90/50 BENEFITS
BENEFITS IN-NETWORK OUT OF NETWORK
Deductible (calendar year) $500 Individual $1,000
Individual
$1,500 Family $3,000 Family
(Not including deductible) $1,500 Family $30,000 Family
Lifetime Maximum $5,000.000 Lifetime Maximum, unless noted
below
Doctor Office Visit $25.00 co pay, then 100% 50% after decductible
Allergy Shots 100% 50% after deductible
($1,000
per calendar year)
Preventative
Care
Well Baby/Child Care-birth to age 7 100
% 50% no deductible
Immunizations-birth to age 16 100% 50%
no deductible
Routine Physical Age 7 and over 100% 50%
after deductible
(Maximum $300 per Calendar year)
Preventative
Screenings
Annual Pap Smear 100% 50%
after deductible
Routine Mammography 100% 50%
after deductible
Prostrate Screening 100% 50%
after deductible
Colorectal Screening 100% 50%
after deductible
Hospital
Charges
Hospital Room & Board 90% after deductible 50% after
deductible
Maternity Services 90%
after deductible 50%
after deductible
Same Day (Outpatient) Surgery 90% after deductible 50% after deductible
Anesthesiologists, Radiologists, 90% after deductible 50% after
deductible
Pathologists
Emergency
Room Charges 100% after $50.00 co pay same as in network
(Waived
if admitted)
*If there is an office visit associated with this service, the co pay
will apply
Mental Nervous
& Alcohol and Substance Abuse
Inpatient Serious Mental Health 90% after deductible 50% after
deductible
(45 days per Calendar Year)
Outpatient Serious Mental Health 90% after deductible 50% after
deductible
(35 visits per Calendar Year)
90/50
BENEFITS (Continued)
Other
Expenses
Skilled Nursing* 90%
after deductible 50%
after deductible
(100 days per Calendar Yr)
Hospice Care 90%
after deductible 50%
after deductible
($10,000 Lifetime Maximum)
Home Health Care* 90%
after deductible 50%
after deductible
(100 visits per Calendar Yr.)
Durable Medical Equipment 90% after deductible 50%
after deductible
($5,000 per Calendar Yr.)
Ambulance Services 90%
after deductible 50%
after deductible
($5,000 per Calendar Yr.)
Prosthetics 90%
after deductible 50%
after deductible
($5,000 per Calendar Yr.)
*Precertification Required for Hospital admittance: Failure to
precertify results in a $250, penalty per hospital stay
PRESCRIPTION DRUG PLAN
Retail (30
day supply)
Generic Drugs (Level 1) $15
Brand Drugs (Level 2) $30
Generic or Brand Drugs (Level 3) $60
Mail Order
(90 day supply)
Generic Drugs (Level 1) $30
Brand Drugs (Level 2) $60
Generic or Brand Drugs (Level 3) $120
(Not included on preferred drug list)
Self-injectables Benefit
(Level 4) 20% coinsurance up to $200. Maximum per prescription insulin included
annual out of pocket maximum of $5,000
Out of Network: 50% co-insurance
Out of Network Pharmacy Applicable co pay plus 30%
coinsurance
All plans include Active
Generic Substitution and Prior Authorization of Benefit Programs
No deductible is required for prescription drug coverage.
*The
summary is for illustrative purposes only and is not a legal document. The plan booklet, contract and/or Summary
Plan Description both now and in the future are legal documents you should rely
on for specific information.
For more information on the 90/50 plan and
its exclusions and limitation please call the IHHA office.
HMO BENEFITS
The Unicare HMO service area includes the counties of Cook,
DuPage,
McHenry, and will in the State of Illinois , and the counties of Porter
and Lake in the State of
Each member
should choose a primary care physician from the provider directory. Your
primary
Physician is responsible for providing referrals for specialty care.
Female members can also
Designate a network obstetrician/gynecologist or family practitioner as
a women’s principal health
Care provider.
Basics You
Pay
Annual
Deductible (if applicable) None
Out of
Pocket Maximum
Individual Aggregate
co pays for basic health care services will not exceed $1,500 per year
Family Aggregate
co pays for basic health care services will not exceed $1,500 per year
Lifetime
Maximums (if applicable) Unlimited
Preexisting
Condition Limitations Does Not Apply
Doctor’
Office You
pay
Office Visit-Primary
Care Physician 0% after $10 co pay
Specialist 0%
after $25 co pay
Routine Physical Exam 0% after $10 co pay
Diagnostic Tests and X Rays 0%
Immunizations 0%
Allergy Treatment and Testing 0%
Wellness Care 0%
Hospital
Charges You pay Plan Pays
Number of Days of Inpatient Care Over plan limits Up to 365 days annually
Room and Board-Semi Private 0% after $250 co pay per admit
Surgeon’s Fees 0%
Doctor’s Visits 0%
Medications 0%
Other Miscellaneous Charges 0%
Emergency
Care 0% after $75 co pay
(co pay waived if admitted)
Medical Services
Maternity
Care
Hospital Care 0%
Physician
Care 0% after $10 initial co pay
Outpatient
Surgery 0%
Infertility Services 0%-Diagnosis
and Treatment
(for groups over 25 employees)
HMO BENEFITS (Continued)
Mental
Nervous & Alcohol and Substance Abuse
Mental Health-Outpatient-20
visits 0% after $20 co
pay (100% for visits over limits)
Inpatient-30
days 0%(100% for days over limits)
Substance Abuse-Outpatient-20
visits 0% after $20 co pay
(100% for visits over limits)
Inpatient-30 days 0%(100% for
visits over limits)
Outpatient
Rehabilitation Services
Physical, occupational and speech therapy 0% after $10 co pay (100% for visits
over limits)
60 visits
Other
Services You
Pay
Plan Pays
Durable Medical Equipment-Rental or 20% 80%
Purchase per plan decision
Home Health Care-Intermittent Registered 0%(100% for
visits over limit)100% for 60 visits
Nurse
Skilled Nursing-Skilled Nursing Facility 0%(100% for days over
limit) 100% for 60 days
Room
and board
Hospice-Services and Supplies furnished 0% to $10,000 per period 100% to $10,000 per period
of
care of
care
PRESCRIPTION DRUG PLAN
Retail
(30-day supply)
Generic Drugs (Level 1) $10
Brand Drugs (Level 2) $20
Generic or Brand (Level 3) $40
(Not included on preferred drug list)
Self-injectables 20% to a maximum of $100 up to a 100% after member satisfies
30-day
supply. Annual out of pocket applicable
coinsurance up to
maximum
$5,000 a
30-day supply
Mail Order (90-day supply)
Generic
Drugs (Level l) $20
Brand
Drugs (Level 2) $40
Generic
or Brand (Level 3) $80
(Not included on preferred drug list)
Self-injectables(Level
4) 20% to a maximum of $200 up
to a 100% after member
satisfied
Eligible self injectables on 90 day supply, Annual out of pocket applicable coinsurance up to a
A preferred drug list obtained maximum $5,000 90-day
supply
from the network mail order
pharmacy including insulin
infertility drugs
*The
summary is for illustrative purposes only and is not a legal document. The plan booklet, contract and/or Summary
Plan description both now and in the future are legal documents you should rely
on for specific information.
For more information on the HMO plan and
its Exclusions and Limitations please call the IHHA office.