Member Welcome Kit

Advantage PPO plan and benefit information in a format for you to save or print.

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Advantage PPO

How Advantage PPO Plans Work

Not all health plans work the same way. This website will explain how the Advantage PPO plan works, so be sure to read through it carefully to understand your plan.

You can also visit mytuftshealthplan.com, our secure members-only site, to learn the details of the specific plan your employer has chosen for you. And be sure to read your Benefit Document, available at mytuftshealthplan.com, to see a complete list of your specific plan’s covered and non-covered benefits.

Knowledge is power, and knowing how your plan works will give you the power to plan for and control your out-of-pocket costs.

The overall idea behind the Advantage PPO plan is to enable employers to offer high-quality health care to their valuable employees (you). The Advantage PPO plan helps accomplish this by incorporating a fee structure that requires some cost-sharing on your part.

This cost-sharing is primarily in the form of two components: the deductible and the copay.

The Deductible

The deductible is the amount you must pay before your insurance kicks in. We’re speaking here only of the services that are subject to a deductible. Not everything you go to the doctor for is subject to the deductible. In other words, there are some things you can go to the doctor for that are covered right away, without your having to meet your deductible. These are generally preventive services, but they’re spelled out in greater detail in the second section of this Member Kit.

The deductible for your specific plan can vary. The amount is chosen by your employer, based on how much the entire plan costs them. We work closely with your employer to provide the best possible plan at the best possible cost for both employer and employee.

Here’s an example of how the deductible works. Let’s say your plan has a $1000 family deductible and a $500 individual deductible. You’re working in the yard, you have an accident, and you have to make a trip to the emergency room. Your maximum responsibility as an individual would be $500, not the entire $1000. Let’s say you have another accident in the same plan year. Your individual deductible of $500 has already been met, so you’re not responsible for any deductible amount.

Now let’s say your spouse needs surgery. Your family is now responsible for the remaining $500 deductible, since it’s a different individual. But now your total amount paid toward your $1000 deductible has been met. The next time anyone in your family needs medical services that are subject to the deductible, you don’t have to worry about the deductible. The deductible for the plan year has been met.

Services Not Subject to Deductible

Services Subject to Deductible

The Copay
Regardless of the status of your deductible, there are some services that may also require a copay. A copay is a fee that you pay as partial payment for certain services. For instance, a visit to the doctor’s office requires a copay. That means you pay, for example, $20 out-of-pocket as your copay.

Whether or not your deductible has been met, if a copay is required for the type of medical service you want, you are responsible for the copay. Again, the best way to control out-of-pocket costs is to read this Member Kit so you understand what you are and what you are not responsible for.

And you can always find out exactly what your specific plan covers by reading your Benefit Document or accessing your secure member account at mytuftshealthplan.com.

A Word About Coinsurance
There’s one more component of the Advantage PPO plan’s fee structure that bears mentioning. It’s called coinsurance, and it applies primarily to durable medical equipment (such as a wheelchair or crutches), hearing aids, low-protein foods and prosthetics. If you require any of those items, you would share a percentage of the cost.

In some cases, coinsurance may also apply to other items. You can find the specifics of your plan, including the exact amount of your coinsurance, by reading your Benefit Document or by visiting mytuftshealthplan.com.

The Out-of-Pocket Maximum
You’ll be glad to know there’s a limit on what you may possibly pay during a calendar year. It’s called an Out-of-Pocket maximum. The Out-of-Pocket maximum is the most you can pay during your coverage period (typically one year) for your share of the cost of covered services.

Online Tools

We’ve made managing your health plan easier.

When you sign up for a plan through Tufts Health Plan, we give you an easy way to manage it. It’s our members-only site called mytuftshealthplan.com. As a member, you’ll be able to check to see what your plan covers, see what your benefits are, search for doctors in your network, request prescription refills, check on claim updates and much more. Be sure to have your member ID number handy, and sign up today.

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