PacifiCare/United HealthCare Assn. Plans

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Information Request Form

OPEN ENROLLMENT
APRIL 1st THROUGH APRIL 30th
(COVERAGE EFFECTIVE MAY 1st)

WHO CAN ENROLL?

ALL DUES PAYING ASSOCIATION MEMBERS - INCLUDING AFFILIATE MEMBERS.

THREE (3) HMOPLANS*

Unlimited Benefits

Excellent Selection of Local Physicians

No Claim Forms

Low Co-Pay for Generic and Brand Name Prescriptions

Low Co-Pay for X-Ray and Laboratory Services

Low Co-Pay for Office Visits

                     PacifiCare HMO Plan Descriptions

                                  $10 PCP Co-Pay HMO* (10-30/100)

                                 $30 PCP Co-Pay HMO* (30-40/500d)

               $20 PCP Co-Pay HMO w/ $1500 Deductible* (20-40/1500ded)

*PCP - Primary Care Physician

UnitedHealthCare PPO PLAN*

$5 Million Lifetime Maximum Benefit

Choice of Physicians and Hospitals (30,000+ California Physicians available)

Low Co-Pay for Generic and Brand Name Prescriptions

Low $40 Co-Pay for Office Visits

                        UnitedHealthCare PPO Plan Description

                $1000 Deductible PPO w/ $40 Office Visits (5ES)

UnitedHealthCare

HSA - COMPATIBLE PPO PLAN*

$5 Million Lifetime Maximum Benefit

Choice of Physicians and Hospitals (30,000+ California Physicians Available)

Tax Advantaged Savings Tool

Affordable Premiums with a Wide Range of Benefits Including Prescription Drugs

Easy To Use – NO Claim Forms When Using Preferred Providers

UnitedHealthCare HSA Compatible PPO Plan Description

                        $4000 Deductible HSA Compatible PPO (5EM)

*Pleaser refer to the PlanSummary and Enrollment Materials for a complete description of each program.

PDF Download Problems?

PacifiCare/UnitedHealthCare Enrollment Form and Instructions

Health Savings Account (HSA) FAQ

Student Certification

PacifiCare/UnitedHealthCare Change Request Form

PacifiCare/UnitedHealthCare Change in Plans Form

Credit Card Authorization Form

UnitedHealthCare Electronic Funds Transfer Form

Medco Mail Order Prescription

Medco Pharmacy Reimbursement Form

PPO Medical Claim Form

Rx Solutions Pharmacy Reimbursement Form

Rx Solutions Mail Order Prescription

HMO Help Center -You and Your Doctor

LARGE SELECTION OF PHYSICIANS AND HOSPITALS
IN YOUR AREA AND THROUGHOUT CALIFORNIA

Physician Directories:
Customer Service Phone Numbers: (800) 624-8822 (866) 316-9776 (866) 316-9776	Directory Links PacifiCare "SignatureValue" HMO Directory PPO Directory (outside California) UnitedHealthCare Website

Request your FREE QUOTE by clicking Here.

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