Oleg Skurskiy Authorized Agent for PacifiCare  

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Plan Name
Premium (monthly)
Deductible
Physician Office Visits
Inpatient Hospital Benefits
Emergency & Urgently Needed Services
Outpatient Prescription Drugs (generic / brand)
Maternity Care
Annual Copay Max
 
PacifiCare SignatureValue
HMO 35/50

pacificare application
Application

 

Instant Quote
None
$35 Copay
50% of cost Copayment
$100 Copayment
$20 Copayment generic/$35 Copayment brand
$35 Copayment per visit
$5,000/Individual
 
PacifiCare SignatureValue
HMO 35/70


pacificare hmo application
Application
Instant Quote
None
$35 Copay
30% of Cost Copay
$100 Copay
$20 Copay/$35 Copay
30% of Cost Copay
$5,000 No per family Limit
 

PacifiCare Signature Value
HMO 20-35/80


pacificare hmo application
Application

Instant Quote
None
$20 Copay
20% of Cost Copay
$100 Copay
$20 Copay/$35 Copay
20% of Cost Copay
$2,500 2 per family
 

PacifiCare Signature Value
HMO 10-35/250


pacificare hmo application
Application

Instant Quote
None
$10 Copay
$250/admit
$100 Copay
$10 Copay/$30 Copay
$250 Copay
$2,500 2 per family
 
PacifiCare Signature Options
PPO 70-50/5000



pacificare hmo application
Application
Instant Quote
*I= $5,000 individual/$10,000 family
II= N/A
*I= 30% after deductible
II= N/A
*I= 30% after deductible
II= N/A
*I= Additional $200 deductible per occurrence (waived if admitted)
II= N/A
*I= Not Covered/Not Covered
II= N/A/N/A
*I= Not Covered
II= N/A
*I= $4,000 individual/$8,000 family
II= N/A
 
PacifiCare Signature Options
PPO 70-50/3000


pacificare hmo application
Application
Instant Quote
*I= $3,000 Individual, $6,000 Family (2 x Individual Deductible)
II= $3,000 Individual, $6,000 Family (2 x Individual Deductible)
*I= 70% Deductible
II= 50% of Limited Fee Schedule after Deductible
*I= 70% after Deductible
II= 50% after Deductible(s) up to $500 maximum benefit per day. Covered Expenses for these services do not apply to Coinsurance Maximum
*I= Subject to Inpatient Hospital deductible plus $200 per occurrence (waived if admitted)
II= Subject to Inpatient Hospital deductible plus $200 per occurrence (waived if admitted)
*I= Not Covered/Not Covered
II= Not Covered/Not Covered
*I= Not Covered
II= Not Covered
*I= $4,000 per person, $8,000 family plus Deductible(s), Copayments and penalties
II= $8,000 per person, $16,000 family plus Deductible(s), Copayments, penalties and all amounts above the Limited Fee Schedule
 
PacifiCare Signature Options
HDHP 100-50/5000


pacificare hmo application
Application
Instant Quote
*I= $5,000 Individual, $10,000 Family
II= $10,000 Individual, $20,000 Family
*I= Not Specified
II= Not Specified
*I= 100% of Covered Expenses after satisfying the Deductible
II= 50% of Covered Expenses after satisfying the Deductible up to $1,000 maximum benefit per day
*I= Not Applicable
II= Not Applicable
*I= 100% of Covered Expense after satisfying the deductible (per Prescription Unit or up to 30-day supply)/100% of Covered Expense after satisfying the deductible (per Prescription Unit or up to 30-day supply)
II= 50% of Covered Expense after satisfying the deductible (per Prescription Unit or up to 30-day supply)/50% of Covered Expense after satisfying the deductible (per Prescription Unit or up to 30-day supply)
*I= Not Covered
II= Not Covered
*I= $5,000 Individual, $10,000 Family (plus Deductible(s), Copayments and penalties)
II= $20,000 Individual, $40,000 Family (plus Deductible(s), Copayments and penalties)
 
PacifiCare Signature Freedom
SDHP 70-50/5000
Benefit Details


pacificare hmo application
Application
Instant Quote
*I= $5,000 individual/$10,000 family (2 members)
II= N/A
*I= First $250 per quarter is covered under the Self Directed Account (SDA). The SDA also applies to certain other covered services. Any unused SDA balance is rolled over to the next quarter. After the SDA account is depleted, services are covered at the coin
II= N/A
*I= 30% of Covered Expenses after Deductible
II= N/A
*I= $200 per occurrence (waived if admitted)
II= N/A
*I= $20 co payment generic/$35 co payment brand ($750 Deductible on brand only)
II= 50% after Copayment/50% after Copayment ($750 Deductible on brand only)
*I= Not covered
II= Not covered
*I= $4,000 Individual/$8,000 Family plus Deductible(s), Copayments and penalties
II= $8,000 Individual/$16,000 Family (Plan Year) Family plus Deductible(s), Copayments and penalties and all amounts above the Limited Fee Schedule
 
