Plan Overview
The UniCare State Indemnity Plan/Basic offers access to any licensed doctor or hospital throughout the United States and outside of the country. Massachusetts members pay lower office visit copays when they see Tier 1 or Tier 2 specialists. Contact the plan to see how a physician is rated.
The plan determines allowed amounts for out of state providers; you may be responsible for a portion of the total charge. To avoid these additional provider charges, if you use non-Massachusetts doctors or hospitals, contact the plan to find out which doctors and hospitals in your area participate in UniCare’s national network of providers.
The mental health benefits of this plan, administered by Beacon Health Strategies effective July 1, 2013, 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 benefits and the national network of providers.
Medical Benefits:
UniCare 1.800.442.9300
Mental Health, Substance Abuse and EAP Benefits:
Beacon Health Strategies 1-855-750-8950
Prescription Drug Benefits
CVS Caremark 1.877.876.7214 TDD 1-800-238-0756
Calendar Year Deductible
$250 per individual up to a maximum of $750 per family.
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.
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
***Tier 1 (excellent): $25 per visit
**Tier 2 (good): $35 per visit
*Tier 3: (standard): $45 per visit
Out-of-State Primary Care Physician and Specialist Office Visit $35 per visit
Retail Clinic
$20 per visit
Network Outpatient Mental Health and Substance Abuse Care (See the
UniCare Basic 
grid for employees and retirees or the
UniCare Basic grid for RMTs and EGRs
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)
$200 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: $20
Tier 2: $25 Tier 2: $50
Tier 3: $50 Tier 3: $110
Who is Eligible?
Employees, Retirees, GIC Retired Municipal Teachers (RMTs), Elderly Governmental Retirees (EGRs), Survivors, and their eligible dependents without Medicare are eligible, regardless of where they live.
Where You Live Determines Which Plan You May Enroll In:
The UniCare State Indemnity Plan/Basic is the only Non-Medicare plan offered by the GIC that is available throughout the United States and outside of the country.
Handbooks:
UniCare State Indemnity Plan Basic FY13 Handbook file size 1MB
- for employees and Non-Medicare retirees (Series 1)
UniCare State Indemnity Plan Basic FY13 Handbook file size 3MB
- for retirees in the Retired Municipal Teacher (RMT) and EGR programs (series 3)
This information provided by the Group Insurance Commission.
