
88902        89033         89117         89147
88903        89036         89118         89150
88904        89039         89119         89151
88905        89040         89120         89152
89004        89046         89121         89153
89005        89070         89122         89154
89006        89100         89123         89155
89007        89101         89124         89158
89009        89102         89125         89159
89011        89103         89126         89160
89012        89104         89127         89163
89014        89105         89128         89164
89015        89106         89129         89170
89016        89107         89130         89177
89018        89108         89131         89180
89019        89109         89132         89185
89021        89110         89133         89191
89024        89111         89134         89193
89025        89112         89135         89195
89026        89113         89137         89199
89027        89114         89138
89030        89115         89139




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                   PacifiCare Addresses and Telephone Numbers



                              Desert Regional Service Center
                                 4601 East Hilton Avenue
                                   Phoenix, AZ 85034




                             Customer Service: 1-800-347-8600

             Telephone number for the hearing impaired (TTY) 1-800-360-1797.



                             PacifiCare Administrative Offices
                                 700 E. Warm Springs Rd.
                                   Las Vegas, NV 89119



                                   www.pacificare.com

                                 www.securehorizons.com




86
BLANK INSIDE BACK COVER
                                            PACIFICARE SERVICE AREA



                                   Humboldt

                                                                                           Elko




                              Pershing



                                                         Lander
        Washoe
                                                                           Eureka

                                Churchill                                                      White Pine
               rey
           Sto




      Ormsby         Lyon

         Douglas



                              Mineral
                                                                     Nye




                                            Esmeralda


                                                                                                     Lincoln




                                                                                             Clark




Service Area includes all or selected Zip Codes in the shaded counties above. Refer to the Section 3 of this combined
Evidence of Coverage and Disclosure Form for a list of zip codes for the Secure Horizons’ Service Area.




                                                                                                                         CM-601-26586.075
                                                                                                                        PNV1004 Rev. 6/00

				
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