UNICARE STATE INDEMNITY PLAN

Community Choice Acute Care Hospital Listing Effective July 1, 2017 When you use a Community Choice hospital, you pay a $275 inpatient copay per calendar quarter. Community Choice members can also use additional hospitals for the same $275 copay for certain complex procedures and neonatal ICUs. To look for hospitals, go to unicarestateplan.com and, under the Quick Links tab on the Members page, select Look for health care providers. When you use non-Community Choice hospitals, your out-of-pocket costs are higher. Addison Gilbert Hospital Lawrence Memorial Hospital Anna Jaques Hospital Leominster Hospital (UMass Memorial) Athol Memorial Hospital Leonard Morse Hospital Baystate Franklin Medical Center Lowell General Hospital Baystate Medical Center Mary Lane Hospital (Baystate) Berkshire Medical Center Massachusetts Eye and Ear Beth Israel Deaconess Medical Center – Boston Melrose-Wakefield Hospital Beverly Hospital Mercy Medical Center Brockton Hospital Merrimack Valley Hospital Burbank Hospital (UMass Memorial) Milford Regional Medical Center Cambridge Hospital Milton Hospital (Beth Israel Deaconess) Cape Cod Hospital Morton Hospital Carney Hospital Mount Auburn Hospital Charlton Memorial Hospital Nashoba Valley Medical Center Children’s Hospital Boston Needham Hospital (Beth Israel Deaconess) Cooley Dickinson Hospital New England Baptist Hospital *Dana-Farber Cancer Institute (Boston location only) Noble Hospital (Baystate) Emerson Hospital Norwood Hospital Everett Hospital (formerly Whidden Hospital) Plymouth Hospital (Beth Israel Deaconess) Fairview Hospital Saint Vincent Hospital Framingham Union Hospital Saints Medical Center Good Samaritan Medical Center South Shore Hospital Harrington Memorial Hospital St. Anne’s Hospital Heywood Hospital St. Elizabeth’s Medical Center Holy Family Hospital – Methuen St. Luke’s Hospital Holyoke Medical Center Sturdy Memorial Hospital Lahey Hospital & Medical Center – Burlington Tobey Hospital Lahey Medical Center – Peabody Winchester Hospital Lawrence General Hospital Wing Hospital (Baystate) *Dana-Farber often admits patients to Brigham & Women’s Hospital for inpatient care. If you are admitted to the Brigham directly from Dana-Farber, please contact UniCare to avoid paying the non-Community Choice copay and coinsurance. UNICARE STATE INDEMNITY PLAN

PLUS Acute Care Hospital Listing Effective July 1, 2017 As a PLUS member, you can choose from among our list of Massachusetts hospitals, which are assigned to one of three tiers (Tier 1, Tier 2 or Tier 3). When you use a Tier 1 hospital, you pay a $275 inpatient copay per calendar quarter. You can also use additional hospitals for the same $275 copay for certain complex procedures and neonatal ICUs. For a list of these procedures and facilities, visit our website at unicarestateplan.com under the Quick Links tab on the Members page, select Look for health care providers. PLUS members who live in Connecticut, Maine, New Hampshire and Rhode Island can use UniCare network hospitals in their state at the $500 inpatient quarterly copay. To look for hospitals, go to unicarestateplan.com and, under the Quick Links tab on the Members page, select Look for health care providers. Or call UniCare Customer Service at 800-442-9300.

PLUS Tier 1 Hospitals Mercy Medical Center Marlborough Hospital Addison Gilbert Hospital Merrimack Valley Hospital Martha’s Vineyard Hospital Anna Jaques Hospital Milford Regional Medical Center Massachusetts Eye and Ear Athol Memorial Hospital Morton Hospital Milton Hospital Baystate Franklin Medical Center Mount Auburn Hospital (Beth Israel Deaconess) Baystate Medical Center Nashoba Valley Medical Center Nantucket Cottage Hospital Berkshire Medical Center Noble Hospital (Baystate) Needham Hospital Beverly Hospital Norwood Hospital (Beth Israel Deaconess) Brockton Hospital Saint Vincent Hospital New England Baptist Hospital Cambridge Hospital Saints Medical Center Plymouth Hospital Cape Cod Hospital South Shore Hospital (Beth Israel Deaconess) Carney Hospital St. Anne’s Hospital UMass Memorial Medical Center Charlton Memorial Hospital St. Elizabeth’s Medical Center Emerson Hospital St. Luke’s Hospital PLUS Tier 3 Hospitals Everett Hospital Sturdy Memorial Hospital Boston Medical Center (formerly Whidden Hospital) Tobey Hospital Brigham and Women’s Hospital Fairview Hospital Winchester Hospital Faulkner Hospital Framingham Union Hospital Wing Hospital (Baystate) Lahey Hospital & Medical Good Samaritan Medical Center Center – Burlington Harrington Memorial Hospital PLUS Tier 2 Hospitals Lahey Medical Center – Peabody Heywood Hospital Beth Israel Deaconess Medical Center Massachusetts General Hospital Holy Family Hospital – Methuen – Boston Newton-Wellesley Hospital Holyoke Medical Center Burbank Hospital (UMass Memorial) North Shore Medical Center – Lawrence General Hospital Children’s Hospital Boston MassGeneral for Children Lawrence Memorial Hospital Clinton Hospital Salem Hospital Leonard Morse Hospital Cooley Dickinson Hospital Tufts Medical Center and Lowell General Hospital Dana-Farber Cancer Institute Floating Hospital for Children Mary Lane Hospital (Baystate) Falmouth Hospital Union Hospital Melrose-Wakefield Hospital Leominster Hospital

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