UniCare Saver 2000 Health Insurance Benefit Summary for Illinois Residents

Illinois Saver 2000 Plan*

Amounts shown are the member's share of costs.

Plan Features

Participating Providers

Non-Participating Providers

Annual Deductible¹

$2,000 per member, two member maximum per family

Additional Out-of-Network Deductible¹

Does not apply

$1,000 per member

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 or injury

2 office visits per member, per year, participating and nonparticipating providers combined

You pay a $30 copay, deductible waived

3+ office visits: You pay 100% of billed charges

2 office visits per member, per year, participating and nonparticipating providers combined

UniCare pays 60%, deductible waived

3+ office visits: You pay 100% of billed charges

Preventive Care
Office Visit and Immunizations for Babies and Children (through age 6)

Not covered

Adult Preventive Care

Lab/X-ray for routine Pap smear, annual mammogram, colorectal cancer screening or PSA screening

70%

60%

Office visits related to preventive care services as outlined above

See "Office Visits" benefit

Other Routine Care services not outlined above, 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% after member pays an additional $500 deductible for non-emergency stays

Outpatient Hospital or Surgical Center^2,3

70%

60%

Initial Care of a Medical Emergency³
Inpatient or Outpatient Hospital Services

70%

70%⁴

Physical Therapy, Occupational Therapy,
and Acupuncture

Not covered

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

Prescription Drugs⁵

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 Drugs
Not subject to deductible(s)

You pay a $10 copay

UniCare pays 50% of the average wholesale price

Brand Name Drugs
$200 Brand Name Deductible applies

After payment of the $200 deductible per member, per year, you pay a $25 copay

After payment of the $200 deductible per member, per year, UniCare pays 40% of the average wholesale price

Mail Service
Per prescription (up to a 60-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 Drugs
Not subject to deductible(s)

You pay a $20 copay

Not available

Brand Name Drugs
$200 Brand Name Deductible applies

After payment of the $200 deductible per member, per year, 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.
*	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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