UniCare Exclusions & Limitations
Primary limitations and exclusions for UniCare Indiana traditional PPO health insurance plans are listed below. This is an overview only, and should be interpreted as no more than a general representation.
UniCare Limitations
Following are the primary limitations that apply to the FIT plans and the SAVER 2000 plan:
- Infusion Therapy: 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, painmanagement $125 per day; aerosol therapy, AWP + $70 per day; tocolytic therapy, $250 per day; special items, AWP; intravenous hydration, $75 per day.
- Ambulance Service: Limited to a maximum covered expense of $750 per trip (air or ground).
- 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.
- Services for Mental, Emotional or Functional Nervous Disorders -
Inpatient: Benefits for eligible inpatient hospital services are paid up to $100 per day, up to a maximum payment of $3,000 per year.
Outpatient: For all plans except the UniCare Saver Plan, benefits for eligible treatment are
payable up to $30 per visit up to a maximum of 12 visits per year for in- or outpatient professional charges.
- Physical, Occupational Therapy/Medicine and Acupuncture/Acupressure: For the FIT Plans only, benefits are payable up to $30 per visit with a combined maximum of 12 visits per year.
- Hospice: Limited
to a lifetime maximum payment of$10,000.
- Smoking Cessation: For the FIT Plans only, benefits for any smoking cessation program designed to end the dependency on nicotine are payable up to a
maximum of $50 per lifetime.
- Diabetes: Covered expenses for diabetes equipment and diabetes supplies are subject to a maximum of $500 per year.
- Other Preventive Care Services: For the UniCare Premier and the UniCare 500, 1000, 1500, 2000, 3000 and 5000 plans limited to a maximum covered expense of $200 per member, per year.
Additional Limitations for the
UniCare Saver 2000 Plan
- Office Visits: Limited to two office visits per member, per year.
- Lab Work and X-Ray (non-hospital based): Limited to a maximum payment
of $300 per member, per year.
- Prescription Drugs: Limited to a maximum payment of $500 per member per year. Includes generic and brand name drugs, participating and nonparticipating retail and mail service combined.
UniCare Exclusions
The UniCare Illinois traditional PPO plans do not provide benefits for:
- Any amounts in excess of maximum amounts of covered expenses.
- Services not specifically listed in the plan as covered services.
- Services or supplies that are not medically necessary.
- Services or supplies that UniCare considers to be experimental or investigative procedures.
- Services received before the effective date of coverage or during an inpatient stay that began before the effective date.
- Services received after coverage ends.
- Services for which you have no legal obligation to pay or for which no charge would be made if you did not have a health policy or insurance coverage.
- Any condition covered by workers’ compensation or similar laws.
- Any intentionally self-inflicted injury or illness.
- Conditions caused by (a) an act of war; (b) the inadvertent release of nuclear energy when government funds are available for treatment; (c) an insured person’s participation in the
military of any country; (d) an insured person’s participation in an insurrection, rebellion, or riot; (e) services received as a direct result of an insured person’s commission of, or
attempt to commit a felony, or being engaged in an illegal occupation; (f ) an insured person being under the influence of illegal narcotics, alcohol or non-prescribed controlled substances
unless administered on the advice of a physician.
- Any services provided by a local, state or federal government agency except Medicaid and when payment under the plan is expressly required by federal or state law. Veterans
Administration hospitals and military treatment facilities will be considered for payment according to current law.
- If you are eligible for Medicare, any services covered by Medicare under Part A or B regardless of actual enrollment in Medicare or payment by Medicare for those services.
- Any services for which payment may be obtained from any local, state or federal government agency (except Medicaid). Veterans Administration hospitals and military treatment facilities
will be considered for payment according to current law.
- Professional services received or supplies purchased from yourself, a person who lives in the insured person’s home or who is related to the insured person by blood, marriage or
adoption, or the insured person’s employer.
- Inpatient or outpatient services of a private duty nurse.
- Inpatient room and board charges in connection with a hospital stay primarily for environmental change, physical therapy or treatment of chronic pain; custodial care or rest cures;
services provided by a rest home, a home for the aged, a nursing home or any similar facility service.
- Inpatient room and board charges in connection with a hospital stay primarily for diagnostic tests which could have been performed safely on an outpatient basis.
- Treatment of drug or other substance addiction or abuse, except for treatment of alcoholism as specifically provided for in the plan.
- Dental services.
- Orthodontic services.
- Dental implants or any associated procedure.
- Hearing aids.
- Routine hearing tests except as provided under Well Baby and Well Child Care.
