Members' Frequently Asked Questions about the UNICARE PPO Health Plan

The following topics contain a broad list of our members' Frequently Asked Questions. Please use the links below to refine your search, or simply scroll down to locate the subjects of most interest to you. The answers are only a general description of coverage. Please refer to your Certificate of Coverage or plan booklet for more complete details about your plan including benefits, limitations and exclusions. In case of any discrepancies between the information contained in these FAQs, and the most recent edition of the Certificate of Coverage or plan booklet, the terms of the Certificate of Coverage or plan booklet shall govern.

1. How do I get additional information about my plan or benefits?

To learn more about what services your health plan covers, you may log in to online Member Services and access your Benefits Detail. In addition, your plan booklet will describe the covered services in the health plan. Covered services are the medically necessary procedures and types of care for which the plan will provide benefits. The limitations and exclusions section of the booklet will describe types of care that the plan does not cover. The booklet will also indicate if there are services that require pre-certification from UNICARE before you receive care and any services that may be restricted to an annual or lifetime maximum benefit.

This is only a brief summary of the plan. Please refer to your Certificate of Coverage or plan booklet for more complete details about your plan including benefits, limitations and exclusions.

2. How and when can I contact the health plan?

Any question- large or small- is important.

Whenever you have a question about your plan, you can either contact us through online Member Services or you may call a trained customer service representative at the toll-free number on your ID card. Call to:

• Pre-certify hospital admissions and any outpatient services as required by your plan
• Report an emergency admission
• Access care when you are away from home
• Verify your membership eligibility and benefits
• Get the name of a network provider
• Ask a question about your benefits or a claim
• Access health information, case management and health promotion services
• Appeal a benefit decision

Up-to-date information about your benefit plan is kept on our computer system and is readily accessible by our customer service representatives. This means most of your questions can be resolved on the spot, in one phone call!

3. How can I change my name or address?

To change your address, please call a customer service representative at the phone number on the back of your ID card. If you are a small group employee, be sure to tell your employer about your change of address as well.

If you are a small group employee and need to change your name, please consult your employer.

4. What are your customer service hours?

Our customer service hours are Monday through Friday, during normal business hours. We also have online Member Services, which provides you with 24 hours a day, seven days a week customer service capability.

5. How do I get a provider directory?

To obtain a provider directory, call the customer service number listed on your ID card. Small Group employees may also consult your employer. The Directory is updated annually. Provider information is also available online via our website, www.unicare.com. Through our online provider finder feature, you have the ability to print a listing of providers in your area. In addition, you may also call customer service at anytime for questions regarding a physician's participation.

6. How do I get a list of preferred drugs?

UNICARE distributes a Formulary Selection Guide that lists the most commonly prescribed drugs on the formulary. If you have questions about whether a drug is on the prescription drug formulary or needs to be approved, please call Pharmacy customer service at the number on your ID card.

7. How can I cover my newborn from birth?

If you are a Small Group employee, please contact your Human Resources department IMMEDIATELY. To add a newborn to health insurance coverage, you must complete and return the appropriate forms to your Benefits Department within 31 days of the date of birth. If the forms are not submitted to UNICARE in time, the newborn is considered a late enrollee and you must wait until the next open enrollment period to obtain insurance coverage for the newborn.

If you have individual coverage, you must notify UNICARE in writing within 31 days of birth that you wish to have the newborn added as an insured family member and pay any additional premium. If UNICARE receives this request after 31 days, you must complete an Individual Enrollment Application. The application is subject to medical underwriting and approval by UNICARE.

This is only a brief summary of the plan. Please refer to your Certificate of Coverage or plan booklet for more complete details about your plan including benefits, limitations and exclusions.

8. How do I obtain coverage for my newly adopted child?

If you are a Small Group employee, please contact your Human Resources department IMMEDIATELY. To add a newly adopted child to health insurance coverage, you must complete and return the appropriate forms to your Benefits Department within 31 days of the date of adoption. If the forms are not submitted to UNICARE in time, the newborn is considered a late enrollee and you must wait until the next open enrollment period to obtain insurance coverage for the child.

If you have individual coverage and wish to add a newly adopted child as an insured family member, you must notify UNICARE in writing within 31 days of adoption and pay any additional premium. If UNICARE receives this request after 31 days, you must complete an Individual Enrollment Application. The application is subject to medical underwriting and approval by UNICARE.

This is only a brief summary of the plan. Please refer to your Certificate of Coverage or plan booklet for more complete details about your plan including benefits, limitations and exclusions.

9. How do I add or delete family members from my coverage?

If you are a Small Group employee, please contact your Human Resources department.

If you have individual coverage, please contact UNICARE at the customer service number on your ID card.

10. Can I cover a dependent who lives out of state or my child away at school?

Coverage for dependents who live out of state or are away from school depends on your plan's benefit design. Please read your Certificate of Coverage or plan booklet to determine whether you have this coverage.

