CALL ¾ THE HEALTH CARE FRAUD HOTLINE

202-418-3300

OR WRITE TO:

United States Office of Personnel Management

Office of the Inspector General Fraud Hotline

1900 E Street NW Room 6400

Washington, DC20415-1100

Identification cards

We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you receive services from a Plan provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card, use your copy of the Health Benefits Election Form, SF-2809, your health benefits enrollment confirmation (for annuitants), or your Employee Express confirmation letter.

If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at 312/234-8855 or 888/234-8855 (outside of the SBC local calling area), or write to us at the address on your ID card.

Where you get covered care

You get care from “Plan providers” and “Plan facilities.” You will only pay copayments, deductibles, and/or coinsurance, and you will not have to file claims.

Plan providers

Plan providers are physicians and other health care professionals in our service area that we contract with to provide covered services to our members. We credential Plan providers according to national standards.

We list Plan providers in the provider directory, which we update periodically. The list is also on our Web site at http://www.unicare.com.

Plan facilities

Plan facilities are hospitals and other facilities in our service area that we contract with to provide covered services to our members. We list these in the provider directory, which we update periodically. The list is also on our Web site.

What you must do to get covered care

It depends on the type of care you need. First, you and each family member must choose a primary care physician. This decision is important since your primary care physician provides or arranges for most of your health care. To select a Primary Care Physician, call us at 312/234/8855 or 888/234-8855 (outside of the SBC local calling area).

Primary care

Your primary care physician can be a family practitioner, internist or pediatrician. Your primary care physician will provide most of your health care, or give you a referral to see a specialist.

If you want to change primary care physicians or if your primary care physician leaves the Plan, call us. We will help you select a new one.

Specialty care

Your primary care physician will refer you to a specialist for needed care. When you receive a referral from your primary care physician, you must return to the primary care physician after the consultation, unless your primary care physician authorized a certain number of visits without additional referrals. The primary care physician must provide or authorize all follow-up care. Do not go to the specialist for return visits unless your primary care physician gives you a referral. However, female members may see an obstetrician/gynecologist (OB/GYN), also know as a “woman’s principal health care provider”, who is in the Plan’s network and has been designated by the member, without a referral. Although a woman may directly see her “woman’s principal health care provider,” a referral arrangement must exist between that provider and her PCP so her care can be coordinated. This will also eliminate any potential billing issues. Female members must call the Plan’s Customer Services Department for assistance in designating a provider where the referral arrangement exists.

Here are some other things you should know about specialty care:

If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your primary care physician will develop a treatment plan that allows you to see your specialist for a certain number of visits without additional referrals. Your primary care physician will use our criteria when creating your treatment plan (the physician may have to get an authorization or approval beforehand).

If you are seeing a specialist when you enroll in our Plan, talk to your primary care physician. Your primary care physician will decide what treatment you need. If he or she decides to refer you to a specialist, ask if you can see your current specialist. If your current specialist does not participate with us, you must receive treatment from a specialist who does. Generally, we will not pay for you to see a specialist who does not participate with our Plan.

If you are seeing a specialist and your specialist leaves the Plan, call your primary care physician, who will arrange for you to see another specialist. You may receive services from your current specialist until we can make arrangements for you to see someone else.

If you have a chronic and disabling condition and lose access to your specialist because we:

Terminate our contract with your specialist for other than cause; or

Drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB program Plan; or

Reduce our service area and you enroll in another FEHB Plan,

you may be able to continue seeing your specialist for up to 90 days after you receive notice of the change. Contact us, or if we drop out of the Program, contact your new plan.

If you are in the second or third trimester of pregnancy and you lose access to your specialist based on the above circumstances, you can continue to see your specialist until the end of your postpartum care, even if it is beyond the 90 days.

Hospital care

Your Plan primary care physician or specialist will make necessary hospital arrangements and supervise your care. This includes admission to a skilled nursing or other type of facility.

If you are in the hospital when your enrollment in our Plan begins, call our customer service department immediately at 312/234-8855 or 888/234/8855 (outside the SBC local calling area. If you are new to the FEHB Program, we will arrange for you to receive care.

