Accessing Care

How to Access the Care You Need

Your Tufts Health Pan coverage provides access to health care, helping you build relationships with providers and achieve a higher level of wellness. Learn how to access the various types of health care you may need below.

Routine Medical Care

For 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:

  • Outpatient behavioral health counseling
  • Preventive mammography screening
  • Maternity care
  • OB/GYN visits
  • Routine eye exams (if you have this benefit)
  • Emergency care

Specialty Care

For office visits with a specialist (surgeon, cardiologist, neurologist, etc.):

  1. Make an appointment with your PCP for an initial assessment. If necessary, your PCP will refer you to an in-network specialist.
  2. Show your Tufts Health Plan member ID card and pay your copayment amount

Hospitalization

If you need to be admitted to the hospital for non-emergency services (such as medical care and inpatient or outpatient surgery), your PCP will refer you, authorize, and coordinate all your hospital care.

If you are hospitalized for emergency care, you should call your PCP or Tufts Health Plan within 48 hours of admission.

Emergency Care

For emergency care (such as chest pains, poisoning, unconsciousness, or an accident), 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.

Behavioral Health + Substance Use Support

Because behavioral health can affect your physical health, we’re here to help you with both.

We encourage you to take advantage of your behavioral health benefits should you need them.

Learn how to select outpatient counseling providers, what to do if you’re a new member with an existing outpatient provider, how to access inpatient behavioral health care, and how to access inpatient care for substance use disorder with our guide to Understanding Your Behavioral Health Benefits.

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 Caremark mail-order pharmacy service. Just call the Caremark FastStart program toll free at 866-281-0629 to get started. Please have the following ready:

  • Tufts Health Plan ID card
  • Credit card (for copayment amount)
  • Prescription information
  • Doctor's name and telephone number
  • Shipping address

Imaging

Sometimes when you are receiving care, your doctor may order diagnostic imaging. There are two main types: low-tech imaging and high-tech imaging.

  • Low-Tech Imaging—includes services such as x-rays, bone density tests, mammography, and ultrasounds. Low-tech imaging is sometimes performed in your doctor’s office or during an emergency room visit. It is covered as part of your visit and does not require a separate copayment. If your plan has a deductible, low-tech imaging services will apply toward the deductible.
  • High-Tech Imaging—includes CT/CTA, MRI/MRA, PET Scans, and Nuclear Cardiology. These procedures require prior authorization. This means your doctor needs to submit a request for approval before they will be covered. Many members are on a plan that has a high-tech imaging copayment. If this applies to you, this means you are responsible to pay a copayment for the procedure that is separate from your office visit or hospital copayment.

    Please note: Members are exempt from paying the high-tech imaging copayment when the imaging is required as part of an active treatment plan for a cancer diagnosis. If you aren’t sure whether your plan has a high-tech imaging copayment, please check your Benefit Document or contact a Member Services Representative.
plans card