Although services are covered both in- and out-of-network, your benefits are greater when you choose in-network providers.
Benefit Tip: When you choose to use providers in the Valleywise Health Network, you will receive lower cost services and therefore, maximize your benefits.
|Valleywise Health Network||In-Network (UHC Choice Plus)||Out-of-Network*|
|Plan Year Deductible (PYD)|
|Plan Year Out-of-Pocket Maximum (Includes plan deductible and copays)|
|Preventive Services**||Covered at 100%||Covered at 100%||Not Covered|
|Primary Care Physician Office Visit||$25 copay||20% after PYD||50% after PYD*|
|Specialist Physician Office Visit||$50 copay||20% after PYD||50% after PYD*|
|7th Avenue Walk-in Clinic||$25 copay||N/A||N/A|
|Urgent Care Visit||N/A||$75 copay||$75 copay|
|Emergency Room Visit||$250 copay (waived if admitted)|
|In / Outpatient Physician Services DMG Physician Services||20% after PYD||20% after PYD||50% after PYD|
|Inpatient Hospital Services - Excludes all Physician Charges|
|Room & Board||Covered at 100%||$750 copay + PYD then 20%||50% after PYD|
|Outpatient Facility Services - Excludes all Physician Charges|
|Operating, Recovery & Procedure Rooms Treatment Room; Anesthesia||Covered at 100%||$500 copay + PYD then 20%||50% after PYD|
|Physical, Occupational, Speech, and Respiratory Therapy (60-visit maximum for all combined services)||Covered at 100%||$70 copay||50% after PYD|
|Lab and Radiology/X-ray||Covered at 100%||Office setting: Covered at 100%|
Outpatient: 20% after PYD
|50% after PYD|
|Advanced Radiological Imaging||Covered at 100%||$100 copay + PYD then 20%||50% after PYD|
|Primary Care Physician Recommended||No||Yes||No|
** Claims must be coded by the provider as routine, preventive care. Copays will not be waived for diagnostic services rendered. Note: Only covered if authorization received through UMR Care Management. Dialysis covered in-network only.