Plan Name

Independent Health

Univera Healthcare

Community Choice 2000 - Referred Care

QPOS 

Community Choice 2000 - Self-Referred Care

QPOS

www.aetnaushc.com

Member Service Number

716-631-8701 or 1-800-501-3439

Pre-Enrollee No. 1-800-755-5802

Group No. 30459H

1-800-337-3338 

Pre-Enrollee No. 1-800-427-8490

1-888-403-0400

1-888-403-0400

Individual Lifetime Maximum Benefits

None

Through UniveraAccess Option Only

None

$1 Million

Annual Deductible

None

Through UniveraAccess Option Only

          Individual

None

Through UniveraAccess Option Only

None

None

          Family

None

Through UniveraAccess Option Only

None

None

Coinsurance

None

Through UniveraAccess Option Only

None

25%

Annual Out-of-Pocket Maximum 

          Individual

None

Through UniveraAccess Option Only

None

$2,000

          Family

None

None

None

$4,000

Inpatient Hospital

100% covered

100% covered

100%

75%

Physician Services: PCP Office Visit

$15 copay

$15 copay

$10 copay

75%

Emergency Care: In-area Hospital

$25 copay

$50 copay

(Waived If Admitted)

100% - $25 copay applies/  Waived if admitted. 75% for non-emergency care

100% - $25 copay applies.  Waived if admitted. 75% for non-emergency care

Outpatient X-Ray and Lab

$15 copay (x-ray); 100% covered (lab work)

X-ray $15 copay; Lab 100% covered

100%

75%

Durable Medical Equipment

50% member copay

50% covered

100%

75%

Retail Prescription Coverage

          Generic

$10 copay for a 30-day supply

$10 copay for a 30 day supply

20%

20%

          Brand Name

$20 copay for a 30-day supply of preferred brand-name drugs $35 copay for 30-day supply of non-preferred brand-name drugs

$20 copay for a 30-day supply of preferred brand-name drugs $45 copay for 30-day supply of non-preferred brand-name drugs

30% if generic unavailable; 50% if Generic available and medically necessary

30% if generic unavailable; 50% if Generic available and medically necessary

Mail-Order Prescription Coverage

10% Generic; 20% Brand if Generic unavailable; 40% if Generic available and medically necessary

10% Generic; 20% Brand if Generic unavailable; 40% if Generic available and medically necessary

          Brand Name

Not available

$20 copay preferred; $45 copay for non-preferred 30 day-supply

See Above

See Above

Diabetic Benefits

          Insulin

$8 copay for a 30-day supply

$15 copay

Covered Under Pharmacy Benefit

Covered Under Pharmacy Benefit

          Chem. Strips/Lancets

$8 copay or 20% copay whichever is less, for a 30-day supply

$15 copay

Covered Under Pharmacy Benefit

Covered Under Pharmacy Benefit

          Home Health Care

$15 copay, when approved up to 40 visits per year

$15 copay unlimited visits

100%

75% - limited to 100 visits per calendar year

Mental Health 

          Inpatient 

100% covered up to 30 days per calendar year

100% covered for up to 30 days per calendar year

100% up to 30 days per calendar year

75% up to 30 days per calendar year 

          Outpatient

50% copay for up to 20 visits per  calendar year

$15 copay visit 1-6; 50% copay visit  7-20

100% after $10 copay limited to 20 visits per calendar year

75% limited to 20 visits per calendar year

Substance Abuse

          Inpatient

100% covered for detoxification only

100% covered for up to 7 days per calendar year for detoxification.  Rehab Not Covered

100% - 30 days per calendar year; 90 days lifetime

75% - 30 days per calendar year; 90 days lifetime

          Outpatient

$15 copay up to 60 visits per calendar year

$15 copay up to 60 visits per calendar year

100% after $10 copay - 30 visits per calendar year; 120 visits per lifetime

75% - 30 visits per calendar year; 120 visits per lifetime

Vision Care

          Routine Eye Exam

$15 copay once every two calendar years up to age 19

$10 copay

VisionOne Discount Program

Not Covered

Eyeglasses and Contact Lenses

Not Covered

Discount service available 

VisionOne Discount Program

Not Covered

Hearing Care

          Exam

$15 copay

$15 copay

Provided by National Ear Care Plan 

(NECP) - 1-800-999-1458

Not Covered

          Hearing Aids

Not Covered

Not Covered

Provided by National Ear Care Plan 

(NECP) - 1-800-999-1458

Not Covered

Dental Care

          Basic Services

Discounts available

Not Covered

Not Covered

Not Covered

          Major Services

Not Covered

Not Covered

Not Covered

Not Covered

          Preventive Services

Not Covered

Discount service for preventive service

Not Covered

Not Covered

Wellness Benefits

Yes

Yes

$10 Copay

Not Covered