Managing Costs

Control costs through our Utilization Management program

Paying the least out-of-pocket costs possible.

We have a few tips that can save you some out-of-pocket costs. This is one of those times a little extra effort can go a long way.

Managing Out-of-Pocket Costs

You can choose urgent care centers or retail clinics.

If you need immediate medical attention and are unable to visit your Primary Care Provider for some reason, you have options that may save you time and money.

There is the emergency room, of course, but there are also two types of clinics that are available when the emergency room isn’t necessary.

  • Urgent care centers are staffed by qualified doctors. Consider an urgent care center when you can’t get to your doctor and you need care for a non life-threatening injury. Examples of non life-threatening injuries include cuts or burns that don’t respond to basic first aid, back muscle strains, sprains, and broken bones.
  • Retail clinics (eg. CVS MinuteClinic) are staffed by nurse practitioners and physician assistants. This is an option when you need routine, non-urgent care like routine vaccinations, treatment for strep throat, and other similar illnesses.

You can take advantage of member discounts.

As a Tufts Health Plan member, you can save money on things other than provider care. You can save on services designed to keep you healthy, like vitamins, protein bars, acupuncture and more. Learn more at

Save money on prescriptions.

There are also ways to save a little money on prescriptions without compromising your treatment’s effectiveness.

  • Get a prescription for a generic drug when possible.
  • Use CVS Caremark Mail Service Pharmacy for maintenance medications (those you use regularly).
  • Talk to your doctor about less expensive alternatives to your medications.

Controlling costs through our Utilization Management program.

We want you to utilize all the services you need to keep you as healthy as possible. However, we also want to make sure services aren’t over-utilized, which affects costs for everyone.

That’s the idea behind our Utilization Management (UM) program. Through this program, we make clinical care coverage decisions based on carefully evaluated available information.

Utilization Management

To help you receive quality health care in an appropriate treatment setting, we provide utilization management (UM). UM includes evaluating requests for coverage by applying medically and necessary coverage guidelines (clinical criteria guidelines) to determine the medical necessity and appropriateness of the health care services under your benefit plan. These guidelines include the following:

  • Prospective (Before Treatment): We determine whether a treatment is medically necessary before it begins.
  • Concurrent (During Treatment): We review treatment during the course of care to determine medical necessity.
  • Retrospective (After Treatment): We review treatment for medically necessity after treatment is complete.

For services and prescriptions that require preauthorization, we conduct pre-service reviews. If you are hospitalized, we review all available information in order to facilitate the transition from hospital to home, or hospital to another health care environment. Reviews are also conducted postservice, to review prescriptions and other medical needs.

Who makes utilization management decisions?

For clinical coverage decisions regarding medical services, denials are made only by board-certified physicians. For clinical coverage decisions regarding medications, denials are made only by board-certified physicians or registered pharmacists.

If you have any questions about what your specific plan covers, please read your Benefit Document or access your secure member account at

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