Your Choice 3-Tier Network Option Plan
What is Your Choice? Click Here to Watch Video
Your Top Questions What is Your Choice? Are my doctors in the plan? Are my medications covered by the plan? If I get sick what do I do? How much will I pay out of my pocket?
What is Your Choice? Tufts Health Plan offers a comprehensive network of quality primary care providers (PCPs), specialists and hospitals. The Your Choice plan gives you access to our full network of providers* Hospitals and affiliated physicians are grouped into tiers based on quality and cost measures Not all health care providers and hospitals charge the same costs. We ve factored in costs and have separated the providers into tiers * EPO members must stay in network to have benefits covered. PPO members have out-of-network benefits as well
What is Your Choice? Find a Participating Provider 1. Go to tuftshealthplan.com 2. Pick your Plan and then Submit 3. Select a provider type, enter your location, and search
What is Your Choice? Can you mix and match? Yes! A Tier 1 doctor/provider is typically associated with a Tier 1 hospital system You can go to a Tier 1 doctor and your spouse and children can go to doctors in different tiers Scenario 1 Scenario 2 Dad s PCP is Tier 1, Mom and two kids have Tier 2 PCPs PCP is Tier 1, Specialist is Tier 2 * * EPO members need referrals to see a specialist.
2016 Your Choice EPO/PPO Copays Service Tier 1 Tier 2 Tier 3 YC PPO Out-of-Network Deductible (per calendar year) N/A N/A N/A $1,500 Individual $3,000 Family Routine Physical Exams (including most preventive screenings) Covered in full Plan covers 80% after deductible Non-routine Primary Care Physician Office Visits $20 $35 $50 Plan covers 80% after deductible Non-routine Specialist Office Visits $35 $45 $60 Plan covers 80% after deductible Inpatient Hospital Care and Surgery (per admission) $250 $750 $1,500 Plan covers 80% after deductible
2016 Your Choice EPO/PPO Copays Service Tier 1 Tier 2 Tier 3 Emergency Room Copay (waived if admitted and then Tier 1 inpatient copay applies) $150 YC PPO Out-of-Network Day Surgery: Freestanding outpatient surgery center $200 per admission Plan covers 80% after deductible Day Surgery: Hospital surgery center Diagnostic High-Tech Imaging: At a freestanding imaging center $250 $750 $1,500 $50 Plan covers 80% after deductible Plan covers 80% after deductible Diagnostic High-Tech Imaging: Hospital-affiliated imaging center $50 $250 $450 Plan covers 80% after deductible
Your Prescription Drug Coverage $ $$ $$$ Tier 1 Lowest Cost Tier 2 Middle Cost Tier 3 High Cost Retail: $15 $30 $50 Mail: $30 $60 $100 Use CVS Caremark Mail Service Pharmacy for maintenance medications (those you use regularly)
2016 Out-of-Pocket Maximums Your Choice EPO Your Choice PPO In-Network Your Choice PPO Out-of Network Individual $ 5,000 $5,000 $ 5,000 Family $ 10,000 $10,000 $10,000 Your out-of-pocket maximum is the total expense you will have to pay out of your pocket before the plan pays 100% of eligible charges. All medical and Rx copays and coinsurance (for DME) will count toward your out-of-pocket maximum. Copays include: Office visits Day surgery High-Tech Imaging (MRIs, CT/CAT scans, PET scans & nuclear radiology) Emergency room Inpatient admissions
Find Out How Your Drug is Covered tuftshealthplan.com I am a Member Pharmacy Choose Your Choice 3-tier Plan
Once you find your drug on the list, check to see if it has one of the following program designations Pharmacy Program Program Code What does it mean? Prior Authorization (PA) Prior authorization is needed for your treatment. Quantity Limitation (QL) There may be a limit on how much of a drug we will cover for a given period of time. Step Therapy (ST PA ) You may be required to try a certain drug or drugs to treat a specific medical condition before Tufts Health Plan will approve the coverage of another drug to treat the same condition. Designated Specialty Pharmacy (SP) Prescriptions for certain type of specialty drugs must be filled by designated pharmacies. Non Covered (NC) Certain drugs that are experimental, are available over the counter, or have a generic equivalent may not be covered by Tufts Health Plan. New-to-Market Drug Evaluation (NT) In an effort to make sure the new-to-market prescriptions we cover are safe, effective and affordable, we delay coverage of many new drug products until our P & T Committee and physician specialist have review them. These drugs require prior authorization.
