About My Care and Coverage

My Care

Do you have my doctor?

Chances are good that your doctor is in our network, which has more than 51,000 health care professionals and 100 hospitals across New England. Our network stretches across all of Massachusetts, Rhode Island and New Hampshire, and extends into parts of Maine, Vermont, New York and Connecticut.

Take a look at our provider directory to see if your doctor is in our network.

What if I am under the care of a specialist?

If your plan requires a referral from your PCP for specialist care, you’ll need to get a Tufts Health Plan referral. Any referral you had with your old insurance plan will not carry over.

Also, if you see any other providers for care, be sure to let them know that you have new health insurance. If one of your current providers is not in our network, you may need to switch to one who is.

What if I am scheduled for surgery?

Contact member services at the phone number on your ID card as soon as possible. We can coordinate any necessary evaluation or prior authorization in a timely manner.

What if I am pregnant?

Please call Member Services at 800-462-0224. Let us know your expected delivery date and the name of your doctor. This will allow us to pre-register you for your hospital admission.

My Medications

Is my medication covered? What do I do if it isn't?

If your plan includes a pharmacy benefit, you can find out by searching the name of your medication on our list of covered drugs (also referred to as a formulary). You can find your plan’s formulary in the My Coverage section of mytuftshealthplan.com by selecting Pharmacy.

If you’re prescribed a brand-name drug that has a safe, effective alternative or a generic version, we'll cover that instead. In some cases, your doctor may believe you should be treated because of a medical reason with a drug that is not covered. If so, he or she may submit a request for coverage, and we will review it closely for consideration.

If you have any questions about your drug coverage, you can always call the Member Services number on your ID card.


What is a referral and when do I need one?

A referral is written permission from your Primary Care Provider to see a specialist for care. Certain plans, such as HMO and POS plans, require you to get a referral. Other plans, including PPO plans, do not require a referral. If you’re uncertain about whether or not you need a referral, call the Member Services number on your ID card.

If your plan requires a referral, your PCP will write a referral for you. Always make sure your PCP has made the referral before you see the specialist or you may be responsible for costs from the appointment.

How long is a referral valid?

A referral is valid for the number of visits approved by your Primary Care Provider. If you don’t use all the visits, the referral expires one year from the date it was written. Also, if you change your PCP, you will need to get a new referral from your new PCP regardless of whether you have visits left on a referral written by your former PCP.

Prior Authorizations

What is prior authorization?

Prior authorization means that we must approve a certain procedure or service before you receive it. Your doctor submits a request to us and we review it for medical necessity. We check to make sure you receive the appropriate level of care, at the appropriate time, in the right setting, and in the most efficient manner.

We use your plan’s Medical Necessity Guidelines and work with your doctor(s) to determine prior authorization. The guidelines are based on the latest medical evidence, leading scientific information, and expert opinion. We review our guidelines annually and as new information becomes available.

How do I get prior authorization?

Your in-network doctor is responsible for obtaining prior authorization from us on your behalf. If you go to an out-of-network doctor, then you are responsible for making sure the doctor obtains prior authorization.

Why do I need prior authorization if I already have a referral?

They are two different things. Your PCP issues a referral, which is his or her written permission for you to see a specialist. Your treating practitioner requests a prior authorization, which is permission from Tufts Health Plan for a specific service.

Care When I Travel Out-of-Network

How can I get access to a doctor when traveling?

If you have a life-threatening emergency medical condition, seek care immediately at the nearest medical facility. Tufts Health Plan covers any emergency medical care you may need, whether or not you receive the care from a provider in our network.

If you’re traveling outside Massachusetts, Rhode Island or New Hampshire, you have access to the Cigna PPO Network for both emergency and urgent care.

About My Documents

Please refer to the Understanding Your Documents section for descriptions of common documents, including the:

  • Summary of Benefits + Coverage (SBC)
  • Evidence of Coverage (EOC), and
  • Explanation of Benefits (EOB)

About My Costs

Why did I receive a bill from the provider?

You may have received a bill from the provider because you are responsible for paying a cost-share amount for the care you received, such as a deductible, copayment, or coinsurance.

Before you pay a provider’s bill, we encourage you to compare it to your claims summary on mytuftshealthplan.com to confirm how much you owe. Simply select Claims in the menu after you’ve logged in.

The claims summary shows details for each of your claims, including:

  • the date of service
  • the provider and provider specialty
  • the amount billed
  • the amount you may be responsible for*

Select the Details link next to a claim to view the claim status and a breakdown of services and payment details for that claim.

If the amount you owe on the provider’s bill differs from that of your claims summary, call member services at the phone number on your ID card. A representative can help determine the correct amount, if any, that you should pay—and can contact the provider if necessary.

*Note: If you received any non-covered services, you may also be responsible for the cost of those.


What are claim details?

Claim details show the specific information we used to process your claim. They include:

  • the date of service
  • a description of the service
  • the amount billed
  • the amount Tufts Health Plan paid, and
  • your cost-share responsibility, if there is one

In the Claims section of mytuftshealthplan.com, select the Details link next to a claim in the claims summary to view the claim details.