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 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, 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
Tufts Health Plan
Mental Health, Substance Abuse and EAP Benefits:
Beacon Health Strategies 1.855.750.8980
$250 per individual up to a maximum of $750 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, 2014
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): $25 per visit
**Tier 2 (good): $35 per visit
*Tier 3 (standard): $45 per visit
$20 per visit
Outpatient Mental Health and Substance Abuse Care (See the attached grid Tufts Health Plan Navigator 43 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)
$150 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: $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:
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
This information provided by the Group Insurance Commission .