Visiting the Doctor
So now that you know a bit more about the fee structure of the Advantage PPO plan, how do you actually use it to visit a doctor?
The Advantage PPO plan gives you the freedom to visit the health care provider you want. You may visit a Primary Care Provider (PCP), or you can visit a specialist. No referral is required.
When you choose a doctor, you should also consider whether that doctor is in our network or not. Take a look at our provider directory to view the Tufts Health Plan network. Our extensive network stretches throughout Massachusetts and Rhode Island, and extends to parts of New Hampshire, Vermont and Connecticut, as well.
With many plans, you need a referral from a Primary Care Provider (PCP). And while we encourage you to regularly visit a PCP, the Advantage PPO plan does not require a referral from a PCP. That means you may visit any specialist you like, subject to the copays, deductibles and guidelines already mentioned. As always, you can find out exactly what your specific plan covers by reading your Benefit Document or accessing your secure member account at mytuftshealthplan.com.
In-Network Doctor Visits
If the doctor you choose is in our network, your office visit will be covered in full, with the exception of any copay your plan requires. Any services the doctor provides that are subject to a deductible will be covered in full once your deductible has been met.
Choosing an in-network doctor will result in the lowest out-of-pocket costs possible.
Out-of-Network Doctor Visits
If there’s a doctor who’s not in our network, but provides a covered service, you can still see them. The out-of-network service is subject to a deductible, and is subject to coinsurance. If you’ve already met your deductible, you’ll have to pay a percentage, up to your out-of-pocket maximum.
Choosing an out-of-network doctor will provide maximum flexibility, but with higher out-of-pocket costs.