Plan Overview

Effective July 1, 2015, Navigator by Tufts Health Plan will become a POS plan that that provides coverage for treatment by a network of doctors, hospitals and other health care providers.  Members must select a PCP to manage their care and obtain referrals to specialists to receive care at the in-network level of coverage. It also allows treatment by out-of-network providers or in-network care without a Primary Care Provider (PCP) referral, but at a lower level of coverage.

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

Specialist and Hospital Tiering

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. Members pay lower office visit copays when they see Tier 1 or 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.  Effective July 1, 2015, the plan will change from two to three hospital tiers.  Members pay a lower inpatient hospital copay when they use Tier 1 or Tier 2 hospitals.  Contact the plan to see which tier your hospital is in.

Plan Contact Information

Medical Benefits:
Tufts Health Plan
1.800.870.9488

Mental Health, Substance Abuse and EAP Benefits:
Beacon Health Options 1.855.750.8980

Calendar Year Deductible - will transition to fiscal year

$300 per individual up to a maximum of $900 per family. 

In-Network Out-Of-Pocket Maximum

Excludes Prescription Drugs

$5,000 per individual; $10,000 per family

In-Network Copays Effective July 1, 2015

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, Obstetricians/Gynecologists, Ophthalmologists, Orthopedists, Otolaryngologists (ENTs), Pulmonologists, Rheumatologists, and Urologists.  Contact the plan to see how your provider is rated.
***Tier 1 (excellent):  $30 per visit
**Tier 2 (good):          $60 per visit
*Tier 3 (standard): $90 per visit

Retail Clinic

$20 per visit

Outpatient Mental Health and Substance Abuse Care (See the attached grid Tufts Health Plan Navigator doc format of Beacon_benefitgrid_tuftsnavigatorfy16.doc
 grid for additional benefit details.)

$20 per visit

Beacon 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 hospitals, based on quality and/or cost:

Tier 1:   $275 per admission

Tier 2:   $500 per admission

Tier 3:   $1,500 per admission

Contact the plan to see which tier your hospital is in.
 

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

$250 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:   $25
Tier 2:   $30                                        Tier 2:   $75
Tier 3:   $65                                        Tier 3:   $165

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

Handbook

Tufts Health Plan Navigator Handbook FY15 doc format of tufts_navigator_fy15handbook.doc
file size 2MB


This information provided by the Group Insurance Commission .

Recommended Content

People also viewed...

You recently viewed...

Personalization is OFF. Your personal browsing history at Mass.gov is not visible because your personalization is turned off. To view your history, turn your personalization on.

Learn more on our .

*Recommendations are based on site visitor traffic patterns and are not endorsements of that content.