Benefits & Services


Case & Disease Management

Case Management

Case management is a benefit UFC offers at no cost to you. Our goal is to help you be healthy through education and your own health care planning. A staff of nurses will help you and/or a family member gets the health care needed, understand your medicines and work with you and your PCP to get any other services you need to keep you healthy. For more information please call and ask about Case Management at (800) 582-8686.


Disease Management

Disease Management is another service offered at no cost to UFC members. If you have a health problem such as diabetes or asthma, or if you are looking for ways to stay healthy, our Disease Managers are here to help you. Please call and ask about Case Management at (800) 582-8686 for more information.


Dental Care

  • All health plan members ages 20 and younger are assigned to a Dental Home, also known as a Primary Dental Provider (PDP). A Dental Home is a dentist’s office that is visited every six months for a check-up.
  • All dental health checkups, cleanings and treatments are covered for health plan members ages 20 and younger.
  • Children do not need to be referred by his/her PCP to see a dentist.

At 12 months of age children should begin to see a dentist for a checkup every six months. UFC sends dental checkup reminders. Dentists can help prevent cavities. They can use dental sealants (a coating painted on the back teeth) and fluoride treatments. Dentists also teach you and your child how to care for teeth. It is important for your child to go to the dentist every six months.

Look in the Plan’s Provider Directory to choose a dental clinic near you or call Customer Care Center for help scheduling a visit.

  

Use these guidelines for scheduling appointments for your child:

  • Emergency dental appointments – same day appointments; for extreme pain and dental emergencies
  • Urgent dental appointments – within 3 days for lost fillings, broken tooth
  • Routine dental appointments – within 45 days, for routine checkups and dental cleanings
  • Make sure you take your child’s UFC ID card with you to the dental appointment

  

Any member age 21 years and older can only receive emergency dental services if you have a need for care immediately, like a bad infection in your mouth or pain in your teeth or jaw.

Pre-transplantation members may also get treatment for oral infections, oral disease, periodontal disease, medically necessary extractions, and simple restorations like a filling or crown. Call Customer Care Center to see if you have been approved for your transplant before you seek dental care.


EPSDT Program

Well-child Care / Early and Periodic Screening, Diagnostic and Treatment (EPSDT)

UFC wants to help your children grow up healthy. Early Periodic Screening, Diagnostic and Treatment (EPSDT) is a comprehensive child health program of prevention, treatment, correction, and improvement (amelioration) of physical and mental health problems for AHCCCS members under the age of 21. The purpose of EPSDT is to ensure the availability and accessibility of health care resources, as well as to assist Medicaid members in effectively utilizing these resources. EPSDT services provide comprehensive health care through primary prevention, early intervention, diagnosis, medically necessary treatment, and follow-up care of physical and behavioral health problems for AHCCCS recipients less than 21 years of age. EPSDT services include screening services, vision services, dental services, hearing services and all other medically necessary mandatory and optional services listed in federal law 42 USC 1396d (a) to correct or ameliorate defects and physical and mental illnesses and conditions identified in an EPSDT screening whether or not the services are covered under the AHCCCS state plan.


Limitations and exclusions, other than the requirement for medical necessity and cost effectiveness do not apply to EPSDT services.

A well-child visit is synonymous with an EPSDT visit and includes all screenings and services described in the AHCCCS EPSDT and dental periodicity schedules.

Amount, Duration and Scope: The Medicaid Act defines EPSDT services to include screening services, vision services, dental services, hearing services and “such other necessary health care, diagnostic services, treatment and other measures described in federal law subsection 42 USC 1396d(a) to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the (AHCCCS) state plan. This means that EPSDT covered services include services that correct or ameliorate physical and mental defects, conditions, and illnesses discovered by the screening process when those services fall within one of the 29 optional and mandatory categories of “medical assistance” as defined in the Medicaid Act. Services covered under EPSDT include all 29 categories of services in the federal law even when they are not listed as covered services in the AHCCCS state plan, AHCCCS statutes, rules, or policies as long as the services are medically necessary and cost effective.

EPSDT includes, but is not limited to, coverage of: inpatient and outpatient hospital services, laboratory and x-ray services, physician services, nurse practitioner services, medications, dental services, therapy services, behavioral health services, medical supplies, prosthetic devices, eyeglasses, transportation, and family planning services. EPSDT also includes diagnostic, screening, preventive and rehabilitative services. However, EPSDT services do not include services that are solely for cosmetic purposes, or that are not cost effective when compared to other interventions.