If you changed from another FEHB plan to us, your former plan will pay for the hospital stay until:

You are discharged, not merely moved to an alternative care center; or

The day your benefits from your former plan run out; or

The 92^nd day after you become a member of this Plan, whichever happens first.

These provisions apply only to the benefits of the hospitalized person. If your plan terminates participation in the FEHB Program in whole or in part, or if OPM orders an enrollment change, this continuation of coverage provision does not apply. In such case, the hospitalized family member’s benefits under the new plan begin on the effective date of enrollment.

Circumstances beyond our control

Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them. In that case, we will make all reasonable efforts to provide you with the necessary care.

Services requiring our prior approval

Your primary care physician has authority to refer you for most services. For certain services, however, your physician must obtain approval from us. Before giving approval, we consider if the service is covered, medically necessary, and follows generally accepted medical practice.

We call this review and approval process precertification . Your physician must obtain preauthorization for the following services:

Surgical procedures that must be performed in an ambulatory surgery unit or a hospital operating room, or if the procedure requires anesthesia;

23 hour hospital observations;

Skilled nursing facility care;

Home health care;

Durable medical equipment and prosthetic devices;

Certain prescription drugs such as human growth hormones or drugs to treat sexual dysfunction; and

Any services performed by a non-participating provider;

Temporomandibular joint dysfunction treatment.

Copayments

A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive services.

Example: When you see your primary care physician you pay a copayment of $15 per office visit.

Deductible

A deductible is a fixed expense you must incur for certain covered services and supplies before we start paying benefits for them. Copayments do not count toward any deductible.

We have a deductible for durable medical equipment and prosthetic devices.

Note: If you change plans during open season, you do not have to start a new deductible under your old plan between January 1 and the effective date of your new plan. If you change plans at another time during the year, you must begin a new deductible under your new plan.

And, if you change options in this Plan during the year, we will credit the amount of covered expenses already applied toward the deductible of your old option to the deductible of your new option.

Coinsurance

Coinsurance is the percentage of our allowance that you must pay for your care. Coinsurance doesn’t begin until you meet your deductible.

Example: In our Plan, you pay 20% of our allowance for durable medical equipment after you have satisfied the durable medical equipment deductible.

Your catastrophic protection out-of-pocket maximum

After your copayments and coinsurance $2,900 per person or $7,000 per family enrollment in any calendar year, you do not have to pay any more for covered services. However, copayments for the following services do not count toward your catastrophic protection out-of-pocket maximum, and you must continue to pay copayments for these services:

Prescription drugs

Be sure to keep accurate records of your copayments since you are responsible for informing us when you reach the maximum.

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Here are some important things you should keep in mind about these benefits:

Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

Plan physicians must provide or arrange your care.

We have a $100 calendar year deductible per person for durable medical equipment and prosthetic devices.

Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

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Professional services of physicians

In a physician’s office

Office medical consultations

Second surgical opinion

$15 per office visit

Professional services of physicians

During a hospital stay

In a skilled nursing facility {plan specific}

Nothing

At home

$15 per visit

Tests, such as:

Blood tests

Urinalysis

Non-routine pap tests

Pathology

X-rays

Non-routine Mammograms

CAT Scans/MRI

Ultrasound

Electrocardiogram and EEG

Nothing

You pay

Routine screenings, such as:

Total Blood Cholesterol – once every three years

Chlamydial Infection Screening

Colorectal Cancer Screening, including:

Fecal occult blood test

Sigmoidoscopy screening – every five years starting at age 50

$15 per office visit

Prostate Specific Antigen (PSA) test – one annually for men age 40 and older

$15 per office visit

Routine pap test

Note: The office visit is covered if pap test is received on the same day; see Diagnosis and Treatment, above.

$15 per office visit

Mammogram – covered for women age 35 and older, as follows:

From age 35 through 39, one baseline mammogram during this five year period

From age 40 and older, one routine mammogram every calendar year

$15 per office visit

Not covered: Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, or travel.

