2017 Individual & Family Plan Options
Prime Network – Cost Share Reduction Plans
(Columbia, Dane, Dodge, Green, Iowa, Jefferson and Sauk Counties)
100 - 150% of Federal Poverty Level
Benefits
Prime Silver
10 / 20
Prime Silver
Deductible*
Prime Silver
Maintenance
Prime Silver
5 / 10 Value*
Prime Silver
10 / 25 Value*
Prime Silver
Standard
$0
$250 / $500
$0
$100 / $200
$0
$250 / $500
10%
10%
0%
10%
0%
5%
$950 / $1,900
$500 / $1,000
$1,700 / $3,400
$750 / $1,500
$1,200 / $2,400
$1,250 / $2,500
$5
Deductible then Coinsurance
$2
$3
$5
$3
$10 / $20
Deductible then Coinsurance
$3 / $15
$5 / $10
$10 / $25
$5 / $15
Urgent Care Copay
$20
Deductible then Coinsurance
$15
$10
$25
$25
Emergency Room Copay
$100
Deductible then Coinsurance
$100
$100
$200
$100 copay after deductible
Mental Health
Outpatient Copay
$10
Deductible then Coinsurance
$3
$5
$10
$5
Deductible (Single / Family)
Coinsurance
Maximum Out-of-Pocket
e-Visits
Office Visit Copay
(PCP / Specialist)
Hospital Copay
(Inpatient / Outpatient)
Pharmacy Copay
Deductible then Coinsurance Deductible then Coinsurance
$500 per diem /
Deductible then Coinsurance Deductible then Coinsurance Deductible then Coinsurance
Deductible then Coinsurance
$5 / $20 / $45 / $200
Deductible then Coinsurance
$3 / $20 / $50 / $300
$5 / $20 / $45 / $200
$5 / $20 / $45 / $200
$3 / $5 / $10 / 25%
Dental Coverage Available
for an Additional Charge?
Yes
No
Yes
Yes
Yes
No
HSA Eligible?
No
No
No
No
No
No
INDP0706
INDP0206
INDP3006
INDP0806
INDP0906
INDP6706
Summary of Benefits of
Coverage (SBC) Tracking ID
* Unity’s Value / HSA plans have an aggregate deductible. This means if more than one person is covered by the plan, the “per person” deductible does not apply. The family deductible must be met before Unity will pay benefits
and one person may accumulate to the entire family deductible. The “per person” maximum-out-of-pocket limit also does not apply. However, one member of a family will not pay more than $2,350.
Unity Health Insurance is a Qualified Health Plan issuer in the Health Insurance Marketplace.
Unity Health Insurance does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation, or health status in the administration of the plan, including
enrollment and benefit determinations.
UH01446 (1116)
Unity Health Plans Insurance Corporation
2017 Individual & Family Plan Options
Prime Network – Cost Share Reduction Plans
(Columbia, Dane, Dodge, Green, Iowa, Jefferson and Sauk Counties)
150 - 200% of Federal Poverty Level
Benefits
Prime Silver
20 / 40
Prime Silver
Deductible*
Prime Silver
Maintenance
Prime Silver
10 / 25 Value*
Prime Silver
30 / 70 Value*
Prime Silver
Standard
Deductible (Single / Family)
$600 / $1,200
$750 / $1,500
$250 / $500
$700 / $1,400
$85 / $170
$700 / $1,400
10%
20%
0%
20%
0%
20%
$2,350 / $4,700
$1,250 / $2,500
$2,350 / $4,700
$2,350 / $4,700
$2,350 / $4,700
$2,000 / $4,000
$10
Deductible then Coinsurance
$5
$5
$20
$5
$20 / $40
Deductible then Coinsurance
$10 / $20
$10 / $25
$30 / $70
$10 / $25
Coinsurance
Maximum Out-of-Pocket
e-Visits
Office Visit Copay
(PCP / Specialist)
Urgent Care Copay
$40
Deductible then Coinsurance
$20
$25
$70
$40
Emergency Room Copay
$250
Deductible then Coinsurance
$375
$150
$250
$150 copay after deductible
Mental Health
Outpatient Copay
$20
Deductible then Coinsurance
$10
$10
$30
$10
Hospital Copay
(Inpatient / Outpatient)
Pharmacy Copay
Deductible then Coinsurance Deductible then Coinsurance
$1,500 per diem /
Deductible then Coinsurance Deductible then Coinsurance Deductible then Coinsurance
Deductible then Coinsurance
$5 / $20 / $45 / $200
Deductible then Coinsurance
$5 / $40 / $100 / $350
$5 / $20 / $45 / $200
$10 / $50 / $100 / $400
$5 / $25 / $50 / 30%
Dental Coverage Available
for an Additional Charge?
Yes
No
Yes
Yes
Yes
No
HSA Eligible?
No
No
No
No
No
No
INDP0705
INDP0205
INDP3005
INDP0805
INDP0905
INDP6705
Summary of Benefits of
Coverage (SBC) Tracking ID
* Unity’s Value / HSA plans have an aggregate deductible. This means if more than one person is covered by the plan, the “per person” deductible does not apply. The family deductible must be met before Unity will pay benefits
and one person may accumulate to the entire family deductible. The “per person” maximum-out-of-pocket limit also does not apply. However, one member of a family will not pay more than $2,350.
