The Cruiser - $1500 Deductible

Illinois Schedule of Benefits

BENEFIT CATEGORY

NETWORK: You Pay

NON-NETWORK: You Pay

Annual Deductible	$1,500 per calendar year
Additional Non-Network Deductible		$1,000 per calendar year. This deductible applied only to covered expenses incurred for services received from non-network providers before your annual deductible is applied.
Out-of-Pocket Maximum	$1,500 annual deductible per calendar year	$15,000 per calendar year plus deductibles

Amounts shown are UniCare's payment after applicable deductibles are met -- unless otherwise noted.

BENEFIT CATEGORY

NETWORK: Plan Pays

NON-NETWORK: Plan Pays

Lifetime Medical Benefit Maximum		$5,000,000 lifetime maximum benefits paid by UniCare
Professional Services
	Surgery, Anesthesia, Radiation Therapy, In-Hospital Doctor Visits, Diagnostic X-ray and Lab •	100%	60%
	Office Visits including X-ray and Lab Work performed in the Physician Office and billed by the Physician on the same date of service •	All except a $40 co-payment with annual deductible waived	60%
Preventive Care for Young Children Preventive care services for babies/children (through age 6) including immunizations and lab work -
	Office Visits including Immunizations and Lab Work related to Preventive Care as described above, performed in the Physician's Office and billed by the Physician on the same date of service •	All except a $40 co-payment with annual deductible waived	60%
	Professional Services in absence of an Office Visit related to Preventive Care as described above •	100%	60%
Preventive Care for Adults Preventive care services for adults including routine pap smears, annual mammograms, colorectal cancer screenings and PSA (prostate specific antigen) tests for men -
	Office Visits including Immunizations and Lab Work related to Preventive Care as described above, performed in the Physician's Office and billed by the Physician on the same date of service •	All except a $40 co-payment with annual deductible waived	60%
	Professional Services in absence of an Office Visit related to Preventive Care as described above •	100%	60%
Outpatient Hospital Care		100%	60%
Emergency Room Services¹ Including x-ray and lab work performed and billed during the visit -		All except a $150 co-payment for each visit with annual deductible waived	All except a $150 co-payment for each visit with deductibles waived
Services for		100%	As much as $30 per visit
	Physical Therapy •	As many as 12 visits per year for physical therapy, occupational therapy and acupuncture/acupressure combined
	Occupational Therapy • Acupuncture/Acupressure •	Additional physical therapy and occupational therapy visits may be covered following an inpatient hospitalization due to severe trauma such as spinal injury or stroke
Mental, Emotional or Functional Nervous Disorders and Treatment for Alcohol Abuse		100%	As much as $30 per visit
	Inpatient Hospital Charges² •	$100 per day, and as much as $3,000 per year. Exception: Inpatient treatment of alcoholism is payable as any other medial condition
	Inpatient or Outpatient Professional Charges •	As much as $30 per visit, and as many as 12 visits per year
Smoking Cessation		Up to a maximum payment of $50 for pharmaceuticals, and $50 for other covered services per lifetime, per insured, for any smoking cessation program -- Deductibles waived
Infusion Therapy⁴ Administration of drugs and other substance sin ways other than oral, such as chemotherapy through a vein -		100%	60%
Durable Medical Equipment		100%	60%
Inpatient Hospital Services²		100%	60% less an additional $500 deductible per continuing hospital confinement for non-emergency stays
	Surgery, X-rays, In-Hospital Doctor Visits, Organ/Tissue Transplant⁴ •	100%	60%
	Inpatient Medical Emergency/Emergency Medical Condition² •	100%	100% until transferable to a network hospital. Once transferable -- 60% subject to a $500 deductible per continuing hospital confinement
Ambulatory Surgical Center³		100%	60%
Ambulance Service
	Ground Transport •	100% with a maximum covered expense of $1,000 per trip	60% with a maximum covered expense of $1,000 per trip
	Air Transport •	100% with a maximum covered expense of $5,000 per trip	60% with a maximum covered expense of $5,000 per trip
Home Health Care⁴		100% of covered expenses, as many as 60 visits per year	60% of covered expenses, as many as 60 visits per year
Skilled Nursing Facilities⁴		100% with a maximum covered expense of $400 per day, as many as 100 days per year	60% with a maximum covered expense of $400 per day, as many as 100 days per year
Hospice⁴		100% with a maximum payment of $10,000 per lifetime	60% with a maximum payment of $10,000 per lifetime
Vision Care		Up to a maximum payment of $50 per year for an eye exam or other vision services or supplies such as eyeglasses or contact lenses, deductibles waived
Retail Pharmacy⁵ Maximum 30-day supply - Brand name drugs subject to a $2,000 deductible per year - Pharmacy deductible and co-payments/coinsurance are not applied to your out-of-pocket maximum or to any deductible(s) -		When you use a network pharmacy, UniCare pays based on the negotiated rate	When you use a non-network pharmacy, UniCare pays based on the Average Wholesale Price (AWP) of the drug
	Generic Drugs •	All except a $10 co-payment per prescription	50%
	Brand Name Formulary Drugs •	All except a $30 co-payment per prescription -- subject to $2,000 brand name drug deductible	50% -- subject to $2,000 brand name deductible
	Brand Name Non-Formulary Drugs •	All except a $50 co-payment per prescription -- subject to $2,000 brand name drug deductible	50% -- subject to $2,000 brand name deductible
	Self-Administered Injectable Drugs (except Insulin⁶) •	80% -- subject to $2,000 brand name drug deductible	50% -- subject to $2,000 brand name drug deductible
Mail Service Pharmacy⁵ Maximum 60-day supply - Brand name drugs subject to a $2,000 deductible per year - Pharmacy deductible and co-payments/coinsurance are not applied to your out-of-pocket maximum or to any deductible(s) - Some prescription drugs and/or medicines are not available through the mail service -
	Generic Drugs •	All except a $20 co-payment per prescription	Not available
	Brand Name Formulary Drugs •	All except a $60 co-payment per prescription -- subject to $2,000 brand name drug deductible	Not available
	Brand Name Non-Formulary Drugs •	All except a $100 co-payment per prescription -- subject to $2,000 brand name drug deductible	Not available
	Self-Administered Injectable Drugs (except Insulin⁶) •	80% -- subject to $2,000 brand name drug deductible	Not available

