Plan-A Nevada PacifiCare of Nevada Medical Options

Plan A Nevada United Healthcare Choice EPO Plan Medical Options

Medical Procedure	United Healthcare Choice EPO Plan
Medical Procedure	United Healthcare Choice EPO Plan
Annual Deductible	None
Annual Co-Payment Limit on Allowable Charges	None
Overall Lifetime Maximum	$5,000,000 per person
Hospital -
Inpatient	You pay $400 per admission
Outpatient	You pay $100 per procedure
*Extended Care Facility (Skilled Nursing)*	You pay $400 per admission; 60 days maximum per calendar year
Physician Services - Routine Physical
Adults	You pay $20 per visit
Children	You pay $20 per visit
Office Visits	You pay $20 per visit
Diagnostic X-Ray and Lab	you pay $20 for routine procedure
CAT Scans & MRI's	You pay $20 per visit
Durable Medical Equipment	Plan pays 100%, limited to $2,500 per calendar year
Casts, Splints, Trusses, Braces & Crutches	Plan pays 100%
Home Nursing Care	Plan pays 100%, limit of 100 visits per calendar year
Chiropractic Care	You pay $20 per visit; limit of 24 visits per calendar year
Physical Therapy	You pay $20 per visit, limit of 20 visits per calendar year
Speech Therapy	You pay $20 per visit; limit of 20 visists per calendar year
Maternity Care	Same as any other illness
Psychiatric Care -
Inpatient	You pay $400 per admission; prior authorization required from the MH/SA designee
Outpatient	You pay $20 per visit; 40 visit maximum per benefit period, prior authorization required from the MH/SA designee
Substance Abuse -	You may choose between coverage under the Beat It! Program or your HMO, or a combination of both, as follows (See Nevada Fee-for-Service Plan A for details):
Inpatient	You pay $400 per admission, prior authorization required from the MH/SA designee
Outpatient	You pay $20 per visit; prior authorization required from the MH/SA designee
Prescription Drugs	*Must be obtained at a participating pharmacy*
Short-term (outpatient)	You pay $10 per formulary generic, $25 per formulary brand name and $50 non-formulary prescription
Maintenance (30 day supply or more thru the Mail Order)	Mail order - you pay 2^1/2 co-pays per prescription for a 90-day supply
Hearing Aids	Plan pays 100%, limited to $2,500 per calendar year
Emergency Room Care	You pay $35 per visit

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The information contained on this website is intended to provide only highlights of the benefits available under the Sheet Metal Workers Trust Funds' plans and plans of benefits. Complete details about the plans are contained in the governing plan documents. In the event of any inconsistency between the information on this website and the official plan documents, the terms of the plan documents, as interpreted by the plan's Board of Trustees in its sole and absolute discretion, will control. The respective Boards of Trustees of the plans reserve the right to amend, modify, or terminate all or part of the plans at any time, subject to applicable law.