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Indiana Saver 2000 Plan* |
Amounts shown are the member's share of costs. |
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| Plan Features | Participating Providers | Non-Participating Providers | |||||||||
| Annual Deductible | $2,000 per member, two member maximum per family | ||||||||||
| Additional Out-of-Network Deductible | Does not apply | $2,000 | |||||||||
| 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 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 |
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| 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 | 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 Services1 | 70% | 60% after member pays an additional $500 deductible for non-emergency stays | |||||||||
| Outpatient Medical Care2 | 70% | 60% | |||||||||
| Initial Care of a Medical Emergency Inpatient or Outpatient Hospital Services |
70% | 70% | |||||||||
| Physical Therapy, Occupational Therapy, and Acupuncture |
Not covered | ||||||||||
| Ambulatory Surgical Center1 | 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 | 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) |
Maximum payment by UniCare of $500 per member, per year
Includes generic and brand, participating and nonparticipating retail and mail service combined |
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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 $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 |
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| 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 | |||||||||
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