This is only a brief summary of the plan. Please refer to your Certificate of Coverage or plan booklet for more complete details about your plan including benefits, limitations and exclusions.

11. How often can I change benefit plans?

If you are a Small Group employee, benefit plans can only be changed at open enrollment.

The benefits you select when you first enroll or during open enrollment will remain in effect throughout the calendar year. However, if you have a qualified change in status, or if you meet special enrollment requirements of the Health Insurance Portability and Accountability Act of 1996, IRS rules and the plans allow you enroll persons who were not previously enrolled to enroll.

The following is a list of qualified change in status that permit you to make new coverage elections:

• Marriage, divorce or legal separation
• Death of your spouse or dependent
• Birth or adoption of a child, or change in a child custody arrangement
• A change in employment status by your spouse or dependent (e.g., termination, retirement, new job)
• A significant change in health care coverage by the employer of your spouse or dependent, not including open enrollment
• Unpaid leaves of absences

Please contact your Human Resources Department immediately or call customer service to determine if you qualify for a mid-year change.

If you have individual coverage, please contact your UNICARE agent or call customer service at the number listed on your ID card for other plans that may be available. UNICARE does not limit plan changes at this time.

This is only a brief summary of the plan. Please refer to your Certificate of Coverage or plan booklet for more complete details about your plan including benefits, limitations and exclusions. :

12. How long can my children remain covered?

Children can remain covered usually until age 18, however, different plans have different benefits.
Please refer to your Certificate of Coverage or plan booklet to determine your plan benefits. For additional information, call the toll-free customer service number on your ID card. If you are a Small Group employee, you may also contact your employer's Human Resources department.

This is only a brief summary of the plan. Please refer to your Certificate of Coverage or plan booklet for more complete details about your plan including benefits, limitations and exclusions.

13. How long can my child be covered if he/she has disabilities?

If your child has a physical handicap or metal retardation and reached the age limits (age limits and specifics defined in your Certificate of Coverage or plan booklet), your child can still qualify if he or she is: covered under this plan, still dependent on you or your spouse, not able to get a job or self-support him or herself because of the handicap or mental retardation. A physician's certification is required.

This is only a brief summary of the plan. Please refer to your Certificate of Coverage or plan booklet for more complete details about your plan including benefits, limitations and exclusions.

14. How do I use my UNICARE identification card?

Your identification (ID) card is your passport to your UNICARE health plan benefits. Showing your ID card in a physician's office or hospital admissions office enables the provider to confirm that you are eligible for benefits. When you use network providers, your ID will ensure you receive maximum benefits and advantages of your plan, including not having to file claims.

Your ID card lists one or more toll-free telephone numbers that will link you to UNICARE staff if you need to:

• Pre-certify required inpatient hospital admissions and any other services specified in your plan booklet.
• Report an emergency hospital admission.
• Access in-network care when traveling outside your network's operating area.
• Ask a question about your network, your benefits or a specific claim.
• Access UNICARE's health information, case management or health promotion services.
• Appeal a benefit decision.

This is only a brief summary of the plan. Please refer to the Certificate of Coverage for complete details about the plan including benefits, limitations and exclusions.

15. Who may use the UNICARE ID card?

Only you and the covered family members that you enrolled may use your ID card and receive your plan benefits. Never lend your ID card to anyone.

16. Whose name and member ID/certificate number should appear on the ID card?

The subscriber's name and certificate number will always appear on an ID card. Depending on your plan specifics, additional cards may be issued in a spouse or dependent's name, in conjunction with the subscriber's certificate number.

17. What if the member loses the ID card or needs to order additional cards?

If you lose your card and need a replacement, or you would like to order additional ID cards, call our toll-free customer service number. Small Group employees may also notify your company's benefits administrator immediately. You may also go to online Member Services Your card will be delivered within 7 working days from the time you place your request. If medical care is required before your ID cards are received, please give the provider of care your certificate number that was used to access your account.

18. Do I need to carry my ID card with me at all times?

To receive the highest levels of benefits from your plan, it is recommended that you carry your UNICARE ID card with you at all times. You should always show it when you go to your network doctor, pharmacy, hospital, or any other health care provider.

19. How do I know what network is affiliated with my health plan?

The name of your network appears in the upper right hand corner of your UNICARE identification card.

20. How can I find the names, addresses and other important information concerning physicians, hospitals and other health care providers in my network?

There are three sources:

• The Provider Finder on this website
• The Network Provider Directory
• UNICARE's Customer Service Department, which you can reach at the toll-free number on your identification card.

All of these sources can give you the names, addresses, medical specialties, and hospital affiliations of network providers. You can ask for providers in certain ZIP Codes that may be convenient to where you live or work. In some cases, these sources can help you identify physicians who speak languages other than English and give you detailed directions from your home or workplace to the provider's location.

