UniCare Life & Health Insurance Company

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1 UniCare Life & Health Insurance Company INDIVIDUAL TEXAS CONSUMER CHOICE $1,000, $2,000 $5,000 DEDUCTIBLE PARTICIPATING PROVIDER PLAN A MAJOR MEDICAL PLAN WRITTEN PLAN DESCRIPTION READ YOUR PLAN CAREFULLY. This written plan description provides a very brief description of the important features of Your plan. This is not the insurance contract and only the actual plan provisions will control. The plan itself sets forth, in detail, the rights and obligations of both You and UniCare. It is, therefore, important that You READ YOUR PLAN CAREFULLY! IMPORTANT NOTICE This Consumer Choice of Benefits Health Insurance Plan, either in whole or in part, does not provide state-mandated health benefits normally required in accident and sickness insurance policies in Texas. This standard health benefit plan may provide a more affordable health insurance policy for You although, at the same time, it may provide You with fewer health benefits than those normally included as state-mandated health benefits in policies in Texas. Please consult with Your insurance agent to discover which state mandated health benefits are excluded in this policy. This is not a policy of worker s compensation insurance. The employer does not become a subscriber to the workers compensation system by purchasing this Plan, and if the employer is a non-subscriber, the employer loses those benefits which would otherwise accrue under the workers compensation laws. The employer must comply with the workers compensation law as it pertains to non-subscribers and the required notifications that must be filed and posted. A. Coverage is provided by UniCare Life & Health Insurance Company (UniCare), an insurance company that provides participating provider benefits. B. To obtain additional information, including provider information write to the following address or call the toll-free number: UniCare Life & Health Insurance Company Individual Services Unit P.O. Box 5061 Bolingbrook, IL (800) C. A Participating Provider Plan enables the Insured to incur lower medical costs by using providers in the UniCare network. A Participating Provider has a signed agreement with UniCare at the time services are rendered to accept previously Negotiated Rates as payment in full for covered services. A Non-Participating Provider is a physician or other health care provider who has not entered into an agreement with UniCare at the time the services were rendered. Covered Expenses for Non- Participating Providers are based on Reasonable Charges which may be less than actual billed charges. Non-Participating Providers can bill You for amounts exceeding Covered Expenses. D. Covered Services and Benefits Deductibles Your Annual Deductible is $1,000, $2,000, $5,000 per Insured Person per Year. Additional Deductibles will apply under the following circumstances: 1. Non-Emergency inpatient Hospital stays in Non-Participating Hospitals are subject to a $500 Deductible per Continuing Hospital Confinement. 2. An additional $1,000 Deductible per Insured Person per calendar Year applies to Brand Name Formulary and Non-Formulary Prescription Drugs. TXICCDEDWPD

2 After any applicable Deductibles are applied, the benefits outlined in the table below show the payment percentages for Covered Expenses as follows: Out-of-Pocket Maximum When You use Participating Providers, We pay based on the Negotiated rate: When You use Non-Participating Providers, We pay based on Reasonable Charges: 1. First Level Payment Until You meet the innetwork Out-of-Pocket maximum outlined below We pay: 80% for the Consumer Choice $1,000; 75% for the Consumer Choice 2. Second Level Payment In Network Out-of- Pocket maximum: Once You accumulate $3,000 in Out-of-Pocket expenses per Year from Participating Providers We pay: 100% In addition, if You cover other Insured Family Members, once You and Your Insured Family Members reach a combined total of $6,000 in Out-of-Pocket expenses in a calendar Year for services received from Participating Providers, You and Your Insured Family Members will no longer have to pay any Copayment or Coinsurance for Participating Providers for the remainder of that Year. We will NOT apply Copayments or Coinsurance paid to Non-Participating Providers toward the Out of Pocket Maximum for Participating Providers. There is no Out-of-Pocket Maximum for Covered Expenses incurred at Non-Participating Providers. TXICCDEDWPD

