Plan Features

Texas FIT

500 PLAN

1000 PLAN

Texas FIT 1500,2000 Plans

3000, 5000 Plans

Annual Deductible 1

Per member, two member maximum

$500 or $1,000

$1,500,  $2,000

$3,000,  $5,000

Additional Out-of-Network Deductible 1

$2,000 per member, per year

$2,000 per member, per year

Annual Out-of-Pocket Maximum 1

(Amounts shown plus applicable annual deductibles)

Par: $3,000 per member, $6000 per family,

Nonpar: $10,000 per member, $20,000 per family

Par: $3,000 per member, $6,000 per family,

Nonpar: $10,000 per member, $20,000 per family

$5,000,000 per member

Office visits

Exam only for any covered illness, injury or certain preventative care services for adults and children through age 6

Par: You pay a $30 copay, unlimited visits,

deductible waived

Nonpar: 50%, unlimited visits, deductible applies

Par: You pay a $30 copay, unlimited visits,
deductible waived

Nonpar: 50%, unlimited visits, deductible applies

Preventative Care

Well baby/Children (through age 6) Immunizations

Par/Nonpar: 100% deductible(s) waived

Par/Nonpar: 100% deductible (s) waived

Adult Preventative Care
Lab work and x-rays for routine Pap smears, annual mammograms and PSA screenings

Par: 100% deductible waived Maximum payment of $300 per member, per year. After maximum payment has been met, 80% deductible applies.

Nonpar: 50%, deductible applies

Par: 100% deductible waived Maximum payment of $300 per member, per year. After maximum payment has been met, 75% deductible applies.

Nonpar: 50%, deductible applies

Colorectal Cancer Screening

Par: 80%

Nonpar: 50%

Par: 75%

Nonpar: 50%

Professional Services

Surgery, anesthesia, radiation therapy, and in-hospital doctor visits

Par: 80%

Nonpar: 50%

Par: 75%

Nonpar: 50%

Lab Work and X-rays

Par: 80%

Nonpar: 50%

Par: 75%

Nonpar: 50%

Ambulance Service

Par: 80%

Nonpar: 50%

With a maximum covered expense of $1000 per trip for Ground; $5000 per family

Par: 75%

Nonpar: 50%

With a maximum covered expense of $1000 per trip for Ground; $5000 per family

Initial Care of Medical Emergency 2,3

Inpatient or outpatient

Par: 80%

Nonpar: 50%

Par: 75%

Nonpar: 50%

Par: 80%

Nonpar: 50%

Par: 75%

Nonpar: 50%

Outpatient Hospital 2,3

Or Surgical Center 2

Par: 80%

Nonpar: 50%

Par: 75%

Nonpar: 50%

Physical, Occupational and Speech Therapy, Acupuncture

Maximum payment of $30 per visit, up to 12 visits per member, per year, for all of these services combined

Maximum payment of $30 per visit, up to 12 visits per member, per year, for all of these services combined

Retail Pharmacy 5

Per prescription (up to a 30-day supply)

FIT 500 or FIT 1000

$250 Brand Name Deductible

FIT 1500 FIT 2000 - $250 Brand Name Deductible

FIT 3000 FIT 5000 - $500 Brand Name Deductible

Generic Drugs

Not subject to deductible(s)

Par: You pay a $10 copay

Nonpar: UniCare pays 50% of the average wholesale price

Par: You pay a $10 copay

Nonpar: UniCare pays 50% of the average wholesale price

Brand Name Drugs

Par: You pay a $30 copay for formulary drugs, or a $50 copay for non-formulary drugs

Nonpar: UniCare pays 50% of the average wholesale price

Par: You pay a $30 copay for formulary drugs, or a $50 copay for nonformulary drugs

Nonpar: UniCare pays 50% of the average wholesale price

Self Injectible Drugs

Brand name Deductible applies to brand name Self-administered injectable drugs

Par: UniCare pays 80%

Nonpar: UniCare pays 50% of the average wholesale price

Par: UniCare pays 75%

Nonpar: UniCare pays 50% of the average wholesale price