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 but does not require members to select a Primary Care Provider (PCP). The plan provides
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 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 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
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.
In-Network Copays Effective July 1, 2013
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.
***Tier 1 (excellent): $25 per visit
**Tier 2 (good): $35 per visit
*Tier 3 (standard): $45 per visit
Out-of-State Primary Care Providers and Specialist Office Visit $30 per visit
Retail Clinic
$20 per visit
Outpatient Mental Health and Substance Abuse Care (See the Attached grid
UniCare PLUS 
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
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. Members must live in the plan’s service area.
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
Handbooks:
UniCare State Indemnity Plan PLUS FY13 Handbook file size 1MB
- series 4
This information provided by the Group Insurance Commission.