3 Note: All payment levels listed are AFTER any applicable Deductibles or penalties are applied 1. Professional Services a. Surgery, anesthesia, radiation therapy, in-hospital doctor visits, diagnostic X-ray and lab work b. Office visits (including preventive care office visits for Babies/Children and Adults) i) First 4 Office Visits per Insured Person per Calendar Year ii) After 4 Office Visit 2. Preventive Care Babies/ Children (through age 6): a. Immunization 1 b. lab work c. Office Visit/examination related to services in a or b above for Babies/Children d. Other routine care services other than a, b & c above, for Babies/Children, for example, flu shots, routine physical exams/tests that do not directly treat an actual Illness, Injury, or condition. (Office Visit Copayment does not apply) Adults: a. Routine Pap smears, annual mammograms, and PSA for men. b. Office Visit/examination related to the services in (a.) for Adults, including a physical examination for the detection of prostate cancer for men c. Other routine care services other than a & b above, for adults, for example, flu shots, routine physical exams/tests that do not directly treat an actual Illness, Injury, or condition. (Office Visit Copayment does not apply) When You use UniCare Participating Providers, We pay based on the Negotiated Rate: 80% for Consumer Choice $1,000 All but a $30 Copayment with Annual Deductible waived. 100% (with Annual Deductible waived) Refer to Office Visits under Professional Services above. with a maximum Covered Expense of $200 per Insured Person per Year Refer to Office Visits under Professional Services above. with a maximum Covered Expense of $200 per Insured Person per Year When You use Non Participating Providers, We pay based on Reasonable Charges: 100% (with Annual Deductible waived) with a maximum Covered Expense of $200 per Insured Person per Year. with a maximum Covered Expense of $200 per Insured Person per Year TXICCDEDWPD

4 Note: All payment levels listed are AFTER any applicable Deductibles or penalties are applied When You use UniCare Participating Providers, We pay based on the Negotiated Rate: 3. Outpatient Medical Care 2 When You use Non Participating Providers, We pay based on Reasonable Charges: 4. Services for: a) Physical Therapy b) Occupational Therapy c) Speech Therapy d) Acupuncture/Acupressure As much as $30 per visit, with a combined total maximum of 12 visits per year for a, b, c & d. Additional physical therapy, occupational therapy, and speech therapy visits may be covered following an inpatient hospitalization following severe trauma such as Spinal Injury or Stroke. Refer to the Comprehensive Benefits section for details. 5. Infusion Therapy 4 (Administration of drugs and other substances in ways other than oral; such as chemotherapy through a vein.) 6. Durable Medical Equipment 7. Inpatient Hospital Services 3 a. Surgery, X-rays, In-hospital doctor visits, Organ/Tissue Transplant 6 b. Inpatient Medical Emergency 3 8. Ambulatory Surgical Center 5 9. Ambulance Service ground transport with a maximum Covered Expense of $750 per trip. air transport with a maximum Covered Expense of $2,000 per trip. less an additional $500 Deductible per Continuing Hospital confinement for non-emergency stays. 80% for the Consumer Choice $1,000; until transferable to a Participating Hospital, then subject to a $500 Deductible per Continuing Hospital Confinement once transferable. with a maximum Covered Expense of $750 per trip. with a maximum Covered Expense of $2,000 per trip air. TXICCDEDWPD

5 Note: All payment levels listed are AFTER any applicable Deductibles or penalties are applied 10. AIDS/ARC treatment (limit of $10,000 per year; $50,000 lifetime maximum.) When You use UniCare Participating Providers, We pay based on the Negotiated Rate: When You use Non Participating Providers, We pay based on Reasonable Charges: 11. Home Health Care 6 of Covered Expenses, as many as 60 visits per year. 12. Skilled Nursing Facilities 6 with a maximum Covered Expense of $400 per day, as many as 100 days per year 13. Hospice 6 with a maximum Covered Expense of $10,000 per lifetime. When You use a Participating Pharmacy, We pay based on the UniCare Negotiated Rate. of Covered Expenses, as many as 60 visits per year. with a maximum Covered Expense of $400 per day, as many as 100 days per year. with a maximum Covered Expense of $10,000 per lifetime. When You use a Non-Participating Pharmacy, We pay based on the Average Wholesale Price of the Drug. 14. Pharmacy 7 Retail Pharmacies: Maximum 30-day supply. Pharmacy Deductibles and Copayments are not applied to Your Out-of-pocket maximum or annual Deductible 1. Generic drugs All except a $10 Copayment per Prescription 2. Brand name Formulary Drugs (Subject to a separate $1,000 Brand Formulary and Non-Formulary Deductible per Insured Person per Year) 3. Brand Name Non-Formulary Drugs (Subject to a separate $1,000 Brand Formulary and Non-Formulary Deductible per Insured Person per Year) 4. Self-administered Injectable Drugs 7 (except Insulin 8 ) (Brand Name Self-adminstered Injectable Drugs will be subject to the Brand Name Prescription Deductible) All except a $30 Copayment per Prescription All except a $50 Copayment per Prescription of the Average Wholesale Price of the Drug of the Average Wholesale Price of the Drug of the Average Wholesale Price of the Drug of the Negotiated Rate of the Average Wholesale Price of the Drug TXICCDEDWPD

