Snapshot of Your Plan
 
 

Your Advantage HMO Plan, at a Glance

Deductible Yes. Your plan has a deductible.
Copay **Please see details below**
Coinsurance **Please see details below**
Out-of-Pocket Max Yes.
Health Savings Account (HSA) No.
Primary Care Physician (PCP) You are required to select an in-network PCP.
Referrals Yes. Referrals are required to see a specialist. 
Out-of-Network Coverage No.
Routine Vision Care Yes.

Important note: You will see the term “Benefit Document” throughout this Welcome Kit. Your Benefit Document is a legally binding document provided by us that explains your medical coverage, including covered benefits, exclusions, termination, continuation of coverage, and appeals. It is sometimes referred to as an Evidence of Coverage (EOC) document or a Certificate of Insurance (COI). If there is a difference between the information in this Welcome Kit and your Benefit Document, please rely on your Benefit Document.

You can find your Benefit Document in the My Coverage section of mytuftshealthplan.com.

Cost Sharing

Deductible

The amount you have to pay for covered health care services before Tufts Health Plan starts to pay. After you pay your deductible, you usually pay only a copayment or coinsurance for covered services, and Tufts Health Plan pays the rest. Please check your benefit document (located in the My Coverage section of mytuftshealthplan.com) for details.

The benefit document is also called an Evidence of Coverage(EOC) or Certificate of Insurance (COI).

How does my deductible work?

How your deductible works depends on whether you are a member on an individual or family plan. Below are examples for both an individual plan
with a $1,500 annual deductible, and a family plan with a $3,000 annual deductible.

  • For an individual plan -- Let’s say you’re working in the yard, have an accident, and need to go to the emergency room (ER). The maximum amount you would have to pay for your ER care is $1,500.
  • For a family plan -- Let’s say you’re working in the yard, have an accident, and need to go to the emergency room (ER). The maximum amount you would have to pay for your ER care is $3,000. Now let’s say your spouse needs to get surgery later in the year, after you’ve had your ER visit. If the cost of your spouse’s surgery and your ER visit total more than $3,000, then you will have met your family deductible for the plan year. The plan would then pay for all remaining covered services. You would be responsible for any copayments or coinsurance that apply to your plan.

In the Claims (1) section of mytuftshealthplan.com, select the Deductible (2) tab to view your specific deductible information.


Copayments

There are some services that may require a copayment with your plan. A copayment is the cost-share that you pay for certain covered pharmacy or medical services. Depending on your plan, you might have a copayment for a doctor’s office visit or for a prescription drug.

You can find your copayment amounts in 3 places:

  • On the front of your ID card
  • In the My Coverage section of mytuftshealthplan.com
  • In your Benefit Document

Coinsurance

The percentage of costs you pay for certain covered services. As an example, if your plan has 20% coinsurance, Tufts Health Plan will pay 80% of the cost, and you’ll be responsible for paying 20% of the cost.

You can find out which services require coinsurance in 2 places:

  • In your Benefit Document 
  • In the My Coverage section of mytuftshealthplan.com, select the My Benefits tab to see alist of benefits and the member repsonsibility for each benefit (2).

Out-of-Pocket Maximum

The most you can pay during your plan year for your share of covered medical, pharmacy, vision and mental health services. After you spend this amount on deductibles, copayments, and coinsurance, Tufts Health Plan will pay 100% of remaining costs for covered services. However, your monthly premium does not count toward this total.

You can find the Out-of-Pocket Max for your plan in 2 places:

  • In your Benefit Document
  • In the Claims (1) section of mytuftshealthplan.com, select the Out-of-Pocket Maximum (2) tab

Getting Care

Choosing a Primary Care Provider

As part of your plan, you must choose a Primary Care Provider (PCP) who is in our network. Your PCP can be a primary care physician, nurse practitioner or physician assistant, but you cannot choose a specialist as your primary doctor. Your PCP will refer you to specialists for care when needed.

Take a look at our provider directory to view our extensive network. If your current doctor is part of our network, you may choose them. If they’re not there or you would simply like a new PCP, select a new one you find in the directory.

From the mytuftshealthplan.com home page, you can use the link under My Account (1) or the quick link (2) to select or change your PCP.

Referrals

You are required to get a referral from your PCP every time he or she refers you to a specialist. The referral can be for one or more visits, different types of services, or authorization for a standing referral to the specialty provider.

There are a few exceptions when a referral is not needed including:

  • Preventive mammography screening
  • OB/Gyn care
  • Maternity care
  • Routine eye exams
  • Emergency care

You can find the full list of exceptions in your Benefit Document or by calling the Member Services number on your Member ID card.

Vision

You have access to EyeMed Vision Care, one of the nation’s leading vision care organizations. You can receive routine eye exams and other vision care services provided through EyeMed’s extensive network of providers, which includes many independent practices, as well as retail stores like LensCrafters, Sears Optical, Target Optical, JCPenney Optical and Pearle Vision (most locations).

Search for an EyeMed provider here.