What s On My ID Card? Your ID card explains the type of plan you have (3 Tier) and the associated costs by tier. The copay by the provider s tier The number of tiers providers fall under your plan Examples include DME coinsurance This is your pharmacy ID# information
Not All Services Are Tiered Service Emergency Room (ER) Chiropractic/Spinal Manipulation Speech/Physical Therapy Routine Eye Care Mental Health Providers (inpatient and outpatient) Nutritional Counselors Minute Clinics
Preventive Services are covered in full Getting preventive care is one of the best ways to keep you and your family happy and healthy. Examples include: Yearly checkups Health screenings Immunizations In order to be covered in full, preventive care must be received from a doctor or provider in the Tufts Health Plan network. Only certain services qualify as preventive. If you have any questions regarding whether a specific service is considered preventive, please check your benefit document or call Member Services at the number on your ID card.
Examples of Services That Are Not Covered Acupuncture Cosmetic Surgery Dental care (adult) Long-term care/custodial care Non-emergency care when traveling outside the U.S. Private-duty care Routine foot care Treatment that is experimental, for education or development purposes, or does not meet Tufts Health Plan Medical Necessity Guidelines This is not a complete list, so please check your policy or plan document for a list of other excluded services.
Reducing Your Out-of-Pocket Costs for Procedures Use Free Standing Centers Day Surgery Colonoscopy Endoscopy Cataract Surgery High Tech Imaging MRIs Computer Tomography Scans (CT) PET Scans Nuclear Radiology If you choose to have these services in a hospital, or a hospitalaffiliated medical facility, you will likely pay more than if you receive them in a non-hospital setting.
Minimizing Your Out-of-Pocket Expense When You re Sick or Injured Cost $ $$ Convenient Care Center Usage Retail Care Clinic Diagnose and prescribe medications to treat conditions such as strep throat, pinkeye, and infections of the ears, nose and throat. Administer routine vaccinations for flu. Urgent Care Center Diagnose and treat conditions such as head colds, ear or throat infections and minor trauma (e.g. eye injuries, cuts and burns that do not respond to basic first aid). Back/muscle pain, strain or sprain. Call 911 or go to the nearest emergency room if you think you have a medical condition that could endanger your life or limb if not treated immediately.
Utilization Management How we use medical guidelines and standards to determine appropriateness of care To help members receive quality health care in an appropriate treatment setting, we provide utilization management (UM). UM includes evaluating requests for coverage by applying medically and necessary coverage guidelines (clinical criteria guidelines) for a determination of the medical necessity, appropriateness, of the health care services under a member s benefit plan. Before (prospective): determine whether a treatment is medically necessary before it begins During (concurrent): reviews treatment during the course of care to determine medical necessity After (retrospective): review treatment for medically necessity after treatment is complete If you have any questions about what your specific plan covers, please read your Summary of Benefits or access your secure member account at mytuftshealthplan.com
Managing Your Plan Online and On the Go A secure online site has been created just for you at mytuftshealthplan.com Sign up to: Check your specific plan benefits Search for a doctor in your network Find a specialist Request prescription refills Check on a claim, authorization, or referral Check your deductible status (if applicable) View your ID card *Provider Tier data is updated annually in January
EmpowerMe EmpowerMe is a personalized treatment cost estimator tool that will help you control your health care costs and stay informed. With EmpowerMe, you can estimate in advance how much a treatment or service will cost you for things like specialist fees, x-rays, and routine lab tests. With EmpowerMe, you can: Research costs of treatments based on your specific health plan Search for a doctor or service Look up treatments for a condition Compare providers by quality, cost, and location Find options for services Manage your deductible Register or log on to mytuftshealthplan.com to take advantage of EmpowerMe today!
