Forms and Documents

Here is a list of all the forms and documents available on unicarestateplan.com. This page will be updated as new documents become available. To access an item, click on the link for the desired form or document.

• Member Handbooks — Look up benefits and other Plan information in your Member Handbook.
  


• Benefit Descriptions — View benefit descriptions of certain Plan benefits that members often have questions about. These descriptions provide detailed information about benefits and coverage for these selected services available under the UniCare State Indemnity Plan, such as outpatient laboratory services and preventive care. New: 2008 Benefit Descriptions Coming Soon. Please note that a routine eye exam (including refraction) will be covered once every 24 months effective July 1, 2008.
  


• Plan Option Comparison Guide (2008-09) — This guide contains a benefits summary of our three non-Medicare plan options, along with a comparison of lifestyle, access, medical care and premium cost factors, to help you decide which option best meets your needs.
  
  
• Physician Tiering Information (2008-09) (for non-Medicare members only) – Basic, PLUS and Community Choice members pay lower office visit copays when they use Tier 1and Tier 2 physicians.
  
  
• Claim Form — You can complete this form online and print it from your computer. To access the link to the claim form and get information on how to file a claim, click here.
  
  
• 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.



• Dependent Age 19 or Over Application for Coverage — Complete this form to continue coverage for your dependent who has reached age 19. This form also explains the eligibility policy for these dependents.

For Community Choice Members

Frequently asked questions (FAQs) about the Community Choice Plan

Other Materials Available by Mail

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

For Providers

• Pre-certification Worksheets — Find out which procedures require pre-notification and how much notice is required. View and print pre-certification worksheets.



• Reference Sheet for Contracted Providers (updated version available in late July) — If you are a contracted provider for the UniCare State Indemnity Plan, use this sheet as a convenient reference for member copays, managed care notification requirements, selected procedures for pre-review and preferred vendors. Please refer to the applicable Member Handbook for more information on Plan benefits, conditions, limitations and exclusions.