UniCare HSA-Compatible Plan 3 Benefit Summary

Amounts shown below are the member's share of costs.

Plan Features

Single Party

Family

Participating
Provider

Non-Participating
Provider

Participating
Provider

Non-Participating
Provider

Annual Deductible

$5,000

$10,000

Additional $4,000 out-of
network deductible

Additional $8,000 out-of
network deductible

Annual Out-of-pocket Maximums
(Includes annual deductible
and out-of-network coinsurance)

$5,000

$15,000

$10,000

$20,000

Amounts shown below are UNICARE's payment after applicable deductibles are met.

Plan Features

Participating Provider

Non-Participating Provider

Lifetime Maximum

$5,000,000 per member

Professional Services
Office visits, surgery, anesthesia,
radiation therapy, in-hospital doctor visits
and diagnostic X-ray/lab

100%

60%

Preventive Care for Babies and Children
(through age 6) Immunizations, exams
and lab tests

100%

60%

Adult Preventive Care
Routine Pap smears, annual mammograms,
colorectal cancer screenings, PSA screenings

100%

60%

Initial Care of a Medical Emergency
Inpatient or Outpatient

100%

60%

Inpatient Hospital Services¹

100%

60%

Outpatient Medical Care²

100%

60%

Physical / Occupational Therapy / Medicine
and Acupuncture / Acupressure

$30 maximum per visit with a combined maximum of 12 visits per year

Durable Medical Equipment³

100%

60%

Ambulatory Surgical Center⁴

100%

60%

Home Health Care⁵

100%

60%

Skilled Nursing Facilities⁵

100%

60%

Hospice⁵

100%

60%

Ambulance Service

100%

60%

Pharmacy⁶
Retail Pharmacy
Per prescription
(up to a 30-day supply)

Generic drugs:
100% after member pays a $10 copay

Brand name formulary drugs:
100% after member pays a $30 copay

Brand name nonformulary drugs:
100% after member pays a $50 copay

Generic and brand name drugs:
50% of the average wholesale price

Mail Service Drugs
Per prescription
(up to a 60-day supply)

Generic drugs:
100% after member pays a $20 copay

Brand name formulary drugs:
100% after member pays a $60 copay

Brand name nonformulary drugs:
100% after member pays a $100 copay

Not Available

¹	Inpatient medical care has an additional $250 penalty without preservice benefit review. This penalty is waived on emergency admissions; however, utilization benefit review is still required.
²	Emergency room visits that do not result in inpatient admissions will require an additional $30 deductible.
³	Covered durable medical equipment is restricted to items specifically listed as covered services in the Certificate of Coverage.
⁴	All surgical services of an ambulatory surgical center require preservice benefit review or you pay an additional $50 penalty. Ambulatory surgical centers must be licensed and accredited, and must meet all requirements of state and local laws and agencies.
⁵	In addition to the preservice benefit review, you will pay an additional $1000 penalty unless UNICARE authorizes benefits before you receive services. This applies to: Organ/Tissue Transplants, Infusion Therpay, Home Health Services, Skilled Nursing Facilities, and Hospice.
⁶	Certain prescription drugs may require prior authorization by UNICARE.
*	This matrix provides a brief description of the plan features and reflects UNICARE's share of costs for covered expenses after the annual and out-of-network deductibles are met. When you use UNICARE independently contracted participating (in-network) providers, your costs are based on a specially negotiated rate for UNICARE that may often save you money. when you use nonparticipating (out-of-network) providers, your costs are based on charges deemed by UNICARE to be reasonable for that service and area. Reasonable charges may be less than your provider's billed charge and often result in higher costs to you. Refer to the UNICARE provider directory or to the UNICARE website at www.unicare.com to determine which providers in your area are participating (in-network) providers. For a more detailed description of coverage, benefits, limitations and exclusions, preservice and utilization review, preauthorization process, additional deductibles, and penalties that may apply, please refer to the applicable Certificate of Coverage. If there are any conflicts between the terms of the Certificate of Coverage and the information in this document, the terms of the Certificate of Coverage will prevail.

LIMITATIONS

The following are the primary limitations that apply to these plans:

Ambulance Service
UNICARE pays a maximum coved expense of $5,000 per trip for air transport or $1000 per trip for ground transport.

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, pain management $125 per day; aerosol therapy, AWP+$70 per day; tocolytic therapy, $250 per day; special items, AWP; intravenous hydration, $75 per day.

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

Hospice
Limited to a lifetime maximum payment of $10,000

Services for Mental, Emotional or Functional Nervous Disorders
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. Benefits for eligible inpatient hospital service are paid up to $100 per day, up to a maximum payment of $3,000 per year.

Smoking Cessation
Benefits for any smoking cessation program designed to end the dependency on nicotine are payable up to a maximum of $50 per lifetime.

Additional Waiting Periods -- Hernia and Varicose Vein
An insured person must be covered by the plan for 6 consecutive months to be eligible for payment for removal or treatment of hernia (except strangulated or incarcerated) and varicose vein.

Pre-existing Conditions
For medical conditions that existed 12 months prior to the effective date of your coverage, there will be no coverage for such conditions for 12 months after the effective date of your coverage.