Arizona - Retired Employees

"Bold" print identifies plan changes effective 1/1/2003
Plan Name	PacifiCare of Arizona, Inc. AZ	Community Choice 2000 Referred Care QPOS	Community Choice 2000 Self-Referred Care QPOS
Web Site	www.pacificare.com	www.aetnaushc.com	www.aetnaushc.com
Member Service Number	1-800-347-8600	1-888-403-0400	1-888-403-0400
Individual Lifetime Maximum Benefits	None	None	$1 Million
Annual Deductible
Individual	None	None	None
Family	None	None	None
Coinsurance	None	None	25%
Annual Out-of-Pocket Maximum
Individual	$1,000	None	$2,000
Family	$3,000	None	$4,000
Inpatient Hospital	100% covered	100%	75%
Physician Services: PCP Office Visit	$15 copay	$10 copay	75%
Emergency Care: In-area Hospital	$75 copay (waived if admitted)	100% - $25 copay applies/ Waived if admitted. 75% for non-emergency care	100% - $25 copay applies. Waived if admitted. 75% for non-emergency care
Outpatient X-Ray and Lab	$10 copay for x-ray, lab 100% covered	100%	75%
Durable Medical Equipment	100% covered, no maximum	100%	75%
Retail Prescription Coverage
Generic	$10 copay for 30 -day supply	20%	20%
Brand Name	$20 copay for 30 day supply	30% if generic unavailable; 50% if Generic available and medically necessary	30% if generic unavailable; 50% if Generic available and medically necessary
Mail-Order Prescription Coverage
Generic	$20 copay for 90-day supply	10% Generic; 20% Brand if Generic unavailable; 40% if Generic available and medically necessary	10% Generic; 20% Brand if Generic unavailable; 40% if Generic available and medically necessary
Brand Name	$40 copay for a 90-day supply	See Above	See Above
Diabetic Benefits
Insulin	$10 copay generic or $20 copay brand name	Covered Under Pharmacy Benefit	Covered Under Pharmacy Benefit
Chem. Strips/Lancets	100% covered	Covered Under Pharmacy Benefit	Covered Under Pharmacy Benefit
Home Health Care	100% covered	100%	75% - limited to 100 visits per calendar year
Mental Health
Inpatient	100% covered for up to 30 days per calendar year	100% up to 30 days per calendar year	75% up to 30 days per calendar year
Outpatient	$15 copay for up to 20 visits per calendar year	100% after $10 copay limited to 20 visits per calendar year	75% limited to 20 visits per calendar year
Substance Abuse
Inpatient	Covered in full; limited to two 30-days treatments programs or two 60-day partial hospitalization treatment programs per lifetime	100% - 30 days per calendar year; 90 days lifetime	75% - 30 days per calendar year; 90 days lifetime
Outpatient	$15 copay per visit; limited to one year of aftercare treatment after completion of an inpatient program	100% after $10 copay - 30 visits per calendar year; 120 visits per lifetime	75% - 30 visits per calendar year; 120 visits per lifetime
Vision Care
Routine Eye Exam	$15 copay	VisionOne Discount Program	Not Covered
Eyeglasses and Contact Lenses	Not Covered	VisionOne Discount Program	Not Covered
Hearing Care
Exam	$15 copay	Provided by National Ear Care Plan (NECP) - 1-800-999-1458	Not Covered
Hearing Aids	Not Covered	Provided by National Ear Care Plan (NECP) - 1-800-999-1458	Not Covered
Dental Care
Basic Services	Not Covered	Not Covered	Not Covered
Major Services	Not Covered	Not Covered	Not Covered
Preventive Services	Not Covered	Not Covered	Not Covered
Wellness Benefits	Yes	$10 Copay	Not Covered