Plan Overview
The UniCare State Indemnity Plan/Community Choice is a PPO-type plan with a hospital network based at community and some tertiary hospitals. Or, you may seek care from an out-of-network hospital for 80% coverage of the allowed amount for inpatient care and outpatient surgery, after you pay a copay. The plan offers access to all Massachusetts physicians and members are encouraged but not required to select a Primary Care Provider (PCP). 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 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.
! Your Responsibility
Are your hospitals in the UniCare Community Choice network?
Contact the Plan.
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 Provider 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
Retail Clinic
$20 per visit
Outpatient Mental Health and Substance Abuse Care (See the Attached grid
UniCare Community Choice 
for additional benefit details.)
$20 per visit
UBH 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;)
$250 per admission
Outpatient Surgery (Maximum one copay per person per calendar year quarter)
$110 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/Community Choice is available in the following Massachusetts counties:
Barnstable, Berkshire, Bristol, Essex, Franklin, Hampden, Hampshire, Middlesex, Norfolk, Plymouth, Suffolk, Worcester
Handbooks:
UniCare State Indemnity Plan Community Choice FY13 Handbook file size 1MB
- series 5
This information provided by the Group Insurance Commission.
