UniCare Logo
UniCare 30 Years GIC Logo

Forms and Documents for Members

This page contains links to various UniCare forms and documents, such as handbooks, benefit descriptions and claim forms.

 

Not sure which plan you’re in? You’ll find your plan name on the front of your ID card, under your member ID number.

General plan materials

Member Handbooks – Look up benefits and other plan information in your member handbook.

Summary of Benefits and Coverage (SBC) – Check the SBCs for our non-Medicare plan options to get an easy-to-understand breakdown of your coverage under each plan.

Summary of Plan Benefits – These summaries show the plan benefits for many medical and behavioral health services. (For a complete and detailed description of benefits and Plan provisions, see your member handbook.)

Benefit Descriptions – View benefit descriptions for some plan benefits that members often have questions about. These descriptions give you detailed information about benefits and coverage for these selected services available under the UniCare State Indemnity Plan, such as preventive care and durable medical equipment.

Ever feel confused by your health plan? (for non-Medicare members only) – Get help with understanding the difference between copays, deductibles and coinsurance and when you need to pay them.

Your member costs at a glance (for non-Medicare members only) – Find out your member costs for some common medical services.

UniCare FAQ – Provides an overview of UniCare's four health plan options.

Compare Our Plans brochure – View our 2018-2019 guide to learn more about our three non-Medicare health plan options: Basic, PLUS and Community Choice. You can also listen to our short video comparing these plan options.

Medicare Extension brochure – Outlines the benefits of our Medicare plan plus a summary of benefits.

Physician Tiering Information (for non-Medicare members only) – Basic, PLUS and Community Choice members pay lower office visit copays for specialty care when they use Tier 1 and Tier 2 specialists in Massachusetts. Learn about our physician tiering program.

Preventive Care Guidelines – Preventive care is an important key to your health. Find out which screenings and other services are covered based on your age, sex and health. These services are covered at 100%, so don’t miss out on these important ways to protect your health.

Express Scripts National Preferred Formulary List for Massachusetts Group Insurance Commission – This formulary is the list of drugs included in the prescription drug plan for Basic, PLUS and Community Choice members. It does not apply to Medicare Extension members.

Member Forms

Authorization to Disclose Protected Health Information – You can fill out the Member Authorization form to designate someone to receive your protected health information (PHI). It includes instructions on how to complete the authorization form.

Claim Form – You can complete this form online and print it from your computer. You'll also find helpful information on how to file a claim.

Fitness Club Reimbursement Form – You can get reimbursed for up to $100* per family on your membership at a fitness club. The reimbursement is paid once per plan year, to the Plan enrollee, upon proof of membership and payment. Use our fitness club reimbursement form to request your reimbursement. Check the instructions for details on the types of fitness clubs that qualify under this benefit and how to complete the reimbursement form.

* Medicare Extension members are eligible for reimbursement up to $100 per enrollee per plan year for a fitness club membership.

Diabetes Prevention Program Reimbursement Form (for non-Medicare members only) – You can get reimbursed up to $500 when you complete 20 or more sessions in an approved diabetes prevention program. See the reimbursement form for details.

Other Health Insurance Form – If you have medical benefits under another health plan in addition to the UniCare State Indemnity Plan, you need to let us know by completing our Other Health Insurance form.

Other materials available by mail

Visit our Request Plan Materials page for a list of additional member materials you can order by email using our online order form. We will mail them to you promptly.


About UniCare
| Legal | Site Map | Contact Us


For self-funded plans, claims are administered by UniCare Life & Health Insurance Company. © 2018 UniCare