- Optometric services, eye exercises including orthoptics, eyeglasses, contact lenses, routine eye exams, and routine eye refractions, except as specifically stated in the plan.
- An eye surgery solely for the purpose of correcting refractive defects of the eye.
- Outpatient speech therapy.
- Any drugs, medications, or other substances dispensed or administered in any outpatient setting except as specifically stated in the plan. This includes, but is not limited to items dispensed by a physician.
- Cosmetic surgery or other services for beautification, including any medical complications that are generally predictable and associated with such services by the organized medical
community. This exclusion does not apply to reconstructive surgery to restore a bodily function or to correct a deformity caused by injury or congenital defect of a newborn child, or to
medically necessary reconstructive surgery performed to restore symmetry incident to a mastectomy.
- Procedures or treatments to change characteristics of the body to those of the opposite sex. This includes any medical, surgical or psychiatric treatment or study related to sex change.
- Treatment of sexual dysfunction, impotence and/or inadequacy.
- All services related to the evaluation or treatment of fertility and/or infertility, including, but not limited to all tests, consultations, examinations, medications, invasive, medical,
laboratory or surgical procedures, including sterilization reversals and in vitro fertilization.
- Cryopreservation of sperm or eggs.
- All nonprescription contraceptive drugs, devices, and/or supplies that are available over-the-counter or without a prescription and non-FDA approved prescription contraceptive drugs, devices, and/or supplies.
- Cryopreservation of sperm or eggs.
- Orthopedic shoes (except when joined to braces) or shoe inserts, including orthotics.
- Services primarily for weight reduction or treatment of obesity including morbid obesity, or any care which involves weight reduction as a main method for treatment.
- Routine physical exams or tests that do not directly treat an actual illness, injury or condition, including those required by employment or government authority.
- Charges by a provider for telephone consultations.
- Items which are furnished primarily for your personal comfort or convenience (air purifiers, air conditioners, humidifiers, exercise equipment, treadmills, spas, elevators and supplies for hygiene or beautification, including wigs, etc.).
- Educational services except for diabetes self-management training and as specifically provided or arranged by UniCare.
- Nutritional counseling or food supplements.
- Any services received on or within twelve months after the effective date of coverage if they are related to a pre-existing condition.
- Incidental supplies used by a provider in the administration of infusion therapy.
- Foreign country provider charges except as specified in the plan.
- Growth hormone treatment except when such treatment is medically proven to be effective for the treatment of documented growth retardation due to deficiency of growth hormones, growth
retardation secondary to chronic renal failure before or during dialysis, or for patients with AIDS wasting syndrome. Services must also be clinically proven to be effective for such use and
such treatment must be likely to result in a significant improvement of the insured person’s condition.
- Routine foot care.
- Charges for which we are unable to determine our liability because you or an insured person failed, within 60 days, or as soon as reasonably possible to (a) authorize us to receive all
the medical records and information we requested, or (b) provide us with information we requested regarding the circumstances of the claim or other insurance coverage.
- Charges for animal to human organ transplants.
- Charges for normal pregnancy or maternity care, including normal delivery, elective abortions and elective non-emergency cesarean sections, as long as the services are not due to complications of pregnancy.
- Drugs and medications not requiring a prescription, except insulin.
- Drugs and medications to induce nonspontaneous abortions.
- Dietary supplements, cosmetics, health or beauty aids.• Any vitamin, mineral, herb or botanical product which does not have an FDA (Food and Drug Administration) approved indication to
treat, diagnose or cure a medical condition even if it is thought to have health benefits.
- Any expense incurred in excess of the UniCare negotiated rate.
- Any drug labeled “Caution, limited by federal law to investigational use” or non-FDA approved investigational drugs. Any drug or medication prescribed for experimental indications.•
Drugs used for cosmetic purposes.
- Drugs used for the primary purpose of treating infertility or promoting fertility.
- Anorexiants or drugs associated with weight loss.
- Drugs obtained outside the United States.
- Drugs for treatment of a condition, illness, or injury for which benefits are excluded or limited by a waiver, pre-existing condition, or other contract limitation.
- Prescription drugs with a nonprescription (over-the-counter) chemical and dose equivalent.
- Lost or stolen prescriptions.
Additional Exclusions for
the UniCare Saver 2000 Plan
- Any services of a physician, except as specifically stated in the Certificate.
- Surgical procedures for sterilization.
- Acupuncture/acupressure
- Durable medical equipment.
- Physical and/or occupational therapy/medicine, except when provided during an inpatient hospital confinement.
- Smoking cessation program or pharmaceuticals related to smoking cessation.
