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, 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.

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, 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

None 

Preventive Services

Covered at 100% - no copay

Retail Clinic

None

Network Outpatient Mental Health and Substance Abuse Care (See the Attached Beacon OME Grid doc format of    Beacon_benefit_grid_OMEFY15.doc   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.

Emergency Room
$25 per visit (waived if admitted)

Prescription Drug

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 FY14 Handbook doc format of    UniCareOMEseries2FY14.doc  file size 1MB - series 2


This information provided by the Group Insurance Commission.