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: Subject to deductible and coinsurance	Subject to deductible and coinsurance
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 after deductible	50% covered after deductible
Coinsurance Limit	Consumer Choice PPO $2000	Consumer Choice PPO $2000
Out-of-Pocket Maximum	(In additional to deductible) $3,000 plus deductible per member $6,000 plus deductible per family	No out-of-pocket maximum
Lifetime Maximum	$5 million per member	$5 million per member
Prescription Drugs	Retail Pharmacies (30-day supply) Generic Drugs: $10 copay Brand Name Formulary Drugs (subject to $1,000 deductible): $30 copay Brand Name Nonformulary Drugs (subject to $1,000 deductible): $50 copay Self-Injectable Drugs- 50% of negotiated rate	Retail Pharmacies (30-day supply) Generic Drugs: 50% of agverage wholesale price Brand Name Formulary Drugs (subject to $1,000 deductible): 50% of average wholesale price Brand Name Nonformulary Drugs (subject to $1,000 deductible): 50% of average wholesale price Self-Injectable Drugs- 50% of average wholesale price
Emergency Room	Subject to deductible and coinsurance	75% covered until transferable to a participating hospital, 50% covered if stay continues
Adult Preventative Care	Subject to deductible and coinsurance	Well baby/children care and Immunizations (children through age 6)- 100% covered (deductible waived)
Child Preventative Care	Well baby/children care and Immunizations (children through age 6)- 100% covered (deductible waived)	Well baby/children care and Immunizations (children through age 6)- 100% covered (deductible waived)
Lab / X-Ray	Subject to deductible and coinsurance	Subject to deductible and coinsurance
Maternity	Consumer Choice PPO $2000	Consumer Choice PPO $2000
Physical Therapy	Physical/Occupational Therapy and Accupuncture- Subject to deductible and coinsurance (12 visit max per year, All services combined)	Physical/Occupational Therapy and Accupuncture- Subject to deductible and coinsurance (12 visit max per year, All services combined)
Skilled Nursing	Subject to deductible and coinsurance (Limited to a maximum expense of $400 per day, 100 days per year)	Subject to deductible and coinsurance (Limited to a maximum expense of $400 per day, 100 days per year)
Home Health Care	Subject to deductible and coinsurance (Limited to a combined maximum of 60 visits per year)	Subject to deductible and coinsurance (Limited to a combined maximum of 60 visits per year)
Mental Health	Inpatient- Subject to deductible and coinsurance (paid up to $100 per day, up to a maximum payment of $3,000 per year) Outpatient- Subject to deductible and coinsurance (payable up to $30 per visit up to a maxium of 12 visits per year)	Inpatient- Subject to deductible and coinsurance (paid up to $100 per day, up to a maximum payment of $3,000 per year) Outpatient- Subject to deductible and coinsurance (payable up to $30 per visit up to a maxium of 12 visits per year)
Hospital Care	Subject to deductible and coinsurance	50% less a $500 deductible for nonemergency stays
Optional Benefits	Consumer Choice PPO $2000	Consumer Choice PPO $2000