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
Tufts Health Plan
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
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
$20 per visit
Outpatient Mental Health and Substance Abuse Care (See the attached grid Tufts Health Plan Navigator 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
$100 per visit (waived if admitted)
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:
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
Tufts Health Plan Navigator Handbook FY15 file size 2MB
This information provided by the Group Insurance Commission .
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