PacifiCare Signature Options
PPO 60-50/2500
Benefit Details


pacificare hmo application
Application
Instant Quote
*I= $2,500 Individual, $5,000 Family
II= $2,500 Individual, $5,000 Family
*I= 60% of Covered Expense after satisfying the Deductible
II= N/A
*I= 60% of Covered Expenses after satisfying the Deductible
II= 50% of Covered Expenses after satisfying the Deductible up to $1,000 maximum benefit per day
*I= $100 per occurrence
II= N/A
*I= $20/Not Covered
II= Not Covered/Not Covered
*I= Not Covered
II= Not Covered
*I= $8,000/Individual (plus Deductible(s), Copayments and penalties)
II= N/A
 
PacifiCare Signature Options
HDHP 35/80-50/2700
Benefit Details



pacificare hmo application
Application
Instant Quote
*I= $2,700 Individual, $5,400 Family
II= $5,000 Individual, $10,000 Family
*I= $35 Copayment
II= N/A
*I= 80% of Covered Expenses after satisfying the Deductible
II= 50% of Covered Expenses after satisfying the Deductible up to $1,000 maximum benefit per day
*I= $100 per occurrence
II= N/A
*I= 80% of Covered Expense after satisfying the deductible (per Prescription Unit or up to 30-day supply)/80% of Covered Expense after satisfying the deductible (per Prescription Unit or up to 30-day supply)
II= 50% of Covered Expense after satisfying the deductible (per Prescription Unit or up to 30-day supply)/50% of Covered Expense after satisfying the deductible (per Prescription Unit or up to 30-day supply)
*I= Not Covered
II= Not Covered
*I= $5,000 Individual, $10,000 Family (plus Deductible(s), Co payments and penalties)
II= $15,000 Individual, $30,000 Family (plus Deductible(s), Copayments and penalties)
 

PacifiCare Signature Freedom
SDHP 70-50/3000

Benefit Details



pacificare hmo application
Application

Instant Quote
*I= $3,000 Individual/$6,000 Family (2 Members)
II= N/A
*I= First $250 per quarter is covered under the Self Directed Account (SDA). The SDA also applies to certain other covered services. Any unused SDA balance is rolled over to the next quarter. After the SDA account is depleted, services are covered at the coin
II= N/A
*I= 70% of Covered Expenses after Deductible
II= 50% after Deductible up to $500 maximum benefit per day. Covered Expenses for these services do not apply to Coinsurance Maximum
*I= $200 per occurrence (waived if admitted)
II= N/A
*I= $20 Copayment generic/$35 copayment brand ($750 Deductible on brand only)
II= 50% after Copayment/50% after Copayment ($750 Deductible on brand only)
*I= Not covered
II= Not covered
*I= $4,000 Individual/$8,000 Family plus Deductible(s), Copayments and penalties
II= $8,000 Individual/$16,000 Family (Plan Year) Family plus Deductible(s), Copayments and penalties and all amounts above the Limited Fee Schedule
 

PacifiCare Signature Options
PPO 70-50/2000

Benefit Details



pacificare hmo application
Application

Instant Quote
*I= $2,000 Individual, $4,000 Family (2 x Individual Deductible)
II= $2,000 Individual, $4,000 Family (2 x Individual Deductible)
*I= 70% after satisfying Deductible
II= 50% of Limited Fee Schedule after satisfying Deductible
*I= 70% after satisfying Deductible(s)
II= 50% after satisfying Deductible to $1,000 maximum benefit per day. Covered Expenses for these services do not apply to Coinsurance Maximum
*I= $100 per occurrence (waived if admitted)
II= $100 per occurrence (waived if admitted)
*I= $20/$35 ($250 Deductible on brand only)
II= 50% after Copayment/50% after Copayment ($250 Deductible on brand only)
*I= Not covered
II= Not covered
*I= $4,000 per person, $8,000 family plus Deductible(s), Copayments and penalties
II= $8,000 per person,$16,000 family plus Deductible(s), Copayments, penalties and all amounts above the Limited Fee Schedule
 

PacifiCare Signature Options
PPO 70-50/1000

Benefit Details


pacificare hmo application
Application

Instant Quote
*I= $1,000 Individual, $2,000 Family (2 x Individual Deductible)
II= $1,000 Individual, $2,000 Family (2 x Individual Deductible)
*I= 70% - Deductible waived
II= 50% of Limited Fee Schedule after satisfying Deductible
*I= 70% after satisfying Deductible(s)
II= 50% after satisfying Deductible to $1,000 maximum benefit per day. Covered Expenses for these services do not apply to Coinsurance Maximum
*I= $100 per occurrence (waived if admitted)
II= $100 per occurrence (waived if admitted)
*I= $20/$35 ($250 Deductible on brand only)
II= 50% after Copayment/50% after Copayment ($250 Deductible on brand only)
*I= Not covered
II= Not covered
*I= $4,000 per person, $8,000 family plus Deductible(s), Copayments and penalties
II= $8,000 per person,$16,000 family plus Deductible(s), Copayments, penalties and all amounts above the Limited Fee Schedule
 

PacifiCare Signature Options
PPO 70-50/1500 (Maternity)

