Accessing Care

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

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 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, poisoning, 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 Caremark mail-order pharmacy service. Just call the Caremark FastStart program toll free at 1-866-281-0629 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. Important 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.
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