UniCare State Indemnity Plan / PLUS (PPO-Type)

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 Deductible

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                                                    Mail Order up to 90-day supply:
up to 30-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

Handbook

FY18 UniCare State Indemnity Plan/PLUS Handbook docx format of FY18_S4_PLUS_FINAL.docx
- series 4
FY18 UniCare State Indemnity Plan/PLUS Handbook pdf format of FY18_S4_PLUS_Handbook.pdf
file size 2MB - series 4

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