21. What if a provider I would like to use is not listed in the Provider Finder or the Network Provider Directory?

Call the provider or UNICARE Customer Service to find out if the provider has joined the network since the website information was last updated or the directory was last printed.

If the provider is not in the network, you may nominate him or her via e-mail through the link provided in the FAQs option on the Provider Finder or by calling customer service. Otherwise, your PPO benefits will cover your provider on an out-of-network basis. Out-of-network benefits may be limited and receiving services out-of-network could cost you substantially more.

22. What if my provider has left the network since the Provider Finder was last updated or the directory was last printed?

The status of payment (in or out-of-network) will be determined at the time the claim is paid. To ensure that you receive in-network benefits, you should always ask the provider's office staff to confirm when you make the first appointment that the provider is still in the network noted on the identification card.

23. How do I find a network provider?

There are three sources:

• The Provider Finder on this website
• The Network Provider Directory
• UNICARE's Customer Service Department, which you can reach at the toll-free number on your identification card.

All of these sources can give you the names, addresses, medical specialties, and hospital affiliations of network providers. You can ask for providers in certain ZIP Codes that may be convenient to where you live or work. In some cases, these sources can help you identify physicians who speak languages other than English and give you detailed directions from your home or workplace to the provider's location.

24. What are the advantages of using a network provider?

When you choose to receive care from hospitals and physicians in a network affiliated with your UNICARE PPO plan, you pay less out-of- pocket (sometimes only a small copayment for each visit) and generally do not have to file claims.

When the provider is not a member of a UNICARE-affiliated network, your share of the costs will be higher, including deductible, coinsurance, and possibly balance billing. In addition, many out-of-network providers may charge you in full, requiring you to submit a claim to UNICARE in order to receive benefits.

25. What happens if my current physician is not a network provider?

It is worth calling the provider or UNICARE Customer Service to find out if the provider has joined the network since the website information was last updated or the directory was last printed.

If the provider is not in the network, you may nominate him or her via e-mail through the link provided in the FAQs option on the Provider Finder or by calling customer service.

Benefits are available for non-network providers under our PPO plans, however, you will be responsible for a higher out of pocket expense.

26. What if a network provider isn't available to treat my condition?

Generally, the in-network level of benefits is available only when a network provider is used. However, if a certain service is required and there is not an appropriate network specialist within reasonable driving distance (as defined in the Certificate of Coverage), you can request an out-of-network referral if out-of-network referrals are permitted by the plan of benefits. Such a referral must be approved by the network through the UNICARE Utilization Review process prior to services being rendered.

For more information, please call customer service at the number listed on your ID card.

27. Can I go to a non-network provider?

Yes, under a PPO, you have out-of-network benefits. Generally, the UNICARE PPO Health Plan covers the same health services whether you receive them in-network or out-of-network. You will, however, usually pay higher out-of-pocket costs for out-of-network care.

28. How do you recommend that I choose a new physician?

In choosing a new physician, whether in-network or out-of-network, you may want to consider:

• Is the physician's office location convenient to your home or workplace? UNICARE's Provider Finder supplies maps and driving directions for most network provider locations.
• Does the physician have admitting privileges at a (network) hospital that you prefer?
• Does the physician have office hours that fit in with your schedule?
• If English is not your primary language, does the physician speak the language you prefer?
• Is the physician board-certified?
• Do you have friends or colleagues who recommend the physician from first-hand experience?

29. What if I cannot keep my appointment?

UNICARE health plans do not cover charges for broken appointments. You should always try to keep an appointment or notify the provider in plenty of time if you must cancel.

30. What services require prior approval or a referral?

All hospital admissions require pre-certification in advance from UNICARE if you want to receive the maximum benefits available. Your Certificate of Coverage or plan booklet will indicate if your plan also requires pre-certification of certain outpatient surgical and diagnostic procedures. Some plans require pre-certification of services like home health care, infusion therapy, hospice and skilled nursing facilities if your plan has benefits for these services.

Of course, the final decision about care your receive is between you and your doctor. UNICARE only determines what will be eligible for benefit payment under your plan, based on medical necessity.

Our PPO plans do not require referrals if you would like to see a specialist. You may select a specialist of your choice and make an appointment directly. Choosing an in-network specialist will minimize our out-of-pocket expenses.

In addition, to ensure that prescription drugs meet accepted national standards of quality and effectiveness, some plans require your physician to provide a letter of medical necessity to UNICARE when prescribing certain drugs. In addition, certain medications require prior authorization. Please refer to your Certificate of Coverage or plan booklet for more details.

31. How do I get prior approval or a referral?

For pre-certification, the patient, physician or representative simply calls UNICARE utilization r eview staff at the toll-free number on the ID card. In a PPO environment, you can select both primary care and specialist physicians from a broad network without having to obtain referrals.

