UniCare FIT 3000 Health Insurance Benefit Summary for Illinois Residents

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Illinois FIT 3000 Plan*

Amounts shown are the member's share of costs.

Plan Features

Participating Providers

Non-Participating Providers

Annual Deductible¹

$3,000 per member, two member maximum per family

Additional Out-of-Network Deductible¹

Does not apply

$2,000

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 are UniCare's payment after applicable deductibles are met, unless otherwise noted.

Plan Features

Participating Providers

Non-Participating Providers

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

You pay a $30 copay,
unlimited visits, deductible waived

60%, unlimited visits

Preventive Care
Well Baby/Children (through age 6),
immunizations

100%, deductible waived

Maximum payment of $300 per member per year.

After maximum payment has been met, 80% and deductible applies.

60%

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%

Colorectal Cancer Screening

70%

60%

Professional Services
Surgery, anesthesia, radiation therapy
and in-hospital doctor visits

70%

60%

Lab Work and X-rays

70%

60%

Inpatient Hospital Services^2,3

70%

60%,
less a $500 deductible for non-emergency stays

Outpatient Hospital^2,3
or Surgical Center²

70%

60%

Initial Care of a Medical Emergency^2,3
Inpatient or outpatient

70%

70%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

70% 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

70%

60%

Prescription Drugs⁵

Retail Pharmacy
Per prescription (up to a 30-day supply)

Generic Drugs
Not subject to deductible(s)

You pay a $10 copay

UniCare pays 50% of the average wholesale price

Brand Name Drugs
$500 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 30%

UniCare pays 50% of the average wholesale price

Mail Service
Per prescription (up to a 60-day supply)

Generic Drugs
Not subject to deductible(s)

You pay a $20 copay

Not available

Brand Name Drugs
$500 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 30%

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.
*	This matrix provides a brief description of plan features and reflects UniCare’s share of costs for covered expenses after the annual and out-of-network deductibles are met. When you use UniCare independently contracted participating (in-network) providers, your costs are based on a specially negotiated rate for UniCare that may often save you money. When you use nonparticipating (out-of-network) providers, your costs are based on charges deemed by UniCare to be reasonable for that service and area. Reasonable charges may be less than your provider’s billed charges and often result in higher costs to you. Refer to the UniCare provider directory to determine which providers in your area are participating (in-network) providers. For a more detailed description of coverage, benefits, limitations and exclusions, preservice and utilization review, preauthorization process, additional deductibles, and penalties that may apply, please refer to the applicable Certificate of Coverage. If there are any conflicts between the terms of the Certificate of Coverage and the information in this matrix, the terms of the Certificate of Coverage will prevail.

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