Plan Overview

The UniCare State Indemnity Plan/PLUS is a PPO-type plan that provides access to all Massachusetts physicians and hospitals and out-of-state UniCare providers at 100% coverage, after a copayment.  Out-of-state non-UniCare providers have 80% coverage of allowed charges. The plan encourages members to select a Primary Care Provider (PCP). Members will also pay a low copay if they see a Centered Care PCP.  Contact the plan to find out if your PCP is a Centered Care provider.

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.  The plan also tiers hospitals based on quality and/or cost; members pay a lower inpatient hospital and outpatient surgery copay when they use Tier 1 or Tier 2 hospitals.  Contact the plan to see which tier your hospital is in.

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.

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 Strategies 1.855.750.8950

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

$250 per individual up to a maximum of $750 per family. 

In-Network Out-Of-Pocket Maximum

Excludes Prescription Drug Costs

$5,000 per individual; $10,000 per Family

In-Network Copays Effective July 1, 2014

Primary Care Providers 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):           $25 per visit
 **Tier 2 (good):                 $35 per visit
    *Tier 3 (standard):          $45 per visit

Retail Clinic

$20 per visit

Outpatient Mental Health and Substance Abuse Care (See the attached grid UniCare PLUS doc format of Beacon_benefit_grid_UniCarePLUS_FY15.doc
grid  for additional benefit details.)

$20 per visit

Beacon also offers EAP services.

Inpatient Hospital Care  - Medical

UniCare tiers hospitals based on quality and/or cost

(Maximum one copay per person per calendar year quarter;  waived if readmitted within 30 days in the same calendar year)
Tier 1:   $250 per admission
Tier 2:   $500 per admission
Tier 3:   $750 per admission

Contact the plan to see which tier your hospital is in.

Outpatient Surgery

UniCare’s outpatient surgery copay is based on the hospital’s tier, with Tier 1 and Tier 2 hospitals having the same outpatient surgery copay  (Maximum one copay per person per calendar year quarter).

Tier 1 and Tier 2: $110 per occurrence
Tier 3:  $250 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:   $20
Tier 2:   $25                                                     Tier 2:   $50
Tier 3:   $50                                                     Tier 3:   $110

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/PLUS is available throughout Massachusetts.

The plan is also available in the following other states:

Maine, New Hampshire, Rhode Island

The UniCare State Indemnity Plan/PLUS is available only in certain parts of the following state; contact the plan to find out if you live in the service area:

Connecticut

Handbook

UniCare State Indemnity Plan PLUS FY15 Handbook doc format of UniCarePLUSseries4FY15.doc
- series 4

UniCare State Indemnity Plan PLUS FY15 Handbook pdf format of UniCarePLUSseries4FY15.pdf
- series 4


This information provided by the Group Insurance Commission .