Plan Overview

Limited Network Plan logo

Tufts Health Plan Spirit is an Exclusive Provider Organization (EPO) plan that provides coverage through the plan’s network of doctors, hospitals and other providers.  The plan encourages members to select a Primary Care Provider (PCP).

The mental health benefits of this plan are administered by Beacon Health Strategies. 

Contact the plan to see if your doctors and hospitals are in the network. There are no out-of-network benefits, with the exception of emergency care. 

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; members pay a lower inpatient hospital copay when they use Tier 1 hospitals.  Contact the plan to see which tier your hospital is in.

! Your Responsibility

Do your doctors and hospitals participate in Tufts Spirit?

Contact the Plan.

Plan Contact Information

Contact the plan for additional information on
participating providers and benefits.

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 Drug Costs

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

Copays Effective July 1, 2015

Primary Care Physician 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 Spirit doc format of Beacon_benefitgrid_tuftsspiritfy16.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:   $300 per admission

Tier 2:   $700 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 Spirit is available in the following Massachusetts counties:

Barnstable, Bristol, Essex, Franklin, Hampden, Middlesex, Norfolk, Plymouth, Suffolk, Worcester

Tufts Health Plan Spirit is available only in certain parts of the following Massachusetts counties; contact the plan to find out if you live in the service area: 

Berkshire, Hampshire

Handbook  

FY16 Tufts Spirit EPO handbook docx format of Tufts_Spirit_FY16Handbook.docx
file size 1MB


This information provided by the Group Insurance Commission .