Advantage PPOTufts Health Plan’s Advantage PPO is a deductible plan that offers comprehensive coverage at a competitive price. Members are not required to select a primary care provider (PCP) and they may choose to use out-of-network providers for covered services. Advantage PPO is easy to administer and use, with no claim forms to fill out—plus it is designed to deliver value for employers and plan members alike.
The Advantage PPO features:
- A deductible that applies to inpatient hospital care, day surgery, outpatient diagnostic services, emergency room, and certain other services.
- In-network services—After a member meets the deductible, services subject to the deductible are covered in full.
- Out-of-network services—After a member meets the deductible, services are covered at a percentage of the reimbursement rate. The member pays the remaining percentage, up to a specified out-of-pocket maximum. Once the out-of-pocket maximum has been reached, these services are covered in full.
- Preventive services covered with no member cost sharing.
- Office visits and specialist consultations are covered with a copayment for each visit.
- Services to diagnose, treat, or monitor health conditions are subject to the deductible.
- Emergency and urgent care coverage anywhere in the world, 24 hours a day, seven days a week.
- Out-of-network coverage, subject to deductible and coinsurance, offering flexibility for members.
How the Plan Works
Members do not need to choose a PCP, and referrals are not required. A member simply presents his or her ID card at each doctor’s office visit. Depending on the service, a copayment, deductible, or coinsurance may apply. For in-network care, members will be covered in full or pay only a copayment for office visits. Services subject to the deductible are covered in full after the member meets the deductible. Members may choose to receive out-of-network covered services. Out-of-network care is subject to the deductible and coinsurance. When a member meets the deductible, services are covered at a percentage of the reimbursement rate. The member pays the remaining percentage, up to a specified out-of-pocket maximum. Once the out-of-pocket maximum has been reached, these services are covered in full.
Pharmacy CoverageIf your plan includes the optional pharmacy benefit, members will pay a copayment for each prescription, according to our three-tier pharmacy copayment program:
- Tier 1: Lowest copayment; includes most generic drugs
- Tier 2: Middle copayment; includes many brand-name drugs
- Tier 3: Highest copayment; includes the most costly covered brand-name drugs not included in other tiers.
Our Member Services department offers your employees a staff of highly trained professionals. One phone call is all it takes to reach our Member Specialists. They are available to answer members’ questions about the plan and their benefits. We also offer language-translation services and TTY capabilities as needed.
Superior Customer Service
For more information, contact your sales office:
Watertown 800-208-8013 | Worcester 800-208-9545 | Providence 800-455-2012