Coordination of care with schools and state agencies may occur within the limits of applicable regulations.

EPSDT/WELL CHILD VISITS INCLUDE:

  • A comprehensive health and developmental history, including growth and development screening which includes physical, nutritional and behavioral assessments
  • Nutritional Assessment provided by a PCP
  • Behavioral Health Screening and services provided by a PCP
  • Developmental Screening Tools used by a PCP
  • A comprehensive unclothed physical examination
  • Appropriate immunizations according to age and health history
  • Laboratory tests including blood lead screening assessment and blood lead testing appropriate to age and risk. Required blood lead screening for children under six years of age is based on the child’s risk as determined by either the member’s residential zip code or presence of other known risk factors
  • Health education, counseling, and chronic disease self-management
  • Appropriate oral health screening, intended to identify oral pathology, including tooth decay and/or oral lesions, and the application of fluoride varnish conducted by a physician, physician assist or nurse practitioner
  • Appropriate vision, hearing and speech screenings
  • TB testing as appropriate to age and risk
  • Eye examinations and prescriptive lenses
  • Ocular photoscreenng for children ages 3-5 is covered when due to challenges with a child’s ability to cooperate with traditional vision screening techniques. Limited to lifetime coverage of 1
  • Medicines listed in the UFC Drug Formulary
  • Special medical foods when medically necessary
  • Well-Child* Care will also give you ideas about how to:
    • Keep your child well
    • Protect your child from getting hurt
    • Spot health problems early
    • Apply for services like WIC, Head Start, Children’s Rehabilitative Services (CRS), and the Arizona Early Intervention Program (AzEIP). 

Pharmacy Benefits

PRESCRIPTIONS

If you need medicine, your doctor will choose one from our list of covered drugs and write you a prescription. Ask your doctor to verify that the medication is on the UFC list of covered drugs.

If the medicine your doctor feels you need is not on our list and you can’t take any other medication except the one prescribed, he/she may request prior authorization from UFC.

Some over-the counter medicines are also covered when a prescription is written by your doctor. All prescriptions should be filled at a pharmacy listed in your Provider Directory. If you have other insurance, UFC will only pay the co-pays if the drug is also on the UFC drug list.


E-PRESCRIPTIONS

To help you get your prescription more easily, your doctor can e-mail your prescription to the pharmacy of your choice.

WHAT YOU NEED TO KNOW ABOUT YOUR PRESCRIPTION

Your doctor or dentist may give you a prescription for medication. Be sure and let him/her know about any medications you get from another doctor or medications you buy on your own including non-prescription or herbal products.

Carefully read the drug information the pharmacy will give you when you fill your prescription. It will explain what your medicine is for and possible side effects. If you do not understand how to take your medicine or why you should take it, ask to speak to the pharmacist.

WHAT HAS CHANGED FOR DUAL-ELIGIBLE MEMBERS?

AHCCCS covers drugs which are medically necessary, cost effective and allowed by federal and state law.

For AHCCCS recipients with Medicare, AHCCCS does NOT pay for any drugs eligible for coverage by Medicare or for the cost-sharing (coinsurance, deductibles and copayments) for drugs available through Medicare Part D even if the member chooses not to enroll in the Part D plan.

For AHCCCS recipients with Medicare, AHCCCS does NOT pay for any drugs eligible for coverage by Medicare Part D or for the cost-sharing for drugs available through Medicare Part D.

REFILLS

The label on your medication bottle tells you how many refills your doctor has ordered for you. If your doctor has ordered refills, you may only get one 30-day refill at a time.

If your doctor has not ordered refills, you must call him/her at least five (5) days before your medication runs out. Talk to him/her about getting a refill. The doctor may want to see you before giving you a refill.

WHAT SHOULD I DO IF THE PHARMACY DENIES MY PRESCRIPTION?

Call Customer Care and we can help you find out why your prescription is not approved to fill. Sometimes a primary insurance may be entered wrong or it may be too soon to refill. Other times the medication is not on our list of covered drugs. If a pharmacy turns you away or will not fill your prescription, ask if you and /or the pharmacist can call Customer Care together to find out what is happening. We will work with you and the pharmacy to find the best options for you. When you call for help before leaving the pharmacy, we can try to take care of the problem so you will not need to make another trip. We want to make it easy for you.

