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PacifiCare HMO_ Secure Horizons HMO

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					     PacifiCare HMO, Secure Horizons HMO
     Please check the website for a copy of the Evidence of Coverage: www.benefitenroll.com.

                                                                                                            Secure Horizon HMO2
                                        PacifiCare HMO2                      PacifiCare HMO2
                                                                                                          PacifiCare 65 and Over Plan
                                     CSEA & Non-represented                        TALB
                                                                                                              All Classifications
      Calendar-Year
                                                  None                               None                              None
      Deductible
      Coinsurance                                N/A                                 N/A                    Must pledge Medicare
      Annual Out-of-Pocket                   $250/person                        $800/person                            None
      Maximum1                               $500/family                        $2,400/family
      Lifetime Maximum                        Unlimited                          Unlimited                          Unlimited
      Room and Board                          No charge                          No charge                          No charge
      Surgeon                                 No charge                          No charge                          No charge
      Outpatient Surgery                      No charge                          No charge                          No charge
                                              $25 copay                          $35 copay                          $50 copay
      Emergency Room                     (waived if admitted)               (waived if admitted)               (waived if admitted)
      Physician Visits                         $5 copay                           $5 copay                           $5 copay
      Prenatal and Postnatal                  No charge                          No charge                          No charge
      X-ray and Laboratory                    No charge                          No charge                          No charge
                                              $5 copay                           $5 copay                           $5 copay
      Chiropractic                      (up to 30 visits/year)             (up to 30 visits/year)             (up to 30 visits/year)
      Ambulance                                No charge                          No charge                        No charge
                                                                                                              Basic dental (refer to
      Dental                                      None                               None                      member materials)
                                                                                                                 Exam $5 copay
      Vision                                   Eye exam                           Eye exam                     Eyeglasses to $125
                                                                                                               (every 24 months)
      Routine Physicals                        No charge                          $5 copay                          $5 copay
      Mental Health3
       Inpatient                               No charge                          No charge                         No charge
                                                                                                           (190 days lifetime maximum)
        Outpatient                             $5 copay                           $5 copay                           $5 copay
        (through PBH)

      Prescription Drugs                Retail         Mail Order          Retail         Mail Order          Retail         Mail Order
        Generic                        $5 copay         $5 copay          $5 copay        $10 copay          $5 copay        $10 copay
        Brand                         $10 copay        $10 copay         $10 copay        $20 copay         $10 copay        $20 copay
        Non-formulary                 $35 copay        $35 copay        Prior authorization required Prior authorization required
      Maximum Supply                   30 days           90 days          30 days           90 days          30 days           90 days
     This booklet is intended to provide highlights of your benefits only; it is not an Evidence of Coverage (EOC) plan document. Official
     plan and insurance documents actively govern your rights and benefits under each plan. For more details about your benefits,
     including a complete list of exclusions and limitations, please refer to each carrier’s EOC.
     1 Annual out-of-pocket maximum does not apply to prescription drugs.
     2 If you are enrolled in an HMO plan, you can obtain services only within the plan’s geographic service area, except that emergency
       services maybe obtained outside the plan’s geographic service area as needed.
     3 Severe mental illnesses of adults and children and emotional disturbances of children are treated like any other illness.




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posted:10/2/2011
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