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 →

HEALTH INSURANCE CARRIERSPHONEWEBSITE
AllWays Health Partners1.866.567.9175allwayshealthpartners.org/gic-members
Fallon Health1.866.344.4442fallonhealth.org/gic
Harvard Pilgrim Health Care1.800.542.1499harvardpilgrim.org/gic
Health New England1.800.842.4464healthnewengland.org/gic
Tufts Health Plan1.800.870.9488
Medicare Products:
1.888.333.0880
tuftshealthplan.com/gic
UniCare State Indemnity Plan
Medicare Plans
Non-Medicare Plans

1.800.442.9300
1.833.663.4176
unicarestateplan.com
Pharmacy Benefits Manager
Express Scripts
SilverScript

1.855.283.7679
1.877.876.7214

express-scripts.com/gicRx
gic.silverscript.com
Life/AD&D Insurance1.617.727.2310bit.ly/giclifeinsurance
GIC Retiree MetLife Dental Plan1.866.292.9990metlife.com/gic
Social Security Administration1.800.772.1213 or your local Social Security Officessa.gov
Medicare1.800.633.4227medicare.gov
MONTHLY GIC RETIREE DENTAL PLAN RATES - EFFECTIVE JULY 1, 2020
Includes 0.35% Administrative Fee
$1,250 Maximum Annual Benefit per Member
COVERAGE TYPERETIREE PAYS MONTHLY
Single$29.92
Family$72.07
Blank CellMEDICARE ADVANTAGEMEDICARE SUPPLEMENT

HEALTH INSURANCE PRODUCTS

Tufts Health Plan Medicare PreferredTufts Health Plan Medicare ComplementUnicare State Indemnity Plan Medicare Extension (OME) with CIC* (Comprehensive)Harvard Pilgrim Medicare EnhanceHealth New England Medicare Supplement Plus
PRODUCT TYPEHMOINDEMNITYINDEMNITYINDEMNITYINDEMNITY
PCP Designation Required?YesNoNoNoNo
PCP Referral to Specialist Required?YesNoNoNoNo
Calendar Year DeductibleNoneNoneNoneNoneNone
Preventive Care Office visits according to health plan's scheduleNo CopayNo CopayNo CopayNo CopayNo Copay

Physician's Office Visit Per Visit
(except behavioral health)

$15$15$10$15$15
Retail Clinic
Per Visit
$15$15$10$15$15
Outpatient Behavioral Health / Substance Abuse Disorder Care
Per Visit
$15$15First 4 visits: no copay; visits 5 and over: $10 / visit$15$15

Inpatient Hospital Care

No CopayNo CopayNo CopayNo CopayNo Copay

Hospice Care

No CopayNo CopayNo CopayNo CopayNo Copay

Diagnostic Laboratory Tests and X-Rays

No CopayNo CopayNo CopayNo CopayNo Copay

Surgery Inpatient and Outpatient

No CopayNo CopayNo copay in MA and for out-of-state providers that accept Medicare; call the plan for details if using out-of-state providers that do not accept MedicareNo CopayNo Copay

Emergency Room Care Per Visit
(includes out-of-area)

$50 (waived if admitted)$50 (waived if admitted)$50 (waived if admitted)$50 (waived if admitted)$50 (waived if admitted)

Hearing Aids

$100First $500 covered at 100%; 80% coverage for the next $1,200 per person, per two-year period
Prescription Drugsx

Retail
(up to a 30-day supply)

  Tier 1

$10$10$10$10$10

  Tier 2

$30$30$30$30$30

  Tier 3

$65$65$65$65$65

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

  Tier 1

$25$25$25$25$25

  Tier 2

$75$75$75$75$75

  Tier 3

$165$165$165$165$165

* Without CIC, deductibles are higher and coverage is only 80% for some services. Contact UniCare for details.

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

Out-of-pocket maximums apply to medical and behavioral health benefits across all health insurance products.
Prescription drug (Rx) benefits are included in the out-of-pocket maximums for all health insurance products.

