Tufts Health Plan Spirit EPO (HMO-type)

Exclusive Provider Organization (EPO) plan.

Plan Overview

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 behavioral health plan of this plan are administered by Beacon Health Options. Beacon also offers EAP services

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 Changes

Tufts Health Plan is 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 specialists and Tier 1 hospitals.  Contact the plan to find out each of your provider’s tier at the office location you visit.   Also 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

Behavioral, Substance Use Disorder and EAP Benefits:
Beacon Health Options 1.855.750.8980

Fiscal Year Deductibles

Medical Deductible
$500 per individual/$1,000 per family. 

Prescription Drug Deductible

$100 per individual/$200 per family

In-Network Out-Of-Pocket Maximum

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

Copays Effective July 1, 2017

Primary Care Physician Office Visit

$20 per visit

Preventive Services

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 Mental Health and Substance Abuse Care (See the attached grid Tufts Health Plan Spirit 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)

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

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