How much are my copays for medical, hospital and other benefits with my Tufts Medicare Preferred HMO plan?

Every Medicare Advantage Plan is required to include a document called a "Summary of Benefits" in your enrollment kit.  We've provided an easy to use index below to help you find copays, deductibles and coverage information on each benefit covered under our Tufts Medicare Preferred HMO plans.  When the government created this document, they numbered every benefit category in a specific order and labeled them as items 1 through 31.  This was designed to help consumers compare coverage not only within Tufts Medicare Preferred HMO product lines (Basic, Value and Prime) but our competitors as well.

Each column in the "Summary of Benefits" represents a specific product line offered by Tufts Medicare Preferred HMO - Basic, Value or Prime. Each row represents a specific benefit covered by our products including medical, hospital, prescription and wellness benefits. Please use this index to find the copays, cost sharing and coverage information on each benefit covered in each of our Tufts Medicare Preferred HMO plans. Click here to find a copy of the HMO Summary of Benefits.

 

SERVICEPAGE NUMBER
IMPORTANT INFORMATION
1. Premium and Other Important Informationpg 6 - Includes out-of-pocket limit
INPATIENT CARE
2. Doctor and Hospital Choicepg 8 - Includes Description of Referrals
3. Inpatient Hospital Carepg 10 - Includes Copay for Hospital, Substances Abuse and Rehabilitation Services
4. Inpatient Mental Health Carepg 14 - Includes Copay for Psychiatric and Lifetime Limit
5. Skilled Nursing Facility Carepg 16 - Includes Copay and Days Covered in Each Benefit Period
6. Home Health Carepg 18 - Includes Copay for Intermittent Skilled Nursing Care, Home Health Aid Services and Rehabilitation Services
7. Hospice Carepg 18 - Medicare-certified Hospice

 

OUTPATIENT CARE
8. Doctor Office Visitspg 20 - Includes Copay for Physical Exam
9. Chiropractic Servicepg 20 - Includes Copay for Manual Manipulation of the Spine
10. Podiatry Servicepg 22 - Includes Copay for Medically Necessary Foot Care
11. Outpatient Mental Health Carepg 24 - Includes Copay for Medicare-covered Visit
12. Outpatient Substance Abuse Carepg 26 - Includes Copay for Medicare-covered Visit
13. Outpatient Services and Surgerypg 26 - Include Copay for Medicare-covered Ambulatory or Hospital Visit (i.e., injectible, intravenous, or oral chemotherapy)
14. Ambulance Servicepg 28 - Includes Copay for Medicare-covered Ambulance Benefits
15. Emergency Carepg 28 - Includes Copay for Medicare-covered Emergency Room Visit
16. Urgently Needed Carepg 30 - Includes Copay for Medicare-covered Urgently Needed Care (Primarily Out-of-Area Care)
17. Outpatient Rehabilitation Servicespg 30 - Includes Copay for Medicare-covered Occupational Therapy, Physical Therapy, Speech & Language Therapy, Respiratory Therapy, Social/Psychological Services and more.

 

OUTPATIENT MEDICAL SERVICES AND SUPPLIES
18. Durable Medical Equipmentpg 32 - Includes cost sharing for Wheelchairs, Oxygen, etc.
19. Prosthetic Devicespg 32 - Includes cost sharing for Braces, Artificial Limbs & Eyes, etc.
20. Diabetes Self-Monitoring Training, Nutrition Therapy, and Suppliespg 34 - Includes copays for Glucose Monitors, Test Strips, Lancets, Screening Tests, Self Monitoring Training, Retinal Exam, Glaucoma Test, Foot Exam, and Therapeutic Soft Shoe
21. Diagnostic Test, X-Rays, Lab Services, and Radiological Servicespg 36 - Includes copays for Lab Services, Diagnostic Procedures and Tests, X-rays, Diagnostic Radiology Services, Therapeutic Radiology Services
22. Cardiac and Pulmonary Rehabilitation Servicespg 38 - No Copay for Medicare-covered Services

 

PREVENTIVE SERVICESHealth reform legislation eliminated out-of-pocket cost sharing for most Medicare-covered preventive services.
23. Preventive Services and Wellness/Education Programspg 40 - No Copay for Medicare-covered Screenings (separate Office Visit Copay may apply) includes: 
 Abdominal Aortic Aneurysm Screening
 Bone Mass Measurement
 Cardiovascular Screening
 Cervical and Vaginal Cancer Screening (Pap Test and Pelvic Exam)
 Colorectal Cancer Screening
 Diabetes Screening
 Influenza Vaccine
 Hepatitis B Vaccine
 HIV Screening
 Breast Cancer Screening (Mammogram)
 Medical Nutrition Therapy Services
 Personalized Prevention Plan (Annual Wellness Visits)
 Pneumococcal Vaccine
 Prostate Cancer Screening (Prostate Specific Antigen (PSA) test only)
 Smoking Cessation (Counseling to stop smoking)
 Screening and behavioral counseling interventions in primary care to reduce alcohol misue
 Screening for depression in adults
 Screening for sexually transmitted infections (STI) and high intensity behavioral counseling to prevent STIs
 Intensive behavioral counseling for Cardiovascular Disease (bi-annually)
 Intensive behavior therapy for obesity
 Welcome to Medicare Physical Exam (Initial Preventive Physical Exam)
24. Kidney Disease and Conditionspg 48 - $0 Copay for renal dialysis and kidney disease education services

 

PRESCRIPTION DRUGS 
25. Drugs Covered under MedicarePart B pg 50 - No Copay
Drugs Covered under Medicare Part Dpg 51 - Plans With and Without Coverage
Retail Pharmacy Copayspg 56 - Plans With and Without Coverage
Long Term Care Pharmacy Copayspg 62 - Plans With and Without Coverage
Mail Order Copayspg 66 - Plans With and Without Coverage
Coverage gap/Donut Hole Copayspg 72 - Plans With and Without Coverage
Catastrophic Coverage Copayspg 74 - Plans With and Without Coverage
Out-of-Network Coverage Copayspg 74 - Plans With and Without Coverage
Out-of-Network Coverage Gap Copayspg 80 - Plans With and Without Coverage
Out-of-Network Catastrophic Copayspg 82 - Plans With and Without Coverage

 

OTHER BENEFITS 
26. Dental Servicespg 94 - Preventive Dental Not Covered
27. Hearing Servicespg 94 - Includes Copay for Medicare-covered Diagnostic Hearing Exams and Annual Hearing Test
28. Vision Servicespg 96 - Includes Copay for Medicare-covered Diagnostic and Routine Eye Exams
29. Over-the-Counter Itemspg 98 - Not Covered
30. Routine Transportationpg 98 - Not Covered
31. Acupuncturepg 98 - Not Covered


This table lists some of the features of our plans. It does not list every service that we cover or list every limitation or exclusion. To get a complete list of our benefits, please download a copy of our Summary of Benefits document or call Tufts Health Plan Medicare Preferred and ask for a copy. 

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