PacifiCare Mental Health

Mental Health benefits provided by PacifiCare Behavioral Health are provided to self-Funded, PacifiCare and Health Net enrolled participants only. Kaiser participants receive Mental Health Benefits from Kaiser.

SCHEDULE OF MENTAL HEALTH BENEFITS

Inpatient Deductible	None
Inpatient Per Admission Fee	Same as Medical Plan
Impatient, Partial and Day Treatment	30 Days per calendar year* covered at 100% after any applicable admission fee
*Days to be determined based on the following ratios:
Inpatient Treatment -	1 Day
Residential Treatment -	70% of 1 Day
Day Treatment -	60% of 1 Day
Outpatient Mental Health	30 Visits $5 co-payment per visit

SERIOUS MENTAL ILLNESS BENEFITS

Inpatient Deductible	None
Inpatient Per Admission Fee	Same as Medical Plan
Impatient, Partial and Day Treatment	Unlimited days covered at 100% after any applicable admission fee
Annual Maximum Benefit for Inpatients Treatment	None
Outpatient Mental Health Treatment	Unlimited Visits $5 co-payment per visit
Lifetime Dollar Maximum for Parity Diagnosis: Applied to Medical Plan lifetime dollar maximum benefit.

Additional Information

Pre-Authorization is required for all Inpatient and Outpatient and Serious Mental Illness benefits.

Serious Mental Illness Diagnosis include: Schizophrenia, Schizoaffective Disorder, Bipolar Disorder, Major Depressive Disorder, Panic Disorder, Obsessive-Compulsive Disorder, Pervasive Developmental Disorders (Autism), Anorexia, Bulimia Nervosa, Severe Emotional Disturbances of Children (SED).

Chemical Dependency Benefits

Chemical Dependency Benefits are provided to all participants and their eligible dependents regardless of their medical plan chosen by PacifiCare Behavioral Health.

SCHEDULE OF CHEMICAL DEPENDENCY BENEFITS

All levels of chemical dependency care includes detox.

$25,000 Annual Maximum
$0 copay and covered at 100%
$35,000 Lifetime Maximum

Pre-Authorization is required for all Chemical Dependency Benefits. Contact PacifiCare Behavioral Health 24 hours a day, 7 days a week toll-free at: 1-877-225-2267.