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.
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.
For added convenience, Valleywise Health employees can use the Employee Appointment Line at 602-344-8585, Monday through Friday, 7:00am – 5:00pm, to schedule an appointment.
|Valleywise Health Network||UHC Choice Plus Network|
|Plan Year Deductible (PYD)|
|Plan Year Out-of-Pocket Maximum (Includes plan deductible and copays)|
|Preventive Services**||Covered at 100%||Not Covered|
|Primary Care Physician Office Visit||$20 copay||$25 copay***|
|Specialist Physician Office Visit||$40 copay||$50 copay***|
|Urgent Care Visit||$75 copay||$75 copay|
|Emergency Room Visit||$250 copay (waived if admitted)|
|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***|
|Lab and Radiology/X-ray||Covered at 100%||Office setting: Covered at 100%***|
Outpatient: Not covered***
|Advanced Radiological Imaging||$0||Office setting: Covered at 100%***|
Outpatient: Not covered***
|Primary Care Physician Recommended||Yes||No|
** 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 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: