Personal Options Individual Health Insurance

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This table compares benefit and coverage information for each of the Personal Options plans Unity offers.

Benefit HMO 25/50 HMO 500 HMO 1000 HMO-HSA 1 HMO-HSA 2 HMO-HSA 3

Lifetime Maximum		 $2 Million $2 Million $2 Million $2 Million $2 Million $2 Million

Annual Deductible (Single/Family)
 $500/$1,000 $500/$1,000 $1,000/$2,000 $1,250/$2,500 $2,000/$4,000 $5,000/$10,000

Annual Out-of-Pocket Limit (Single/Family)
 $1,500/$3,000 $1,500/$3,000 $2,000/$4,000 $1,250/$2,500 $2,000/$4,000 $5,000/$10,000

Physician Services (See Certificate of Coverage for benefits applicable to immunizations for children under age 6)

 

$25 Copayment for Primary Care Physicians; $50 Copayment for Specialty Practitioners

 Deductible, then 20% Coinsurance Deductible, then 20% Coinsurance Deductible, then 100% coverage Deductible, then 100% coverage Deductible, then 100% coverage

Diagnostic Services
(Radiology & Laboratory)

 

 


100% coverage when part of a physical examination (except for MRI, MRA, CAT and PET)

 

Deductible, then 20% Coinsurance

 

Deductible, then 20% Coinsurance

 

Deductible, then 100% coverage

 

Deductible, then 100% coverage

 

Deductible, then 100% coverage

 


MRI, MRA, Pet & CAT Scans

 

 Deductible, then 20% Coinsurance Deductible, then 20% Coinsurance Deductible, then 20% Coinsurance Deductible, then 100% coverage Deductible, then 100% coverage Deductible, then 100% coverage


Chiropractic Services
(Maintenance care is not covered)

$25 Copayment Deductible, then 20% Coinsurance Deductible, then 20% Coinsurance Deductible, then 100% coverage Deductible, then 100% coverage Deductible, then 100% coverage

Prescription Drugs

 Optional coverage $10/$25/$50 Optional coverage $10/$25/$50

Optional coverage
$10/$25/$50

 Deductible, then 100% coverage Deductible, then 100% coverage Deductible, then 100% coverage
Maternity Care
Maternity Rider is available for purchase
Maternity Rider is available for purchase
Maternity Rider is available for purchase
Not available
Not available
Not available
Urgent Care $50 Copayment
Deductible, then 20% Coinsurance
Deductible, then 20% Coinsurance
Deductible, then 100% coverage
Deductible, then 100% coverage
Deductible, then 100% coverage


Emergency Room Care
(If you are admitted to a hospital, the Hospital Services benefit applies)

Deductible, then 20% Coinsurance Deductible, then 20% Coinsurance Deductible, then 20% Coinsurance Deductible, then 100% coverage Deductible, then 100% coverage Deductible, then 100% coverage

Hospital Services
 Deductible, then 20% Coinsurance Deductible, then 20% Coinsurance Deductible, then 20% Coinsurance Deductible, then 100% coverage Deductible, then 100% coverage Deductible, then 100% coverage

Ambulance Services (Ground and air)
 Deductible, then 20% Coinsurance Deductible, then 20% Coinsurance Deductible, then 20% Coinsurance Deductible, then 100% coverage Deductible, then 100% coverage Deductible, then 100% coverage


Therapy Services
(40 combined visits for Physical Therapy/Speech Therapy/Occupational Therapy per benefit year. There is no limit on the number of therapy visits for autism spectrum disorder.)

Deductible, then 20% Coinsurance Deductible, then 20% Coinsurance Deductible, then 20% Coinsurance Deductible, then 100% coverage Deductible, then 100% coverage Deductible, then 100% coverage
Durable Medical Equipment & Supplies
(Coinsurance does not apply to the Annual Out-of-Pocket Limit)

20% Coinsurance

 

20% Coinsurance

 

20% Coinsurance

 

Deductible, then 100% coverage

 

Deductible, then 100% coverage

 

Deductible, then 100% coverage

 

Home Health Care
(Limited to 50 visits per Benefit Year)
 100% coverage 100% coverage 100% coverage Deductible, then 100% coverage Deductible, then 100% coverage Deductible, then 100% coverage
Hospice Care 100% coverage 100% coverage 100% coverage Deductible, then 100% coverage Deductible, then 100% coverage Deductible, then 100% coverage

Skilled Nursing Care
(30 days per covered confinement)
 100% coverage 100% coverage 100% coverage Deductible, then 100% coverage Deductible, then 100% coverage Deductible, then 100% coverage

 

Kidney Disease Treatment

 

See specific benefit category for applicable copayment, deductible and coinsurance.

 

Transplants

 

See specific benefit category for applicable copayment, deductible and coinsurance.