Routine immunizations, limited to:

Tetanus-diphtheria (Td) booster – once every 10 years, ages19 and over (except as provided for under Childhood immunizations)

Influenza vaccine, annually

Pneumococcalvaccine, age 65 and older

$15 per office visit

Not covered: Immunizations required for obtaining or continuing employment or insurance, attending schools or camp, or travel.

All charges.

Childhood immunizations recommended by the American Academy of Pediatrics

$15 per office visit

Well-child care charges for routine examinations, immunizations and care (up to age 22)

Examinations, such as:

Eye exams through age 17 to determine the need for vision correction

Ear exams through age 17 to determine the need for hearing correction

Examinations done on the day of immunizations (up to age 22)

$15 per office visit

Complete maternity (obstetrical) care, such as:

Prenatal care

Delivery

Postnatal care

Note: Here are some things to keep in mind:

You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery. We will extend your inpatient stay if medically necessary.

We cover routine nursery care of the newborn child during the covered portion of the mother’s maternity stay. We will cover other care of an infant who requires non-routine treatment only if we cover the infant under a Self and Family enrollment.

We pay hospitalization and surgeon services (delivery) the same as for illness and injury. See Hospital benefits (Section 5c) and Surgery benefits (Section 5b).

$15 for initial maternity office visit and nothing for subsequent maternity office visits

Not covered: Routine sonograms to determine fetal age, size or sex.

All charges.

A range of voluntary family planning services, limited to:

Voluntary sterilization (See Surgical procedures Section 5 (b)

Surgically implanted contraceptives (such as Norplant)

Injectable contraceptive drugs (such as Depo provera)

Intrauterine devices (IUDs)

Diaphragms

Note: We cover oral contraceptives under the prescription drug benefit.

$15 per office visit

Not covered:

Reversal of voluntary surgical sterilization

Genetic counseling.

All charges.

Diagnosis and treatment of infertility such as:

Artificial insemination:

intravaginal insemination (IVI)

intracervical insemination (ICI)

intrauterine insemination (IUI)

Fertility drugs

In vitro fertilization

Uterine embryo lavage

Embryo transfer

Gamete intrafallopian tube transfer

Zygote intrafallopian tube transfer

Low tubal ovum transfer

Note: We cover injectable fertility drugs under medical benefits when administered in the doctor’s office (not self-injected) subject to the $15 office visit copay. Non-fertility self-injectables and oral fertility drugs are covered under the prescription drug benefit.

$15 per office visit

Not covered:

Collection and storage of sperm, oocytes (eggs), or embryos for later use

Services and supplies in connection with the reversal of voluntary sterilization or sex change

Cost of donor sperm

Cost of donor egg

All charges.

Testing and treatment

Allergy injections

$15 per office visit

Allergy serum

Nothing

Not covered: Provocative food testing and sublingual allergy desensitization

All charges.

Chemotherapy and radiation therapy

Note: High do Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed under Organ/Tissue Transplants on page 25.

Respiratory and inhalation therapy

Dialysis – hemodialysis and peritoneal dialysis

Intravenous (IV)/Infusion Therapy – Home IV and antibiotic therapy

Note: Growth hormone therapy (GHT) is covered under Prescription Drug Benefits (Section 5f) as self-injectable drug.

$15 per office visit

Sixty (60) visits per condition per calendar yearfor the services of each of the following:

Qualified physical therapists and

Occupational therapists

Note: We only cover therapy to restore bodily function when there has been a total or partial loss of bodily function due to illness or injury.

Cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction is provided for up to sixty (60) visits if determined to be medically necessary.

Note: Occupational therapy is limited to services that assist the member to achieve and maintain self-care and improved functioning in other activities of daily living. Rehabilitation is based on medical necessity.

$15 per office or outpatient visit

Nothing per visit during covered inpatient admission

Not covered:

Long-term rehabilitative therapy

Exercise programs

All charges.

Sixty (60) visits per condition per calendar year for the services of a qualified speech therapist.

$15 per office or outpatient visit

Hearing testing only when necessitated by accidental injury

Hearing testing for children through age 17 (see Preventive care, children)

$15 per office visit

Not covered:

All other hearing testing

Hearing aids, testing and examinations for them

All charges.