Notes

Co-payment waived if the emergency room visit results in an inpatient admission immediately following the emergency room visit.

All inpatient medical care requires pre-service review or you will be subject to a $500 penalty per continuing hospital confinement without pre-service review. This penalty is waived on emergency admissions, however, utilization review is still required.

All surgical services of an ambulatory surgical center require pre-service review or you pay a $50 penalty. Ambulatory surgical centers must be licensed and accredited an meet all requirements of state and local laws and agencies.

In addition to pre-service review, certain services require authorization to be eligible for maximum benefits. This applies to: organ/tissue transplants, infusion therapy, home health services, skilled nursing facilities, and hospice. Failure to obtain authorization will result in a $1,000 penalty for covered expenses.

Certain prescription drugs may require prior authorization.

Insulin will be paid according to the generic or rand name formulary or non-formulary prescription drug benefit, as applicable.

Additional penalties are not counted toward any deductible or out-of-pocket maximum.

Waiting Periods

An insured person must be covered for six consecutive months under this plan to be eligible for benefits concerning all service related to:

Hernia except for strangulated or incarcerated hernia

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Varicose veins

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This includes, but is not limited to, all tests, consultations, examinations, medications, and invasive medical laboratory or surgical procedures that are related to the evaluation or treatment of the above items.

Medical Limitations and Exclusions

The primary limitations and exclusions for these medical insurance plans are listed below. These listings are an overview only. A more detailed list of each plan's limitations and exclusions can be found in the applicable certificate of coverage.

