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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| HEALTH INSURANCE CARRIERS | PHONE | WEBSITE |
|---|---|---|
| AllWays Health Partners | 1.866.567.9175 | allwayshealthpartners.org/gic-members |
| Fallon Health | 1.866.344.4442 | fallonhealth.org/gic |
| Harvard Pilgrim Health Care | 1.800.542.1499 | harvardpilgrim.org/gic |
| Health New England | 1.800.842.4464 | healthnewengland.org/gic |
| Tufts Health Plan | 1.800.870.9488 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 Insurance | 1.617.727.2310 | bit.ly/giclifeinsurance |
| GIC Retiree MetLife Dental Plan | 1.866.292.9990 | metlife.com/gic |
| Social Security Administration | 1.800.772.1213 or your local Social Security Office | ssa.gov |
| Medicare | 1.800.633.4227 | medicare.gov |
| MONTHLY GIC RETIREE DENTAL PLAN RATES - EFFECTIVE JULY 1, 2020 Includes 0.35% Administrative Fee $1,250 Maximum Annual Benefit per Member | ||
|---|---|---|
| COVERAGE TYPE | RETIREE PAYS MONTHLY | |
| Single | $29.92 | |
| Family | $72.07 | |
| Blank Cell | MEDICARE ADVANTAGE | MEDICARE SUPPLEMENT | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|
HEALTH INSURANCE PRODUCTS | Tufts Health Plan Medicare Preferred | Tufts Health Plan Medicare Complement | Unicare State Indemnity Plan Medicare Extension (OME) with CIC* (Comprehensive) | Harvard Pilgrim Medicare Enhance | Health New England Medicare Supplement Plus | |||||
| PRODUCT TYPE | HMO | INDEMNITY | INDEMNITY | INDEMNITY | INDEMNITY | |||||
| PCP Designation Required? | Yes | No | No | No | No | |||||
| PCP Referral to Specialist Required? | Yes | No | No | No | No | |||||
| Calendar Year Deductible | None | None | None | None | None | |||||
| Preventive Care Office visits according to health plan's schedule | No Copay | No Copay | No Copay | No Copay | No Copay | |||||
Physician's Office Visit 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 | $15 | First 4 visits: no copay; visits 5 and over: $10 / visit | $15 | $15 | |||||
Inpatient Hospital Care | No Copay | No Copay | No Copay | No Copay | No Copay | |||||
Hospice Care | No Copay | No Copay | No Copay | No Copay | No Copay | |||||
Diagnostic Laboratory Tests and X-Rays | No Copay | No Copay | No Copay | No Copay | No Copay | |||||
Surgery Inpatient and Outpatient | No Copay | No Copay | No 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 Medicare | No Copay | No Copay | |||||
Emergency Room Care Per Visit | $50 (waived if admitted) | $50 (waived if admitted) | $50 (waived if admitted) | $50 (waived if admitted) | $50 (waived if admitted) | |||||
Hearing Aids | $100 | First $500 covered at 100%; 80% coverage for the next $1,200 per person, per two-year period | ||||||||
| Prescription Drugs | x | |||||||||
Retail | ||||||||||
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 | ||||||||||
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 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 | |||||||||||
Out-of-pocket maximums apply to medical and behavioral health benefits across all health insurance products. | ||||||||||||||||||||||
| Blank Cell | Blank Cell | Blank Cell | MEDICARE HEALTH INSURANCE PRODUCTS |
|---|---|---|---|
HEALTH INSURANCE PRODUCTS | PRODUCT CATEGORY | PRODUCT TYPE | PER PERSON |
| Tufts Health Plan Medicare Preferred | Medicare Advantage | HMO | $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 Supplement | Indemnity | $388.80 |
| Harvard Pilgrim Medicare Enhance | $404.04 | ||
| Health New England Medicare Supplement Plus | $404.80 |
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| Blank Cell | Blank Cell | Blank Cell | EMPLOYEE AND NON-MEDICARE RETIREE/SURVIVOR HEALTH INSURANCE PRODUCTS | ||
|---|---|---|---|---|---|
HEALTH INSURANCE PRODUCTS | PRODUCT CATEGORY | PRODUCT TYPE | INDIVIDUAL COVERAGE | FAMILY COVERAGE | |
| 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 | PPO-Type | $723.74 | $1,722.50 | ||
| Tufts Health Plan Navigator | Broad Network | POS | $799.04 | $1,951.46 | |
| Fallon Health Select Care | HMO | $836.19 | $2,033.04 | ||
| Harvard Pilgrim Independence Plan | POS | $917.18 | $2,239.19 | ||
| Health New England | Regional Network | HMO | $594.29 | $1,414.80 | |
| AllWays Health Partners Complete HMO | HMO | $687.87 | $1,789.45 | ||