Unity Health Insurance is a Qualified Health Plan issuer in the Health Insurance Marketplace.
Unity Health Insurance does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation, or health status in the administration of the plan, including
enrollment and benefit determinations.
UH01446 (1116)
Unity Health Plans Insurance Corporation
2017 Individual & Family Plan Options
Prime Network – Cost Share Reduction Plans
(Columbia, Dane, Dodge, Green, Iowa, Jefferson and Sauk Counties)
200 - 250% of Federal Poverty Level
Benefits
Prime Silver
30 / 60
Prime Silver
Deductible*
Prime Silver
Maintenance
Prime Silver
25 / 50 Value*
Prime Silver
30 / 70 Value*
Prime Silver
Standard
Deductible (Single / Family)
$2,750 / $5,500
$1,850 / $3,700
$1,200 / $2,400
$2,875 / $5,750
$2,600 / $5,200
$3,000 / $6,000
10%
30%
0%
20%
10%
20%
$5,700 / $11,400
$3,800 / $7,600
$5,700 / $11,400
$5,700 / $11,400
$5,700 / $11,400
$5,700 / $11,400
$20
Deductible then Coinsurance
$15
$15
$20
$20
$30 / $60
Deductible then Coinsurance
$25 / $75
$25 / $50
$30 / $70
$30 / $65
Coinsurance
Maximum Out-of-Pocket
e-Visits
Office Visit Copay
(PCP / Specialist)
Urgent Care Copay
$60
Deductible then Coinsurance
$75
$50
$70
$75
Emergency Room Copay
$250
Deductible then Coinsurance
$500
$250
$300
$300 copay after deductible
Mental Health
Outpatient Copay
$30
Deductible then Coinsurance
$25
$25
$30
$30
Hospital Copay
(Inpatient / Outpatient)
Pharmacy Copay
Deductible then Coinsurance Deductible then Coinsurance
$2,500 per diem /
Deductible then Coinsurance Deductible then Coinsurance Deductible then Coinsurance
Deductible then Coinsurance
$10 / $50 / $100 / $400
Deductible then Coinsurance
$5 / $75 / $150 / $500
$10 / $50 / $100 / $400
$10 / $50 / $100 / $400
$10 / $50 / $100 / 40%
Dental Coverage Available
for an Additional Charge?
Yes
No
Yes
Yes
Yes
No
HSA Eligible?
No
Yes*
No
No
No
No
INDP0704
INDP0204
INDP3004
INDP0804
INDP0904
INDP6704
Summary of Benefits of
Coverage (SBC) Tracking ID
* Unity’s Value / HSA plans have an aggregate deductible. This means if more than one person is covered by the plan, the “per person” deductible does not apply. The family deductible must be met before Unity will pay benefits
and one person may accumulate to the entire family deductible. The “per person” maximum-out-of-pocket limit also does not apply. However, one member of a family will not pay more than $5,700.
Unity Health Insurance is a Qualified Health Plan issuer in the Health Insurance Marketplace.
Unity Health Insurance does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation, or health status in the administration of the plan, including
enrollment and benefit determinations.
UH01446 (1116)
Unity Health Plans Insurance Corporation
2017 Individual & Family Plan Options
Prime Network – Cost Share Reduction Plans
(Columbia, Dane, Dodge, Green, Iowa, Jefferson and Sauk Counties)
Optional Family Dental
Adult Benefits
In-Network
Out-Of-Network
Benefit Maximum
100% Coverage
No Coverage
1 visit per 6 months
Basic Restorative (Class B)
Includes therapeutic pulpotomy, repair / adjustment of dentures and
oral surgery procedures such as wisdom tooth or other tooth extractions.
Benefit limits may apply to posterior composite fillings.
20% Coinsurance
No Coverage
Major Restorative (Class C)
Includes such services as crowns, root canals, apicoectomy,
gingivectomy, dentures, implants and occlusal guards.
50% Coinsurance
No Coverage
Orthodontics
Not Covered
Not Covered
Not Covered
Pediatric (up to age 19) Benefits
In-Network
Out-Of-Network
Benefit Maximum
100% Coverage
No Coverage
1 visit per 6 months
Basic Restorative (Class B)
Includes therapeutic pulpotomy, repair / adjustment of dentures and
oral surgery procedures such as wisdom tooth or other tooth extractions.
Benefit limits may apply to posterior composite fillings; age limits
may apply to certain procedures.
30% Coinsurance
No Coverage
No Benefit Maximum
Major Restorative (Class C)
Includes such services as crowns, root canals, apicoectomy,
gingivectomy, dentures, implants and occlusal guards.
50% Coinsurance
No Coverage
No Benefit Maximum
Orthodontics
Covered only when medically necessary and a 24 month wait
period is satisfied.
50% Coinsurance
No Coverage
No Benefit Maximum
Cleanings / x-rays (Class A)
Includes exams, x-rays, bitewings, cleanings and fluoride.
Cleanings / x-rays (Class A)
Includes exams, x-rays, bitewings, cleanings, fluoride, sealants and
space maintainers.
$1,000 Benefit Maximum per Year
Unity Health Insurance is a Qualified Health Plan issuer in the Health Insurance Marketplace.
Unity Health Insurance does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation, or health status in the administration of the plan, including
enrollment and benefit determinations.
UH01446 (1116)
Unity Health Plans Insurance Corporation