Unicare Illinois Fit 1000 Plan - Benefit Summary
| FIT 500 Documents |
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| Plan Feature | In-Network | Out-of-Network |
| Annual Deductible1 | $1,000 per member, per year with a two-member family maximum | Additional $2,000 out-of-network deductible per member, per year |
| Annual Out-of-Pocket Maximum1 Amounts shown plus applicable deductibles |
$3,000 per member $6,000 per family |
$10,000 per member $20,000 per family |
| Amounts shown below are UniCare's payment after applicable deductibles are met, unless otherwise noted. | ||
| Plan Feature | In-Network | Out-of-Network |
| Lifetime Maximum Benefit | UniCare pays up to $5,000,000 per member | |
| Office Visits Exam only for any covered illness, injury or certain preventive care services for adults and children through age 6 |
$30 copay, unlimited visits, deductible waived | 60%, unlimited visits, deductible applies |
| Preventive Care Immunizations for babies and children (through age 6) |
100%, deductible waived Maximum payment of $300 per member, per year. After maximum payment has been met, 80% and deductible applies. |
60%, deductible applies |
| Adult Preventive Care Screenings Lab work and x-rays for routine Pap smears, annual mammograms and PSA screenings |
100%, deductible waived. Maximum payment of $300 per member per year. After maximum payment has been met, 80% and deductible applies. | 60%, deductible applies |
| Colorectal Cancer Screening | 80% | 60% |
| Professional Services Surgery, anesthesia, radiation therapy and in-hospital doctor visits |
80% | 60% |
| Lab Work and X-rays | 80% | 60% |
| Inpatient Hospital Services |
80% | 60%, less a $500 deductible for non-emergency stays |
| Outpatient Hospital |
80% | 60%, less a $500 deductible for non-emergency stays |
| Initial Care of a Medical Emergency2,3 Inpatient or outpatient |
80% | 80%4 |
| Physical Therapy, Occupational Therapy, and Acupuncture | Maximum payment of $30 per visit, up to 12 visits per member, per year for all of these services combined | |
| Ambulance Service | 80% with a maximum covered expense of $1,000 per trip for Ground, $5,000 per trip for Air | 60% with a maximum covered expense of $1,000 per trip for Ground, $5,000 per trip for Air |
| Durable Medical Equipment | 80% | 60% |
| Outpatient Prescription Drug Benefit5 | In-Network | Out-of-Network |
| Retail Pharmacy Per prescription (up to a 30 day supply) |
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| Generic Not subject to deductible |
$10 co-payment | UniCare pays 50% of the average wholesale price |
| Brand Name Drugs $250 Brand Name Deductible applies |
You pay a $30 copay for formulary drugs, or a $50 copay for nonformulary drugs | UniCare pays 50% of the average wholesale price |
| Self Injectable Drugs Brand Name Deductible applies to brand name self-administered injectable drugs |
You pay 20% | UniCare pays 50% of the average wholesale price |
| Mail Service Per prescription (up to a 60-day supply) |
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| Generic Not subject to deductible |
$20 co-payment | Not available |
| Brand Name Drugs $250 Brand Name Deductible applies |
You pay a $60 copay for formulary drugs, or a $100 copay for nonformulary drugs | Not available |
| Self Injectable Drugs Brand Name Deductible applies to brand name self-administered injectable drugs |
You pay 20% | Not available |
| 1 Copays do not apply toward satisfying any deductible. Copays, except pharmacy copays, apply toward your annual out-of-pocket maximum. 2 Services may require preservice review or authorization by UniCare or you will be required to pay an additional penalty. 3 Emergency room visits that do not result in an inpatient admission will be subject to a $60 deductible. 4 Until transferable to a participating hospital; then 60% subject to a $500 deductible per continuing hospital confinement once transferable. 5 Certain prescription drugs may require prior authorization by UniCare. |
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| READ YOUR POLICY CAREFULLY; This outline of coverage provides a brief description of the important features of the Policy. This is not the insurance contract, and only the actual Policy provisions will control. The Policy itself sets forth in detail the rights and obligations of both you and your insurance company. It is, therefore, important that you READ YOUR POLICY CAREFULLY! |