In addition, to ensure that prescription drugs meet accepted national standards of quality and effectiveness, some plans require your physician to provide a letter of medical necessity to UNICARE when prescribing certain drugs. Please refer to your plan booklet for more detail.

This is only a brief summary of the plan. Please refer to your Certificate of Coverage or plan booklet for more complete details about your plan including benefits, limitations and exclusions.

32. What if I do not obtain prior approval or a referral?

Without obtaining pre-certification, you run the risk of having benefits reduced or being subject to a penalty.

33. What if I Need Specialists, Lab Tests or X-rays?

If you or a covered dependent need any of these services, you will not need a referral from UNICARE. If you go to a network provider, you will reduce your out-of-pocket expenses. If requested, network physicians can usually help refer you to another provider in the network. In some cases, especially if your personal physician is out-of-network, you may have to ask f or a referral to a network specialist whom you have chosen.

34. What if I Need Inpatient Hospital Care?

UNICARE must certify all inpatient hospital admissions (those requiring an overnight stay in the hospital).

• For elective admissions, you, your physician or a representative must obtain UNICARE's certification before expenses are incurred. The person making the call should be prepared to give the UNICARE ID number of the insured, the name of the patient (if different), the hospital or other provider location, and the full name, address and phone number of the attending physician.
• For emergency admissions, you or a representative should notify UNICARE within 48 hours of the admission.
• If your plan has maternity benefits, UNICARE urges women to notify us in the first trimester of a pregnancy. In any case, hospitalization for maternity, like any planned inpatient admission, requires pre-certification two weeks in advance for a scheduled or full-term delivery. Emergency admissions for premature deliveries require notification within 48 hours.

If you do not pre-certify those services which require notification, UNICARE may reduce benefits apply a penalty or deny benefits altogether if the care is not deemed medically necessary.

Patients needing a hospital admission will pay the least out-of-pocket if they select a network hospital.

This is only a brief summary of the plan. Please refer to your Certificate of Coverage or plan booklet for more complete details about your plan including benefits, limitations and exclusions.

35. Do any other services require pre-certification?

Coverage for dependents who live out of state or are away from school depends on your plan's benefit design. Please read your Certificate of Coverage or plan booklet to determine whether you have this coverage.

This is only a brief summary of the plan. Please refer to your Certificate of Coverage or plan booklet for more complete details about your plan including benefits, limitations and exclusions.

36. What qualifies as an Emergency?

Emergency means medical care and treatment required to treat a medical condition of sudden onset or deterioration. It must be expected that failure to obtain immediate care could place the your life in danger or lead to serious physical impairment.

Emergency rooms are highly specialized health care facilities. Go to the emergency room only for true emergencies, not for routine ailments or for convenience.

Emergencies can vary widely. Some examples of medical emergencies are:

• Possible heart attack (severe chest pain or pressure)
• Uncontrollable bleeding
• Confusion or loss of consciousness, especially after a head injury
• Severe shortness of breath or difficulty breathing
• Severe or multiple injuries, including obvious fractures

This is only a brief summary of the plan. Please refer to the Certificate of Coverage for complete details about the plan including benefits, limitations and exclusions.

37. What should I do in the case of an emergency?

If faced with a life-threatening emergency, always seek immediate care by going directly to the nearest emergency room or calling 911.

"Emergency" means medical care and treatment required to treat a medical condition of sudden onset or deterioration. It must be expected that failure to obtain immediate care could place your life in danger or lead to serious physical impairment. Emergency rooms are highly specialized health care facilities. Go to emergency rooms only for true emergencies, not for routine ailments or for convenience.

This is only a brief summary of the plan. Please refer to your Certificate of Coverage or plan booklet for more complete details about your plan including benefits, limitations and exclusions.

38. Do you cover emergency care?

UNICARE covers emergency care wherever and whenever our members need it - 24 hours a day, seven days a week. If faced with a life-threatening emergency, always seek immediate care by going directly to the nearest emergency room or calling 911. Benefits for covered emergency services will be the same whether or not the hospital is in-network or out-of-network. Many plans require a special copayment for emergency room care. You make the same copayment whether the emergency room is an in-network or out-of-network facility.

This is only a brief summary of the plan. Please refer to your Certificate of Coverage or plan booklet for more complete details about your plan including benefits, limitations and exclusions.

39. What happens if I need health care services outside my network's operating area?

You or the family member needing care may go to any doctor or facility wherever you are and receive covered services, subject to out-of-network benefits.

In addition, if you are a member of UNICARE's Platinum PPO (if there is a Platinum PPO logo on your UNICARE ID Card), you can receive in-network benefits from any provider in UNICARE's Platinum network all across the country. To access Platinum travel access benefits, call the travel access phone number on the back of your ID Card and the travel access representative will help you to find a provider and can even help you make your appointment. This benefit is available when you are away from home on vacation or on business and is also available to students at school away from home.

