GIC Medicare Health Plan Options

UniCare State Indemnity Plan/Medicare Extension (OME)
Eligibility
Plan Contact Information
Plan Service Area

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 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)
(Without CIC deductibles are higher and coverage is only 80% for some services.  Contact the plan for details.)

Physician Office Visit
100%

Preventive Care
100% after $5 per visit

Network Outpatient Mental Health and Substance Abuse Care (contact UBH for other mental health and substance abuse benefit details)
First four visits 100%; visits 5 and over: 100% after $10 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 $50 deductible

Outpatient Surgery
100% within Massachusetts; call the plan for out-of-state details
:
Emergency Room
100% after $25 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
Retirees, Retired Municipal Teachers (RMTs), Elderly Governmental Retirees (EGRs), survivors, and their eligible dependents with Medicare Part A and Part B are eligible, regardless of where they live.

Service Area
The UniCare State Indemnity Plan/Medicare Extension is 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