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Oregon Medical Insurance > PacifiCare > Personal SDHP 1500 Benefits

PacifiCare

PacifiCare® Life Assurance Company
Summary of Benefits
PacifiCare Personal SDHP 80-60/1500
Self Directed Account Maximum per Calendar Year*
Individual
$250 per Calendar Quarter Benefit

Family
$500 per Calendar Quarter Benefit
Self Directed Account Rollover per Calendar Year*
Individual
$1,000 per Calendar Year Benefit

Family
$2,000 per Calendar Year Benefit
Deductible & Policy Maximums
Participating Provider
Non-Participating Provider
Calendar Year Deductible
Individual
$1,500

Family
$3,000
Additional Deductible (per occurance)
Inpatient Hospital Services
Not Applicable
$500

Outpatient Surgical Services
Not Applicable
$250

Emergency Room Services (waived if admitted)
$100

Failure to obtain Pre-Authorization of Services
Not Applicable
$500
Coinsurance Maximum
Individual
$2,500
$7,500

Family (2x indifidual)
$5,000
$15,000
Policy Maximum While Insured (per individual)
$2,000,000
Inpatient Benefits
Participating Provider

Services subject to the Deductible
Non-Participating Provider

Services subject to the Deductible
Inpatient Hospital Services
80%
60%
Organ Transplant Services (1)

Maximum benefit while Insured (24 month waiting period)
80%
Not Covered
Covered under Policy Maximum up to $2,000,000
Inpatient Maternity & Newborn Care (1)
Labor, Delivery and Postnatal Hospital Services
80%
60%
Inpatient Skilled Nursing Facilities
Maximum benefit Up to 90 days per Calendar Year
80%
60%
Inpatient Hospice Care
Maximum benefit $10,000 combined for Inpatient/Outpatient benefits per Calendar Year
80%
60%
Inpatient Rehabilitation Care
80%
60%
Mental Illness & Mental Health Inpatient Treatment
Maximum benefit $10,000 combined for Inpatient/Outpatient benefits per Calendar Year
80%
60%
Outpatient Benefits
Participating Provider

Services subject to the Deductible
Non-Participating Provider

Services subject to the Deductible
Physician Office Visits (1 & 2)
100% for Physician's Office Visit Services to SDA maximum then 80% after deductible
100% for Physician's Office Visit Services to SDA maximum then 60% after deductible
Periodic Health Evaluations (age 19 and over) (1)
Hearing and Vision Screening; Immunizations; Routine Laboratory tests; Weight Evaluations;
100% for Physician's Office Visit Services to SDA maximum then 80% after deductible
100% for Physician's Office Visit Services to SDA maximum then 60% after deductible
Allergy Testing and Treatment
80%
60%
Outpatient Maternity Care (1)
80%
60%
Urgent Care Services
100% for Physician's Office Visit Services to SDA maximum then 80% after deductible
100% for Physician's Office Visit Services to SDA maximum then 60% after deductible
Ambulance (emergency services and specified transfers)
Maximum Benefit $3,000 per Calendar Year
80%
Durable Medical Equipment (DME), Prosthetics, and Corrective Appliances Maximum Benefit $5,000 combined for DME, Prosthetics and Corrective Appliances per Calendar Year
80%
60%
Home Health Care
Maximum Benefit 130 visits combined per Calendar Year
80%
60%
Outpatient Hospice Services
Maximum benefit $10,000 combined for Inpatient/Outpatient benefits per Calendar Year
80%
60%
Radiology & Laboratory Services (1)
(other than Physician Office visit)
80%
60%
Specialized Scanning, Imaging and Laboratory Services (1)
80%
60%
Outpatient Medical Rehabilitative Therapy (1)
Speech, Physical, Occupational therapy - Maximum Benefit $2,000 per Calendar Year
80%
60%
Mental Illness and Mental Health (1)
Maximum benefit $2,000 combined for Inpatient/Outpatient benefits per Calendar Year
80%
60%
Complementay and Alternative Medicine Chiropractor and Acupuncture Services (1)
Maximum Benefit $500 per Calendar Year
80%
60%
Outpatient Surgery (1)
80%
60%
Outpatient Prescription Benefits
Participating Pharmacy
Non-Participating Pharmacy
3-Tier Retail Pharmacy
Generic / Brand Name / Non-Formulary (per one Prescription Unit or up to 30 days supply)
$250 Deductible then 100% after Co-Payment of $15 / $40 / $70
$250 Deductible then 80% after Co-Payment of $15 / $40 / $70
3-Tier Mail-Service Pharmacy
Generic / Brand Name / Non-Formulary (per one Prescription Unit or up to 90 days supply)
$0 Deductible then 100% after Co-Payment of $30 / $80 / $140
Not Covered
Maximum Benefit
$5000 combined maximum for Retail and Mail-Service per Calendar Year
Supplemental Benefit Rider
Participating Provider
Non-Participating Provider
ALCOHOLISM TREATMENT
Inpatient and Outpatient Treatment
- Maximum Benefit: Combined maximum of $4,500 in any 24-consecutive months.
80%

