Preferred Plan

This plan requires you to use the Valleywise Health Network for all services. In the case that Valleywise Health does not provide a service, you must have your Valleywise Health Primary Care Physician (PCP) contact UMR and obtain prior authorization before using the UnitedHealthcare Choice Plus Network for services outside of the Valleywise Health Network. While Valleywise Health does not require that you designate a Primary Care Physician (PCP) at the time of enrollment, we strongly encourage you to select a PCP for you and each of your family members.

Prior Authorization

If prior authorization is required and not received, your benefits could be reduced. If you are enrolled in the Preferred Plan, almost all services (with the exception of emergency services), require prior authorization. If you do not obtain prior authorization, services will not be covered.

Approved Providers

All services, including pharmacy, must be received by a Valleywise Health facility. To search for a Valleywise Health provider, use the “Find a Physician” page on the Valleywise Health website.

Appointment Line

For added convenience, Valleyview Health employees can use the Employee Appointment Line at 602-344-8585, Monday through Friday, 7:00am – 5:00pm, to schedule an appointment.

Preferred Plan
Valleywise Health NetworkUHC Choice Plus Network
Plan Year Deductible (PYD)
Individual
$0
$750
Family
$0
$1,500
Plan Year Out-of-Pocket Maximum (Includes plan deductible and copays)
Individual
$2,750
$2,750
Family
$5,500
$5,500
Office Visits
Preventive Services**
Covered at 100%
Not Covered
Primary Care Physician Office Visit
$10 copay
$25 copay***
Specialist Physician Office Visit
$20 copay
$50 copay***
Urgent Care Visit
N/A
$75 copay
Emergency Room Visit
$250 copay (waived if admitted)
Physician Services
In / Outpatient Physician Services DMG Physician Services
Covered at 100%
20% after PYD
Inpatient Hospital Services - Excludes all Physician Charges***
Room & Board
$0
$750 Copay + PYD then 20%***
Outpatient Facility Services - Excludes all Physician Charges
Operating, Recovery & Procedure Rooms Treatment Room; Anesthesia
$0
$500 Copay + PYD then 20%***
Physical, Occupational, Speech, and Respiratory Therapy (60-visit maximum for all combined services)
$0
$25 or $50 Copay***
Additional Details
Lab and Radiology/X-ray
Covered at 100%
20% after PYD
Advanced Radiological Imaging
$0
Not Covered
Primary Care Physician Recommended
Yes
No
* Out-of-Network provider charges are subject to Reasonable & Customary (R&C) plan limits, which may be less than the provider’s actual charge. Members are fully responsible for all charges above R&C limits.
** Claims must be coded by the provider as routine, preventive care. Copays will not be waived for diagnostic services rendered.
*** Only covered if authorization received through UMR Care Management.

Prior Authorization

Prior authorization may be required for certain services; please refer to plan documents. If prior authorization is required and not received, the claim is the participant’s responsibility. If you are enrolled in the Valleywise Health Preferred Plan almost all services, with the exception of emergency services, require prior authorization. If there is any question, request that your Valleywise Health (DMG) provider contact UMR prior to scheduling an appointment. Examples include:

Z

Inpatient Hospitalization

Z

Maternity Stays

Z

Inpatient Behavioral Health

Z

Skilled Nursing Facilities

Z

Home Health Care

Z

Durable Medical Equipment

Z

Non-Emergent Ambulance

Z

Clinical Trials

Z

Transplants & Related Services

Z

Prosthetics

Z

Dialysis

Z

Chemotherapy & Radiation