If you are not part of UNICARE's Platinum network, call the toll-free customer service on your ID Card and a UNICARE representative will let you know if the type of care you need is available in the area where you are traveling. Typically only hospital care is available to members who are not part of the Platinum PPO.

This is only a brief summary of the plan. Please refer to your Certificate of Coverage or plan booklet for more complete details about your plan including benefits, limitations and exclusions.

40. What routine coverage do I have while traveling?

You or the family member needing care may go to any doctor or facility wherever you are and receive covered services, subject to out-of-network benefits.

In addition, if you are a member of UNICARE's Platinum PPO (if there is a Platinum PPO logo on your UNICARE ID Card), you can receive in-network benefits from any provider in UNICARE's Platinum network all across the country. To access Platinum travel access benefits, call the travel access phone number on the back of your ID Card and the travel access representative will help you to find a provider and can even help you make your appointment. This benefit is available when you are away from home on vacation or on business and is also available to students at school away from home.

If you are not part of UNICARE's Platinum network, call the toll-free customer service on your ID Card and a UNICARE representative will let you know if the type of care you need is available in the area where you are traveling. Typically only hospital care is available to members who are not part of the Platinum PPO.

This is only a brief summary of the plan. Please refer to your Certificate of Coverage or plan booklet for more complete details about your plan including benefits, limitations and exclusions.

41. What routine coverage do I have while traveling?

UNICARE covers emergency care whenever and wherever you need it- 24 hours a day, seven days a week. If you are faced with a life-threatening emergency, always seek immediate care by going directly to the nearest emergency room or by calling 911. Benefits for eligible emergency care will be the same whether the hospital is in or out-of-network.

This is only a brief summary of the plan. Please refer to your Certificate of Coverage or plan booklet for more complete details about your plan including benefits, limitations and exclusions.

42. How do I get prescriptions filled through a mail order pharmacy?

To order maintenance medications through the UNICARE Mail Order Drug Program:

• Ask your doctor for a written prescription for up to the maximum amount of the medication, plus refills, if appropriate, as indicated in your Certificate of Coverage or plan booklet.
• Complete the Patient Profile Questionnaire and Mail Order Drug Request Form; available through UNICARE. Include a check, money order, or a VISA, MasterCard or Discover card number.
• Mail the completed form and written prescription in the provided self-addressed envelope, included in the packet you receive from your company's Human Resource department or that you can request by calling customer service at the number listed on your ID card.

To refill a mail order prescription, simply call the toll-free number on your mail order form or on the box or bottle containing the medication. That label will indicate whether refills are available. When you call the mail order program, be prepared to give your certificate number, the prescription number indicated on the drug container and your credit card information for the copayment.

This is only a brief summary of the plan. Please refer to your Certificate of Coverage or plan booklet for more complete details about your plan including benefits, limitations and exclusions.

43. What is the difference between generic and brand-name drugs and how does that difference affect my benefits?

Brand name drugs are those drugs that are marketed under a specific trade name by a pharmaceutical manufacturer. In most cases, these drugs are still under patent protection, meaning the manufacturer is the sole source for the product.

Generic drugs are safe, effective and equivalent to brand name medications that may cost considerably less than the brand name medications. Generic drugs must meet the same high standards of quality as brand name drugs and are formulated to have the same effect in the body as the brand name version.

44. Can I get reimbursed for drugs I got from a pharmacy not in the network?

Your UNICARE Prescription Drug Plan is a managed pharmacy program that provides benefits for prescription drugs wherever you purchase them. Your out-of-pocket costs are lowest when your use a network pharmacy. UNICARE's pharmacy network includes over 52,000 major chain and independent drug stores: more than 84% of pharmacies nationwide.

45. If I am going to be out of town for an extended time, how do I obtain an extra supply of drugs to cover me through that period?

Plans differ in respect to supplying additional quantities of drugs. For more information on your pharmacy program, please contact Pharmacy Customer Service at the number on your ID card.

This is only a brief summary of the plan. Please refer to your Certificate of Coverage or plan booklet for more complete details about your plan including benefits, limitations and exclusions.

46. What is a drug formulary (or preferred drug list) and how does that affect me?

A formulary is a list of effective, affordable and commonly prescribed medications, comprised of brand name and generic drugs. Your plan may feature a formulary to encourage you to use quality, affordable prescription medications that are proven to be effective. If your plan does include a formulary, you may pay a lower copayment when your physician prescribes formulary drugs. Some plans may limit coverage to drugs on the formulary.

The complete drug formulary is usually quite long and technical. UNICARE distributes a Formulary Selection Guide that lists the most commonly prescribed drugs on the formulary. Members who wish to keep their out-of-pocket costs at a minimum should share this guide with their physicians and encourage them to prescribe generic or formulary brand name drugs (if no generic version exists) whenever possible.

