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Medical Procedure
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United Healthcare of Arizona
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Not Eligible for Medicare
"United Healthcare Choice EPO Plan"
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Enrolled in Medicare
"Secure Horizons"
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| Annual Deductible |
None
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None
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| Annual Co-Payment Limit on Allowable Charges |
None
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None
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| Overall Lifetime Maximum |
$5,000,000 per person
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None
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| Hospital - |
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You pay $100 per admission |
Plan pays 100% |
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You pay $100 per procedure |
You pay $5 per visit |
| Skilled Nursing Facility |
You pay $100 per inpatient stay; 60 per calendar year |
Plan pays 100% - 100 days maximum per benefit period |
| Physician Services - Routine Physical |
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You pay $10 per visit |
You pay $5 per visit |
Inpatient Surgery
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Plan pays 100% |
Plan pays 100% |
Outpatient Surgery
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Plan pays 100% (You pay $10 for office visit) |
Plan pays 100% (you pay $5 for office visit) |
Hospital Visits
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Plan pays 100% |
Plan pays 100% |
Office Visits
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You pay $10 per visit |
You pay $5 per visit |
| Diagnostic X-Ray and Lab |
Plan pays 100% (you pay $10 per office visit) |
Plan pays 100% (you pay $5 per office visit) |
| Durable Medical Equipment |
Plan pays 100%; maximum of $2,500 per year |
Plan pays 100% |
| Casts, Splints, Trusses, Braces & Crutches |
Plan pays 100% |
Plan pays 100% |
| Home Health Care |
Plan pays 100%; maximum of 100 days per calendar year |
Plan pays 100% |
| Chiropractic Care |
You pay $10 per visit, limited to 24 visits per calendar year
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You pay $5 per visit, limited to 12 self-referred visits per calendar year |
| Physical Therapy |
You pay $10 per visit (limited to 20 visits per year) |
You pay $5 per visit, referral required |
| Speech Therapy |
You pay $10 per visit (limited to 20 visits per year) |
You pay $5 per visit, referral required |
| Psychiatric Care - |
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You pay $100 per inpatient stay; prior authorization is required from the MH/SA Designee |
Plan pays 100%, maximum of 190 days per lifetime in a Medicare approved psychiatric facility (Combined with Substance Abuse) |
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You pay $10 per visit; prior authorization is required from the MH/SA Designee |
You pay $5 per visit |
| Substance Abuse - |
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You pay $100 per inpatient stay; prior authorization is required from the MH/SA Designee |
Plan pays 100%, maximum of 190 days per lifetime (Combined with Psychiatric Care) |
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You pay $10 per visit; prior authorization is required from the MH/SA Designee |
You pay $5 per visit |
| Prescription Drugs |
Must be obtained at a participating pharmacy
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You pay $10 per formulary generic and $30 per formulary brand name |
You pay $7 per generic and $14 per brand name prescription for a 30 day supply |
Maintenance (30 day supply or more thru the Mail Order)
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Mail order - you pay 21/2 co-pays per prescription for a 90-day supply |
Mail order - You pay 2 co-pays per prescription for a 90-day supply |
| Hearing Aids |
Not covered
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$500 allowance every 2 years |
| Vision Care |
You pay $30 for exam, one exam per year; lenses & frames not covered |
You pay $5 for exam, $125 materials allowance every 24 months |
| Dental Care |
Not covered
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Not covered
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| Ambulance |
Plan pays 100% |
Plan pays 100% |
| Emergency Care from Non-Participating Provider |
Within Service Area - You pay $35
Outside Service Area - You pay $35
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Within Service Area - You pay $50 (waived if admitted)
Outside Service Area - You pay $50 (waived if admitted)
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