Our Plans

Tufts Health Plan offers a variety of plan options for our products. Below are overviews of Tufts Health Plan’s offerings, which include benefit information, authorization requirements, overviews of specific plans and coverage information.

Note: This information is intended to provide an overview. Providers are reminded to check the member’s ID card to verify the plan in which the member is enrolled. Services and subsequent payment are pursuant to the member's benefit plan document. Prior to initiating services, member eligibility and benefits should be verified by logging on to the secure Provider website.

Commercial

General Benefit Information
Most plans cover appropriately authorized, medically necessary services in full, minus the applicable copayment, deductible and/or coinsurance. Cost-share amounts vary by plan design and can be verified by using one of the electronic services options. For more information on network coverage, refer to the Use of Out-of-Network Providers Policy.

Authorization of Services
An inpatient notification is required for all inpatient admissions prior to rendering services. Prior authorization by Tufts Health Plan’s Precertification Operations Department is required for certain procedures and services. For a complete description of Tufts Health Plan’s authorization and notification requirements, refer to the Commercial Authorization Policy and the Authorizations chapter of the Commercial Provider Manual.

Pharmacy
For pharmacy formularies and updates, refer to Commercial Pharmacy.

Behavioral Health
Tufts Health Plan covers medically necessary outpatient, inpatient and intermediate services for behavioral health and substance use disorders (BH/SUDs), as defined by the member’s benefit plan document. For information on BH/SUDs, refer to the Outpatient BH/SUD Professional Payment Policy, the Inpatient and Intermediate BH/SUD Facility Payment Policy or the Behavioral Health section.

Commercial Plans

Medicare

General Benefit Information
Most plans cover appropriately authorized, medically necessary services covered in full, minus the applicable copayment, deductible and/or coinsurance. Cost-share amounts vary by plan design and can be verified by using one of the electronic services options.

Authorization of Services
Tufts Health Plan’s Precertification Operations Department requires a referral, inpatient notification, or prior authorization for certain services. For a complete description of authorization and notification requirements, refer to the Prior Authorizations and Notifications chapters of the Tufts Medicare Preferred HMO Provider Manual, as well as the Authorization and Notification Policy.

Pharmacy
For formularies, updates, and prior authorization or step therapy guidelines, refer to Medicare Pharmacy.

Behavioral Health
Tufts Health Plan covers medically necessary outpatient, inpatient and intermediate services for behavioral health and substance use disorders (BH/SUDs), as defined by the member’s benefit plan document. For more information, refer to the Outpatient BH/SUD Professional Payment Policy, the Inpatient and Intermediate BH/SUD Facility Payment Policy or the Behavioral Health section.

Note: Refer to tuftsmedicarepreferred.org for more information.

Medicare Plans

Tufts Health Plan Senior Care Options

General Benefit Information
Coverage is provided for appropriately authorized, medically necessary services.

Authorization of Services
Tufts Health Plan’s Precertification Operations Department may require a referral, inpatient notification, or prior authorization for certain services. For a complete description of authorization and notification requirements, refer to the Prior Authorizations and Notifications chapters of the Tufts Health Plan Senior Care Options Provider Manual, as well as the Authorization and Notification Policy.

Pharmacy
For pharmacy information pertaining to Tufts Health Plan Senior Care Options, refer to the Pharmacy section in the Provider Resource Center.

Behavioral Health
Tufts Health Plan covers medically necessary outpatient, inpatient and intermediate services for behavioral health and substance use disorders (BH/SUDs), as defined by the member’s benefit plan document. For more information, refer to the Outpatient BH/SUD Professional Payment Policy, the Inpatient and Intermediate BH/SUD Facility Payment Policy and the Behavioral Health section.

Tufts Health Plan Senior Care Options Plans
Tufts Health Plan SCO

Tufts Health Public Plans

General Benefit Information
Most plans cover appropriately authorized, medically necessary services in full, minus the applicable copayment, deductible and/or coinsurance. Coverage of services and subsequent payment are based on Tufts Health Public Plans medical and behavioral health benefit summary grids.

Authorization of Services
Prior authorizations are required for certain services. To find detailed information about prior authorization requirements, refer to the Tufts Health Public Plans medical and behavioral health benefit summary grids.

Pharmacy
For information on pharmacy copayments, preferred drug lists and pharmacy updates, refer to the Tufts Health Public Plans Pharmacy section or the Pharmacy chapter in the Provider Manual.

Behavioral Health
Tufts Health Plan authorizes medically necessary behavioral health services as defined by the member’s benefit plan document. For more information, refer to the Behavioral Health section or the Behavioral Health chapter in the Provider Manual.

Tufts Health Public Plans

 

 

 

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