- What is covered when I travel?
Knowing that your health plan will be there for you when you’re away from home is an important part of enjoying your next trip. Tufts Medicare Preferred HMO members have the peace of mind that comes with worldwide coverage for emergency and urgent care. Below is more detail of what is covered when you travel. Review the below detail and enjoy your trip!
What is covered when I travel?
Tufts Medicare Preferred HMO covers members for emergency and urgently needed care anywhere in the world.
You can be outside of our service area for up to 6 consecutive months and still be covered for emergency and urgently needed care.
What is a medical emergency?
A medical emergency is when you believe your health is in serious danger.
A medical emergency includes severe pain, a bad injury, sudden illness, or a medical condition that is quickly getting much worse.
If you have a medical emergency:
Get medical help as quickly as possible.
Call 911 for an ambulance or go to the nearest emergency room, hospital, or urgent care center.
You do not need to get approval or a referral first from your Primary Care Physician (PCP).
As soon as possible, you or someone else should call to tell us about your emergency (usually within 48 hours), because we need to follow up on your emergency care. The Customer Relations number is conveniently located on the back of your membership card.
What is urgently needed care?
Urgently needed care is when you need medical care right away because of an illness, injury, or condition that you did not anticipate, but your health is not in serious danger.
Because of the situation, it isn’t reasonable for you to obtain medical care from a network provider.
If you require urgently needed care:
If you are outside of our service area and cannot get care from a network provider, our plan will cover urgently needed care that you get from any provider.
- What if I don't have enough medication when I travel?
Below are some helpful Medication Travel Tips for you:
Requesting a vacation override
- A vacation override allows you to bring a larger supply of your prescription medication with you when traveling out of the country or to a remote location.
- To request a vacation override, contact Customer Relations 5 business days before leaving for your trip with your prescription and pharmacy information.
Filling prescriptions when you travel
- If you lose or run out of prescriptions when traveling, we will cover prescriptions that are filled at an out-of-network pharmacy if a network pharmacy is not available. (This applies to Tufts Medicare Preferred HMO members whose plan includes prescription drug coverage).
- At a non-network pharmacy, you will have to pay the full cost (rather than paying just your copayment) when you fill the prescription. You can then ask us to reimburse you for our share of the cost by submitting a paper claim form. Just save your receipt and call Customer Relations to ask for a Prescription Claim Form. Mail the completed form with your receipt to the address on the form.
- Check your supply of prescription drugs you take on a regular basis before leaving for a trip and if possible, take all the medication you need with you.
- Bring copies of your prescriptions so you can fill them in the event you lose your medications.
- Have a list of the generic names of your medications, especially when traveling overseas. If you need an emergency refill, physicians or pharmacists will be more likely to recognize generic names.
- Bring the name and telephone number of your doctor and pharmacy.
Protect your medications
- Read the storage instructions on the prescription label or talk with your doctor if you’re not sure how to store your medications when traveling.
- When traveling by plane, pack medications in your carry-on, not in checked luggage.
- When traveling by car, remember not to leave your medications in the car, especially in warm weather, and never leave them in the trunk.
- The Transportation Security Administration Web site www.tsa.gov/travelers has helpful tips to get you through airport checkpoints quickly and securely, including which medications and supplies you can transport by plane.
- What if I need medical care when my primary care physician's office is closed?
Sometimes you may need to talk with your Primary Care Physician (PCP) or get medical care when your PCP’s office is closed. If you have a non emergency situation and need to talk to your PCP after hours, you can call your PCP’s office at anytime and there will be a physician on call to help you. Hearing or speech-impaired members with TTY machines can call the Massachusetts Relay Association at 1-800-439-0183 (TTY 1-800-439-2370) for assistance contacting your PCP after hours.
If you have a medical emergency, get help as quickly as possible by calling 911 for an ambulance or by going to the nearest emergency room, hospital, or urgent care center. You do not need to call your PCP’s office first when you have a medical emergency. A medical emergency is when you believe your health is in serious danger and can include severe pain, a bad injury, a sudden illness, or a medical condition that is quickly getting much worse.
- What is EFT and how do I sign up?
EFT stands for Electronic Funds Transfer. When you sign up for EFT, your monthly premium payment is automatically deducted from your checking or savings account each month and transferred to Tufts Health Plan Medicare Preferred. EFT allows you to make payments without writing checks or having to pay for postage.
What are the benefits of EFT?
- Plan premium payments will not be late or lost
- Your plan premium is paid even when you are away from home or on vacation
- You save postage costs and spend less time writing checks
- It is a safe, easy, and convenient way to make timely payments
- There is no charge to use the EFT payment option
How do I sign up?
