Plan Overview

Limited Network Plan logo

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.

Specialist Tiering

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.

Medical Benefits:
UniCare 1.800.442.9300

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.

Prescription drug:

$1,500 per individual: $3,000 per family.

In-Network Copays Effective July 1, 2015

Primary Care Provider Office Visit
$20 per visit
Preventive Services

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

Retail Clinic

$20 per visit

Outpatient Mental Health and Substance Abuse Care (See the Attached grid UniCare Community Choice doc format of Beacon_benefitgrid_unicarecommunitychoicefy16.doc
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

Emergency Room
$100 per visit (waived if admitted)

Prescription Drug

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

Handbook

UniCare State Indemnity Plan Community Choice FY15 Handbook doc format of UniCareCCseries5FY15.doc
file size 1MB  - series 5

UniCare State Indemnity Plan Community Choice FY15 Handbook pdf format of UniCareCCseries5FY15.pdf
file size 2MB - series 5


This information provided by the Group Insurance Commission .

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