Pacificare of Colorado

Colorado Health Insurance

Testimonials

Company:
Plans:	PPO - 25 / PPO - 35

Coverage synopsis

Underwriting

PacifiCare is one of the nation's largest consumer health organizations. If you are looking for a plan with copays for doctor visits and prescription drugs, PacifiCare often compares favorably to Blue Cross Blue Shield and Humana.

PacifiCare has been given a rating of "A-" (Excellent) from the A.M. Best Company, an independent insurance rating organization.

To be considered for reimbursement, expenses must qualify as covered expenses. Expenses are also subject to reasonable and customary limits, unless you use a network.

See the PacifiCare brochures (PPO - 25 , PPO - 35 ) for Plan Provisions, Limitations & Exclusions, and State Variation information.

Plans at a Glance:

Plan Names

PPO 25/80-60/1000 - PPO 35/80-50/1000

Plan Type

PPO

Network

Non-Network

Copay

PPO 25 - $25
PPO 35 - $35

Deductibles

PPO 25 - Single: $500, Family: $1,500
PPO 35 - Single: $1,000, Family: $3,000

Coinsurance (% Paid by Insurance Company)

80%	PPO 25 - 60% PPO 35 - 50%

Coinsurance Limit

$10,000 per Person / $20,000 Family

$20,000 per Person / $40,000 Family

Out-of-Pocket Maximum

PPO 25 - $1,500 per Person / $3,000 Family
(excludes Deductibles, Co-payments and penalties)
PPO 35 - $2,000 per Person / $4,000 Family
(excludes Deductibles, Co-payments and penalties)
Out of Network - Two times in network cost

Lifetime Maximum

$2,000,000

Office Visits

100% after $25 or $35 Co-payment; 80% after Deductible for associated lab and X-ray services

60% or 50% of Usual and Customary after Deductible

Prescription Drugs

100% after Co-payment of $10 or $15 generic/$40 brand/$60 non-Formulary and a $100 Deductible

60% or 50% after Co-payments of $15 generic/$40 brand/$60 non-Formulary and a $100 Deductible

Emergency Room

80% after Deductible and $75 Co-payment per visit

Adult Preventive Care

100% after $35 Co-payment
80% after Deductible for associated lab and X-ray services
$300 maximum benefit per Calendar Year

60% or 50% of Usual and Customary
60% or 50% after Deductible for associated lab and X-ray services
$300 maximum benefit per Calendar Year

Child Preventive Care

100% after $35 Co-payment
80% Deductible for associated lab and X-ray services

60% or 50% Usual and Customary
60% or 50% after Deductible for associated lab and X-ray services

Lab / X-ray

80% after Deductible

60% or 50% of Usual and Customary after Deductible

Maternity

Not Covered

Physical Therapy

80% after Deductible
$2,000 maximum benefit Per Year

60% or 50% of Usual and Customary after Deductible
$2,000 maximum benefit Per Year

Skilled Nursing

80% after Deductible(s)
Up to 30 days per Calendar Year maximum

60% or 50% of Usual and Customary after Deductible
Up to 30 days per Calendar Year maximum

Home Health Care

80% after Deductible
60 visits per Calendar Year Max

60% or 50% of Usual and Customary after Deductible
60 visits per Calendar Year Max

Mental Health

50% after Deductible
$500 maximum benefit per Calendar Year; applies toward $2,500 Calendar Year benefit

60% or 50% of Usual and Customary after Deductible
$500 maximum benefit per Calendar Year; applies toward $2,500 Calendar Year benefit

Hospital Care

80% after Deductible

60% or 50% of Usual and Customary after Deductible; Up to $500 maximum benefit per day (Covered Expenses for these services do not apply to the Coinsurance Maximum)

This information is presented only as a very brief overview of some of the benefits of this plan, and is intended only for general education. The amount of benefits provided depends on the plan selected. Premium will vary with the type of benefits selected. These plans contain exclusions from and limitations of coverage. Please see the product brochure for more complete information, as well as information about terms of renew ability, preexisting conditions, out-of-network penalties, and notification requirements. Plans are subject to health underwriting. To be considered for reimbursement, expenses must qualify as covered expenses. Expenses are also subject to reasonable and customary limits, unless you use a network, and all other policy provisions, including determinations of medical necessity.

For complete details on each plan, please view the PacifiCare plan description pdfs:

PPO - 25/80-60/1000

PPO - 35/80-50/1000

Coverage Synopsis:

PPO 25/80-60/1000

This coverage will provide you with hospitalization, doctor visits ($25 co-pay, with NO limits on the number of covered visits), and prescription ($10 for generics, $40 for brand name drugs). The plan has 80% co-insurance after your deductible, and becomes 100% coverage after $7,500 of covered expenses, for a total annual out of pocket limit of $2,000.

