UniCare State Indemnity Plan / Community Choice PPO-Type

UniCare State Indemnity Plan/Community Choice is a PPO-type plan.

Plan Overview

The UniCare State Indemnity Plan/Community Choice is a PPO-type plan with a hospital network of community and some tertiary hospitals at 100% coverage, after a copayment.  Or, you may seek care from an out-of-network hospital at 80% coverage of the allowed amount for inpatient care and outpatient surgery, after you pay a copay. Contact the plan to find out if your hospital is in the network.

The plan offers access to all Massachusetts physicians and members are encouraged to select a Primary Care Provider (PCP). 

The behavioral health benefits of this plan, administered by Beacon Health Options, 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. Beacon also offers EAP services.  Prescription drug benefits are administered by CVS Caremark.

Specialist Tiering

UniCare tiers Massachusetts specialists based on quality and/or cost efficiency 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. 

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

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

CVS Caremark for Existing Members

CVS Caremark for Prospective Members 

Fiscal Year Deductibles

Medical Deductible
$500 per individual/$1,000 per family. 

Prescription Drug Deductible

$100 per individual/$200 per family

In-Network Out-Of-Pocket Maximum

Medical & Behavioral Health:

$4,000 per individual: $8,000 per family.

Prescription drug:

$1,500 per individual: $3,000 per family.

In-Network Copays Effective July 1, 2017

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. Contact the plan to see how your provider is rated.
***Tier 1 (excellent):           $30 per visit
  **Tier 2 (good):                $60 per visit
    *Tier 3 (standard):           $90 per visit

Retail Clinic and Urgent Care Center

$20 per visit

Outpatient Behavioral Health and Substance Use Disorder Care (See the Attached grid UniCare Community Choice  for additional benefit details.)

$20 per visit

Beacon 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)
$275 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 up to 30-day s                                                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?

Employees, Retirees, Survivors, and their eligible dependents without Medicare are eligible.   

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

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