6 Note: All payment levels listed are AFTER any applicable Deductibles or penalties are applied When You use UniCare Participating Providers, We pay based on the Negotiated Rate: Mail Service Prescriptions Up to a maximum 60-day supply. Some Prescription Drugs and/or medicines are not available through the mail service. 1. Generic Drugs All except a $20 Copayment per Prescription When You use Non Participating Providers, We pay based on Reasonable Charges: Not Available 2. Brand Name Formulary Drugs (Subject to a separate $1,000 Deductible per Insured Person per Year) All except a $60 Copayment per Prescription Not Available 3. Brand Name Non-Formulary Drugs (Subject to a separate $1,000 Deductible per Insured Person per Year) 4. Self-administered Injectable Drugs 7 (except Insulin 8 ) (Brand Name Selfadministered Injectable Drugs will be subject to the Brand Name Prescription Deductible) All except a $100 Copayment per Prescription Not Available of the Negotiated Rate Not Available Childhood immunizations only include immunization against diphtheria, haemophilus influenzae type b, hepatitis B, measles, mumps, pertussis, polio, rubella, tetanus, varicella, and any other immunization that is required by law. Emergency room visits that do not result in inpatient admissions will be subject to a $60 penalty. All Inpatient medical care requires pre-service review or You will be subject to a $500 penalty per continuing hospital confinement without pre-service review. This penalty is waived on Emergency admissions, however, utilization review is still required. To receive maximum benefits, Infusion therapy must be authorized by UniCare. Covered Expense includes professional services, compounding fees, incidental supplies, medications, drugs, solutions, durable medical equipment and training related to infusion therapy. Failure to obtain authorization will result in a reduction in benefits for Covered Expenses. All surgical services of an Ambulatory Surgical Center require pre-service review or You pay a $50 penalty. Ambulatory Surgical Centers must be licensed and accredited and meet all requirements of state and local laws and agencies. In addition to pre-service review, certain services require Authorization to be eligible for maximum benefits. This applies to: Organ/Tissue Transplants, Infusion Therapy, Home Health Services, Skilled Nursing Facilities, and Hospice. Failure to obtain authorization will result in a reduction in benefits for Covered Expenses. Certain Prescription Drugs including Self-Administered Injectable Drugs and injectable Drugs administered in an outpatient setting may require prior Authorization. Insulin does not require prior Authorization. Insulin is covered under the Generic or Brand Name Prescription Drug benefit. TXICCDEDWPD

