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Tufts Health Plan Navigator is a Point-of-Service (POS) plan. Members must select a Primary Care Provider (PCP) to manage their care and obtain referrals to specialists to receive care at the in-network level of coverage. Members who get care from specialists without a PCP referral have higher out-of-pocket costs.
The Navigator by Tufts Health Plan is closed to new members. See the Benefit Change section for more information.
Navigator by Tufts Health Plan is 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 with higher out-of-pocket costs.
The Behavioral health benefits of this plan, administered by Beacon Health Options, 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. Beacon also offers EAP services
Primary Care Provider (PCP), Specialist, and Hospital Tiering Changes
Tufts Health Plan is implementing PCP tiering and changing its tiering program to one based on provider group value instead of individual performance. This change may affect your copays. Members will pay lower copays for Tier 1 and Tier 2 PCPS and specialists and Tier 1 and Tier 2 hospitals. Contact the plan to see each of your provider’s tiers for the office location you visit. Also contact the plan to see which tier your hospital is in.
Contact the plan for additional information on participating providers and benefits.
Tufts Health Plan
Behavioral Health, Substance Use Disorder and EAP Benefits:
Beacon Health Options 1.855.750.8980
$500 per individual/$1,000 per family.
Prescription Drug Deductible
$100 per individual/$200 per family
$5,000 per individual; $10,000 per family
Primary Care Provider Office Visit
Tier 1: $10 per visit
Tier 2: $20 per visit
Tier 3: $40 per visit
Most covered at 100% - no copay
Specialist Physician Office Visit
Contact the plan to see how your provider is rated.
Tier 1: $30 per visit
Tier 2: $60 per visit
Tier 3: $90 per visit
Retail Clinic and Urgent Care Center
$20 per visit
Outpatient Behavioral Health and Substance Use Disorder Care (See the attached grid Tufts Health Plan Navigator for additional benefit details.)
$10 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)
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
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
M-F 8:45 a.m.-5 p.m.