Copayments

OPTIONAL (NON-MANDATORY) COPAYMENT AMOUNT

Non-mandatory copays are also called optional copays. If a member has a non-mandatory copay, then a provider cannot deny the service if the member states that s/he is unable to pay the copay.

Prescriptions Copayment $2.30

Pharmacy providers will ask you to pay these amounts but will NOT refuse you services if you are unable to pay. If you cannot afford your copay, tell your pharmacy provider you are unable to pay these amounts so you will not be refused services.

REQUIRED (MANDATORY) COPAYMENT AMOUNTS FOR PERSONS RECEIVING TMA BENEFITS

Some AHCCCS members have required (or mandatory) copays. Mandatory copays are charged to persons in Families with Children that are no Longer Eligible Due to Earnings - also known as Transitional Medical Assistance (TMA). Adults on TMA have to pay required (or mandatory) copays for some medical services. If you are on the TMA Program now or if you become eligible to receive TMA benefits later, the notice from DES or AHCCCS will tell you so.

Ask your provider to look up your eligibility to find out what copays you may have. You can also find out by calling UFC Customer Care Center. 


Prior Authorizations

Some of the medical services may need prior approval by UFC. If they do, your provider must request prior authorization for these services. UFC must review these authorization requests before you can get the service.Your PCP’s office will let you know when authorization is obtained. No prior authorization is necessary for emergency care.

*Prior authorization means your doctor has requested permission for you to get a special service. UFC must approve these requests before the delivery of services. Prior authorization is approved based on a review of medical need.

You can also call our Customer Care Center to find out the status of the request. UFC will let you know by mail if prior authorization is denied. In the letter, you will have instructions on how to file an appeal. The letter will also describe the reason for the denial. If you have a question about the denial and need help, please call or our Customer Care Center or write to us.


COVERED SERVICES

You do not have to see your PCP for the following services:

  • Emergency Services
  • Behavioral Health issues
  • OB/GYN services
  • Dental services

The care listed below will be covered through UFC. Some services may have limitations and/or require a prior authorization, contact our Customer Care Center for more information:

  • Ambulance for emergency care
  • Behavioral Health Care
  • Care while you are pregnant
  • Case management
  • Checkups for children, pregnant women, QMB, and SMI members
  • Children’s services including routine dental care
  • Chiropractic services for children and QMB
  • Emergency medical and surgical services related to dental (oral) care
  • Disease Management
  • Dialysis
  • Emergency or Urgent Care medical treatment
  • Eyeglasses or contacts for children, or adults only after cataracts are removed
  • Family planning / birth control
  • Health care services through screenings, diagnosis and medically necessary treatments for members 21 years of age or older
  • Hospice care
  • Hospital care
  • Lab work and x-rays
  • Medical tests
  • Medically needed foot care performed by a licensed podiatrist,a Podiatrist may provide foot care for members when ordered by a primary care physician or primary care practitioner
  • Medicine from the approved drug list, the UFC Drug Formulary
  • Organ transplants
  • Orthotics
  • PCP office visits
  • Preventative and routine gynecological services for female members (no referral needed)
  • Transportation to health care visits
  • Speech, Physical and Occupations Therapies
  • Second opinions: You have the right to have a second opinion from a qualified health care professional within the network. If one is not available in the network, you have the right to request a second opinion outside the network at no cost to you
  • Supplies and equipment, including UFC Drug Formulary diabetic testing equipment and supplies
  • Well-child checkups including dental, hearing, shots and vision careYour PCP may want you to see a specialist or get special services.
He/she will arrange for the special care listed below. Some of these may require prior authorization from UFC:

 

  • Diet and health teaching
  • Home health care
  • Organ transplants
  • Skilled nursing home care
  • Rehabilitation services like physical therapy
  • Occupational therapy, or speech therapy (for members 20 years and younger)
  • Specialist careSocial Services

Tobacco-Free Lifestyle

Tobacco Education and Prevention

UFC Tobacco Cessation Program offers a number of nicotine replacement products (patches, lozenges, gum) and medications to help you quit tobacco. When you and your doctor decide which product is best for you, a twelve week supply is available by prescription every six months as necessary. Only one product can be selected at a time. Members also have no cost telephone support from the Arizona Smoker’s Hotline (ASHLine) sponsored by the Arizona Department of Health Services and Prevention Program (ADHS-TEPP). ASHLine can help you at no cost by setting a quit date and giving you support. If you would like more information about quitting tobacco, please call the ASHLine at (800) 556-6222, visit their website at www.ashline.org.