EmpowerMe on mytuftshealthplan.com EmpowerMe Link
Make Everyday Moments Matter Momentum is our health and wellness program designed to help you become and stay healthier. This includes: Lifestyle programs to help you stay healthy including preventive tips, online tools, and lifestyle coaching Programs to help you manage your care, Nurse24 SM 24 hour nurse line, and prescription support Special programs for asthma and heart disease, where you can get extra support to help manage your condition
Take a Moment To Be Healthier Lifestyle Management Program Wellness and Prevention Personal online tools including a Personal Health Assessment (PHA) Preventive care covered in full for in-network routine exams, screenings, and immunizations Maternity Care includes pre-natal education and support to ensure mom and baby are healthy Alternative therapy discounts to help inspire life balance and reduce stress
Nurse24 SM Nurse Line Have a question about your health? Not sure if you should go to the doctor or ER? With the Nurse24 SM 24-hour nurse line, members can talk to a nurse 24 hours a day, seven days a week. Translators are available in more than 170 languages to help you get the answers you need. Call 866-201-7919 to speak to a nurse today!
Routine Eye Care Eye Care Benefits Routine eye exams and other vision services are covered through the EyeMed Vision Care Network. To receive full coverage for routine eye exams and other vision care services you must visit an optometrist or ophthalmologist in the EyeMed network. You will also receive discounts on glasses and contacts from eye care providers in the EyeMed network. To find an eye care provider in the EyeMed network or to find out if your eye doctor is in the network, go to tuftshealthplan.com and click EyeMed Vision Care on the left. Contact EyeMed Vision Care at 866.504.5908
Momentum Supports You and Your Family What happens if you have a serious condition? Our team of nurse care managers may contact you to support you with one of our Care Management Programs Condition Management: If you have a serious illness or injury, or a chronic condition such as diabetes, heart failure, COPD, or chronic kidney disease, a Nurse Care Manager can work with you and your doctor to support your specific health needs. Priority Care: The Tufts Health Priority Care Program supports the wellness of our members with the most complex medical needs. If you have complex medical needs like cancer, multiple sclerosis, multiple chronic conditions, stroke, or congenital illnesses, our Priority Care Program is available for you.
Momentum Supports You and Your Family Healthy Birthday: Our Obstetrical Nurse Care Managers support moms at risk for preterm labor or those who have underlying complex medical conditions. Priority Newborn Care: Sometimes parents of new babies especially those with complex medical needs need a little extra help. Our Pediatric Care Managers are available to provide family centered support across all care settings from hospital to home. Transition to Home: Going home after a hospital stay can be overwhelming and challenging. You might need some help to get you back on your feet or someone to talk to about any questions you may have and a Nurse Care Manager can help!
Drive Your Own Health Momentum Let Us Help! Member Discounts Fitness and Exercise: Boys & Girls Clubs, Curves, Appalachian Mt. Club, Curves, discounts on our fitness network, and more! Health and Wellness: Mindfulness & Stress Management Program, acupuncture & massage discounts, CVS Caremark ExtraCare health card discounts, idiet, and BrainIQ Nutrition: Jenny Craig, Nutrisystem, Nutritional Counseling, and ChooseHealthy.com Vision: EyeMed Vision Care Network and Eyewear Discounts Visit mytuftshealthplan.com to learn more!
We re here to help! Member Services 877.658.3635 Hours: Monday-Thursday: 8 am 7 pm; Fri: 8 am 5 pm Behavioral Health 800.208.9565 Hours: Monday-Thursday: 8:30 am 5 pm; Fri: 8 am 5 pm