Insurance coverage provided by or through PacifiCare Life and Health Insurance Company, PacifiCare Life
Assurance Company or their affiliates. Administrative services provided by PacifiCare Health Plan Administrators,
Inc., United Healthcare Insurance Company, United HealthCare Services, Inc., Prescription Solutions, Ingenix,
Inc. or ACN Group. Behavioral health products are provided by PacifiCare Behavioral Health, Inc. (PBHI) or United
Behavioral Health (UBH).
Health plan coverage provided by or through 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. and PacifiCare of Washington, Inc. Administrative services provided by PacifiCare Health Plan
Administrators, Inc., Prescription Solutions, Ingenix, Inc. or ACN Group. Behavioral health products are provided by
PacifiCare Behavioral Health of California (PBHC), PacifiCare Behavioral Health, Inc. (PBHI) or United Behavioral
Health (UBH).
Administrative services provided by PacifiCare Health Plan Administrators, Inc., Prescription Solutions,
Ingenix, Inc. or ACN Group.
PacifiCare of Oregon, Inc. is licensed as an HCSC (Health Care Service Contractor, a managed care organization).
PacifiCare of Washington, Inc. is licensed as an HCSC (Health Care Service Contractor, a managed care
organization).
Oklahoma Only: Oklahoma Policy Numbers OKEOC2009, GHC-SMGRP-2006-OK and GHC-LGGRP-2006-OK.
Texas Only: DISCLOSURE OF PROVIDER STATUS Not all physicians and providers at contracted facilities
(hospital, ambulatory surgical center, etc) are contracted with your plan. If you receive health care services at or
through a contracted facility and the physicians or providers who provided that care are not contracted with your
plan, the services may be denied or paid at the non-network level. In those cases, you may be responsible for
payment of all or part of the fees for those services. In these situations, the facility or non-contracted physician or
provider can choose to bill you for the balance not paid by the health plan for non-covered or out-of-network
services. Should you have a complaint regarding payments of health care services, you may contact the Texas
Department of Insurance Consumer Protection Division at 1-800-252-3439.