One eye refraction every 24 months for enrollees age 18 and older

Eye exam to determine the need for vision correction for children through age 17 (see Preventive care, children)

$15 per office visit

Not covered:

Eyeglasses or contact lenses or the fitting of either

Eye exercises and orthoptics

Radial keratotomy and other refractive surgery

All charges.

Routine foot care when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes.

Note: See Orthopedic and prosthetic devices for information on podiatric shoe inserts.

$15 per office visit

Not covered:

Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot, except as stated above

Treatment of weak, strained or flat feet or bunions or spurs; and of any instability, imbalance or subluxation of the foot (unless the treatment is by open cutting surgery)

All charges.

External prosthetic devices such as artificial limbs and eyes and lenses (following cataract removal); stump hoses; and

Externally worn breast prostheses and surgical bras, including necessary replacements following a mastectomy

Internal prosthetic devices, such as artificial joints, pacemakers, insulin pumps, and surgically implanted breast implant(s) following mastectomy.

Note: We pay internal prosthetic devices as hospital benefits, see Section 5 (c) for payment information. See 5 (b) for coverage of the surgery to insert the device. The internal prosthetic device must be medically necessary to restore bodily function and require a surgical incision (as opposed to an external prosthetic device).

Note: Call us at 312/234-8855 or 888/234/8855 (if outside the SBC local calling area) as soon as your Plan physician prescribes these devices. We will arrange with a health care provider to rent or sell you these devices at discounted rates and will tell you more about this service when you call.

$15 per office visit

Not covered:

Orthopedic and corrective shoes (unless permanently attached to an approved device)

Arch supports

Foot orthotics

Braces

Heel pads and heel cups

Lumbosacral supports

Cochlear implant devices

Corsets, trusses, elastic stockings, support hose, and other supportive devices

Prosthetic replacements provided less than 3 years after the last one we covered

All charges.

Rental or purchase, at our option, of durable medical equipment prescribed by your Plan physician, such as oxygen and dialysis equipment. Under this benefit, we also cover:

Hospital beds;

Wheelchairs;

Crutches;

Walkers; and

Blood glucose monitors

Note: Call us at 312/234-8855 or 888/234/8855 (if outside the SBC local calling area) as soon as your Plan physician prescribes this equipment. We will arrange with a health care provider to rent or sell you durable medical equipment at discounted rates and will tell you more about this service when you call

20% of the charges after you have satisfied a calendar year deductible of $100 per Self Only enrollment or $300 per Self and Family enrollment

DME continued on next page

Not covered:

Cam walkers

Scooters;

Blood pressure cuffs

Breast pumps

All charges.

Home health care ordered by a Plan physician and provided by a registered nurse (R.N.), licensed practical nurse (L.P.N.), licensed vocational nurse (L.V.N.), or home health aide.

Services include oxygen therapy, intravenous therapy and medications.

Nothing

Not covered:

Nursing care requested by, or for the convenience of, the patient or the patient’s family

Home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or rehabilitativ.

Services primarily for hygiene, feeding, exercising, moving the patient, homemaking, companionship or giving oral medication

All charges.

Manipulation of the spine and extremities

Adjunctive procedures such as ultrasound, electrical muscle stimulation, vibratory therapy, and cold pack application

$15 per office visit

No benefit

All charges

Coverage is limited to:

Diabetes self-management

$15 per office visit if performed in physician’s office

Smoking cessation classes in the service area. Members should call 312/234-7037 for times and locations.

Nothing

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Here are some important things you should keep in mind about these benefits:

Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

Plan physicians must provide or arrange your care.

Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

The amounts listed below are for the charges billed by a physician or other health care professional for your surgical care. Look in Section 5(c) for charges associated with the facility (i.e. hospital, surgical center, etc.).

YOUR PHYSICIAN MUST GET PRECERTIFICATION OF SOME SURGICAL PROCEDURES. Please refer to the precertification information shown in Section 3 to be sure which services require precertification and identify which surgeries require precertification.

