GIC Health Plan Options

Commonwealth Indemnity Plan Basic
Eligibility
Plan Contact Information
Plan Service Area

Plan Overview
The UniCare State Indemnity Plan/Basic offers access to any licenced doctor or hospital throughout the United States and outside of the country. Your co-pays are determined by your choice of physician.   Massachusetts members pay lower office visit co-pays when they see Tier 1 or Tier 2 physicians.  Contact the plan to see how your physician is rated. 

The plan determines “allowed amounts” for out of state providers; you may be responsible for a portion of the total charge.  To avoid these additonal provider charges, if you use non-Massachusetts doctors or hospitals, contact the plan to find out which doctors and hospitals in your area participate in UniCare’s national network of providers. 

The mental health benefits of this plan, administered by United Behavioral Health (UBH), offer you a choice of using network providers and paying a co-payment, or seeking care from out-of-network providers at higher out-of-pocket costs.


Benefits with CIC (Comprehensive) Effective July 1, 2008
Without CIC, deductibles are higher and coverage is only 80% for some services.  Contact the plan for details.

UniCare tiers Massachusetts physicians based on quality and cost efficiency standards.

Primary Care Physician Office Visit
Tier 1 (excellent):   100% after $10 per visit
Tier 2 (good):   100% after $20 per visit
Tier 3 (standard): 100% after $25 per visit

Specialist Office Visit
Tier 1 (excellent):   100% after $10 per visit
Tier 2 (good):   100% after $20 per visit
Tier 3 (standard): 100% after $30 per visit

Out-of-State Primary Care Physician and Specialist Office Visit: 100% after $20 per visit

Network Outpatient Mental Health and Substance Abuse Care (contact UBH for other mental health and substance abuse benefit details)
100% after $15 per visit
UBH also offers EAP services.

Inpatient Hospital Care – Medical (maximum one deductible per person per calendar year quarter; waived if readmitted within 30 days in the same calendar year)
100% after $200 deductible

Outpatient Surgery
100% after $100 deductible (maximum one deductible per person per calendar year quarter)

Emergency Room
100% after $50 co-pay per visit (waived if admitted)


Prescription Drug Co-payments
Retail up to 30-day supply:                    Mail Order up to 90-day supply:
Tier 1: $7                                                    Tier 1:   $14
Tier 2: $20                                                   Tier 2:   $40
Tier 3: $40                                                   Tier 3:   $90
Value Tier: $2                                             Value Tier: $4
Specialty drug mail order up to 30 day supply: $10

Eligibility
Employees, retirees, Retired Municipal Teachers (RMTs), Elderly Governmental Retirees (EGRs), survivors , and their eligible dependents without Medicare are eligible, regardless of where they live. 

Service Area
The UniCare State Indemnity Plan/Basic is the only GIC Employee/Non-Medicare plan available throughout the United States and outside of the country.

Monthly Rates as of July 1, 2008

Plan Contact Information
Contact the plan for additional benefit information.

Medical Benefits:
UniCare
1.800.442.9300

Mental Health, Substance Abuse and EAP Benefits:
United Behavioral Health (access code: 10910)
1.888.610.9039

Prescription Drug Benefits
Express Scripts
1.877.828.9744