Unicare Indiana Saver 2000 Plan
| Plan Feature | In-Network | Out-of-Network |
| Annual Deductible1 | $2,000 per member, per year with a two-member family maximum | Additional $1,000 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 All medical office visits and exams for any covered illness or injury. Office visits associated with preventive care for babies and children (through age 6). Office visits associated with a routine Pap smear, annual mammogram colorectal cancer screening or PSA screening. |
$30 copay, 1st 2 visits per member per year, participating and nonparticipating providers combined, (deductible waived). After 3+ office visits, you pay 100% of billed charges | 1st 2 visits per member per year, participating and nonparticipating providers combined, Unicare pays 60% (deductible waived). After 3+ office visits, you pay 100% of billed charges |
| Preventive Care Well Baby/Children (through age 6) Office Visit, Immunizations |
Not covered | |
| Adult Preventive Care | ||
| Lab/X-ray for routine Pap smear, annual mammogram, PSA screening, and colorectal cancer screening | 70% | 60% |
| Office visis related to preventive care services | See "Office Visits" benefit above | See "Office Visits" benefit above |
| Other Preventive Services Such as flu shots or routine physical exams/tests |
Not covered | |
| Limited Professional Services Surgery, anesthesia, radiation therapy and in-hospital doctor visits |
70% | 60% |
| Lab Work and X-rays | 70% with a maximum payment of $300 per member per year with deductible waived, participating and nonparticipating providers combined | 60% with a maximum payment of $300 per member per year with deductible waived, participating and nonparticipating providers combined |
| Inpatient Hospital Services2 | 70% | 60%, less a $500 deductible for non-emergency stays |
| Outpatient Medical Care2,3 | 70% | 60% |
| Initial Care of a Medical Emergency3 Inpatient or outpatient |
70% | 70%4 |
| Physical Therapy, Occupational Therapy, and Acupuncture | Not covered/td> | |
| Ambulatory Surgical Center2 | 70% | 60% |
| Ambulance Service | 70% with a maximum covered expense of $750 per trip, air or ground | 60% with a maximum covered expense of $750 per trip, air or ground |
| Durable Medical Equipment | Not covered/td> | |
| Outpatient Prescription Drug Benefit5 | In-Network | Out-of-Network |
| Retail Pharmacy Per prescription (up to a 30 day supply) |
Maximum payment by UniCare of $500 per member, per year. Includes generic and brand, participating and nonparticipating retail and mail service combined | |
| Generic Not subject to deductible |
$10 co-payment | UniCare pays 50% of the average wholesale price |
| Brand Name Drugs $200 Brand Name Deductible applies |
You pay a $25 copay | UniCare pays 40% of the average wholesale price |
| Mail Service Per prescription (up to a 60-day supply) |
aximum payment by UniCare of $500 per member, per year. Includes generic and brand, participating and nonparticipating retail and mail service combined | |
| Generic Not subject to deductible |
$20 co-payment | Not available |
| Brand Name Drugs $200 Brand Name Deductible applies |
You pay a $50 copay | 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! |