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A comprehensive range of services, such as:

Operative procedures

Treatment of fractures, including casting

Normal pre- and post-operative care by the surgeon

Correction of amblyopia and strabismus

Endoscopy procedures

Biopsy procedures

Removal of tumors and cysts

Correction of congenital anomalies (see Reconstructive surgery)

Nothing

Surgical treatment of morbid obesity -- a condition in which an individual weighs 100 pounds or 100% over his or her normal weight according to current underwriting standards; eligible members must be age 18 or over

Insertion of internal prosthetic devices. See 5(a) – Orthopedic and prosthetic devices for device coverage information.

Voluntary sterilization (e.g., Tubal ligation, Vasectomy)

Treatment of burns

Note: Generally, we pay for internal prostheses (devices) according to where the procedure is done. For example, we pay Hospital benefits for a pacemaker and Surgery benefits for insertion of the pacemaker.

Nothing

Not covered:

Reversal of voluntary sterilization

Routine treatment of conditions of the foot; see Foot care

All charges.

Surgery to correct a functional defect

Surgery to correct a condition caused by injury or illness if:

the condition produced a major effect on the member’s appearance and

the condition can reasonably be expected to be corrected by such surgery

Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of congenital anomalies are: protruding ear deformities; cleft lip; cleft palate; birth marks; webbed fingers; and webbed toes.

All stages of breast reconstruction surgery following a mastectomy, such as:

surgery to produce a symmetrical appearance of breasts;

treatment of any physical complications, such as lymphedemas;

breast prostheses and surgical bras and replacements (see Prosthetic devices)

Note: If you need a mastectomy, you may choose to have the procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure.

Nothing

Not covered:

Cosmetic surgery – any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance through change in bodily form, except repair of accidental injury

Surgeries related to sex transformation

All charges.

Oral surgical procedures, limited to:

Reduction of fractures of the jaws or facial bones;

Surgical correction of cleft lip, cleft palate or severe functional malocclusion;

Removal of stones from salivary ducts;

Excision of leukoplakia or malignancies;

Excision of cysts and incision of abscesses when done as independent procedures; and

Other surgical procedures that do not involve the teeth or their supporting structures.

Nothing

Surgical treatment of temporomandibular joint (TMJ) pain dysfunction syndrome due to acute trauma or systemic disease

Note: We must approve your treatment TMJ plan in advance

50% of charges for approved treatment of TMJ pain dysfunction syndrome

Not covered:

Oral implants and transplants

Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone)

Any dental care involved in the treatment of temporomandibular (TMJ) pain dysfunction syndrome

All charges.

Transplants are covered when approved by the Plan’s Medical Director. Transplants are limited to:

Cornea

Heart

Heart/lung

Kidney

Kidney/Pancreas

Liver

Pancreas

Allogeneic (donor) bone marrow transplants

Autologous bone marrow transplants (autologous stem cell and peripheral stem cell support) for the following conditions: acute lymphocytic or non-lymphocytic leukemia; advanced Hodgkin’s lymphoma; advanced non-Hodgkin’s lymphoma; advanced neuroblastoma; breast cancer; multiple myeloma; epithelial ovarian cancer; and testicular, mediastinal, retroperitoneal and ovarian germ cell tumors

Intestinal transplants (small intestine) and the small intestine with the liver or small intestine with multiple organs such as the liver, stomach, and pancreas

Note: We cover related medical and hospital expenses of the donor when we cover the recipient

Nothing

Not covered:

Donor screening tests and donor search expenses, except those performed for the actual donor

Implants of artificial organs

Transplants not listed as covered

All charges.

Professional services provided in –

Hospital (inpatient)

Hospital outpatient department

Skilled nursing facility

Ambulatory surgical center

Office

Nothing

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Here are some important things you should keep in mind about these benefits:

Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

Plan physicians must provide or arrange your care and you must be hospitalized in a Plan facility.

Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

The amounts listed below are for the charges billed by the facility (i.e., hospital or surgical center) or ambulance service for your surgery or care. Any costs associated with the professional charge (i.e., physicians, etc.) are in Sections 5(a) or (b).

YOUR PHYSICIAN MUST GET PRECERTIFICATION OF HOSPITAL STAYS. Please refer to Section 3 to be sure which services require precertification.

