UniCare State Indemnity Plan / PLUS (PPO-Type)

UniCare State Indemnity Plan/PLUS

The UniCare State Indemnity Plan/PLUS is a PPO-type plan that provides access to all Massachusetts physicians and hospitals and out-of-state UniCare providers at 100% coverage, after a copayment.  Out-of-state non-UniCare providers have 80% coverage of allowed charges.

GIC Employee/Non-Medicare Plan

Plan Overview

The UniCare State Indemnity Plan/PLUS is a PPO-type plan that provides access to all Massachusetts physicians and hospitals and out-of-state UniCare providers at 100% coverage, after a copayment.  Out-of-state non-UniCare providers have 80% coverage of allowed charges. To avoid additional non-Massachusetts provider charges, contact UniCare to find doctors and hospitals in your area who participate in UniCare’s national Anthem and Private Healthcare Systems (PHCS) network. Members are encouraged to select a Primary Care Provider (PCP) to manage their care and pay a lower copay if they see a Centered Care PCP.  Contact the plan to find out if your PCP is a Centered Care provider.

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 and Hospital 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. 

The plan also tiers hospitals based on quality and/or cost; members pay a lower inpatient hospital and outpatient surgery copay when they use Tier 1 or Tier 2 hospitals.  Contact the plan to see which tier your hospital is in.

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 1.855.750.8950

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 and Behavioral Heath:

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

Prescription Drugs:

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

In-Network Copays Effective July 1, 2017

Primary Care Providers Office Visit
$15 per visit for Centered Care PCPs

$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 PLUS  for additional benefit details.)

$20 per visit

Beacon also offers EAP services.

Inpatient Hospital Care  - Medical

UniCare tiers hospitals based on quality and/or cost

(Maximum one copay per person per calendar year quarter;  waived if readmitted within 30 days in the same calendar year)
Tier 1:   $275 per admission
Tier 2:   $500 per admission
Tier 3:   $1,500 per admission

Contact the plan to see which tier your hospital is in.

Outpatient Surgery

UniCare’s outpatient surgery copay is based on the hospital’s tier, with Tier 1 and Tier 2 hospitals having the same outpatient surgery copay  (Maximum one copay per person per calendar year quarter).

Tier 1 and Tier 2: $110 per occurrence
Tier 3:  $250 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 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?

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/PLUS is available throughout Massachusetts.

The plan is also available in the following other states:

Maine, New Hampshire, Rhode Island

The UniCare State Indemnity Plan/PLUS is available only in certain parts of the following state; contact the plan to find out if you live in the service area:

Connecticut

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