PPO 35/80-50/1000

This coverage will provide you with hospitalization, doctor visits ($35 co-pay, with NO limits on the number of covered visits), and prescription ($15 for generics, $40 for brand name drugs). The plan has 80% co-insurance after your deductible, and becomes 100% coverage after $10,000 of covered expenses, for a total annual out of pocket limit of $3,000.

These plans work virtually identically, with the primary differences being the different doctor visits and generic drugs, and different co-insurance limits (60% on PPO 25, 50% on PPO 35) coverage for (non-emergency) out of network services.

PacifiCare members are also offered a special enrollee-only program offering savings (through vendor agreements) on selected health-related products and services - at no additional health plan premium. Here's a sampling of what's available to enrollees at a savings of 5 to 25 percent: Child Safety products; products for a Healthy Home; Pharmacy & Personal Care items; products for Healthy Moms & Kids; Fitness & Weight Management items; Complementary & Alternative Care services, and Vision & Hearing products.

Rates:

All deductible options have a 12 month rate guarantee. Your rates may also increase in the month of your date of birth, if you are moving in to a new age bracket. For example, PacifiCare charges the same rate for all male applicants age 30 to 34. You do not receive a rate increase for your age during this five year period, your rates will only go up once per year, based on PacifiCare's claims history for everyone with similar coverage. However, when you do go to a new age bracket (age 35 in the example above), your rates will be adjusted based on your age. It is possible to receive an age-based rate increase during your initial 12 month rate guarantee period.

Preferred rates without riders are available on our instant quote page. Rates depend on gender, smoking status, zip code, and health status.

The premium can be paid via quarterly, semi-annual, or annual billing, or a monthly bank draft or credit card. The bank draft will occur on the premium due date each month. The initial premium can be paid with a check or credit card.

PPO Network:

As a United Healthcare company, PacifiCare policy holders have access to one of the largest PPO networks in the nation. To view the list of providers in your area, simply visit the Pacificare Provider Directory.

Underwriting:

Underwriting of your application with PacifiCare normally takes two to four weeks, though again if medical records are ordered it could take longer. PacifiCare is fairly strict compared to many other companies, and often will decline an application that other companies would accept with an exclusionary rider.

PacifiCare performs Verification Phone Calls (VPCs) for all applicants of individual plans. VPCs are helpful in gathering more information about medical conditions directly from you without necessarily requesting medical records. This often reduces issue time and make it easier for you to do business with PacifiCare than many other companies.

With every individual case submitted, after the application is entered into the system, a VPC is made by the VPC team to the applicant. If you do not respond from the first call or message, a second call is made the following business day. If PacifiCare is unsuccessful in reaching you, they will send a letter asking you to please return their call.

To help expedite the process, please make sure to include the following information with your application:

Make sure to include a daytime phone number where you can be reached, as well as an email address in case they cannot reach you by phone.

If you are unavailable to complete the VPC, PacifiCare will leave a file number and phone number to call PacifiCare back between 6:00AM and 6:00PM MT (limited staff only from 4:30 PM to 6:00 PM - hold time might be required).

Please have your medical information available for the call.

60+ Year Old Applicants

If you are over 60 years old, you will need to have been seen by a licensed medical physician within the past 12 months. If you have not, you will not be considered for coverage until the results of a complete physical exam are received, including

Vital signs

Review of bodily systems (including height and weight)

Notation of all medications(s) being taken

Chemistry panel

Male applicants, PSA (Prostate Specific Antigen) level

Female applicants, Mammogram and Pap

Full medical records will also be requested once the updated exam has been completed.

Effective dates:

The earliest your coverage can go into effect is ten days after you have signed your application. You may request an effective date any time between 10 and 60 days after you sign your application.

Please note, if you are requesting an effective date of less than 21 days from the time you complete the application, you may not receive notification of your approval until after your effective date. If you have claims during this period, they will be eligible for coverage if submitted after you have been approved. Also note that you will be billed starting on your requested effective date, even if you have not yet been notified that you have been approved. This is very good for someone who does not have any present coverage and would like for their benefits to begin right away. For those who are already covered, it is suggested that you maintain your current coverage in force until you have received notice from either ColoHealth or directly from PacifiCare that your coverage has been approved and is in force.

About PacifiCare:

PacifiCare Health Systems was ranked by Fortune magazine in its annual listing of the 500 largest corporations in the world on July 15, 2004, shortly after receiving the National Business Group on Health's 2nd Annual Award for Excellence and Innovation in Value Purchasing for their innovative PacifiCare SignatureValueSM Advantage product in March 2004.

PacifiCare Health Systems serves more than 3 million health plan members and approximately 10 million specialty plan members nationwide with annual revenues of more than $12 billion.

PacifiCare recently celebrated its 25th anniversary as one of the nation's largest consumer health organizations, offering individuals, employers and Medicare beneficiaries a variety of consumer-driven health care and insurance products.

PacifiCare has been given a rating of "A-" (Excellent) from the A.M. Best Company, an independent insurance rating organization.

ColoHealth is an independent authorized PacifiCare agent in Colorado.

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Fort Collins, CO 80525

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