Commercial Plans

Plans and product overview

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.

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

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Provider Update Newsletter

Tufts Health Plan distributes its Provider Update* newsletter by email. In order to receive Provider Update, you must complete the online registration form.

*Copies of this information can be made available upon request by calling the appropriate Tufts Health Plan Provider call center.

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