Do You Have Medical Coverage Under Another Health Plan?

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. This way, we can work with the other health plan to determine which plan has primary responsibility for providing coverage for each service.

This is called "coordination of benefits." This provision lets members with dual coverage use the coverage available to them under both health plans.

You must also complete the Other Health Insurance form if any of your family members covered under the UniCare State Indemnity Plan have medical benefits under another health plan.

Types of Coverage You Don't Need to Tell Us About

• coverage under MassHealth, AARP or TriCare
• other types of coverage such as dental, vision or life insurance plans
• coverage under Medicare, if you are a member of the UniCare State Indemnity Plan/Medicare Extension. However, if you are not a member of the Medicare Extension Plan and you have Medicare A and/or B as your primary payor, you must let us know about this coverage.

If you need to complete the Other Health Insurance form, please also send us a copy of your ID card for the other health insurance plan, if available. Please return the completed form and copy of your ID card for the other plan to:

          UniCare
          Andover Service Center
          P.O. Box 9016
          Andover, MA 01810-9919

View and Print "Other Health Insurance" Form

• For Non-Medicare Members - Other Health Insurance form
• For Medicare Members - Other Health Insurance form

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