UniCare State Indemnity Plan / Medicare Extension OME

The UniCare State Indemnity Plan/Medicare Extension (OME) is a supplemental Medicare plan.

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.   The behavioral health benefits of this plan, administered by Beacon Health Options, offer you in-network benefits with a copay. Beacon also offers EAP services. 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.

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

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.)

Preventive Services

Covered at 100% - no copay

Physician Office Visit

$10 per visit

Retail Clinic

$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.

Emergency Room
$50 per visit (waived if admitted)

Prescription Drug

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.


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