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.
For information on Complaints, Grievances and Appeals processes see the Complaints, Grievances and Appeals page.
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.
For formularies, updates, and prior authorization or step therapy guidelines, refer to Medicare Pharmacy.
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.