Getting Care With Your Advantage HMO Plan

Routine Medical Care - regular office visits to your PCP for medical issues, physical exams, and preventive tests.
  • Just show your Tufts Health Plan member ID card and pay your copayment amount
  • 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
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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.
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.
If You Have Pharmacy Coverage
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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