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Room and board, such as

Ward, semiprivate, or intensive care accommodations;

General nursing care; and

Meals and special diets.

Private accommodations or private duty nursing care when a Plan doctor determines it is medically necessary

Note: If you want a private room when it is not medically necessary, you pay the additional charge above the semiprivate room rate.

Nothing

Other hospital services and supplies, such as:

Operating, recovery, maternity, and other treatment rooms

Prescribed drugs and medicines

Diagnostic laboratory tests and X-rays

Administration of blood and blood products

Blood or blood plasma

Dressings, splints, casts, and sterile tray services

Medical supplies and equipment, including oxygen

Anesthetics, including nurse anesthetist services

Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home

Nothing

InpatientHospital continued on next page

Not covered:

Custodial care

Non-covered facilities, such as nursing homes, schools

Personal comfort items, such as telephone, television, barber services, guest meals and beds

All charges.

Operating, recovery, and other treatment rooms

Prescribed drugs and medicines

Diagnostic laboratory tests, X-rays, and pathology services

Administration of blood, blood plasma, and other biologicals

Blood and blood plasma

Pre-surgical testing

Dressings, casts, and sterile tray services

Medical supplies, including oxygen

Anesthetics and anesthesia service

Note: We cover hospital services and supplies related to dental procedures when necessitated by a non-dental physical impairment. We do not cover the dental procedures.

Nothing

Not covered: Blood and blood derivatives not replaced by the member

All charges.

Extended care benefit:

Skilled nursing facility (SNF):

We cover up to 120 days of skilled nursing facility care per calendar year when we determine that full-time skilled nursing care is medically necessary. You and you Plan doctor must obtain our prior approval. All necessary services are covered including:

Bed, board and general nursing care

Drugs, biologicals, supplies and equipment ordinarily provided or arranged by the skilled nursing facility when prescribed by a Plan doctor.

Nothing

Not covered: Custodial care, rest cures, domiciliary or convalescent care

All charges.

We cover support and palliative care for a terminally ill member in the home or hospice facility. Coverage is provided up to a maximum benefit of $10,000 per period of care. Services include:

Inpatient and outpatient care

Family counseling

Note: Covered hospice services are provided under the direction of a Plan doctor who certifies that the patient is in the terminal stages of illness, with a life expectancy of approximately six (6) months or less.

Nothing

Not covered: Independent nursing, homemaker services

All charges.

Local professional ambulance service ordered or authorized by a Plan doctor

Nothing

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Here are some important things to keep in mind about these benefits:

Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

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What is a medical emergency?

A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your life or could result in serious injury or disability, and requires immediate medical or surgical care. Some problems are emergencies because, if not treated promptly, they might become more serious; examples include deep cuts and broken bones. Others are emergencies because they are potentially life-threatening, such as heart attacks, strokes, poisonings, gunshot wounds, or sudden inability to breathe. There are many other acute conditions that we may determine are medical emergencies – what they all have in common is the need for quick action.

What to do in case of emergency

Emergencies within our area: If you are in an emergency situation, please call your primary care doctor. In extreme emergencies, if you are unable to contact your doctor, contact the local emergency system (e.g. the 911 telephone system) or go to the nearest hospital emergency room. Be sure to tell the emergency room personnel that you are a Plan member so they can notify us. You or a family member must notify us within 48 hours unless it was not reasonably possible to do so. It is your responsibility to ensure that we have been timely notified.

If you need to be hospitalized in a non-Par facility, we must be notified within 48 hours or on the first working day following admission, unless it was not reasonably possible to notify us within that time. If you are hospitalized in a non-Par facility and Plan doctors believe care can be provided in a Plan hospital, we will transfer to a Plan facility when medically feasible. We will cover any ambulance charges in full.

Benefits are available for car from non-Plan providers in a medical emergency only if delay in reaching a Plan provider would result in death, disability or significant jeopardy to your condition.

To be covered by this Plan, any follow-up care recommended by non-Plan providers must be approved by the Plan or provided by Plan providers.

Emergencies outside our service area: Benefits are available for any medically necessary health service that is immediately required because of injury or unforeseen illness.

