Benefit Description

In Network Benefits

Out of Network Benefits

Payment Levels

Unicare pays based on the negotiated PPO rate

Unicare pays based on reasonable charges

Calendar Year Deductible
per person

$0

$ 0

Coinsurance

80%  until your out of pocket maximum, then 100%.

60% until you have reached $2000 out of pocket and then 70% until your out of pocket maximum, then 100%.

Out of pocket max.. Per individual

 $ 2,000

$ 7,000

Out of pocket max.. Per family

$ 10,000

Benefit Description

In Network Benefits

Out of Network Benefits

Professional Services

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

80%

60%

Office visits - including X-rays and lab work billed by the attending physician on the same date of service.

$20 Copayment

60%

Preventive Care

Babies/Children through age 6:

 -- Office visit /examination related to preventive care including lab work billed by the attending physician on the same date of service.

$20 Copayment

60%

- immunizations and lab work not billed with the office visit by the attending physician on the same date of service

100%

60%

Adults

• Office visit/examination related to services for Routine Pap smears, annual mammograms, and PSA for men.
• Routine Pap smears, annual mammograms, and PSA for men

$20 copay

80%

60%

60%

Outpatient Medical Care

80%

60%

Physical/Occupational Therapy/Medicine

As much as $25 per visit and as many as 12 visits per year. Additional visits may also be available through the Home Health benefit if approved by Managed Care Services.

Acupuncture/ Accupressure

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

Mental, Emotional or Functional Nervous disorders & Counseling treatment for Alcoholism

• Inpatient: $100 per day up to $3,000 per year. ( Exception: inpatient treatment of alcoholism is payable as any other medical condition)
• Outpatient: As much as $25 per visit and as many as 20 visits per year.

Smoking Cessation

Up to $50 for drugs and $50 for other services per for any cessation program per lifetime.

Infusion Therapy

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

80%

60%

Durable Medical Equipment

80%

60%

Inpatient Hospital Services

80%

75%

- A surgery, x-rays, election of non-emergency services, organ/tissue transplant.

80%

60% - less an additional $250 penalty.

- Medical emergency Pre-certification required on all plans.

80%

80% until transferable to a participating hospital, then 60%- $250 addl penalty

Ambulatory Surgical Center

80%

60%

Ambulance ( must be necessary) - Max benefit up to $750 per trip.

80%

60%

Home Health Care - of covered expenses to 60 visits per year.

80%

60%

Skilled Nursing Facility - Max. covered expenses $400 per day, 100 days per year.

80%

60%

Hospice - $10,000 lifetime maximum

80%

75%

Prescription Drugs. -

• Generic Drugs
• Brand Name Drugs

Coinsurance from drugs do not apply to your maximum out of pocket. aaa

• 80%
• 60%