2010-2011 UnitedHealthcare Insurance Company Santa Barbara 06-BR-CA 04-202403-77
... 1... 1... 1... 1... 2... 3... 5... 5... 6... 6... 6... 6... 6... 6... 6... 7... 7... 7 X... 7... 7... 7... 8... 8... 8... 8 AIDS... 9... 9... 10... 12 Scholastic Emergency Services... 12... 13
(800) 767-0700 www.uhcsr.com 6 31 19 23 2010 9 20 ( ) 2011 9 19 9/20/2010-9/19/2011 9/20/2010-12/19/2010 12/20/2010-3/20/2011 $ 991.00 $252.00 $252.00 $2,726.00 $693.00 $693.00 $1,736.00 $441.00 $441.00 3/21/2011-6/19/2011 6/20/2011-9/19/2011 $252.00 $255.00 $693.00 $701.00 $441.00 $446.00 14 90 1
UMR Care Management 1. 1-877-295-0720 2. 1-877-295-0720 UMR Care Management 8:00 6:00 1-877-295-0720 2
$75,000 ( ) ( ) $150 ( ) () $250 ( ) () ( ) 80% ( ) 60% $75,000 UnitedHealthcare Options PPO X ( ) 4 / $1,500 Ingenix 50% 50% / $5,000 / $3,500 25% 3 Ingenix / $5,000 50% 50% / $3,500 3
X / $1,500 25% 29 $350 72 X $800 X $15 / 80% $700 $75 / 10 ( ) $500 80% $700 80% $500 4
UnitedHealthcare Options PPO (800) 767-0700 ( ) 80% (800) 767-0700 UnitedHealthcare Options PPO 80% PPO 1) 2) (HCG) RH A (PAPPA) () (hcg) () B HBsAg RPR HIV HIV-ab ( ) (AFP) hcg (AFP) hcg a 35 (CVS) 50 ( 1 ) B 1-800-767-0700 5
180 ( ) $5,000 $5,000 $2,500 ( ) $100 $500 (1) (2) 6
(1) (2) (3) (4) (5) (6) (7) (8) (9) () X X 1. ( ) X 2. X X 3. X (PSA) (PKU) 7
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(ii) 6 (B) (C) 1 7 26.5 AIDS (AIDS) ( ) Medicare Medicaid Medicare (1) (2) (3) (4) 18 (5) (A) (B) II ( 42 402(a) ) XVI ( 42 1381 ) 62 (6) 1) 2) 3) 4) 30 5) 6 ( ) 1) 2) 9
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28. 29. 1) 30 2) 30 30. 31. 6 63 32. a) b) c) (Caution - limited by federal law to investigational use) d) e) f) g) Parlodel Pergonal Clomid Profasi Metrodin Serophene h) i) (1) 33. / ( ) () 34. 35. 48 96 36. 37. 38. ( ) 39. 40. 41. 42. () 43. 44. 45. (ATV) 46. 47. ( ) 11
48. ( ) 24 / Scholastic Emergency Services Scholastic Emergency Services (SES) SES 100 SES SES 911 SES SES, Inc. SES, Inc. * * * * * * * * * * * * www.uhcsr.com SES (877) 488-9833 ( ) (609) 452-8570 ( ) medservices@assistamerica.com SES 1. ( ) 2. 3. 4. ( ) 5. 6. SES SES, Inc. SES www.uhcsr.com SES SES 12
1) 2) 3) 30 90 UnitedHealthcare Insurance Company UnitedHealthcare StudentResources P. O. Box 809025 Dallas, TX 75380-9025 (800) 767-0700 customerservice@uhcsr.com claims@uhcsr.com Niagara National, Inc. 5001 Genesee Street Buffalo, NY 14225 (800) 444-5530 (716) 684-6285 www.niagaranational.com nninfo@niagaranational.com 2010-202403-77 v1 13