Form De-103 - Application For Ahcccs Health Insurance And Medicare Savings Programs (Page 4 of 10) in pdf

How to choose a health plan

YOU NEED TO CHOOSE A HEALTH PLAN THAT SERVES YOUR COUNTY.

• All AHCCCS health plans provide the same covered medical services.

• Review the health plans for your county listed below. Native Americans may choose American Indian Health Program or an AHCCCS Health Plan.

• Before choosing, check with your doctor, pharmacy or hospital, to see if they contract with (work with) the plan that you want. If you want more information about the

doctors, specialists or hospitals that contract with a health plan that serves your county, call the number listed below for the health plan or ask your Eligibility Specialist for

the health plan’s list of health care providers.

• If you do not choose a health plan, one will be assigned to you. If you have been enrolled in an AHCCCS health plan within the past 90 days, you may be enrolled with

your previous health plan.

APACHE COUNTY

MOHAVE COUNTY

UnitedHealthcare Community Plan ........................................... 1-800-348-4058

UnitedHealthcare Community Plan .................................................. 1-800-348-4058

Health Choice Arizona.............................................................. 1-800-322-8670

Health Choice Arizona ................................................................. …1-800-322-8670

American Indian Health Program ................................................. 928-729-8000

American Indian Health Program ........................................................ 928-769-2900

If your zip code is 86434, you must choose from the health plans listed under Yavapai

If your zip code is 85943, you must choose from among the health plans listed under

Navajo County.

County.

COCHISE COUNTY

NAVAJO COUNTY

University Family Care ............................................................. 1-800-582-8686

UnitedHealthcare Community Plan .................................................. 1-800-348-4058

UnitedHealthcare Community Plan ........................................... 1-800-348-4058

Health Choice Arizona ................................................................... 1-800-322-8670

American Indian Health Program ................................................. 520-295-2479

American Indian Health Program ........................................................ 928-338-4911

COCONINO COUNTY

PIMA COUNTY

UnitedHealthcare Community Plan ........................................... 1-800-348-4058

UnitedHealthcare Community Plan ................................................. 1-800-348-4058

Health Choice Arizona.............................................................. 1-800-322-8670

Health Choice Arizona ................................................................... 1-800-322-8670

American Indian Health Program ................................................. 928-283-2501

Care 1

Arizona .............................................................................. 1-866-560-4042

University Family Care .................................................................... 1-800-582-8686

If your zip code is 86336 or 86340, you must choose from among the health plans

Mercy Care Plan ............................................................................. 1-800-624-3879

listed under Yavapai County.

American Indian Health Program ........................................................ 520-295-2479

GILA COUNTY

If your zip code is 85645, you must choose from among the health plans listed under

Health Choice Arizona.............................................................. 1-800-322-8670

Santa Cruz County.

University Family Care ............................................................. 1-800-582-8686

American Indian Health Program ................................................ 928-475-2371

PINAL COUNTY

Health Choice Arizona ................................................................... 1-800-322-8670

If your zip code is 85542, or 85550, you must choose from among the health plans

University Family Care .................................................................... 1-800-582-8686

listed under Cochise County.

GRAHAM COUNTY

American Indian Health Program ........................................................ 520-562-3321

University Family Care ............................................................. 1-800-582-8686

If your zip code is 85242 or 85220, you must choose from among the health plans

UnitedHealthcare Community Plan .......................................... 1-800-348-4058

listed under Maricopa County.

American Indian Health Program ................................................. 928-475-2686

If your zip code is 85292 you must choose from among the health plans listed under

If your zip code is 85643, you must choose from among the health plans listed under

Gila County.

Cochise County.

If your zip code is 85192, you must choose from among the health plans listed under

Cochise County

GREENLEE COUNTY

University Family Care ............................................................. 1-800-582-8686

SANTA CRUZ COUNTY

UnitedHealthcare Community Plan ........................................... 1-800-348-4058

University Family Care .................................................................... 1-800-582-8686

American Indian Health Program ................................................. 928-475-2371

UnitedHealthcare Community Plan .................................................. 1-800-348-4058

American Indian Health Service .......................................................... 520-295-2479

LA PAZ COUNTY

UnitedHealthcare Community Plan ........................................... 1-800-348-4058

YAVAPAI COUNTY

University Family Care ............................................................ 1-800-582-8686

UnitedHealthcare Community Plan .................................................. 1-800-348-4058

American Indian Health Program ................................................. 928-669-2137

University Family Care .................................................................... 1-800-582-8686

American Indian Health Program ........................................................ 602-263-1200

MARICOPA COUNTY

If your zip code is 85342, 85358 or 85390, you must choose from among the health

Health Net of Arizona ............................................................... 1-888-788-4408

plans listed under Maricopa County. If your zip code is 86351 you must choose from

Care 1

Arizona ....................................................................... 1-866-560-4042

among the health plans listed under Coconino County.

Health Choice Arizona.............................................................. 1-800-322-8670

UnitedHealthcare Community Plan .......................................... 1-800-348-4058

YUMA COUNTY

Mercy Care Plan ...................................................................... 1-800-624-3879

UnitedHealthcare Community Plan .................................................. 1-800-348-4058

Maricopa Health Plan ............................................................... 1-800-582-8686

University Family Care .................................................................... 1-800-582-8686

American Indian Health Program ................................................. 602-263-1200

American Indian Health Program ........................................................ 760-572-4100

IMPORTANT

When you have chosen a health plan you can either:

• Write your choice on Page 3, OR

• Call AHCCCS to pre-enroll. From area codes 480, 602 or 623 call (602) 417-7100 or from area codes 520 or 928 call 1-800-334-5283.

When you call to pre-enroll, you will need to give the following information:

Name

•

Sex (male or female)

•

Date of birth, and

•

Social Security Number of all the individuals for whom you applied. Immigrants who are not legally able to obtain a SSN are not required to provide

•

one.

If you have any questions about enrolling with an AHCCCS health plan, need an interpreter, or if you are visually or hearing impaired and need special accommodations to

choose a health plan or to understand the information, from area codes 480, 602 or 623 call (602) 417-7100 or TDD (602) 417-4191 or from area codes 520 or 928 call toll free at

1-800-334-5283 or TDD 1-800-826-5140.

DE-103 (Rev. 6/2017)

Page D