Getting Care For Your Advantage HMO Saver Plan

Getting Care

Routine Medical Care - routine care, like annual physicals, preventive testing, and immunizations
  • Covered 100%
  • Just show your Tufts Health Plan member ID card and pay a copayment, if required.
  • You do not need a PCP referral for the following services if received by an in-network provider:
    • Preventive mammography screening
    • Maternity care
    • OB/GYN visits
    • Routine eye exams (if you have this benefit)
    • Emergency care
  • If your doctor orders any non-routine tests and procedures that fall outside of those included with a routine physical, they may be subject to the plan's deductible.
Specialty Care – office visits with a specialist (surgeon, cardiologist, neurologist, etc.)
  • Make an appointment with your PCP for an initial assessment. If necessary, your PCP will refer you to an in-network specialist.
  • Just show your Tufts Health Plan member ID card and pay your copayment amount. If you have not yet met your deductible, you may be billed for the cost of specialty care visits until your deductible has been met.
Hospitalization – for medical care and inpatient or outpatient surgery
  • If you need to be admitted to the hospital for non-emergency services, your PCP will refer you, authorize, and coordinate all your hospital care.
  • If you need to be hospitalized, it's likely you'll be admitted to your PCP's hospital, unless the treatment you need is unavailable there.
  • If you are hospitalized for emergency care, you should call your PCP or Tufts Health Plan within 48 hours of admission.
Emergency Care – such as chest pains, difficulty breathing, unconsciousness, accident, etc.
  • Seek immediate care at the nearest emergency facility anywhere in the world; call 911, or your local emergency medical services phone number.
  • Emergency medical care is covered, whether or not you receive the care from a provider in our network.
  • You do not need a PCP referral to receive emergency care.
  • If you are hospitalized after receiving emergency care, you should call your PCP or Tufts Health Plan within 48 hours of admission.
  • If you are not hospitalized, notify your PCP of your emergency within 48 hours of receiving care, so that he or she can provide or arrange for any follow-up care you may need.
Pharmacy Coverage

Prescription drugs will be covered under your Advantage Saver plan, subject to the plan's deductible. Once the plan's deductible is met, you will pay a copayment for each prescription, according to our three-tier pharmacy copayment program: If your employer chose to offer pharmacy coverage through Tufts Health Plan, you will pay a copayment for each prescription, according to our three-tier pharmacy copayment program:
  • Tier 1: This is the lowest copayment and includes most generic drugs
  • Tier 2: This is the middle copayment and primarily includes brand-name drugs selected for Tier 2
  • Tier 3: This is the highest copayment and includes covered drugs not selected for Tier 2
Members can save on copayments for most maintenance medications - medications you must take consistently each month - when obtained through our mail-order pharmacy service. For more information, call CVS Caremark® at 1-800-581-5300.
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