The UniCare State Indemnity Plan/Community Choice is a PPO-type plan with a hospital network based at community and some tertiary hospitals at 100% coverage, after a copayment. Or, you may seek care from an out-of-network hospital for 80% coverage of the allowed amount for inpatient care and outpatient surgery, after you pay a copay. Contact the plan to find out if your hospital is in the network.
The plan offers access to all Massachusetts physicians and members are encouraged to select a Primary Care Provider (PCP).
The mental health benefits of this plan, administered by Beacon Health Strategies, offer you a choice of using network providers and paying a copayment, or seeking care from out-of-network providers at higher out-of-pocket costs. Prescription drug benefits are administered by CVS Caremark.
UniCare tiers Massachusetts specialists based on quality and/or cost efficiency Members pay lower office visit copays when they see Tier 1 and Tier 2 specialists. Contact the plan to see how a physician is rated.
! Your Responsibility
Are your hospitals in the UniCare Community Choice network?
Contact the Plan.
Plan Contact Information
Contact the plan for additional information on
participating providers and benefits.
Mental Health, Substance Abuse and EAP Benefits:
Beacon Health Options 1.855.750.8980
Prescription Drug Benefits
1.877.876.7214 TDD: 1-800-238-0756
CVS Caremark for Existing Members
CVS Caremark for Prospective Members
Calendar Year Deductible - will transition to fiscal year
$300 per individual up to a maximum of $900 per family.
In-Network Out-Of-Pocket Maximum
Medical & Behavioral Health:
$4,000 per individual: $8,000 per family.
$1,500 per individual: $3,000 per family.
In-Network Copays Effective July 1, 2015
Primary Care Provider Office Visit
$20 per visit
Most covered at 100% - no copay
Specialist Office Visit
UniCare tiers Massachusetts specialists based on quality and/or cost efficiency. Contact the plan to see how your provider is rated.
***Tier 1 (excellent): $30 per visit
**Tier 2 (good): $60 per visit
*Tier 3: (standard): $90 per visit
$20 per visit
Outpatient Mental Health and Substance Abuse Care (See the Attached grid UniCare Community Choice for additional benefit details.)
$20 per visit
Beacon also offers EAP services.
Inpatient Hospital Care - Medical (Maximum one copay per person per calendar year quarter; waived if readmitted within 30 days in the same calendar year;)
$275 per admission
Outpatient Surgery (Maximum one copay per person per calendar year quarter)
$110 per occurrence
High-Tech Imaging(e.g., MRI, PET and CT scans) (Maximum one copay per day)
$100 per scan
$100 per visit (waived if admitted)
Retail Mail Order up to 90-day supply:
up to 30-day supply:
Tier 1: $10 Tier 1: $25
Tier 2: $30 Tier 2: $75
Tier 3: $65 Tier 3: $165
Who is Eligible?
Employees, Retirees, Survivors, and their eligible dependents without Medicare are eligible.
Where You Live Determines Which Plan You May Enroll In
The UniCare State Indemnity Plan/Community Choice is available in the following Massachusetts counties:
Barnstable, Berkshire, Bristol, Essex, Franklin, Hampden, Hampshire, Middlesex, Norfolk, Plymouth, Suffolk, Worcester
FY16 UniCare State Indemnity Plan/Community Choice handbook file size 4MB - series 5
This information provided by the Group Insurance Commission .