| UniCare State Indemnity Plan/Community Choice | PPO-Type | $552.57 | $1,368.05 | ||
| Tufts Health Plan Spirit | Limited Network | HMO-Type | $606.68 | $1,461.55 | |
| Fallon Health Direct Care | HMO | $618.59 | $1,561.48 | ||
| Harvard Pilgrim Primary Choice Plan | HMO | $665.43 | $1,697.02 | ||
| HEALTH INSURANCE CARRIERS | PHONE | WEBSITE |
|---|---|---|
| AllWays Health Partners | 1.866.567.9175 | allwayshealthpartners.org/gic-members |
| Fallon Health | 1.866.344.4442 | fallonhealth.org/gic |
| Harvard Pilgrim Health Care | 1.800.542.1499 | harvardpilgrim.org/gic |
| Health New England | 1.800.842.4464 | healthnewengland.org/gic |
| Tufts Health Plan | 1.800.870.9488 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 Insurance | 1.617.727.2310 | bit.ly/giclifeinsurance |
| GIC Retiree MetLife Dental Plan | 1.866.292.9990 | metlife.com/gic |
| Massachusetts Teachers’ Retirement System | 1.617.679.6877 | mtrs.state.ma.us |
| Social Security Administration | 1.800.772.1213 or your local Social Security Office | ssa.gov |
| Medicare | 1.800.633.4227 | medicare.gov |
| MONTHLY GIC RETIREE DENTAL PLAN RATES $1,250 Maximum Annual Benefit per Member | ||
|---|---|---|
| COVERAGE TYPE | RETIREE 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 Cell | MEDICARE ADVANTAGE | MEDICARE SUPPLEMENT | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|
HEALTH INSURANCE PRODUCTS | Tufts Health Plan Medicare Preferred | Tufts Health Plan Medicare Complement | Unicare State Indemnity Plan Medicare Extension (OME) with CIC* (Comprehensive) | Harvard Pilgrim Medicare Enhance | Health New England Medicare Supplement Plus | |||||
| PRODUCT TYPE | HMO | INDEMNITY | INDEMNITY | INDEMNITY | INDEMNITY | |||||
| PCP Designation Required? | Yes | No | No | No | No | |||||
| PCP Referral to Specialist Required? | Yes | No | No | No | No | |||||
| Calendar Year Deductible | None | None | None | None | None | |||||
| Preventive Care Office visits according to health plan's schedule | No Copay | No Copay | No Copay | No Copay | No Copay | |||||
Physician's Office 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 | $15 | First 4 visits: no copay; visits 5 and over: $10 / visit | $15 | $15 | |||||
Inpatient Hospital Care | No Copay | No Copay | No Copay | No Copay | No Copay | |||||
Hospice Care | No Copay | No Copay | No Copay | No Copay | No Copay | |||||
Diagnostic Laboratory Tests and X-Rays | No Copay | No Copay | No Copay | No Copay | No Copay | |||||
Surgery | No Copay | No Copay | No 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 Medicare | No Copay | No Copay | |||||
Emergency Room Care Per Visit | $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 Drugs | x | |||||||||
Retail | ||||||||||
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 | ||||||||||
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 Cell | Blank Cell | Blank Cell | Retired Municipal Teachers (RMTs) | |||||
|---|---|---|---|---|---|---|---|---|
RMTs who retired | RMTs | |||||||
| 10% | 15% | |||||||
RMT/SURVIVOR PAYS MONTHLY | RMT PAYS MONTHLY | |||||||
HEALTH INSURANCE PRODUCTS | PRODUCT CATEGORY | PRODUCT TYPE | PER PERSON | PER PERSON | ||||
| Tufts Health Plan Medicare Preferred | Medicare Advantage | HMO | $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 Supplement | Indemnity | $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 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 | |||||||||||
Out-of-pocket maximums apply to medical and behavioral health benefits across all health insurance products. | ||||||||||||||||||||||
| Blank Cell | Blank Cell | RETIRED MUNICIPAL TEACHERS (RMTs) | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|
RMTs who retired on or | RMTs | |||||||||
| 10% | 15% | |||||||||
RETIREE/SURVIVOR PAYS MONTHLY | RETIREE PAYS MONTHLY | |||||||||
HEALTH INSURANCE PRODUCTS | PRODUCT CATEGORY | INDIVIDUAL COVERAGE | FAMILY COVERAGE | INDIVIDUAL COVERAGE | FAMILY 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 Navigator | Broad 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 England | Regional 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 Spirit | Limited 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. | ||||||||||