The UniCare State Indemnity Plan/Basic offers access to any licensed doctor or hospital throughout the United States and outside of the country. 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 Options, 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.
UniCare tiers Massachusetts specialists based on quality and/or cost efficiency. 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.
Plan Contact Information
Contact the plan for additional information on benefits and the national network of providers.
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
$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.
$1,500 per individual; $3,000 per family.
Copays with CIC (Comprehensive) Effective July 1, 2016
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
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 and Urgent Care Center
$20 per visit
$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)
$250 per occurrence
High-Tech Imaging (e.g., MRI, PET and CT scans) (Maximum one copay per day)
$100 per scan
$100 per visit (waived if admitted)
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, GIC Retired Municipal Teachers (RMTs), Elderly Governmental Retirees (EGRs), Survivors, and their eligible dependents without Medicare are eligible.
Where You Live Determines Which Plan You May Enroll In
The UniCare State Indemnity Plan/Basic is the only health plan offered by the GIC that is available throughout the United States and outside of the country.
FY16 UniCare State Indemnity Plan/Basic handbook - for employees and Non-Medicare retirees (Series 1)
FY16 UniCare State Indemnity Plan/Basic handbook file size 2MB - for employees and Non-Medicare retirees (Series 1)
FY16 UniCare State Indemnity Plan/Basic handbook file size 2MB - for retirees in the Retired Municipal Teacher (RMT) and EGR programs (series 3)
FY16 UniCare State Indemnity Plan/Basic handbook file size 7MB - for retirees in the Retired Municipal Teacher (RMT) and EGR programs (series 3)
This information provided by the Group Insurance Commission .