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Comparison of Indiana Traditional PPO Plans* |
Amounts shown are UniCare's payment for participating providers after applicable deductibles are met, unless otherwise noted. |
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| Plan Features for PPO Providers | Premier No Deductible Plan | UniCare 500 UniCare 1000 |
UniCare 1500 / UniCare 2000 UniCare 3000 / UniCare 5000 |
Saver 2000 | |||||
| Annual Deductible1 Per member, two member maximum |
None | $500 $1,000 |
$1,500, $2,000 $3,000, $5,000 |
$2,000 | |||||
| Annual Out-of-Pocket Maximum1 (amounts shown plus deductibles) |
$3,000 (Individual) $6,000 (Family) |
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| Lifetime Maximum Benefit | UniCare pays up to $5,000,000 per member | ||||||||
| Office Visits Exam only for any covered illness or injury, and certain preventive care services for adults |
You pay a $30 copay, unlimited visits, deductible waived |
1st 4 office visits per member per year:
5+ office visits:$30 copay, deductible waived After deductible is satisfied, UniCare pays 80% |
You pay a $30 copay, deductible waived
Limited to two office visits per member, per year, participating and nonparticipating providers combined. |
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| Preventive Care Maximum covered expense of $200 per member per year |
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| Immunizations for Babies and Children (through age 6) |
80% | 70% | Not Covered | ||||||
| Adult Preventive Care Lab/X-ray for routine Pap smear, annual mammogram, colorectal cancer screening or PSA screening |
80% | 70% | |||||||
| Other Routine Care Services, such as flu shots or routine physical exams | 80% | 70% | Not Covered | ||||||
| Adult Preventive Care Screenings Surgery, anesthesia, radiation therapy and in-hospital doctor visits |
100%,
Maximum payment of $300 per member, per year
After maximum payment has been met, 80% |
100%, deductible waived
Maximum payment of $300 per member, per year
After maximum payment has been met, 80%, deductible applies |
100%, deductible waived
Maximum payment of $300 per member, per year
After maximum payment has been met, 70%, deductible applies |
70% | |||||
| Professional Services Surgery, anesthesia, radiation therapy and in-hospital doctor visits |
80% | 70% | 70% - for limited services only | ||||||
| Lab Work and X-rays | 80% | 70% | 70%
Maximum payment of $300 per member, per year, deductible waived, participating and nonparticipating providers combined |
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| Inpatient Hospital Services | 80% | 70% | |||||||
| Outpatient Hospital or Surgical Center |
80% | 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 | Not Covered | |||||||
| Retail Pharmacy Per prescription (up to a 30-day supply) |
No Deductible | UniCare 500 Brand Name Deductible: $50 UniCare 1000 Brand Name Deductible: $100 |
UniCare 1500 Brand Name Deductible: $150 UniCare 2000 Brand Name Deductible: $200 UniCare 3000 Brand Name Deductible: $300 UniCare 5000 Brand Name Deductible: $500 |
$200 Brand Name Deductible
UniCare pays a maximum of $500 per member, per year. Includes generic and brand, participating and nonparticipating pharmacies, retail and mail service combined. |
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| Generic Drugs Not subject to deductible(s) |
You pay a $10 copay | ||||||||
| Brand Name Drugs Brand Name Deductible applies |
You pay a $25 copay | ||||||||
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