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 the provider, you may have to pay: • 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 plan pays less than 100% for physician office visits, you may have additional out-of-pocket costs. This is only a brief summary of the plan. Please refer to your Certificate of Coverage or plan booklet for complete details about your plan including benefits, limitations and exclusions.