These plans do not provide benefits for:

Services not medically necessary or which are experimental, investigational or for research purposes

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Services not specifically listed in the certificate of coverage as covered services

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Services or supplies that are not medically necessary

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Services or supplies that UniCare considers to be for experimental procedures or investigative procedures

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Services received before the effective date of coverage or during an inpatient stay that began before that effective date

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Services received after coverage ends

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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

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Any condition for which benefits are recovered or can be recovered, either by adjudication, settlement or otherwise, under any workers compensation, employers liability law or occupational disease law, even if you do not claim those benefits

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Any intentionally self inflicted injury or illness

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Conditions caused by: (a) an act of war; (b) the inadvertent release of nuclear energy when government funds are available for treatment of Illness or Injury arising from such release of nuclear energy; (c) an insured participating in the military service of any country; (d) an insured participating in an insurrection, rebellion, or riot; (e) services received as a direct result of an insureds commission of, or attempt to commit a felony or as a direct result of the insured being engaged in an illegal occupation; (f) an insured, being under the influence of illegal narcotics, alcohol or non-prescribed controlled substances unless administered under the advice of a physician

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Any services provided by a local, state or federal government agency, except when payment under the certificate of coverage is expressly required by federal or state law

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If you are eligible for Medicare, any services covered by Medicare under parts A or B are excluded regardless of actual enrollment in Medicare or payment by Medicare for those services. However, for any covered services, if there is a balance remaining after the Medicare payment, or the amount that Medicare would have paid had you enrolled in the program, UniCare will pay the remaining balance up to the Medicare allowable amount. In no event, however, will the actual amount UniCare pay exceed the amount that UniCare would have paid if it were the sole insurance carrier.

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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 legislation

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Professional services received or supplies purchased from yourself, a person who lives in the insureds home or who is related to the Insured by blood, marriage or adoption, or any of the insureds employers

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Inpatient or outpatient services of a private duty nurse

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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

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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

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Treatment of drug, or other substance addiction or abuse except as specifically stated in the certificate of coverage

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Dental services except as specifically provided in the certificate of coverage

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Orthodontic services

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Dental implants or associated procedures

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Hearing aids

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Routine hearing tests except as provided under well baby and well child care

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Optometric services except as specifically stated in the certificate of coverage

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An eye surgery solely for the purpose of correcting refractive defects of the eye

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Outpatient speech therapy

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Any drugs, medications, or other substances dispensed or administered in any outpatient setting

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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 for medically necessary reconstructive surgery performed to restore symmetry incident to a mastectomy.

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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.

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Treatment of sexual dysfunction impotence and/or inadequacy except if this is a result of an accidental injury, organic cause, trauma, infection, or congenital disease or anomalies

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All services related to the evaluation or treatment of fertility and/or infertility

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All non-prescription 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. FDA approved prescription contraceptive drugs or devices available through a licensed pharmacy are covered under the prescription drug benefit of this plan.

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Cryopreservation of sperm or eggs

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Orthopedic shoes (except when joined to braces) or shoe inserts, including orthotics

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Services primarily for weight reduction or treatment of obesity

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Routine physical exams or tests that do not directly treat an actual illness, injury or condition

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Charges by a provider for telephone consultations

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Items which are furnished primarily for your personal comfort or convenience

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Educational services except for diabetes self-management training and as specifically provided or arranged by UniCare

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Nutritional counseling or food supplements

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Any services received on or within 12 months after the effective date of coverage if they are related to a pre-existing condition

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Foreign country provider charges are excluded under this plan except as specifically stated in the certificate of coverage

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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's condition.

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Routine foot care

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Charges for which we are unable to determine our liability because you 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

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Charges for animal to human organ transplants

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Charges for pregnancy or maternity care, including normal delivery, elective abortions or cesarean sections

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Claims received after 15 months from the date the service was rendered

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This is a brief summary of the plan. Please refer to the Certificate of Coverage for more complete details including benefits, limitations and exclusions.