7 E. Emergency Care Services and Benefits UniCare is obligated to provide reimbursement for Emergency care at the Participating Provider level if the Insured Person cannot reasonably reach a Participating Provider and until the Insured Person can reasonably be expected to transfer to a Participating Provider. The Emergency care services subject to this section include: 1. any medical screening examination or evaluation required by state or federal law to be provided in the Emergency department of a hospital necessary to determine whether a Medical Emergency exists; 2. necessary Emergency care services including the treatment and stabilization of an Emergency medical condition; and 3. services originating in a hospital Emergency department following treatment or stabilization of an Emergency medical condition. F. Out of Area Services and Benefits If an unforeseen illness or injury occurs during an Insured Person s temporary absence from the Service Area and health care services cannot be delayed until the Insured Person s return to the Service Area, benefits for Medically Necessary services will be reimbursed at the participating provider level. G. Insured s Financial Responsibility The UniCare Insured is responsible for paying the monthly or quarterly premium on a timely basis. The Insured is also responsible to pay providers for charges that are applied to the Copayment, penalties and any amounts charged by non-providers in excess of our Reasonable Charges. In addition, any charges for Medically Necessary items that are excluded under this plan are the responsibility of the Insured. H. Exclusions, Limitations, and Reductions 1. The Participating Provider Plan does not provide benefits for: Services for any condition for which benefits are excluded by a Waiver. Any amounts in excess of maximum amounts of Covered Expenses stated in this service plan. Services not specifically listed in the Plan as Covered Services. Services or supplies that are not Medically Necessary as defined by UniCare. Services or supplies that UniCare considers to be Experimental Procedures or Investigative Procedures. Services received before the Effective Date of coverage or during an inpatient stay that began before that Effective Date. Services received after coverage ends. Services for which You have no legal obligation to pay or for which no charge would be made if You did not have a health plan or insurance coverage. Any condition for which benefits are recovered or can be recovered, either by adjudication, settlement or otherwise, under any workers compensation, employer s liability law or occupational disease law, even if You do not claim those benefits. Any intentionally self-inflicted Injury or Illness. Services received for any condition caused by or contributed by: (a) An act of war. (b) The inadvertent release of nuclear energy when government funds are available for treatment. (c) An Insured Person s participation in the military of any country. (d) An Insured Person s participation in an insurrection, rebellion, or riot. (e) An Insured Person s commission of, or attempt to commit a felony. Or (f) an Insured Person being under the influence of illegal narcotics or non-prescribed controlled substances. Any services for which payment may be obtained from any local, state or federal government agency except when payment under this plan is expressly required by federal or state law. Any services to the extent that You are entitled to receive Medicare benefits for those services whether or not Medicare benefits are actually paid. Any services for which payment may be obtained from any local, state or federal government agency (except Medicaid). Professional services received from or supplies purchased by an Insured Person, a person who lives in the Insured Person's home, a person who is related to the Insured Person by blood, marriage, or adoption, or the patient s employer. Services of a private duty nurse. Inpatient room and board charges in connection with a Hospital stay primarily for environmental change, physical therapy or treatment of chronic pain; Custodial Care or rest cures; services provided by a rest home, a home for the aged, a nursing home or any similar facility service. Services provided by a rest home, a home for the aged, a nursing home or any similar facility service. Inpatient room and board charges in connection with a Hospital stay primarily for diagnostic tests which could have been performed safely on an outpatient basis. Treatment of Mental, Emotional or Functional Nervous Disorders (including a smoking cessation program) including any Mental, Emotional or Functional Nervous Disorder with demonstrable organic disease or psychological testing except as specifically stated in this Plan. However, TXICCDEDWPD

8 medical conditions that are caused by behavior of the Insured Person and that may be associated with these mental conditions are not subject to these limitations, but may be excluded elsewhere Treatment of drug, alcohol, or other substance addiction or abuse. Dental services. Orthodontic Services. Dental Implants or any associated procedures. Hearing aids. Routine hearing tests except as provided under Well Baby and Well Child Care and Newborn Hearing Benefits. Optometric services, eye exercises including orthoptics, eyeglasses, contact lenses, routine eye exams and routine eye refractions. An eye surgery solely for the purpose of correcting refractive defects. Outpatient speech therapy, except as specifically provided by this Plan. Any drugs, medications, or other substances dispensed or administered in any setting other than a licensed pharmacy except as specifically stated in this Plan. Cosmetic surgery or other services for beautification. This exclusion does not apply to Medically Necessary Reconstructive Surgery to restore a bodily function or to correct a deformity caused by Injury or congenital defect of a Newborn child, or to breast reconstruction performed to restore or achieve breast symmetry incident to a mastectomy and abnormal craniofacial structure caused by congenital defects. Procedures or treatments to change characteristics of the body to those of the opposite sex. Treatment of Sexual Dysfunction, impotence and/or Inadequacy. All services related to the evaluation or treatment of fertility and/or Infertility. All contraceptive services, and supplies including but not limited to all consultations, examinations, evaluations, medications, medical, laboratory, devices, Prescription Drugs or surgical procedures. Charges for pregnancy and maternity care including but not limited to, normal delivery, Cesarean sections, elective abortions. Cryopreservation of sperm or eggs. Orthopedic shoes (except when joined to braces) or shoe inserts, including orthotics. Routine foot care. Services primarily for weight reduction or treatment of obesity, including morbid obesity, or any care which involves weight reduction as a main method for treatment. Routine physical exams or tests that do not directly treat an actual Illness, Injury or condition, including those required by employment or government authority except as specifically stated under the Adult Preventative Care, Well Baby Child Care and Other Routine Care Services sections of this Plan. Charges for telephone consultations, Telemedicine Medical Service or Telehealth Service. Items which are furnished primarily for Your personal comfort or convenience. Educational services except for Diabetes Self- Management Training Program, and as specifically provided or arranged by UniCare. Nutritional counseling or food supplements, except for formulas necessary for the treatment of phenylketonuria. Any services received on or within twelve months after the Effective Date of coverage if they are related to a Pre-existing Condition. Services for which a third party may be liable or legally responsible to pay. Growth Hormone Treatment. Charges of a standby physician. Charges for animal to human organ transplants. Charges for any smoking cessation program or pharmaceuticals related to smoking cessation. All Foreign Country Provider charges are excluded under the Plan except as specifically stated under the Plan. Charges for which We are unable to determine Our liability because You or an Insured Person failed, within 90 days, or as soon as reasonably possible to (a) authorize Us to receive all the medical records and information We requested or, (b) provide Us with information We requested regarding the circumstances of the claim. Self administered Injectable Drugs, except as stated in the Prescription Drug Benefit section of this Plan. Syringes, except as stated in the Prescription Drug Benefits section of this Plan. 2. An Insured Person must be enrolled for 6 months under this plan to be eligible for benefits for all services including but not limited to all tests, consultations, examinations, medications, invasive, medical, laboratory or surgical procedures that are related to the evaluation or treatment of: a. hernia except for strangulated or incarcerated hernia. b. any disorder of reproductive organs. c. sterilization. d. varicose veins. e. hemorrhoids. f. any disorder of tonsils or adenoids. 3. If You are admitted to a Hospital or Skilled Nursing Facility for any of the conditions requiring fulfillment of the Waiting Period before the end of the Waiting Period, no benefits will be provided for any portion of that Hospital stay. TXICCDEDWPD

