UNIVERSITY OF ARIZONA ALTERNATIVE HEALTH PLANS
You must complete a Domestic Partner Affidavit to enroll a domestic partner. If you wish to enroll a child of your domestic partner, you must first enroll your domestic partner. You must then complete a Child of Domestic Partner Declaration for each child you enroll.
Health Plans General Information
Imputed Income for Non-Tax-Qualified Dependents
| Provider | Customer Service | Group Number |
|---|---|---|
| United Healthcare | (800) 357-0971 | 730610 |
| Delta Dental Plan of Arizona | (800) 352-6132 | 4602 |
| Total Dental Administrators | (888) 422-1995 | 680110 |
| Avesis, Inc. | (800) 828-9341 | 1101-2182 |
General questions or requests for assistance can be directed to Ginnet Ahumada at (480) 257-1524 or GAhumada@griffinbenefits.com.
Medical Insurance
The UA Alternative Medical Plan is a United Healthcare HMO. If you elect this plan, OptumRx will be the provider for pharmacy benefits. Enrollment is automatic.
Annual Deductible: $200/couple or family
| Service | 2019 |
|---|---|
| Routine Preventive Health Care | $0 |
| Office Visit | |
| - Primary Care Physician (PCP) | $20 |
| - Mental Health Provider | $20 |
| - Therapist (occupational, physical, respiratory, speech) | $40 |
| - Chiropractor | $40 |
| - Other Specialist | $40 |
| Hospital & Outpatient Services | |
| - Urgent Care | $75 |
| - Emergency Room | $200 |
| - Radiology (CAT, MRI, PET) | $100 |
| - Outpatient Services | $50 |
| - Inpatient Hospital Services | $250 |
| Quantity | Generic | Preferred Brand Name | Non-Preferred Brand Name |
|---|---|---|---|
| Retail 30 Days | $10 | $35 | $60 |
| Retail 90 Days | N/A | N/A | N/A |
| Mail Order 90 Days | $25 | $87.50 | $150 |
Medical Plan Information
Prescription Drug List - See Advantage 3 Tier
2020 United Healthcare Choice HMO Summary of Benefits and Coverage
Summary of Benefits and Coverage Nondiscrimination Addendum
Provider Search: Select “United Healthcare Choice Plus” as your plan.
Dental Insurance
The UA Alternative Dental Plan offers a choice of coverage through Total Dental Administrators or Delta Dental.
Total Dental Administrators—Pre-Paid Plan
- Restricted to selected Primary Dental Providers
- Reduced costs for services (co-payments)
Total Dental Administrators Plan Summary
Delta Dental—Preferred Provider Organization (PPO)
- May see any licensed dentist
- Preventive services not subject to annual deductible
- Restorative services subject to annual deductible, then plan pays a percentage of post-deductible expenses for basic and major restorative services.
Delta Dental Summary of Benefits
Vision Insurance
The UA Alternative Vision Plan is offered through Avesis
You may choose from a participating network provider or non-provider.
- Participating network providers are contracted with Avesis to provide services at a reduced rate for Avesis members.
- Co-payments, deductibles, or coinsurance fees may be charged when services are used.
- When using out-of-network providers, you must pay the provider and submit an itemized statement to Avesis for reimbursement of covered expenses.