This is only a brief summary of the plan. Please refer to your Certificate of Coverage or plan booklet for more complete details about your plan including benefits, limitations and exclusions.

47. How can I find a network pharmacy?

To find a network pharmacy in your area, simply call the toll-free number on your ID card, consult the prescription drug plan member handbook, or use the Provider Finder on this website.

48. How do I file a claim?

If you are a PPO member and go to a network provider, no claim form is necessary. If you are a PPO member and seek care at a non-network provider, a claim form may be required. Please call the customer service number on your ID card or contact us through online Member Services if you need additional information.

This is only a brief summary of the plan. Please refer to your Certificate of Coverage or plan booklet for more complete details about your plan including benefits, limitations and exclusions.

49. How long do I have to file a claim?

Claim forms submitted by the member or a provider must be received by us within 90 days of the date the expense is incurred in order to be eligible for benefits. If it is not reasonably possible to submit the claim within that time frame, an extension of up to twelve months will be allowed. UNICARE is not liable for the benefits of the plan if claims are not filed within this time period.

This is only a brief summary of the plan. Please refer to your Certificate of Coverage or plan booklet for more complete details about your plan including benefits, limitations and exclusions.

50. A provider has billed me, how do I know how much of the bill to pay?

After your claim is processed, you will receive an Explanation of Benefits (EOB) from UNICARE. The EOB is not a bill. It simply summarizes services received, how the claim was paid and what your portion of the costs will be.

This is only a brief summary of the plan. Please refer to the Certificate of Coverage for complete details about the plan including benefits, limitations and exclusions.

51. What are the out-of-pocket costs that I may have to pay?

The benefit summary in your plan booklet specifies the amounts and the types of out-of-pocket charges for covered services. Depending on the service and whether the provider is in-network or out-of-network, you may have to pay:

• Copayment - the dollar amount you pay for each physician home or office visit. Network physicians agree to accept your copayment and UNICARE's reimbursement as payment-in-full for covered services if your plan pays 100% of the covered charge. If your plan booklet states that your plans pays less than 100% for physician office visits, you may have additional out-of-pocket costs.
• Deductible - the amount you or your covered family member must pay annually before UNICARE begins to pay for covered services. Copayments do not count towards the annual deductible. Your Certificate of Coverage or plan booklet states the amount of your deductible and whether it exists for both in-network services and out-of-network services, or out-of-network services only.
• Coinsurance -the percentage of the covered charge you pay out-of-pocket after any deductible or copayment. Your percentage of the coinsurance amount for in-network care is usually lower than your percentage of coinsurance for out-of-network care.
• Out-of-Pocket Limit - To protect you from high medical expenses, your plan may limit the amount you must pay out-of-pocket each year for all covered services. Once you reach your participating and non-participating out-of-pocket maximums, your plan pays 100% of covered charges for the rest of the calendar year, subject to the terms and conditions of the plan. Depending on your plan, deductible and coinsurance payments for certain kinds of expenses may not apply toward your out-of-pocket limit. Refer to your plan booklet for your out-of-pocket limit and charges to which the out-of-pocket limit does not apply.
• Reasonable and Customary Charge - the amount, determined by UNICARE, that most providers in your area charge for the same service or procedure in the same setting (office or hospital). Out-of-network deductibles and coinsurance apply only to the provider's charge, or UNICARE's reasonable and customary charge, whichever is less.
• Balance Bill - The amount a provider may bill you if the charge for care is greater that UNICARE's reasonable and customary charge. UNICARE does not cover this amount, nor will it count toward any plan maximums. Network providers never balance bill for covered services. They always accept as payment-in-full the total of any copayment, deductible and coinsurance that you pay and the network reimbursement that UNICARE pays.

This is only a brief summary of the plan. Please refer to the Certificate of Coverage for complete details about the plan including benefits, limitations and exclusions.

52. How can I check the status of my claim?

To check the status of a claim, you may call customer service at the toll-free number on your ID card or go to online Member Services. The member services pages link you to the details of your health care plan, including dependent information and claim status, and serve to connect you electronically to customer service for ID card replacement or benefit issues. To safeguard personal information, you must receive a personal identification number (PIN) before you can access member services. To request a PIN please visit online Member Services.

53. What is the difference between deductibles and copayments?

• Copayment - the dollar amount you pay for each in-network physician home or office visit. Physician copayments are for in-network care only. Network physicians agree to accept your copayment and UNICARE's reimbursement as payment-in-full for covered services if your plan pays 100% of the covered charge. If your Certificate of Coverage or plan booklet states that your plans pays less than 100% for physician office visits, you may have additional out-of-pocket costs.
• Deductible - the amount you or your covered family member must pay annually before UNICARE begins to pay for covered services. Copayments do not count towards the annual deductible. Your Certificate of Coverage or plan booklet states t he amount of your deductible and whether it exists for both in-network services and out-of-network services, or out-of-network services only.

