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BENEFITs

Female Routine Exam

Immunization

Allergy Testing and Treatment

Inpatient, Partial and Day Treatment

Outpatient

Severe Mental Illness/Serious Emotional Disturbance of a Child

4

Plan A & R Comparison

KaIsER

INdEmNITy

$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

Out-

of-Network - 50% of Allowed Charge, no deductible 20 visits maximum per calendar year (combined in-network and

out-of-network maximum)

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

Behavioral

PacifiCare

Provided Health.

by

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.

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