| Facts About Your UNICARE Insurance Plan
Offered by UNICARE Life and Health Insurance Company (UNICARE) Waiting periods | Preexisting conditions | Emergency care | Utilization review, authorization and penalties An insured person must be covered by one of these UNICARE Insurance plans for 6 consecutive months to be eligible for benefits concerning all services related to
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. Coverage will not be provided for the 12 months following the effective date of this plan for medical conditions that existed in the 12 months prior to the effective date. UNICARE will, however, give you credit for the time an insured person was covered by any other creditable coverage that was in effect during the 18 months preceding either UNICARE's Effective Date of Coverage or the date UNICARE received a substantially completed application, if the most recent creditable coverage was under a group health plan, governmental plan, or church plan. UNICARE covers emergency services necessary to screen and stabilize your condition. No utilization review or authorization is required if you reasonably believe an emergency medical condition exists. A medical emergency is an unexpected acute illness, injury or condition that could endanger your health if not treated immediately. When you consider a medical condition to be an emergency, immediately call 911 or go to the nearest hospital emergency room. Once your condition is stabilized, it is important for the hospital, you or your family member to contact UNICARE about authorization of additional services. Utilization review, authorization and penalties This program provides you with valuable information about the medical necessity of services, helping you avoid both unexpected out-of-pocket costs and unnecessary procedures. Utilization review may take place prior to admission to a hospital or ambulatory surgical center. You must initiate preservice review at least three working days prior to admission. Failure to obtain preservice review may result in additional penalties. Certain services require authorization to be eligible for maximum benefits. There will be a 50 percent reduction in benefits for these services unless UNICARE authorizes benefits: organ/tissue transplants, infusion therapy, home health services, skilled nursing facilities, and hospice. For the Performance Plus No Deductible and the Performance 600 Plans, this also applies to self-administered injectable drugs, except insulin. All surgical services of an ambulatory surgical center require preservice review or you will be subject to a $50 penalty. Ambulatory surgical centers must be licensed and accredited, and meet all requirements of state and local laws and agencies. For the Performance Plus No Deductible and Performance 600 Plans, specified outpatient surgeries and diagnostic procedures regardless of place of service also require preservice review or you will be subject to a $50 penalty. All inpatient medical care requires preservice review or you will be subject to a $500 penalty per continuing hospital confinement without preservice review. This penalty is waived on emergency admissions; however, utilization review is still required. To receive maximum benefits, infusion therapy must be authorized by UNICARE. Covered expenses include professional services, compounding fees, incidental supplies, medications, drugs, solutions, durable medical equipment and training related to infusion therapy. Covered expenses will not exceed: total parental 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. Failure to obtain authorization will result in a 50 percent reduction in benefits for covered expenses. Emergency room visits that do not result in inpatient admissions will be subject to a $60 penalty. Certain prescription drugs may require prior authorization. Please refer to your certificate of coverage for details.
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