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Indiana 3000 Health Insurance Plan* |
Amounts shown are the member's share of costs. |
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| Plan Features | Participating Providers | Non-Participating Providers | |||||||||
| Annual Deductible | $3,000 per member, two member maximum per family | ||||||||||
| Additional Out-of-Network Deductible | Does not apply | Additional $1,000 out-of-network deductible per member, per year | |||||||||
| Annual Out-of-Pocket Maximum (amounts shown plus applicable deductibles) |
$3,000 per member, $6,000 per family |
$10,000 per member, $20,000 per family |
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Amounts shown are UniCare's payment after applicable deductibles are met, unless otherwise noted. |
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| Plan Features | Participating Providers | Non-Participating Providers | |||||||||
| Lifetime Maximum Benefit | UniCare pays up to $5,000,000 per member | ||||||||||
| Office Visits All medical office visits and exams for any covered illness or injury. Office visits associated with preventive care for babies and children (through age 6). Office visits associated with a routine Pap smear, annual mammogram colorectal cancer screening or PSA screening. |
1st 4 office visits per member per year:
5+ office visits:$30 copay, deductible waived After deductible is satisfied, UniCare pays 70% |
60% | |||||||||
| Preventive Care Maximum covered expense of $200 per member, per year |
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| Immunizations for Babies and Children (through age 6) | 70% | 60% | |||||||||
| Adult Preventive Care, Lab./X-ray for routine Pap smear, annual mammogram, colorectal cancer screening or PSA screening | 70% | 60% | |||||||||
| Other Routine Care services not outlined above, such as flu shots or routine physical exams/tests | 70% | 60% | |||||||||
| Professional Services Surgery, anesthesia, radiation therapy and in-hospital doctor visits |
70% | 60% | |||||||||
| Lab Work and X-rays | 70% | 60% | |||||||||
| Inpatient Hospital Services1 | 70% | 60%, less a $500 deductible for non-emergency stays |
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| Outpatient Medical Care2 | 70% | 60% | |||||||||
| Initial Care of a Medical Emergency Inpatient or outpatient |
70% | 70% | |||||||||
| 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 | ||||||||||
| Ambulatory Surgical Center1 | 70% | 60% | |||||||||
| Ambulance Service | 80% with a maximum covered expense of $750 per trip for Ground, $5,000 per trip for Air | 60% with a maximum covered expense of $750 per trip for Ground, $5,000 per trip for Air | |||||||||
| Durable Medical Equipment | 70% | 60% | |||||||||
| Mental, Emotional or Functional Nervous Disorders and Treatment of Alcoholism | Covered Expenses will be paid the same as any other medical condition | ||||||||||
| Prescription Drugs3 | |||||||||||
| Retail Pharmacy Per prescription (up to a 30-day supply) |
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| Generic Drugs Not subject to deductible(s) |
You pay a $10 copay | UniCare pays 50% of the average wholesale price | |||||||||
| Brand Name Drugs $300 Brand Name Deductible applies |
You pay a $25 copay | UniCare pays 40% of the average wholesale price | |||||||||
| Mail Service Per prescription (up to a 60-day supply) |
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| Generic Drugs Not subject to deductible(s) |
You pay a $20 copay | Not available | |||||||||
| Brand Name Drugs $300 Brand Name Deductible applies |
You pay a $50 copay | Not available | |||||||||
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