IL Individual Health Plan


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	[Classic] [Illinois/Indiana] [Unicare Texas] [Georgia] [Tx- Maternity]


	Individual Classic Plan Overview


	When you use In-Network providers, we pay at the negotiated rate:


	When you use out-of-netowrk providers, we allow only what we determine are reasonable charges and we pay:


	Professional Services


	Surgery, anesthesia, radiation therapy, in-hospital doctor visits, diagnostic X-ray and lab.


	80%


	50%


	Preventive Care










	Last Updated Friday, February 23, 2001


	Stay Well Care for Babies/Children (through age 6) Exam, Immunization

	Stay Well Care for Adults, routine Pap smears, annual mammograms, and PSA for men.


	80%

	80%


	50%

	50%


	Outpatient Medical Care*****


	80%


	50%


	Physical/Occupational Therapy/Medicine


	As much as $25 per visit, and as many as 12 visits per year.


	Acupuncture/Acupressure


	As much as $25 per visit, and as many as 12 visits per year.


	Mental, Emotional or Functional Nervous Disorders


	Inpatient Hospital Charges***

	In-or Outpatient professional charges


	$100 per day, as much as $3,000 per year.

	As much as $25 per visit, as many as 20 visits per year.


	Smoking Cessation


	Benefits for any smoking cessation program designed to end dependency on nicotine are payable at $50 per insured per lifetime.


	Infusion Therapy****


	(Administration of drugs and other substances in ways other than oral; such as chemotherapy through a vein.)


	80%


	50%


	Durable Medical Equipment


	80%


	50%


	Inpatient Hospital Services***




		Surgery, X-rays, in-hospital doctor visits, Organ/Tissue Transplant*

		In-patient medical emergency***


	80%

	80%

	80%


	50% less an additional $500 deductible per continuing hospital confinement for non-emergency stays.

	50%

	80% until transferable to a participating hospital. Then 50% subject to a $500 deductible once transferable.


	Ambulatory Surgical Center**


	80%


	50%


	Ambulance Service


	80% with a maximum Covered Expense of $750 per trip (air or ground)


	50% with a maximum Covered Expense of $750 per trip (air or ground)


	AIDS/ARC Treatment


	(Limit of $10,000 per year, $50,000 lifetime maximum)


	80%


	50%


	Home Health Care*


	80% of Covered Expenses, as many as 60 visits per year.


	50% of Covered Expenses, as many as 60 visits per year.


	Skilled Nursing Facilities*


	80% with a maximum Covered Expense of $400 per day, as many as 100 days per year.


	50% with a maximum Covered Expense of $400 per day, as many as 100 days per year.


	Hospice*


	($10,000 lifetime maximum)


	80%


	50%


	Pharmacy


	($100 calendar year deductible) Maximum 30-day supply

		Generic drugs

		Brand name drugs


	Participating pharmacy

	80%

	70%


	Non-participating pharmacy paid based on the average wholesale price of the drug

	50%

	40%

Additional Waiting Periods

An insured must be covered by the policy for six consecutive months to be eligible for payment for removal or treatment of hernia (except strangulated or incarcerated), or varicose veins.

Pre-existing Condition

For medical conditions that existed 12 months prior to effective date, there will be no coverage for 12 months after the effective date.

Utilization review / Authorization

This program provides you with valuable information about the medical necessity of services, helping you avoid both unexpected out-of-pocket costs and unnecessary procedures. Utilization review may take place prior to admission to a hospital or ambulatory surgical center, during a hospital stay, or following a discharge from a hospital or ambulatory surgical center.

An important aspect of this program is preservice review. The following medical procedures must be reviewed for medical necessity through a preservice review: All non-emergency inpatient hospital stays, and non-emergency outpatient surgeries at an ambulatory surgical center. You must initiate a preservice review at least three working days prior to admission. There are additional deductibles without a preservice review.

Additional Deductibles

* In addition to preservice review, certain services will be subject to 50% reduction in benefits unless UNICARE authorizes benefits. This applies to: Organ/Tissue Transplants, Infusion Therapy, Home Health Services, Skilled Nursing Facilities, and Hospice.

** All surgical services of an ambulatory surgical center require preservice review or you pay an additional $50 deductible. Ambulatory Surgical Centers must be licensed and accredited and meet all requirements of state and local laws and agencies.

*** Inpatient medical care has an additional $250 deductible without preservice review. This deductible is waived on emergency admissions; however, Utilization Review is still required.

**** Infusion therapy must be authorized by UNICARE. Covered expense includes professional services, compounding fees, incidental supplies, medications, drugs, solutions, durable medical equipment and training related to infusion therapy. Reimbursement will not 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. Failure to obtain authorization will result in a 50% reduction in benefits.

***** Emergency room visits that do not result in inpatient admissions will require an additional $30 deductible.

READ YOUR POLICY CAREFULLY. This summary of benefits provides a very brief description of the important features of your 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!




	feedback legal copyright © 1999 Castle Group Health

	The following summary is NOT a solicitation to sell you insurance. Solicitations can only be made with state, and insurance company, approved brochures. Information contained in this web may contain generalities or inaccuracies. Please read the brochures and policies for specific limitations and exclusions.