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 behavioral health benefits of this plan, administered by Beacon Health Options, 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 SilverScript.
Plan Contact Information
Contact the plan for additional benefit information.
Behavioral Health, Substance Use Disorder and EAP Benefits:
Beacon Health Options 1-855-750-8980
Prescription Drug Benefits
1.877.876.7214 TDD: 1-800-238-0756
Copays with CIC (Comprehensive) Effective July 1, 2017
(Without CIC, deductibles are higher and coverage is only 80% for some services. Contact the plan for details.)
Covered at 100% - no copay
Physician Office Visit
$10 per visit
$10 per visit
Network Outpatient Behavioral Health and Substance Use Disorder Care (See the Attached Beacon OME Grid 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.
$50 per visit (waived if admitted)
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.
FY17 UniCare State Indemnity Plan/Medicare Extension handbook file size 2MB - series 2
FY17 UniCare State Indemnity Plan/Medicare Extension handbook file size 1MB - for retirees in the Retired Municipal Teacher (RMT) and EGR programs (series 3)
FY17 UniCare State Indemnity Plan/Medicare Extension handbook file size 3MB - for retirees in the Retired Municipal Teacher (RMT) and EGR programs (series 3)
2016 UniCare OME Prescription Drug Evidence of Coverage file size 1MB
This information provided by the Group Insurance Commission .