Unicare of Michigan UniCare High-Deductible Health Plan 1 80 Plan Information

Plan Name: UniCare High-Deductible Health Plan 1 80

Plan Type: High Deductible HSA-Qualified

Health Savings Account: Compatibility with tax deferred savings accounts

Physician Choice: Yes

Annual Out-of-Pocket Maximum: Single party: $5000 or Family: $10,000 (includes annual deductible and pharmacy copays)

Annual Deductible: The annual deductible will reflect the U.S. Treasury's minimum deductible requirements for high deductible health plans, which is subject to change annually. The 2007 amounts are: $1100 for single party or $2200 for family coverage

Office Visits: UniCare pays 80%

Professional Services: UniCare pays 80%

Hospital Inpatient: UniCare pays 80%

Hospital Outpatient: UniCare pays 80%

Inpatient Medical Emergency: UniCare pays 80%

Preventive Care for Babies and Children (through age 6): UniCare pays 80%

Preventive Care for Adults: UniCare pays 80%

Drug Benefits: After the annual deductible is met, UniCare pays 100% except for the following: Generic: $10 copay. Brand Formulary: $30 copay. Brand Non-Formulary: $50 copay. Self-Administered Injectable Drugs: You pay 20%

Other Unicare of Michigan health insurance plans:

• UniCare Solaura HIA Plus Plan 3
• MI FIT 5000
• UniCare High Deductible Health Plan 4 100
• UniCare Saver 2000
• UniCare Solaura HSA Plan 2a
• UniCare Solaura HIA Plan 2
• UniCare High Deductible Health Plan 2 80
• MI FIT 3000
• UniCare Solaura HSA Plan 1a
• UniCare Solaura HIA Plus Plan 1
• UniCare Solaura HIA Plan 1
• UniCare High-Deductible Health Plan 3 100
• MI FIT 2000
• UniCare Solaura HIA Plus Plan 2
• MI FIT 1500
• MI FIT 1000
• MI FIT 500