* The Self Directed Account Maximum and Rollover Per Calendar Quarter is subject to increase due to the Covered Person’s participation in designated PacifiCare Wellness Programs

(1) SDA Non-Covered Services: Covered Expenses not eligible for reimbursement under the SDA include, but are not limited to the following:
Allergy Testing/Serum and Treatment, Ambulance, Colonoscopy or flexible sigmoidoscopy, except for qualified individuals as part of Colorectal Cancer Screening, Durable medical equipment, Emergency room, Family Planning Services, Genetic Testing and Counseling, Hearing Aids and Hearing Devices, Hospice Services, Infusion Therapy, Infertility treatment, Injectable or Intravenous drugs (other than antibiotics and immunization injections, Inpatient and Outpatient Alcohol, Drug or Other Substance Abuse, Inpatient and Outpatient Hospital Services, Inpatient and Outpatient Maternity and Newborn Care (Labor, Delivery and Postnatal Hospital Services),Inpatient and outpatient Rehabilitation Care, Inpatient Hospice Care, Inpatient Skilled Nursing Facilities, Laboratory Services (other than those under Physician Office Visits), Mental Illness services, Neuromuscular Skeletal Services, Organ Transplantation Services (Bone Marrow, Stem Cell and Organ Transplants), Outpatient or Physician office based surgery Physician services (other than physician office visits), Prescription drugs, Prosthetic devices, Prosthetics and Corrective Appliances, Radiology Services (other than standard x-rays), Specialized scanning, imaging, and diagnostic procedures such as Computed Tomography (CT), Single Photon Emission Computerized Tomography radionuclide Scanning (SPECT), Positron Emission Tomography (PET), Magnetic Resonance Angiography (MRA) and Magnetic Resonance Imaging (MRI) (with or without oral, rectal, injected or infused contrast media), Electrocardiogram (EKG), Electro-encephalography (EEG), Electromyograph (EMG) and nuclear medicine studies, Sterilization, Therapeutic services, Transplants, Ultrasound, and Urgent Care facility services. Any service shown as not applicable or not covered, Nontraditional or non-Covered Services are also not eligible for reimbursement under the SDA . Please refer to the Certificate for additional plan information, including exclusions and imitations.

Reimbursements under the Self Directed Account (SDA) are limited to Covered Services indicated in this Comparison as SDA -eligible expenses and are subject to the conditions and limitations of the Policy. In all cases, reimbursements will be limited to substantiated qualified medical expenses. SDA Covered Services: The following is a summary of SDA covered services. Please note that this is not a complete list. Refer to the Certificate for additional plan information, including exclusions and limitations. Covered Expenses reimbursable under the SDA include the following: Physician Office Visits, Preventive Screenings -- Breast Cancer Screening including Mammography screening, Pelvic Cancer Screening, Detection of Osteoporosis, Colorectal Cancer Screening, Prostate Cancer Screening, Covered diagnostic laboratory services, Radiology services limited to standard plain x-ray films, Periodic Health Evaluations.

(2) Physician Office Visit Schedule: The detection and treatment of an injury or sickness durine a Physician Office Visit including associated coverd diagnostic X-ray and labroatory services; Breast, Pelvic Cancer and Mammography screening; Detection of Osteoporosis; Prostate Cancer Screening; Periodic health evaluation for children (through age 18); Diabetic Education

 

 

 

 
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