Blank CellBlank CellBlank CellMEDICARE HEALTH INSURANCE PRODUCTS

HEALTH INSURANCE PRODUCTS

PRODUCT CATEGORYPRODUCT TYPEPER PERSON
Tufts Health Plan Medicare PreferredMedicare AdvantageHMO$325.13
Tufts Health Plan Medicare Complement$383.88
UniCare State Indemnity Plan/Medicare Extension (OME) with CIC** (Comprehensive)$399.86
UniCare State Indemnity Plan/Medicare Extension (OME) without CIC (Non-Comprehensive)Medicare SupplementIndemnity$388.80
Harvard Pilgrim Medicare Enhance$404.04
Health New England Medicare Supplement Plus$404.80

fix fonts and rules

Blank CellBlank CellBlank CellEMPLOYEE AND NON-MEDICARE
RETIREE/SURVIVOR HEALTH INSURANCE PRODUCTS

HEALTH INSURANCE PRODUCTS

PRODUCT CATEGORYPRODUCT TYPEINDIVIDUAL COVERAGEFAMILY COVERAGE
UniCare State Indemnity Plan/Basic with CICNational NetworkIndemnity$1,163.76$2,582.71
UniCare State Indemnity Plan/Basic without CIC$1,107.42$2,454.41
UniCare State Indemnity Plan/PLUSPPO-Type$723.74$1,722.50
Tufts Health Plan NavigatorBroad NetworkPOS$799.04$1,951.46
Fallon Health Select CareHMO$836.19$2,033.04
Harvard Pilgrim Independence PlanPOS$917.18$2,239.19
Health New EnglandRegional NetworkHMO$594.29$1,414.80
AllWays Health Partners Complete HMOHMO$687.87$1,789.45
UniCare State Indemnity Plan/Community ChoicePPO-Type$552.57$1,368.05
Tufts Health Plan SpiritLimited NetworkHMO-Type$606.68$1,461.55
Fallon Health Direct CareHMO$618.59$1,561.48
Harvard Pilgrim Primary Choice PlanHMO$665.43$1,697.02
HEALTH INSURANCE CARRIERSPHONEWEBSITE
AllWays Health Partners1.866.567.9175allwayshealthpartners.org/gic-members
Fallon Health1.866.344.4442fallonhealth.org/gic
Harvard Pilgrim Health Care1.800.542.1499harvardpilgrim.org/gic
Health New England1.800.842.4464healthnewengland.org/gic
Tufts Health Plan1.800.870.9488
Medicare Products:
1.888.333.0880
tuftshealthplan.com/gic
UniCare State Indemnity Plan
Medicare Plans
Non-Medicare Plans

1.800.442.9300
1.833.663.4176
unicarestateplan.com
Pharmacy Benefits Manager
Express Scripts
SilverScript

1.855.283.7679
1.877.876.7214

express-scripts.com/gicRx
gic.silverscript.com
Life/AD&D Insurance1.617.727.2310bit.ly/giclifeinsurance
GIC Retiree MetLife Dental Plan1.866.292.9990metlife.com/gic
Massachusetts Teachers’ Retirement System1.617.679.6877mtrs.state.ma.us
Social Security Administration1.800.772.1213 or your local Social Security Officessa.gov
Medicare1.800.633.4227medicare.gov
MONTHLY GIC RETIREE DENTAL PLAN RATES
$1,250 Maximum Annual Benefit per Member
COVERAGE TYPERETIREE PAYS MONTHLY
Single$29.82
Family$71.82
BASIC LIFE INSURANCE - by City/Town/School District (SD)RMT PAYS
MONTHLY
Basic Life: $1,000 Coverage$0.80
Blackstone Valley Regional SD
Bridgewater
Granby
Narragansett Regional SD
Newbury
Paxton
Pioneer Valley Regional SD
Plainville
Salisbury
Wilbraham
Basic Life: $2,000 Coverage$0.80
Barnstable
Dennis
Martha’s Vineyard Regional SD
Milton
Quabbin Regional SD
Rehoboth
Rockland
Shawsheen Valley Regional SD
Stoughton
Upper Cape Cod Regional SD
West Springfield
Whitman-Hanson SD
Basic Life: $4,000 Coverage$1.60
Rockport
Basic Life: $5,000 Coverage$2.00
Amesbury
Billerica
Bourne
Dedham
Eastham
Everett
Greater Lawrence Regional SD
Holyoke
Hudson
Montague
North Adams
North Attleboro
North Middlesex Regional SD
Norwell
Revere
Rutland
Spencer
Wareham
West Bridgewater
Westfield
Woburn
Basic Life: $10,000 Coverage$4.00
Braintree
Blank CellMEDICARE ADVANTAGEMEDICARE SUPPLEMENT

HEALTH INSURANCE PRODUCTS

Tufts Health Plan Medicare PreferredTufts Health Plan Medicare ComplementUnicare State Indemnity Plan Medicare Extension (OME) with CIC* (Comprehensive)Harvard Pilgrim Medicare EnhanceHealth New England Medicare Supplement Plus
PRODUCT TYPEHMOINDEMNITYINDEMNITYINDEMNITYINDEMNITY
PCP Designation Required?YesNoNoNoNo
PCP Referral to Specialist Required?YesNoNoNoNo
Calendar Year DeductibleNoneNoneNoneNoneNone
Preventive Care Office visits according to health plan's scheduleNo CopayNo CopayNo CopayNo CopayNo Copay

