Unicare – Consumer Choice PPO $2000 – Texas

A comparison of the Consumer Choice PPO $2000 offered by Unicare is detailed out below for both Network and Non-Network coverage.

• Compare to other Unicare plans.

• Compare to all carriers in Texas.

	Network	Non-Network
Network	See Provider	See Provider
Application	Consumer Choice PPO $2000 Application	Consumer Choice PPO $2000 Application
Brochure	Consumer Choice PPO $2000 Brochure	Consumer Choice PPO $2000 Brochure
Copay	$30	N/A
Office Visit	$30 copay for first 4 visits per member per year ; 5+ visits: 75% covered subject to deductible; (Amounts shown are payments after applicable deductibles are met.)	50% covered; (After applicable deductibles are met.)
Deductible	Annual deductible is $2,000 with a two-member family maximum	Annual deductible is $2,000 with a two-member family maximum
Coinsurance	75% covered	50% covered
Coinsurance Limit	see brochure	see brochure
Out-of-Pocket Maximum	$3,000 plus deductible per member; $6,000 plus deductible per family	no out-of-pocket maximum
Lifetime Maximum	$5,000,000	$5,000,000
Prescription Drugs	Retail Pharmacies (30-day supply) Generic Drugs: 100% covered after $10 copay Brand Name Drugs (subject to $1,000 deductible): 100% covered after $30 copay Brand Name Formulary Drugs (subject to $1,000 deductible): 100% covered after $50 copay Mail Service (60-day supply) Generic Drugs: 100% covered after $20 copay Brand Name Drugs (subject to $1,000 deductible): 100% covered after $60 copay Brand Name Formulary Drugs (subject to $1,000 deductible): 100% covered after $100 copay (Amounts shown are payments made after applicable deductibles are met.)	Retail Pharmacies (30-day supply) Generic Drugs: 50% of the average wholesale price Brand Name Drugs (subject to $1,000 deductible): 50% of the average wholesale price covered Brand Name Formulary Drugs (subject to $1,000 deductible): 50% of the average wholesale price covered Mail Service Drugs not available. (Amounts shown are payments made after applicable deductibles are met.)
Emergency Room	75% covered; (After applicable deductibles are met.)	75% covered until transferable to a participating hospital, 50% covered if stay continues(subject to a 500$ deductible)
Adult Preventative Care	Routine PAP smears and annual mammograms for women and PSAs for men 75% covered; (After applicable deductibles are met.)	Immunizations through age 6, 100% covered
Child Preventative Care	Immunizations through age 6, 100% covered	Immunizations through age 6, 100% covered
Lab / X-Ray	75% covered; (After applicable deductibles are met.)	50% covered; (After applicable deductibles are met.)
Maternity	see brochure	see brochure
Physical Therapy	$30 maximum per visit totaling to 12 visit maximum per year	$30 maximum per visit totaling to 12 visit maximum per year
Skilled Nursing	see brochure	see brochure
Home Health Care	see brochure	see brochure
Mental Health	see brochure	see brochure
Hospital Care	75% covered; (After applicable deductibles are met.)	50% covered subject to $500 deductible for nonemergency stays
Optional Benefits	see brochure	see brochure