9 4. Penalties will apply under the following circumstances: a. If You submit a claim for services which has a maximum payment limit We will only apply the allowed per visit, per day, or per event amount (whichever applies) toward Your penalty amount. b. Emergency room services that do not result in an inpatient stay admission into that Hospital immediately following the Emergency room visit will have a $60 penalty. c. Inpatient Hospital admissions without a pre-service review are subject to a $500 penalty. d. Ambulatory Surgical Center services: You are responsible for a $50 penalty per admission if You fail to obtain pre-service review. e. Authorization is required prior to receiving services from Skilled Nursing facilities, Infusion Therapy services, Home Health services, Hospice services and for organ and tissue transplants Failure to obtain Authorization prior to receiving these services will result in a reduction in benefits. f. You must also obtain Authorization for Self-Administered Injectable Drugs (except for insulin), injectable drugs administered in an out patient setting (e.g. Physician s office) and other drugs as determined by UniCare. 5. Maximum Benefits The combined total of all benefits paid to You or any Insured Family Member is limited to a maximum of $5 million during each Insured Person's lifetime. I. Authorization Program The UniCare Insured is required to obtain Authorization in order to receive maximum benefits for certain services. This Authorization program applies to the special services of organ and tissue transplants, Infusion Therapy services, Home Health services, Hospice services, and Skilled Nursing Facility services. Benefits for the above mentioned services will be subject to a reduction in benefits per continuing hospital confinement or course of treatment if Authorization is not obtained prior to services being rendered. You must also obtain Authorization for Self-Administered Injectable Drugs (except for insulin), injectable Drugs administered in an outpatient setting (e.g., Physician s office) and other Drugs as determined by UniCare. To initiate this authorization, instruct Your Physician to request Authorization at least three working days before a service requiring Authorization is performed by calling the UniCare Review Center at 1 (800) Utilization Review The UniCare Participating Provider Plan includes a program to evaluate Hospital, Ambulatory Surgical Center admissions. These procedures ensure that such care is received in the most appropriate setting. If UniCare determines that a Hospital stay or any surgery or any other service is not Medically Necessary, You are responsible for payment of the charges for those services. Utilization Review does not guarantee that You have coverage, that benefits will be paid, or the amount of benefits. Payment of benefits will be determined by the terms, conditions, exclusions, Waivers, and limitations of Your UniCare Plan including Medical Necessity, Preexisting Condition Limitations and Waiting Periods. No benefits are payable unless the Insured Person's coverage is in force at the time services are rendered. TXICCDEDWPD

