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.   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.

Effective January 1, 2016 members will be automatically enrolled in Medicare Part D as the drug benefit of this plan transitions to an Employer Group Waiver Plan (EGWP). 

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 Options 1-855-750-8980

Prescription Drug Benefits
SilverScript Effective January 1, 2016

1.877.876.7214 TDD: 1-800-238-0756

SilverScript (Website Effective October 1, 2015)

Copays with CIC (Comprehensive) Effective July 1, 2015

(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


Preventive Services

Covered at 100% - no copay

Retail Clinic


Network Outpatient Mental Health and Substance Abuse Care (See the Attached Beacon OME Grid docx format of UniCareMedicareOMEBenefitGridFY16.docx
 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:   $25
Tier 2:   $30                                       Tier 2:   $75
Tier 3:   $65                                        Tier 3:   $165

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.

FY16 UniCare State Indemnity Plan/Medicare Extension handbook docx format of UniCare_OME_FY16Handbook.docx
 - series 2

FY16 UniCare State Indemnity Plan/Medicare Extension handbook pdf format of UniCare_OME_FY16Handbook.pdf
file size 1MB  - series 2

This information provided by the Group Insurance Commission .