This is only a brief summary of the plan. Please refer to your Certificate of Coverage or plan booklet for more complete details about your plan including benefits, limitations and exclusions.

54. How does my out-of-pocket maximum work?

To protect you from high medical expenses, your plan may limit the amount you must pay out-of-pocket each year for all covered services. Once you reach your out-of-pocket limit, your plan pays 100% of covered charges for the rest of the calendar year, subject to the terms and conditions of the plan.

Depending on your plan, deductible and coinsurance payments for certain kinds of expenses may not apply toward your out-of-pocket limit. Some plans may have an out-of-pocket maximum for covered services from participating providers and an out-of-pocket maximum for covered services for non-participating providers. Refer to your Certificate of Coverage or plan booklet for your out-of-pocket limit and charges to which the out-of-pocket limit do not apply.

This is only a brief summary of the plan. Please refer to your Certificate of Coverage or plan booklet for more complete details about your plan including benefits, limitations and exclusions.

55. What is Coordination of Benefits?

Some plans have Coordination of Benefits (COB) which is the provision that limits health benefits from multiple group health insurance plans in a particular case to 100% of the covered charges and to designate the order in which the multiple carriers are to pay benefits. Under a COB provision, one plan is determined to be primary and its benefits are applied to the claim. The unpaid balance is usually paid by the secondary plan to the limit of its liability. Please note: being covered by two plans does not guarantee 100% of the covered charges will be paid by either plan.

This is only a brief summary of the plan. Please refer to your Certificate of Coverage or plan booklet for more complete details about your plan including benefits, limitations and exclusions.

56. Why did I receive a Coordination of Benefit questionnaire and do I have to return it?

The Coordination of Benefit questionnaire is used to determine if you are covered by more than one health insurance plan. Please fill it out and return to UNICARE so that we may adequately process your claim.

This is only a brief summary of the plan. Please refer to your Certificate of Coverage or plan booklet for more complete details about your plan including benefits, limitations and exclusions.

57. What do I do with a foreign medical bill for care I received outside of the USA?

Foreign claims should be sent directly to UNICARE for processing. UNICARE is responsible for translation, currency conversion and adjudication of the foreign claim.

Benefits for services and supplies received from foreign country providers are covered for medical emergencies and other urgent situations where treatment could not have been reasonably delayed until you are able to return to the United States. You are responsible, at your expense, for obtaining an English translation of foreign country provider claims and medical records that may be required.

All applicable plan limitations and medical necessity provisions will apply to foreign claims.

This is only a brief summary of the plan. Please refer to your Certificate of Coverage or plan booklet for more complete details about your plan including benefits, limitations and exclusions.

58. What is the procedure for lodging a complaint against a provider?

Please call the customer service number on the back of your ID card for assistance.

59. How do I appeal a certification or authorization denial?

Please call customer service at the number listed on your ID card for assistance.

60. How do I appeal a claim payment or denial?

If a claim is denied in whole or in part, you will receive a written notice of the denial. The notice will explain the reason for the denial. You may request a review of the denied claim. The request must be submitted in writing within 60 days after you have received the notice. You must include reasons for requesting this review.

61. What if waiting for UNICARE to make a decision on my appeal would harm my health?

UNICARE has an "expedited review process" to allow you, the attending physician, or hospital facility to expedite the process of obtaining another medical review after a non-authorization has been determined by UNICARE.

The final decision regarding treatment is between you and your doctor. UNICARE only determines what will be eligible for benefit payment under your plan, based on medical necessity.

62. My Explanation of Benefits says I received services that I did not have. What should I do?

Please call the customer service number on the back of your ID card for assistance.

63. What is a PPO?

A Preferred Provider Organization (PPO) is a network of hospitals, physicians and other health-related facilities and providers of care who are under contract by UNICARE to provide care at discounted rates. As a UNICARE PPO Health Plan member you may choose to receive care either in-network or out-of-network. The level of benefits you receive depends on your choice:

In-network benefits apply when you receive covered services from a "preferred provider," a participating member of the PPO network. Out-of-network benefits apply when you receive covered services from a physician, hospital or facility that does not participate in the PPO network.

If you are a UNICARE PPO Health Plan member you can get answers to your questions via online Member Services or by calling the Customer Service number on your UNICARE ID card.

64. What is the difference between in-network and out-of-network?

In-network benefits apply when you receive covered services from a participating and contracted member of the PPO network providing care at a discounted rate. These doctors and hospitals are listed in your directory and may be referred to as "UNICARE" providers". Out-of-network benefits apply when you receive covered services from a physician, hospital or facility that does not participate and is not contracted in the PPO network. They are not listed in your provider directories.

Generally, your UNICARE PPO Plan covers most health services whether you receive them in-network or out-of-network. You will, however, usually pay less for care provided by UNICARE contracted doctors and hospitals.