Physician's Office Visit (except behavioral health)
Per Visit

$15$15$10$15$15
Retail Clinic
Per Visit
$15$15$10$15$15
Outpatient Behavioral Health / Substance Abuse Disorder Care
Per Visit
$15$15First 4 visits: no copay; visits 5 and over: $10 / visit$15$15

Inpatient Hospital Care

No CopayNo CopayNo CopayNo CopayNo Copay

Hospice Care

No CopayNo CopayNo CopayNo CopayNo Copay

Diagnostic Laboratory Tests and X-Rays

No CopayNo CopayNo CopayNo CopayNo Copay

Surgery
Inpatient and Outpatient

No CopayNo CopayNo copay in MA and for out-of-state providers that accept Medicare; call the plan for details if using out-of-state providers that do not accept MedicareNo CopayNo Copay

Emergency Room Care Per Visit
(includes out-of-area)

$50 (waived if admitted)$50 (waived if admitted)$50 (waived if admitted)$50 (waived if admitted)$50 (waived if admitted)

Hearing Aids

First $500 covered at 100%; 80% coverage for the next $1,200 per person, per two-year period
Prescription Drugsx

Retail
(up to a 30-day supply)

  Tier 1

$10$10$10$10$10

  Tier 2

$30$30$30$30$30

  Tier 3

$65$65$65$65$65

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

  Tier 1

$25$25$25$25$25

  Tier 2

$75$75$75$75$75

  Tier 3

$165$165$165$165$165

* Without CIC, deductibles are higher and coverage is only 80% for some services. Contact UniCare for details.

Blank CellBlank CellBlank CellRetired Municipal Teachers (RMTs)

RMTs who retired
before July 1, 1990 and
SURVIVORS*

RMTs
who retired after
July 1, 1990

10%15%

RMT/SURVIVOR

PAYS MONTHLY

RMT

PAYS MONTHLY

HEALTH INSURANCE PRODUCTS

PRODUCT CATEGORYPRODUCT TYPEPER PERSONPER PERSON
Tufts Health Plan Medicare PreferredMedicare AdvantageHMO$32.40$48.60
Tufts Health Plan Medicare Complement$38.25$57.38
UniCare State Indemnity Plan/Medicare Extension (OME) with CIC** (Comprehensive)$49.77$69.15
UniCare State Indemnity Plan/Medicare Extension (OME) without CIC (Non-Comprehensive)Medicare SupplementIndemnity$38.74$58.12
Harvard Pilgrim Medicare Enhance$40.26$60.39
Health New England Medicare Supplement Plus$40.34$60.51
* Survivors are not eligible for life insurance. 
** CIC is an enrollee-pay-all benefit.
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

Out-of-pocket maximums apply to medical and behavioral health benefits across all health insurance products.
Prescription drug (Rx) benefits are included in the out-of-pocket maximums for all health insurance products.

Blank CellBlank CellRETIRED MUNICIPAL TEACHERS (RMTs)

RMTs who retired on or
before July 1, 1990 and
SURVIVORS*

RMTs
who retired after
July 1, 1990

10%15%

RETIREE/SURVIVOR

PAYS MONTHLY

RETIREE

PAYS MONTHLY

HEALTH INSURANCE PRODUCTS

PRODUCT CATEGORYINDIVIDUAL COVERAGEFAMILY COVERAGEINDIVIDUAL COVERAGEFAMILY COVERAGE
UniCare State Indemnity Plan/Basic with CIC** (Comprehensive)National Network$166.50$372.44$221.67$494.73
UniCare State Indemnity Plan/Basic without CIC$110.36$244.59$165.53$366.88
UniCare State Indemnity Plan/Plus$72.12$171.65$108.18$257.47
Tufts Health Plan NavigatorBroad Network$79.63$194.47$119.44$291.70
Fallon Health Select Care$83.33$202.60$124.99$303.89
Harvard Pilgrim Independence Plan$91.40$223.14$137.10$334.71
Health New EnglandRegional Network$59.22$140.99$88.83$211.48
AllWays Health Partners Complete HMO$68.55$178.32$102.82$267.48
UniCare State Indemnity Plan/Community Choice$55.06$136.33$82.60$204.49
Tufts Health Plan SpiritLimited Network$60.46$145.65$90.68$218.47
Fallon Health Direct Care$61.64$155.60$92.46$233.40
Harvard Pilgrim Primary Choice Plan$66.31$169.11$99.47$253.67
* Survivors are not eligible for life insurance. 
** CIC is an enrollee-pay-all benefit.