Benefits-at-a-Glance

You pay both a copay and a deductible for some services. For details, see your plan’s Schedule of Benefits at mass.gov/gic. Prescription drug (Rx) benefits are included in the out-of pocket maximums for all health insurance products.

When viewing on a small screen, drag any column on the right to view more of the table →

Blank CellNATIONAL NETWORKBROAD NETWORKREGIONAL NETWORKLIMITED NETWORK

HEALTH INSURANCE PRODUCTS

Unicare State Indemnity Plan Basic with CIC (Comprehensive)Unicare State Indemnity Plan / PlusTufts Health Plan NavigatorFallon Health Select CareHarvard Pilgrim Independence PlanHealth New EnglandAllways Health Partners Complete HMOUnicare State Indemnity Plan / Community ChoiceTufts Health Plan SpiritFallon Health Direct CareHarvard Pilgrim Primary Choice Plan
PRODUCT TYPEINDEMNITYPPO-TYPEPOSHMOPOSHMOHMOPPO-TYPEEPO (HMO- TYPE)HMOHMO
PCP Designation Required?NoNoYesYesYesYesYesNoNoYesYes
PCP Referral to Specialist Required?NoNoYesYesYesNoYesNoNoYesYes
Out-of-pocket Maximum
Individual coverage$5,000$5,000$5,000$5,000$5,000$5,000$5,000$5,000$5,000$5,000$5,000
Family coverage$10,000$10,000$10,000$10,000$10,000$10,000$10,000$10,000$10,000$10,000$10,000
Fiscal Year Deductible
Individual coverage$500$500$500$500$500$400$500$400$400$400$400
Family coverage$1,000$1,000$1,000$1,000$1,000$800$1,000$800$800$800$800
Primary Care Provider
Per Office Visit
$20$15 for Centered Care PCPs;
$20 for other PCPs
Tier 1: $10
Tier 2: $20
Tier 3: $40
$20Tier 1: $10
Tier 2: $20
Tier 3: $40
$20$20$15 for Centered Care PCPs;
$20 for other PCPs
$20$15$20
Preventive ServicesMost covered at 100% – no copayMost covered at 100% – no copayMost covered at 100% – no copayMost covered at 100% – no copayMost covered at 100% – no copayMost covered at 100% – no copayMost covered at 100% – no copayMost covered at 100% – no copayMost covered at 100% – no copayMost covered at 100% – no copayMost covered at 100% – no copay
Specialist Physician Office Visit

  Tier 1: Per Visit

$30$30$30$30$30$30$30$30$30$30$30

  Tier 2: Per Visit

$60$60$60$60$60$60$60$60$60$60$60

  Tier 3: Per Visit

$60$75$75$75$75(No Tier 3)(No Tier 3)$75$75$75(No Tier 3)

Retail Clinic and Urgent Care Center
Per Visit

$20$20$20$20$10 retail clinic / $20 urgent care$20$20$20$20$15$20

Outpatient Behavioral Health/Substance Use Disorder Care
Per Visit

$15 or $20$15$10$20$10$20$20$15$20$15$20

Emergency Room Care
Per Visit (waived if admitted)

$100$100$100$100$100$100$100$100$100$100$100
Inpatient Hospital Care – Medical

Maximum one copay per person per calendar year quarter. Waived if readmitted within 30 days in the same calendar year.

  Tier 1: Per Admission

$275$275$275$275$275$275$275$275$275$275$275

  Tier 2: Per Admission

$275$500$500$500$500$275$275$275$500$275$500

  Tier 3: Per Admission

$275$1,500$1,500$1,500$1,500$275$275$275No Tier 3$275No Tier 3
Outpatient Surgery
Eye & GI procedures at freestanding facilities in Massachusetts$0$0$150$150$150$150$150$0$150$150$150
All other in Massachusetts$250$110 / $110 / $250$250$250$250$250$250$110$250$250$250
High-Tech Imaging

Maximum one copay per day. Contact the carrier for details.

(e.g., MRI, CT & PET scans) Per Scan$100$100$100$100$100$100$100$100$100$100$100
Prescription Drugs

Prescription Drug Deductible: $100 Individual / $200 Family

Retail
(up to a 30-day supply)

  Tier 1

$10$10$10$10$10$10$10$10$10$10$10

  Tier 2

$30$30$30$30$30$30$30$30$30$30$30

  Tier 3

$65$65$65$65$65$65$65$65$65$65$65

Mail Order Maintenance Drugs
(up to a 90-day supply)

  Tier 1

$25$25$25$25$25$25$25$25$25$25$25

  Tier 2

$75$75$75$75$75$75$75$75$75$75$75

  Tier 3

$165$165$165$165$165$165$165$165$165$165$165

You pay both a copay and a deductible for some services. For details, see your plan’s Schedule of Benefits

Scroll to view more of the table when viewing on a small screen →

What You Need to Know

GIC protects you from balance billing under Massachusetts General Law Chapter 32A, §20.

If you receive covered, medically necessary medical care in Massachusetts, doctors, hospitals, and other medical providers may only collect the amount covered by your GIC plan. You are still responsible for your share of the plan’s copays, deductibles, and any other eligible medical out-of-pocket costs, but not any excess.

Always compare bills to the Explanation of Benefits (EOB) statement provided by your GIC health carrier. If you are not sure your invoice is a balance bill, call your health carrier. If it is a balance bill, advise your provider that as a GIC member, you are not liable for their excess compensation. If your provider persists in efforts to collect, contact the Group Insurance Commission.

Avoid the Retail Refill Penalty!

If you or a family member is taking a long-term medication—such as for high cholesterol or high blood pressure—you will receive a letter from Express Scripts asking you to tell them how you wish to receive your future refills—by mail or at your local CVS pharmacy.

If you choose to have your medication delivered to your home, your copay is lower. You can still pick up your medication at your local CVS pharmacy, but you’ll pay a higher copay*.

Make sure you respond to that letter from Express Scripts before your third refill, or you will be charged a significant penalty.

*If you choose the Express Scripts Pharmacy or a CVS™ pharmacy, you will pay one mail order copay for a 90-day supply of medication. If you use a non-CVS pharmacy, you will pay one retail copay for a 30-day supply of medication.

READY TO ENROLL?