This is only a brief summary of the plan. Please refer to your Certificate of Coverage or plan booklet for more complete details about your plan including benefits, limitations and exclusions.

65. How can I learn what services my health plan covers?

To learn more about what services your health plan covers, you may log in to online Member Services and access your Benefits Detail. In addition, your Certificate of Coverage or plan booklet will describe the covered services in your health plan. Covered services are the medically necessary procedures and types of care for which the plan will provide benefits. The limitations and exclusions section of the booklet will describe types of care that the plan does not cover. The booklet will also indicate if there are services that require pre-certification from UNICARE before the patient receives care and any services that may be restricted to an annual or lifetime maximum benefit.

This is only a brief summary of the plan. Please refer to the Certificate of Coverage for complete details about the plan including benefits, limitations and exclusions.

66. What happens to my coverage if I move out of the area?

Please call customer service and request that your file be updated with your new address to ensure that the appropriate network information is updated and replacement ID cards are ordered if necessary. If you are a Small Group employee, you should also contact your employer to ensure that your file is updated to with your new address.

67. If I am a Small Group employee, what happens to my coverage if I quit my job or I'm laid off or fired?

When your job ends, for any reason other than gross misconduct, you may be able to continue, at your expense and for a limited time, exactly the same benefits you have while employed, through COBRA. COBRA (Consolidated Omnibus Budget Reconciliation Act of 1985) is the federal law that requires employers with more than 20 employees to extend group health insurance coverage.

By law, your employer must provide you with detailed information regarding the terms, cost and duration of COBRA benefits upon termination of your employment.

This is only a brief summary of the plan. Please refer to your Certificate of Coverage or plan booklet for more complete details about your plan including benefits, limitations and exclusions.

68. What happens to my coverage if I turn 65?

Your Certificate of Coverage or plan booklet contains a lot of detailed information about your health plan, including what happens when you become eligible for Medicare. For additional information, call the toll-free customer service number on your ID card or contact your employer's Human Resources department.

This is only a brief summary of the plan. Please refer to your Certificate of Coverage or plan booklet for more complete details about your plan including benefits, limitations and exclusions.

69. If I am a Small Group employee, what happens to my coverage if I retire?

If your employer employs 20 or more people, you may be able to keep your health insurance coverage through COBRA. Consult your employer for more information.

This is only a brief summary of the plan. Please refer to your Certificate of Coverage or plan booklet for more complete details about your plan including benefits, limitations and exclusions.

70. What if I become disabled?

Your Certificate of Coverage or plan booklet contains a lot of detailed information about your health plan. For additional information, call the toll-free customer service number on your ID card.

This is only a brief summary of the plan. Please refer to your Certificate of Coverage or plan booklet for more complete details about your plan including benefits, limitations and exclusions.

71. What if my spouse and I divorce?

Your family members can continue to be covered by UNICARE, if you become divorced or legally separated. Consult UNICARE for more information.

This is only a brief summary of the plan. Please refer to your Certificate of Coverage or plan booklet for more complete details about your plan including benefits, limitations and exclusions.

72. Is my child covered while in college?

Depending on your plan specifics, full time students may be covered. Your plan booklet contains a lot of detailed information about your health plan, including particular age limits regarding this type of coverage. For additional information, call the toll-free customer service number on your ID card. If you are a Small Group employee, you may also contact your employer's Human Resources department.

This is only a brief summary of the plan. Please refer to your Certificate of Coverage or plan booklet for more complete details about your plan including benefits, limitations and exclusions.

73. Do I have coverage for pre-existing conditions?

Your Certificate of Coverage or plan booklet contains a lot of detailed information about your health plan. For additional information, call the toll-free customer service number on your ID card or contact your employer's Human Resources department.

This is only a brief summary of the plan. Please refer to your Certificate of Coverage or plan booklet for more complete details about your plan including benefits, limitations and exclusions.

74. Where can I get more information about my health plan?

Your Certificate of Coverage or plan booklet contains a lot of detailed information about your health plan, including, but not limited to:

• The eligibility of your family members
• What happens if you are a Small Group employee and leave your job.
• What happens if you become eligible for Medicare.
• Your right to appeal UNICARE's claim or membership decisions.
• UNICARE's right to recover any overpayments from you, if that should occur.
• Covered services
• Any limitations and exclusions of your health plan.

For additional information, call the toll-free customer service number on your ID card or contact your employer's Human Resources department.

This is only a brief summary of the plan. Please refer to your Certificate of Coverage or plan booklet for more complete details about your plan including benefits, limitations and exclusions.

Please note: This is only a brief summary of the plan. Should the responses to these questions and your plan documents disagree, or should provisions contained in your plan documents be omitted from these Frequently Asked Questions, your plan documents will always govern. Please refer to your Certificate of Coverage or plan booklet for more complete details about your plan including benefits, limitations and exclusions.