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 and Benefit Updates – Look up benefits and other Plan information in your Member Handbook and Benefit Updates.
  


• 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 preventive care and durable medical equipment.
  
  
• UniCare FAQ (in English and Spanish) – provides an overview of UniCare, as well as the UniCare State Indemnity Plan and our four health plans.



• Plan Comparison Guide – View our 2010-2011 Plan Comparison Guide to learn more about our three non-Medicare plan options: Basic, PLUS and Community Choice.



• Medicare Extension (OME) Brochure – outlines the benefits of our Medicare plan option.



• Physician Tiering Information (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.



• Serious Preventable Adverse Health Care Events - The Plan does not pay for costs associated with 28 serious preventable adverse health care events, in line with the Commonwealth's commitment to patient safety. Learn more.
  
  

For Community Choice Members

Other Materials Available by Mail

For Providers

• Pre-certification Worksheets (Rev. 7/10) – Find out which procedures require pre-notification and how much notice is required.
  
  
• Provider Reference Sheet (Rev. 7/10) – 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 and Benefit Updates for more information on Plan benefits, conditions, limitations and exclusions.