Female Routine Exam
Allergy Testing and Treatment
Inpatient, Partial and Day Treatment
Severe Mental Illness/Serious Emotional Disturbance of a Child
Plan A & R Comparison
$20 per visit
See “Adult Physical Exam” above. For Participant/Spouse only. Services lim- ited to $250 in combination with adult physical exam in any 12-month period. Subject to deductibles and out of pocket limits. Additional allowance for a pap smear.
No Charge (Adults & Children)
Dependent children only. Subject to deductibles and annual out of pocket limits. PPO: paid at 90% Non-PPO: paid at 70%
$20 per testing visit; $3.00 per injection visit
Subject to deductibles and annual out of pocket limits. PPO: paid at 90% Non-PPO: paid at 70%
mENTal HEalTH CaRE
$20 individual / $10 group visits Limited to 20 visits per year. This benefit is provided by Kaiser, not PacifiCare.
In-Network - $20 copay per visit
of-Network - 50% of Allowed Charge, no deductible 20 visits maximum per calendar year (combined in-network and
No charge, up to 45 days per calendar year. This benefit is provided by Kaiser, not PacifiCare.
Provided by PacifiCare Behavioral Health. In-Network - 90%, no deductible. Out-of-Network - 40% of Allowed Charge, no deductible 20 days maximum per calendar year (combined maximum for in-network and out-of-network). All services must be pre-authorized or no benefits will be payable. Days are determined based on the follow- ing ratios: Inpatient treatment - 1 day Residential treatment - 70% of 1 day Day Treatment - 60% of 1 day
For Serious Mental Illness, there is no limit on the number of days or outpatient visits. Severe Mental Illness diagnoses include: Schizophrenia, Schizoaffective Disor- der, Bipolar Disorder, Major Depres- sive Disorder, Panic Disorder, Obsessive Compulsive Disorder, Pervasive Devel- opmental Disorders (Autism), Anorexia, Bulimia Nervosa, Serious Emotional Dis- turbances of Children (SED)
In-Network Inpatient - 90%, no deduct- ible, unlimited days. In-Network Outpatient - $20 copay per visit, unlimited visits. All treatment must be pre-authorized or no benefits are pay- able. Out-of-Network - Not a covered ben- efit.