10 J. Continuity of Care UniCare will provide written notice to Insureds within a reasonable period of time of any participating provider s termination or breach of, or inability to perform under, any provider contract, if UniCare determines that an Insured or an Insured Family Member may be materially or adversely affected and provide You with a current directory. Continuation of Care after Termination of a Provider whose participation has terminated: UniCare will provide benefits to You or Your Insured Family Members at the Participating Provider level for Covered Services of a terminated Provider for the following special circumstances: Ongoing treatment of an Insured Person up to the 90 th day from the date of the provider s termination date. Ongoing treatment of an Insured who at the time of termination has been diagnosed with a terminal illness, but in no event beyond 9 months from the date of the provider s termination date. UniCare will provide Insureds with an updated list of local Participating Providers annually. If an Insured would like a more extensive directory, or need a new provider listing for any other reason, the Insured may call UniCare at 1 (800) , and UniCare will provide one. A directory of local UniCare Participating Providers is also available by calling Our customer service department at 1 (800) or through our web site, K. Complaint Resolution Procedures If the UniCare Insured s claim is denied in whole or in part, the Insured will receive written notification of the denial. The notification will explain the reason for the denial. The Insured has the right to appeal any denial of a claim for benefits by submitting a written request for reconsideration with UniCare. Requests for reconsideration must be filed within 60 days of the written notification of denial. When UniCare receives the written request, UniCare will review the claim and arrive at a determination. If the matter is not resolved to the Insured s satisfaction, a second review may be requested by sending UniCare a written request for a second reconsideration. This written request must be filed within 60 days of the Insured s receipt of the written notification of the result of the first review. If the issue involves a dispute over the coverage of medical services, or the extent of that coverage, the second review will be completed by physician consultants who did not take part in the initial reconsideration. The Insured will be informed, in writing, of UniCare s final decision. If the matter involves an Adverse Determination and the Insured s appeal has been denied, the Insured may seek a review of the second appeal determination by an independent review organization who is granted a certification of registration. To initiate a review by an independent review organization, an Insured must submit a written request to UniCare. An Adverse Determination is a determination by UniCare that the health care services furnished or proposed to be furnished to an Insured are not Medically Necessary. UniCare shall not take any retaliatory action, such as refusing to renew or canceling coverage, against the Insured or provider because the provider has, on behalf of the Insured, filed a complaint against or appealed a decision made by UniCare. TXICCDEDWPD

11 L. Participating Providers UniCare will provide a current list of physicians and other health care providers currently participating with UniCare and their locations to each Insured upon application, (see enclosed). Annually thereafter, UniCare will provide an updated Provider Directory for each Insured. Additional directories are available upon request by contacting UniCare at 1 (800) , or through our web site To verify if a physician or other health care provider is currently participating with UniCare and is accepting new UniCare Insureds, the Insured should contact the Customer Service Unit at 1 (800) , or the Provider directly, prior to making appointments. M. Service Area The UniCare service area is defined as any place that is within fifty (50) miles of a participating provider and in the state of Texas. N. Renewability, Eligibility, and Conversion Privilege 1. The plan will renew except for the specific events stated in the plan. UniCare may change the premiums of the plan after 30 days written notice to the Insured. However, UniCare will not refuse to renew or change the premium schedule for the plan on an individual basis, but only for all Insureds in the same class and covered under the same plan as You. 2. The Individual Consumer Choice Plan is designed for Texans who are not enrolled under or covered by any other group or individual health coverage. You must notify UniCare of all changes that may affect any Insured person s eligibility under the plan. 3. You or Your Insured Family Members will become ineligible for coverage: a. When premiums are not paid according to the due dates and grace periods described in Section IX of the Plan. b. When the Insured s spouse is no longer married to the Insured. c. When the Insured Person no longer meets eligibility requirements as an eligible family member (except that grandchildren do not have to continue to qualify as a dependent of the Insured for federal income tax purposes). 4. If the Insured s spouse becomes ineligible for coverage under the plan because of death or divorce, he or she may request their own plan from UniCare with the same benefits as the plan they were previously on. Other Insured Family Members who are no longer eligible due to age or who no longer qualify as dependents for coverage under this plan may also obtain a similar plan through UniCare. To be eligible for this conversion privilege, You must write UniCare within 31 days of the loss of eligibility to request coverage. Proof of good health is not required. Any and all probationary and/or waiting periods in the new Plan will be shortened and considered as being met to the extent coverage was in force under this Plan. O. Premium 1. The initial premium for the plan for which You have made application is $ for months. Premiums thereafter are payable quarterly by check or monthly through automatic bank draft withdrawals. The initial premium amount must be submitted with Your original application. 2. The premium rates for this plan are based on the sex, age, place of residence, and the number and relationship of the Insured s Family Members covered by the plan. Changes in these factors may result in a change in premium. a. If You reach an age which results in a new premium rate, the premium will automatically change to the rate applicable to Your new age. b. The rate provided You is for the residence shown in Your application. It may not apply to a different place of residence. Your premium rates are subject to automatic adjustment upon change of residence. c. UniCare also has the right to change premiums after 30 days notice to You. d. If both the Insured and the Insured s spouse are covered under the same plan, the premium will be calculated based on the age of the older person. TXICCDEDWPD

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