Benefit Details


pacificare hmo application
Application
Application

Instant Quote
*I= $1,500 Individual, $3,000 Family (2 x Individual Deductible)
II= $1,500 Individual, $3,000 Family (2 x Individual Deductible)
*I= 70% after satisfying Deductible
II= 50% of Limited Fee Schedule after satisfying Deductible
*I= 70% after satisfying Deductible(s)
II= 50% after satisfying Deductible to $1,000 maximum benefit per day. Covered Expenses for these services do not apply to Coinsurance Maximum
*I= $100 per occurrence (waived if admitted)
II= $100 per occurrence (waived if admitted)
*I= $20/$35 ($250 Deductible on brand only)
II= 50% after Copayment/50% after Copayment ($250 Deductible on brand only)
*I= 70% after satisfying Deductible
II= 50% of Limited Fee Schedule after satisfying Deductible
*I= $3,000 per person, $6,000 family plus Deductible(s), Copayments and penalties
II= $6,000 per person, $12,000 family plus Deductible(s), Copayments, penalties and all amounts above the Limited Fee Schedule
 

PacifiCare Signature Options
PPO 70-50/500

 

 


pacificare hmo application
Application

Instant Quote
*I= $500 Individual, $1,000 Family (2 x Individual Deductible)
II= $500 Individual, $1,000 Family (2 x Individual Deductible)
*I= 70% - Deductible waived
II= 50% of Limited Fee Schedule after satisfying Deductible
*I= 70% after satisfying Deductible(s)
II= 50% after satisfying Deductible to $1,000 maximum benefit per day. Covered Expenses for these services do not apply to Coinsurance Maximum
*I= $100 per occurrence (waived if admitted)
II= $100 per occurrence (waived if admitted)
*I= $15/$35
II= 50% after Copayment/50% after Copayment
*I= Not covered
II= Not covered
*I= $2,500 per person, $5,000 family plus Deductible(s), Copayments and penalties
II= $5,000 per person, $10,000 family plus Deductible(s), Copayments, penalties and all amounts above the Limited Fee Schedule
 
PacifiCare Signature Options
PPO 70-50/1000 (Maternity)



pacificare hmo application
Application
Instant Quote
*I= $1,000 Individual, $2,000 Family (2 x Individual Deductible)
II= $1,000 Individual, $2,000 Family (2 x Individual Deductible)
*I= 70% - Deductible waived
II= 50% of Limited Fee Schedule after satisfying Deductible
*I= 70% after satisfying Deductible(s)
II= 50% after satisfying Deductible to $1,000 maximum benefit per day. Covered Expenses for these services do not apply to Coinsurance Maximum
*I= $100 per occurrence (waived if admitted)
II= $100 per occurrence (waived if admitted)
*I= $10/$35 ($100 Deductible on brand only)
II= 50% after Copayment/50% after Copayment ($100 Deductible on brand only)
*I= 70% after satisfying Deductible
II= 50% of Limited Fee Schedule after satisfying Deductible
*I= $2,500 per person, $5,000 family plus Deductible(s), Copayments and penalties
II= $5,000 per person, $10,000 family plus Deductible(s), Copayments, penalties and all amounts above the Limited Fee Schedule

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 is celebrating 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. Specialty operations include behavioral health, dental and vision, life insurance, and complete pharmacy and medical management through its wholly owned subsidiary, Prescription Solutions. Our mission is to create long-term shareholder value as a leading consumer health organization committed to making people's lives healthier and more secure. To find out more about PacifiCare, such as our leadership and our vision and values, look to the links the top.

Products and services are offered by one or more of the following PacifiCare family of companies:

Health plan products and services are offered by PacifiCare of Arizona, Inc., PacifiCare of California, PacifiCare of Colorado, Inc., PacifiCare of Nevada, Inc., PacifiCare of Oklahoma, Inc., PacifiCare of Oregon, Inc., PacifiCare of Texas, Inc., PacifiCare of Washington, Inc., PacifiCare Dental of Colorado, Inc., PacifiCare Behavioral Health of California, Inc., and PacifiCare Dental (in California).

Indemnity insurance products (including PPO, medical, dental, life/AD&D and short term disability products) are underwritten by PacifiCare Life and Health Insurance Company, PacifiCare Life Assurance Company and American Medical Security Life Insurance Company. Other products and services are offered by PacifiCare Health Plan Administrators, Inc., PacifiCare Southwest Operations, Inc., RxSolutions, Inc., SeniorCo, Inc., PacifiCare Behavioral Health, Inc. and American Medical Security Life Insurance Company. PacifiCare? is a federally registered trademark of PacifiCare Life and Health Insurance Company.

For Arizona Residents: Offered by PacifiCare of Arizona, Inc. or offered and underwritten by PacifiCare Life and Health Insurance Company, PacifiCare Life Assurance Company and American Medical Security Life Insurance Company.

WE ARE ONLY LICENSED IN CALIFORNIA AND COLORADO . WE ARE NOT INSURANCE COMPANY .


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Copyright © 2005 Oleg Skurskiy Authorized Independent Agent, CA License 0E50389