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 Options.
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, Obstetricians/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.
$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, 2016
Primary Care Physician 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
Retail Clinic and Urgent Care Center
$20 per visit
Outpatient Mental Health and Substance Abuse Care (See the attached grid Tufts Health Plan Spirit 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
$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 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:
FY16 Tufts Spirit EPO handbook file size 1MB
This information provided by the Group Insurance Commission .