Transition of Care

Transitional Program

The Arizona Long Term Care System (ALTCS) Transitional program is for current ALTCS members whose condition has improved. These members do not need care at a Nursing Facility (NF) or Intermediate Care Facility (ICF). These members still need some long term care services. Members qualify to get other ALTCS services that are medically needed.

ALTCS Transitional members may have a short stay in a NF or ICF if the medical condition gets worse for a short time. The member may have up to 90 straight days of care at any one admission if medically needed.


Transportation

Rides to Medical Appointments

EMERGENCY

Your condition is a medical emergency when your life, body parts or bodily functions are at risk of damage or loss unless immediate care is received.


NON-EMERGENCY

Members can get rides to doctor appointments in several ways. The easiest way is to find a ride with a family member or a friend. There is a mileage reimbursement program available. Before you have a family member or friend transport you to an appointment, please call us for more information. Your family member or friend may be paid for this service.

BUS TICKETS

You can contact Customer Care to see if you qualify for bus tickets to go to medically necessary visits. This is usually only available in urban areas with a public bus system. Providers must be in our network for you to use your bus tickets.

TAXI RIDES

Call Customer Care at least 72 hours before your scheduled visit. Same day transports may not always be available due to the number of transportation vehicles in all counties.

On weekends and holidays, you can call our Customer Care Center for taxi rides to urgent care centers when you are sick. Always remember to dial 911 if it is a medical emergency.

CAR SEAT, WHEELCHAIR OR STRETCHER

If you need a car seat, wheelchair or a stretcher for your ride to a routine doctor’s visit, please be sure to specify that when arranging a ride. You must call our Customer Care Center at least 72 hours before your appointment date.

CHILDREN, COMPANIONS OR ESCORTS

UFC allows Member and one additional passenger per transport. More than one additional passenger is allowed if the member has a medical condition requiring more. Please be sure to call 72 hours or more in advance if car seats are needed for the additional passenger.

IF YOU CALL TO GET A RIDE TO A MEDICAL APPOINTMENT, PLEASE BE READY TO TELL THE REPRESENTATIVE THE FOLLOWING

  • Your name, AHCCCS ID number, date of birth, address, phone number (for verification purposes)
  • The date, time and address of your medical visit
  • If you need a ride one way or a round trip
  • Your travel needs (wheelchair, stretcher or other)
  • Any special needs (oxygen, IVs, someone who needs to travel with you, an extra-wide or electric wheelchair, a high-top vehicle, etc.)
  • Children under the age of 5 require a car seat. Let the representative know if you do not have a car seat

CANCELING RIDES TO YOUR APPOINTMENTS

If you cancel your doctor or dentist visit, you must also call UFC Customer Care Center to cancel your ride to your visit.

URGENT CARE AND EMERGENCY ROOM USE

An Urgent Care is a great place to get medical help because they usually have extended hours, specialists for common problems, and can see you quickly (usually less than an hour)! Urgent Care Centers can help you with ear infections, sore throats, urinary tract infections, minor cuts and burns, sprains, and other common health issues. The Urgent Care can be used for problems your doctor would normally help with. If your doctor wouldn’t be able to take care of the problem, the Urgent Care probably can’t either. Emergency rooms are good choices if you have broken bones, cannot stop bleeding, or you are experiencing chest pains or shortness of breath.

COPAYS FOR TAXI TRANSPORTATION

Members residing in Maricopa and Pima Counties may have a $2.00 per trip copayment.

*The copayment will be charged each time a taxi is called. UFC does not have the authority to waive co-pays for transportation per AHCCCS rules.

If a taxi waits for a member, e.g., while the member picks up a prescription, then a $2.00 copay cannot be charged for the continuation of the one-way trip. If you need to cancel your transportation please call the Customer Care Center 24 to 72 hours in advance.