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.
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| Blank Cell | NATIONAL NETWORK | BROAD NETWORK | REGIONAL NETWORK | LIMITED NETWORK | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
HEALTH INSURANCE PRODUCTS | Unicare State Indemnity Plan Basic with CIC (Comprehensive) | Unicare State Indemnity Plan / Plus | Tufts Health Plan Navigator | Fallon Health Select Care | Harvard Pilgrim Independence Plan | Health New England | Allways Health Partners Complete HMO | Unicare State Indemnity Plan / Community Choice | Tufts Health Plan Spirit | Fallon Health Direct Care | Harvard Pilgrim Primary Choice Plan | |||||||||||
| PRODUCT TYPE | INDEMNITY | PPO-TYPE | POS | HMO | POS | HMO | HMO | PPO-TYPE | EPO (HMO- TYPE) | HMO | HMO | |||||||||||
| PCP Designation Required? | No | No | Yes | Yes | Yes | Yes | Yes | No | No | Yes | Yes | |||||||||||
| PCP Referral to Specialist Required? | No | No | Yes | Yes | Yes | No | Yes | No | No | Yes | Yes | |||||||||||
| 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 | $20 | Tier 1: $10 Tier 2: $20 Tier 3: $40 | $20 | $20 | $15 for Centered Care PCPs; $20 for other PCPs | $20 | $15 | $20 | |||||||||||
| Preventive Services | Most covered at 100% – no copay | Most covered at 100% – no copay | Most covered at 100% – no copay | Most covered at 100% – no copay | Most covered at 100% – no copay | Most covered at 100% – no copay | Most covered at 100% – no copay | Most covered at 100% – no copay | Most covered at 100% – no copay | Most covered at 100% – no copay | Most 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 | $20 | $20 | $20 | $20 | $10 retail clinic / $20 urgent care | $20 | $20 | $20 | $20 | $15 | $20 | |||||||||||
Outpatient Behavioral Health/Substance Use Disorder Care | $15 or $20 | $15 | $10 | $20 | $10 | $20 | $20 | $15 | $20 | $15 | $20 | |||||||||||
Emergency Room Care | $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 | $275 | No Tier 3 | $275 | No 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 | ||||||||||||||||||||||
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 | ||||||||||||||||||||||
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. | ||||||||||||||||||||||
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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.