Unicare - Plan Limitations and Exclusions
The primary Unicare Illinois PPO plan limitations include, but are not limited to:
| Benefits | Limitations |
| Ambulance Services | For the FIT Plans only, benefits are limited to a maximum covered expense of $5,000 per trip for air transport and $1,000 per trip for ground transport. For the Saver Plan, benefits are limited to a maximum covered expense of $750 per trip (air or ground). |
| Home Health Care | Limited to a combined maximum of 60 visits each year. |
| Skilled Nursing Facilities | Limited to a maximum covered expense of $400 per day, and 100 days per year. |
| Mental/Nervous Health Services | Benefits for eligible inpatient hospital services are paid up to $100 per day, up to a maximum payment of $3,000 per year. (Except for inpatient treatment of alcoholism, which is covered as any other medical condition.) |
| Outpatient | For the FIT Plans only, benefits for eligible treatment are payable up to $30 per visit up to a maximum of 12 visits per year for in- or outpatient professional charges. |
| Physical/Occupational Therapy | For the FIT Plans only, benefits are payable up to $30 per visit with a combined maximum of 12 visits per year. |
| Hospice | Limited to a $10,000 lifetime maximum. |
| Smoking Cessation | For the FIT Plans only, benefits for any smoking cessation program designed to end the dependency on nicotine are payable up to a maximum of $50 per lifetime. |
| Diabetes | $500 annual maximum on diabetic equipment and supplies |
Additional Unicare Saver 2000 Plan Limitations
| Benefits | Saver 2000 Limitations |
| Office Visits | Limited to two office visits per member, per year. |
| Lab and X-Rays | Limited to $300 benefit/year per member. |
| Prescription Drugs | Limited to a $500 maximum annual benefit per member. (includes generic and brand name prescriptions.) |
| Infusion Therapy | Covered Expenses cannot exceed: total parenteral nutrition (with or without lipids),$250 per day; antibiotics, average wholesale price (AWP)+$125 per day; chemotherapy, AWP + $150 per day, pain management $125 per day; aerosol therapy, AWP + $70 per day; tocolytic therapy, $250 per day; special items, AWP; intravenous hydration, $75 per day. |