Snapshot of Your Plan
 
 

The Your Choice Plan, at a Glance

Copay **Please see details below**
Coinsurance **Please see details below**
Out-of-Pocket Max Yes.
Health Savings Account (HSA) No.
Primary Care Physician (PCP) **Please see details below**
Referrals **Please see details below**
Out-of-Network Coverage **Please see details below**
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

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:

  1. On the front of your ID card
  2. In the My Coverage section of mytuftshealthplan.com
  3. In your Benefit Document
Coinsurance

There are some services that may require coinsurance with your plan. Coinsurance is 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:

  1. In the My Coverage section of mytuftshealthplan.com
  2. In your Benefit Document 

Login to mytuftshealthplan.com. Under My Coverage (1) you will find a complete list of your plan benefits. Select a benefit category to see your cost sharing responsibility (2) including copayments and coinsurance, if applicable.

Out-of-Pocket Max

The Out-of-Pocket maximum is 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 several places:

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

Login to mytuftshealthplan.com. Under Claims (1) select the Out-of-Pocket Maximum tab (2) to view how your costs have applied to your Individual and Family limits.

Getting Care

Choosing a Primary Care Provider

Depending on your plan, you may need to 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.

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

Depending on your plan, you may be 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.

Out-of-network coverage

Depending on your plan, you may be able to visit an out-of-network provider. But keep in mind that choosing an in-network provider will result in the lowest out-of-pocket costs possible.

Check your Benefits Document in your member portal for more details on in-network and out-of-network costs. 

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.