If you need urgent or emergency medical care when you’re away from home, you should call UNICAR HMO at 800/782-0180. Service is available 24 hours a day, 7 days a week. If your unexpected illness is not an emergency, you must call this number before seeking treatment. For life-threatening medical emergencies, you should seek treatment from the nearest medical facility and inform the hospital or physician that you are a member of UNICARE HMO. You should then contact the Plan at 800/782-0180 within 24 hours after medical care begins.

If you need to be hospitalized, you must notify us within 48 hours or on the first working day following your admission, unless it was not reasonably possible to do so within that time. If a Plan doctor believes care can be provided in a Plan hospital, we will transfer you to a Plan facility at our expense. We must approve all follow-up care recommended by a non-Plan provider or you must receive the follow-up care from a Plan provider.

Emergency care at a doctor’s office

Emergency care at an urgent care center

Emergency care in a hospital emergency room

Note: We waive the copay if you are admitted as an inpatient to the hospital.

Note: We pay reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers.

$15 per office visit

$50 per urgent care center visit

$50 per hospital emergency room visit

Not covered: Elective care or non-emergency care

All charges.

Emergency care at a doctor’s office

Emergency care at an urgent care center

Emergency care in a hospital emergency room

Note: We waive the copay if you are admitted as an inpatient to the hospital.

Note: We pay reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers.

$15 per office visit

$50 per urgent care center visit

$50 per hospital emergency room visit

Not covered:

Elective care or non-emergency care

Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area

Medical and hospital costs resulting from a full-term delivery of a baby outside the service area

All charges

Professional ambulance service when medically appropriate.

Note: See 5(c) for non-emergency service.

Nothing

Not covered: Air ambulance

All charges.

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When you get our approval for services and follow a treatment plan we approve, cost-sharing and limitations for Plan mental health and substance abuse benefits will be no greater than for similar benefits for other illnesses and conditions.

Here are some important things to keep in mind about these benefits:

Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

YOU MUST GET PREAUTHORIZATION OF THESE SERVICES. See the instructions after the benefits description below.

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All diagnostic and treatment services recommended by a Plan provider and contained in a treatment plan that we approve. The treatment plan may include services, drugs, and supplies described elsewhere in this brochure.

Note: Plan benefits are payable only when we determine the care is clinically appropriate to treat your condition and only when you receive the care as part of a treatment plan that we approve.

Your cost sharing responsibilities are no greater than for other illnesses or conditions.

Professional services, including individual or group therapy by providers such as psychiatrists, psychologists, or clinical social workers

Medication management

$15 per office visit

Diagnostic tests

Services provided by a hospital or other facility

Services in approved alternative care settings such as partial hospitalization, half-way house, residential treatment, full-day hospitalization, facility based intensive outpatient

Nothing

Not covered:

Services we have not approved

Psychiatric evaluation or therapy on court order or as a condition of parole or probation unless determined by a Plan doctor to be necessary and appropriate

Note: OPM will base its review of disputes about treatment plans on the treatment plan’s clinical appropriateness. OPM will generally not order us to pay or provide one clinically appropriate treatment plan in favor of another.

All charges

Mental health and substance abuse benefits (Continued)

Preauthorization To be eligible to receive these benefits you must obtain a treatment plan and follow all of the following network authorization processes:

You must contact Magellan Behavioral Health at 1-800-746-6294 before seeking Mental Health or Substance Abuse treatment. Magellan Behavioral Health will review your treatment needs. They will provide you and the provider with written authorization (certification letter) for your initial visit and any ongoing care.

Limitation We may limit your benefits if you do not obtain a treatment plan.

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Here are some important things to keep in mind about these benefits:

We cover prescribed drugs and medications, as described in the chart beginning on the next page.

All benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are medically necessary.

Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

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There are important features you should be aware of. These include:

Who can write your prescription. A Plan physician or referral doctor must write the prescription

Where you can obtain them. You must fill the prescription at a Plan pharmacy, or by mail for a maintenance medication. To obtain a list of Plan pharmacies call UNCARE’s Customer Services Department at 312/234-8855 or 888/234-8855 (outside the SBC local calling area). To order maintenance medications by mails, call UNICARE’s Customer Services Department to obtain the necessary forms. Complete or have your Plan doctor complete the prescription order form. Mail the Plan doctor’s written prescription for up to a 90-day supply of the maintenance drug, along with the completed prescription order form and the appropriate copay amount to the mail order pharmacy provider. Additional refills may be obtained the same way provided the strength and dosage of the medication remain the same.

We use a formulary. A formulary is a list of prescription medications that we cover when your doctor prescribes them for you. These drugs were selected because they have been proven safe and effective. They are included in the formulary because most doctors prefer them to other choices. Drugs are dispensed in accordance with the Plan’s drug formulary. However, we do cover non-formulary drugs when prescribed by a Plan doctor. Your physician must obtain our approval for non-formulary drugs.

We have an open formulary. If your physician believes a name brand product is necessary or there is no generic available, your physician may prescribe a name brand drug from a formulary list. This list of name brand drugs is a preferred list of drugs that we selected to meet patient needs at a lower cost. To order a prescription drug brochure, call UNICARE’s Customer Services at 312/234/8855 or 888/234/8855 (outside the SBC local calling area).

These are the dispensing limitations:

Pharmacy supply limits:

- up to a 30-day supply or 100-unit supply whichever is less; or

- 240 milliliters of liquid (8 oz); or

- 60 grams of ointment, creams or topical preparation; or

- one commercially prepared unit (i.e.; one inhaler)

You pay $5 copay per prescription unit or refill of generic formulary drugs and $15 per prescription unit or refill of name brand formulary drugs. If a generic drug is available and your doctor does not require the use of a name brand drug, you pay the $15 name brand copay plus the difference in cost between the generic and the name brand drug. When generic substitution is not available, you pay the brand name copay.

For non-formulary drugs obtained at a Plan pharmacy, you pay a $25 copay. When generic substitution is permissible (e.g.; a generic drug is available and the prescribing doctor does not required the use of a name brand drug) but you request the name brand drub, you pay the $25 non-formulary copay plus the difference between the cost of the generic drug and the cost of the name brand drug

Mail Order:

You may obtain up to a 90-day supply of formulary maintenance drugs from our mail order pharmacy program. You pay 2-times the per unit copay.

Maintenance medications are drugs used on a continual basis for treatment of chronic health conditions such as high blood pressure, ulcers or diabetes and that are package and intended for self-administration by the patient. Additionally, you may obtain insulin and select oral contraceptives through the pharmacy mail order program.

To order maintenance medications by mail, call UNICARE’s Customer Services Department to obtain the necessary forms. Complete or have your Plan doctor complete the prescription order form. Mail the Plan doctor’s written prescription for up to a 90-day supply of the maintenance drug, along with the completed prescription order form and the appropriate copay amount to the mail order pharmacy provider. Additional refills may be obtained the same way provided the strength and dosage of the medication remain the same.

All drugs are not available by mail order. You cannot obtain antibiotics, cough syrup and self-injected drugs (except insulin) by mail.

Please note that we will only refill prescriptions within 12 months of the date of the initial prescription from you Plan doctor. Also, we will not refill a prescription less than 10 days prior to its completion.

Drugs to treat sexual dysfunction have dispensing limits and require prior approval. Please contact us for details.

A generic equivalent will be dispensed if it is available unless your physician specifically requires a name brand. If you receive a name brand drug when a federally approved generic drug is available, and your physician has not specified “Dispense as Written” for the name brand drug, you have to pay the difference in cost between the name brand drug and the generic.

Why use generic drugs? Generic drugs are lower priced drugs that are the therapeutic equivalent to more expensive brand name drugs. They must contain the same active ingredients and must be equivalent in strength and dosage to the original brand name product. Generics cost less than the equivalent brand name product. The U.S. Food and Drug administration sets quality standard for generic drugs to ensure that these drugs meet the same standards of quality and strength as brand name drugs.

When you have to file a claim. You normally won’t have to submit claims to us unless you receive emergency services from a provider who