Snapshot of Your Plan
 
 

Your HMO Plan, at a Glance

Deductible No. Your plan does not have 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) Yes. 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.

Please 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.

Where are the details?

For your specific deductible amounts, coinsurance information, and other details, please register or login to the member portal.

Login/Register Now

Cost Sharing

Copayment

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 three places:

  • On the front of your ID card
  • In the My Coverage section of the secure member portal, 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 two places:

  • In your Benefit Document
  • In the My Coverage (1) section of mytuftshealthplan.com, select the My Benefits tab to see a list of benefits and the member responsibility 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 two 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 (PCP)

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.

You may select or change your PCP on mytuftshealthplan.com. From the Home page, select the link under My Account (1) or under What Would You Like to Do? (2).

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.