Tufts Health Plan Navigator PPO

Plan Overview

Tufts Health Plan Navigator is a PPO plan that offers coverage through network doctors, hospitals and other health care providers with a copay.  Or, you may seek care from an out-of-network provider for 80% coverage of reasonable and customary charges The plan encourages but does not require members to select a Primary Care Provider (PCP). Members pay lower office visit copays when they see Tier 1 and Tier 2 specialists.  Contact the plan to see if your provider is in the network and how he/she is rated. 

The plan also tiers hospitals based on quality and/or cost; members pay a lower inpatient hospital copay when they use Tier 1 hospitals.  Contact the plan to see which tier your hospital is in.

The mental health benefits of this plan, administered by Beacon Health Strategies effective July 1, 2013, offer you in-network benefits with a copay.  Or, you may seek care from out-of-network providers, but at higher out-of-pocket costs.

Plan Contact Information

Medical Benefits:
Tufts Health Plan
1.800.870.9488

Mental Health, Substance Abuse and EAP Benefits:
Beacon Health Strategies 1-855-750-8980

In-Network Copays Effective July 1, 2013

Primary Care Provider Office Visit

$20 per visit

Preventive Services

Most covered at 100% - no copay

Specialist Physician Office Visit

Tufts Health Plan  tiers the following Massachusetts specialists based on quality and/or cost efficiency: Cardiologists, Dermatologists, Endocrinologists, Gastroenterologists, General Surgeons, Neurologists, Obstetrician/Gynecologists, Ophthalmologists, Orthopedists, Otolaryngologists (ENTs), Pulmonologists, Rheumatologists, and Urologists.
***Tier 1 (excellent):  $25 per visit
**Tier 2 (good):          $35 per visit

*Tier 3 (standard): $45 per visit

Out-of-State Specialist Office Visit: $35 per visit

 

Retail Clinic

$20 per visit

Outpatient Mental Health and Substance Abuse Care (See the Attached grid Tufts Health Plan Navigator   for additional benefit details.)

$20 per visit

UBH also offers EAP services.

Inpatient Hospital Care - Medical (Maximum one copay per person per calendar year quarter; waived if readmitted within 30 days in the same calendar year)

Tufts Health Plan tiers its hospitals for adult medical/surgical services, obstetrics, and pediatrics, based on quality and/or cost.

Tier 1:   $300 per admission

Tier 2:   $700 per admission
 

Outpatient Surgery (Maximum four copays per person per calendar year)

$150 per occurrence

High-Tech Imaging (e.g., MRI, PET and CT scans) (Maximum one copay per day)

$100 per scan

Emergency Room:
$100 per visit (waived if admitted)

Prescription Drug

Retail up to 30-day supply:                    Mail Order up to 90-day supply:
Tier 1:   $10                                        Tier 1:   $20
Tier 2:   $25                                        Tier 2:   $50
Tier 3:   $50                                        Tier 3:   $110

Who is Eligible?

Employees, Retirees, Survivors, and their eligible dependents without Medicare are eligible.  

Where You Live Determines Which Plan You May Enroll In:

Tufts Health Plan Navigator is available throughout Massachusetts.

The Plan is also available in the following other state:

Rhode Island

Tufts Health Plan Navigator is available only in certain parts of the following states; contact the plan to see if you live in the service area:

Connecticut, New Hampshire, New York, Vermont

Handbooks:

Tufts Health Plan Navigator Handbook FY14  file size 3MB  

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This information provided by the Group Insurance Commission .