NHP Prime–Neighborhood Health Plan (HMO) Tufts Health Plan Navigator (POS) (Closed to New Members) Tufts Health Plan Spirit (HMO-type) UniCare State Indemnity/Basic CIC: Yes No UniCare Community Choice (PPO-type) UniCare/PLUS (PPO-type) Coverage Election . We are uniquely positioned to tailor what we do to those who receive their health coverage through the GIC. UniCare State Indemnity Plan/Basic with CIC National Network Indemnity $1,163.76 $2,582.71 UniCare State Indemnity Plan/Basic without CIC $1,107.42 $2,454.41 UniCare State Indemnity Plan/PLUS Broad Network PPO-Type $723.74 $1,722.50 Tufts Health Plan Navigator POS $799.04 $1,951.46 Fallon Health Select Care HMO $836.19 $2,033.04 UniCare State Indemnity Plan/Basic without CIC (Non-Comprehensive) Family 2,245.96 1,122.98 1,122.98 561.49 1,122.98 1,122.98 561.49 UniCare State Indemnity Plan/Basic without CIC (Non-Comprehensive) Indiv 959.09 479.53 479.56 239.78 479.53 479.56 239.78 UniCare State Indemnity Plan/Community Choice Family-PPO type unicare state indemnity plan/basic w/cic indemnity $ 935.94 $ 233.98 $ 280.78 $ 295.56 $ 467.97 $ 561.56 unicare state indemnity plan/community choice ppo-type $ 442.75 $ 110.69 $ 132.83 $ 139.82 $ 221.38 $ 265.65 Plan Website: Massachusetts State Employees' Health Plan Administrator: National Network - UniCare State Indemnity Plan/Basic with CIC (Comprehensive) - - Commonwealth of Mass Group Insurance Commission This plan has no exclusion. UniCare State Indemnity Plan Basic with CIC (Comprehensive) $173.44 $346.88 $385.45 $770.90 UniCare State Indemnity Plan Basic without CIC (Non-Comprehensive) $143.24 $286.49 $316.70 $633.41 UniCare State Indemnity Plan/Community Choice $74.76 $149.53 $184.63 $369.26 UniCare State Indemnity Plan/PLUS $98.20 196.41 233.32 466.64 For more information about a specific plan’s benefits or providers, call the plan or visit its website. The GIC has contracted with CVS SilverScript to manage the prescription drug benefit for all GIC Medicare medical products. UniCare State Indemnity Plan/Basic with CIC 2 (Comprehensive) National Network $167.15 $373.09 $222.65 $495.71 $278.15 $618.32 UniCare State Indemnity Plan/Basic without CIC $111.01 $245.24 $166.51 $367.86 $222.01 $490.47 UniCare State Indemnity Plan/PLUS Broad Network $72.77 $172.30 $109.16 $258.45 $145.54 $344.60 Tufts Health Plan Navigator with cic $399.86 $299.90 $99.97 unicare state indemnity plan 75% 25% medicare ext. CIC is an option retiree-pay-all part of the UniCare State Indemnity Plan (OME & Basic). Individual Family . The choice is yours No network — UniCare plans cover all providers. Sorry, we're experiencing technical difficulties at this time. Your prescription drug benefit is an Employer Group Waiver Plan (EGWP). They include Tufts Health Plan Navigator (POS), Harvard Pilgrim Independence Plan (PPO), and Unicare State Indemnity Plan/Basic with CIC (Indemnity) for active employees. Optional Life Enrollment/Change: (check one) Automatic Increase – UniCare State Indemnity Plan/ PLUS Broad PPO-type 15% 117.30 280.01 Tufts Health Plan Navigator POS 15% 125.50 306.89 Fallon Health Select Care HMO 15% 129.45 315.09 Harvard Pilgrim Independence Plan POS 15% 144.64 353.42 UniCare State Indemnity/ Basic with CIC National Indemnity 40% 481.67 1069.64 UniCareState Indemnity Plan/PLUS PPO-type (82/18) $781.99 $1,866.72 $641.23 $140.76 $1,530.71 $336.01 $7,694.78 $1,689.10 $18,368.52 $4,032.12 Health New England Allways Health Partners Complete UniCare State Indemnity Plan/Basic with CIC (Comprehensive) Tufts Health Plan Navigator UniCareState Indemnity Plan/PLUS Tufts Health Plan Spirit Unicare State Indemnity Plan/Basic with CIC Individual $177.25 $143.17 Family $394.11 $318.32 Unicare State Indemnity Plan/Basic without CIC Individual $147.79 $119.37 Family $327.03 $264.14 Unicare State Indemnity Plan/Community Choice Individual $73.93 $59.17 Family $182.42 $147.34 Unicare State Indemnity Plan/PLUS Individual $99.44 $80.32 Box 8747, Boston, MA 02114. UniCare State Indemnity Plan/Medicare Extension (OME) with CIC (Comprehensive) 12.5% 49.99 12.5% 49.99 UniCare State Indemnity Plan/Medicare Extension (OME) without CIC (Non-Comprehensive) 12.5% 48.60 12.5% 48.60 Retirees and Survivors Dental Coverage Dental Plan Individual Family Basic Low Plan $42.33 $88.89 unicare state indemnity plan/basic w/cic indemnity $ 935.94 $ 233.98 $ 280.78 $ 295.56 $ 467.97 $ 561.56 unicare state indemnity plan/community choice ppo-type $ … Tufts Health Plan Spirit EPO(HMO-Type) Unicare State Indemnity Plan Basic with CIC Unicare State Indemnity Plan/Community Choice PPO -Type Unicare State Indemnity Plan/Plus PPO -Type Not enrolled in any plan listed Bank Name: (See #1 on sample) Checking Account Savings Account The two UniCare State Indemnity Basic Plans (with and without CIC) are the exceptions and are split 50% with the Town. HMO HMO INDEMNITY Yes Yes No Yes Yes No Tufts Health Plan Navigator Individual Famil Tufts Health Plan Spirit Individual Famil UniCare State Indemnity/Basic W/CIC Individual Famil UniCare State Ind/Basic Without CIC/ Individual Famil UniCare State Ind/Community Choice Individual Famil UniCare State Indemnity/Plus Individual Famil 18 Bi-weekl s 60.07 $151.42 s 81.18 s 197.19 s 148.27 tufts health plan medicare 75% 25% 65 - 69 $371.50 $278.62 $92.88 70 - 74 tufts medicare preferred* 84% 16% $322.43 $270.84 $51.59 unicare state indemnity plan 75% 25% medicare ext. The actuarial valuation is based on: Plan … with cic $386.93 $290.20 $96.73 unicare state indemnity plan 75% 25% medicare ext. UniCare Community Choice (PPO-type) {Closed to New Members) ... o elections are binding for the duration of the plan year and that I may only enroll in health insurance or change my coverage elections during the plan year Tufts Health Plan Spirit HMO-type F $ 385.48 $ 96.37 UniCare State Indemnity Plan/Basic w/CIC Indemnity I $ 421.46 $ 105.36 UniCare State Indemnity Plan/Basic w/CIC Indemnity F $ 935.94 $ 233.98 UniCare State Indemnity Plan/Community Choice PPO-type I $ 178.15 $ 44.54 HMO Medicare Plans HMO Unicare State Indemnity Plan w/CIC (Indemnity) Unicare State Indemnity Plan Plus (PPO-Type) Cost: UMass Boston pays 75% of your premium and you are responsible for 25% of the premium which is deducted biweekly from your paycheck on a pre-tax basis. with CIC. Plan and UniCare State Indemnity Plan/ Medicare Extension (OME) are available throughout the United States. UniCare State Indemnity Plan/Basic . Members who retired after 7/1/94, under the 85/15 rate structure, will see the following increase in the Indemnity Plan: individual $1.61 (2.36%), The product combines a standard Medicare Part D prescription drug plan with additional coverage provided by the GIC. UniCare State Indemnity Plan/Basic with CIC (Comprehensive) (Indemnity) 40% 415.52 972.22 UniCare State Indemnity Plan/Basic without CIC (Non-Comprehensive) (Indemnity) 40% 396.72 928.61 UniCare State Indemnity Plan/Community Choice (PPO-TYPE) 40% 208.24 499.78 UniCare State Indemnity Plan/PLUS (PPO-TYPE) 40% 277.28 662.45 UniCare State Indemnity Plan/Basic without CIC (Non-Comprehensive) 10% 110.74 245.44 30% 332.23 736.32 UniCare State Indemnity Plan/Community Choice 10% 55.26 136.81 15% 82.89 205.21 UniCare State Indemnity Plan/PLUS 10% 72.37 172.25 15% 108.56 258.38 INCLUDING THE 0.35% ADMINISTRATIVE FEE UniCare writes state indemnity coverage for members in the state of Massachusetts. UniCare State Indemnity Plan/Basic with CIC (Comprehensive) With Basic, you can live anywhere, you can see any doctor, and you can use any hospital \u2013 no other GIC health plan offers as much. Unicare State Indemnity Plan/Basic without CIC* Individual $13,289.04 $1,107.42 $719.82 $387.60 $89.45 $113.44 $221.48 Family $29,452.92 $2,454.41 $1,595.37 $859.04 $198.24 $251.43 $490.88 Unicare State Indemnity Plan/Community Choice Available for PC, iOS and Android. Gic Unicare Health Care Reimbursement Form. UniCare State Indemnity Plan/Basic with CIC (Comprehensive) Indemnity 207.76 486.11 UniCare State Indemnity Plan/Basic without CIC (Non-Comprehensive) Indemnity 198.36 464.30 UniCare State Indemnity Plan/Community Choice PPO-type 104.12 249.89 UniCare State Indemnity Plan/PLUS PPO-type 138.64 331.23 Medicare Plans Health Plan Plan Type Per Person
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