Plan Overview
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 effective July 1, 2013, offer yu 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.
Medical Benefits:
UniCare 1.800.442.9300
Mental Health, Substance Abuse and EAP Benefits:
Beacon Health Strategies 1-855-750-8980
Prescription Drug Benefits
CVS Caremark 1.877.876.7214 TDD: 1-800-238-0756
Copays with CIC (Comprehensive) Effective July 1, 2013
(Without CIC, deductibles are higher and coverage is only 80% for some services. Contact the plan for details.)
Physician Office Visit
None after $35 calendar year deductible
Preventive Services
Covered at 100% - no copay
Retail Clinic
None after $35 calendar year deductible
Network Outpatient Mental Health and Substance Abuse Care (See the Attached grid
Beacon OME Grid 
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% within Massachusetts – no copay; call the plan for out-of-state details
Emergency Room
$25 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?
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:
UniCare State Indemnity Plan Medicare Extension FY13 Handbook file size 1MB
- series 2
This information provided by the Group Insurance Commission.
