The UniCare State Indemnity Plan /Medicare Extension (OME) is a supplemental Medicare plan offering access to any licensed doctor or hospital throughout the United States and outside of the country. The mental health benefits of this plan, administered by Beacon Health Strategies, offer you in-network benefits with a copay. Or, you may seek care out-of-network, but at higher out-of-pocket costs. Prescription drug benefits are administered by CVS Caremark.
Plan Contact Information
Contact the plan for additional benefit information.
Mental Health, Substance Abuse and EAP Benefits:
Beacon Health Strategies 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
Copays with CIC (Comprehensive) Effective July 1, 2014
(Without CIC, deductibles are higher and coverage is only 80% for some services. Contact the plan for details.)
Calendar Year Deductible $35 per person
Physician Office Visit
Covered at 100% - no copay
Network Outpatient Mental Health and Substance Abuse Care (See the Attached Beacon OME Grid 31 for additional benefit details.)
First four visits $0; visits 5 and over: $10 per visit
Beacon also offers EAP services.
Inpatient Hospital Care (Maximum one copay per person per calendar year quarter)
$50 per admission
Inpatient and Outpatient Surgery
Covered at 100% - No copay - in Massachusetts and for out-of-state providers who accept medicare, call the plan for details if using out-of-state providers who do not accept medicare.
$25 per visit (waived if admitted)
Retail up to 30 day supply: Mail Order up to 90-day supply:
Tier 1: $10 Tier 1: $20
Tier 2: $25 Tier 2: $50
Tier 3: $50 Tier 3: $110
Who is Eligible?
Retirees, GIC Retired Municipal Teachers (RMTs), Elderly Governmental Retirees (EGRs), Survivors, and their eligible dependents with Medicare Part A and Part B are eligible.
Where You Live Determines Which Plan You May Enroll In:
The UniCare State Indemnity Plan/Medicare Extension (OME) is available throughout the United States and outside of the country.
UniCare State Indemnity Plan Medicare Extension FY15 Handbook file size 1MB - series 2
This information provided by the Group Insurance Commission .