UniCare Original HSA-Compatible Plan Benefit Summary

Amounts shown below are the member's share of costs.

Plan Features

Single Party

Family

Annual Deductible

$2,500

$4,950

Annual Out-of-pocket Maximums
(Includes annual deductible
and out-of-network coinsurance)

$3,300

$6,050

Amounts shown below are UNICARE's payment after applicable deductibles are met.

Plan Features

Participating Provider

Non-Participating Provider

Lifetime Maximum

$5,000,000 per member

Professional Services
Office visits, surgery, anesthesia, radiation therapy, in-hospital doctor visits and diagnostic X-ray/lab

100%

60%

Preventive Care for Babies and Children
(through age 6) Immunizations, exams and lab tests

100%

60%

Adult Preventive Care
Routine Pap smears, annual mammograms,
colorectal cancer screenings, PSA screenings

100%

60%

Initial Care of a Medical Emergency
Inpatient or Outpatient

100%

60%

Inpatient Hospital Services¹

Surgery, x-rays, in-hospital doctor visits,
organ/tissue transplant****

Inpatient medical emergency / Emergency
Medical Condition²

100%

100%

100%

60% -- An additional $500 deductible applies
for continuing hospital confinement for
non-emergency stays.

60%

100% until no longer a medical emergency.
Then 60% and a $500 deductible
per continuing hospital confinement

Outpatient Medical Care²

100%

60%

Physical / Occupational Therapy / Medicine

$25 maximum per visit with a combined maximum of 12 visits per year

Acupuncture / Acupressure

$25 maximum per visit with a combined maximum of 12 visits per year

Durable Medical Equipment³

100%

60%

Ambulatory Surgical Center⁴

100%

60%

Home Health Care⁵

100%

60%

Skilled Nursing Facilities⁵

100%

60%

Hospice⁵

100%

60%

Ambulance Service

100%

60%

Pharmacy⁶
Maximum 30-day supply
Generic / Brand Name drugs

100%

60%

¹	Inpatient medical care has an additional $250 penalty without preservice benefit review. This penalty is waived on emergency admissions; however, utilization benefit review is still required.
²	Emergency room visits that do not result in inpatient admissions will require an additional $30 deductible.
³	Covered durable medical equipment is restricted to items specifically listed as covered services in the Certificate of Coverage.
⁴	All surgical services of an ambulatory surgical center require preservice benefit review or you pay an additional $50 penalty. Ambulatory surgical centers must be licensed and accredited, and must meet all requirements of state and local laws and agencies.
⁵	In addition to the preservice benefit review, you will pay an additional $1000 penalty unless UNICARE authorizes benefits before you receive services. This applies to: Organ/Tissue Transplants, Infusion Therpay, Home Health Services, Skilled Nursing Facilities, and Hospice.
⁶	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.

LIMITATIONS
The following are the primary limitations that apply to these plans:

Ambulance Service
UNICARE pays a maximum coved expense of $750 per trip for air transport or for ground transport.

Infusion Therapy
Infusion therapy must be preauthorized by UNICARE. Covered Expenses 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 an additional $1,000 penalty.

Home Health Care
Limited to a combined maximum of 60 visits each year

Skilled Nursing Facilities
Limited to a maximum covered expense of $400 per day, and 100 days per year

Hospice
Limited to a lifetime maximum payment of $10,000

Services for Mental, Emotional or Functional Nervous Disorders
Coverage is the same as for other covered inpatient and outpatient health services.

Smoking Cessation
Benefits for any smoking cessation program designed to end the dependency on nicotine are payable up to a maximum of $50 per lifetime. Benefits for corresponding pharmaceuticals are payable up to $50 per lifetime.

Additional Waiting Periods -- Hernia and Varicose Vein
An insured person must be covered by the plan for 6 consecutive months to be eligible for payment for removal or treatment of hernia (except strangulated or incarcerated) and varicose vein.

Pre-existing Conditions
For medical conditions that existed six months prior to the effective date of your coverage, there will be no coverage for such conditions for 12 months after the effective date of your coverage.