POS Plan
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.
| POS Plan | |||
|---|---|---|---|
| Valleywise Health Network | In-Network (UHC Choice Plus) | Out-of-Network* | |
| Plan Year Deductible (PYD) |
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| Individual | $750 | $1,500 | $3,500 |
| Family | $1,500 | $3,000 | $7,000 |
| Plan Year Out-of-Pocket Maximum (Includes plan deductible and copays) |
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| Individual | $3,250 | $4,500 | Unlimited |
| Family | $6,500 | $9,000 | Unlimited |
| Office Visits |
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| 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) |
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| Physician Services |
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| In / Outpatient Physician Services DMG Physician Services | 20% after PYD | 20% after PYD | 50% after PYD |
| Inpatient Hospital Services - Excludes all Physician Charges |
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| Room & Board | Covered at 100% | $750 copay + PYD then 20% | 50% after PYD |
| Outpatient Facility Services - Excludes all Physician Charges |
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| 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 |
| Additional Details |
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| 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 |
* 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. Note: Only covered if authorization received through UMR Care Management. Dialysis covered in-network only.
** 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.