As long as you are a current member and have no outstanding balance on your account, you can sign up for EFT. Just fill out the EFT Authorization Form envelope. We will contact you by mail when your application has been approved. Please continue to pay your monthly premium until we notify you that you are enrolled in the EFT program.
Signing up for EFT is as simple as 1-2-3.
1. Fill out the EFT form after downloading it here.
2. Mail the application with a voided check to Tufts Health Plan Medicare Preferred in the envelope provided.
Once you sign up and receive your EFT invoice, your monthly plan premium payments will be automatically deducted from your checking or savings account. Just be sure to keep enough money in your account each month for the deduction.
- How will I know when the EFT amount has been deducted from my account and when?
A monthly invoice will be sent to all EFT members confirming the EFT transaction amount. In addition, your EFT deduction will be identified in your monthly bank statement as "Medicare Preferred".
Your monthly plan premium will be withdrawn from your account on the 9th of every month for the current month's plan premium. For example, the premium for the month of July will be withdrawn on July 9th. The withdrawal will occur on the following business day if the 9th falls on a Saturday, Sunday, or holiday. The withdrawal takes place on the 9th in order to allow for payment to be received by the invoice due date of the 15th.
For More Information
For more information on signing up for EFT*, contact Customer Relations at 1-800-701-9000 (TTY 1-800-208-9562). Representatives are available 7 days a week, 8:00 a.m - 8:00 p.m. from Oct 1 - Feb 14. After hours and on holidays, please leave a message and a representative will return your call the next business day.
* If you receive your benefits from a current or former employer, you are not eligible for EFT unless you pay your premium directly to Tufts Health Plan Medicare Preferred. If you are unsure, check with your benefits administrator before enrolling
- How do I receive a reimbursement for joining a fitness club?
Staying fit can help keep you healthy. Our fitness club reimbursement is part of our commitment to helping you lead an active lifestyle. All Tufts Medicare Preferred HMO members are eligible to receive up to $150 per calendar year toward club membership fees and/or exercise classes by enrolling with a qualified health club or fitness facility.
To Receive Your Wellness Allowance, complete the fitness benefit form, found here.
You can also contact Customer Relations at the number below and ask to have a Wellness Allowance Form sent to you.
- Make a photocopy of your health club or fitness facility agreement that includes the name and address of the club/facility, your name, and the dates of your membership or exercise classes.
- Make a photocopy of one of the following:
- Dated, paid receipt with club/facility’s name preprinted on the receipt, and amount paid
- Front and back of cancelled check written to club/facility
- Credit card statement or receipt identifying club/facility
Photocopies must be on 8.5" x 11" paper. Multiple receipts may be included on one page. Mail the form, photocopies of your health club or fitness facility agreement, and paid receipts or statements to:
Attn: Wellness Allowance
P.O. Box 9181
Watertown, MA 02472
We encourage you to keep copies of all the paperwork you send to us. We are not able to return photocopies.
If you have any questions, just call our Customer Relations department at 1-800-701-9000 (TTY 1-800-208-9562). Representatives are available 7 days a week, 8:00 a.m - 8:00 p.m. from Oct 1 - Feb 14. After hours and on holidays, please leave a message and a representative will return your call the next business day.
- How do I know if a health club or fitness facility qualifies for the Wellness Allowance?
Qualified health clubs and fitness facilities provide cardiovascular and strength-training exercise equipment on site. Examples of qualified fitness facilities and health clubs include:
- Traditional health clubs & community fitness centers
- YMCA’s, YWCA’s & Jewish Community Centers with a fitness facility on site
- Tufts Health Plan Medicare Preferred network of fitness centers in Massachusetts; Curves®; & Fitness Together
If you join a health club or fitness facility that meets the above requirements, you are eligible to receive up to $150 per calendar year toward club membership fees and/or exercise classes.
If you have any questions, call Tufts Health Plan Medicare Preferred Customer Relations at 1-800-701-9000, (TTY 1-800-208-9562). Representatives are available 7 days a week, 8:00 a.m - 8:00 p.m. from Oct 1 - Feb 14. After hours and on holidays, please leave a message and a representative will return your call the next business day.
- How can I help prevent medication errors?
Prescriptions are medications that treat illness and help maintain your health. However, if taken improperly, they could seriously jeopardize your well being. This is especially true during times of transition or change, such as if you see a physician who does not know your medical history, if you are transported to an emergency room, or if you are released from a hospital or skilled nursing facility.
Here are some easy ways to stay safe and reduce or eliminate medication mishaps:
* Make a list of all prescription drugs, over-the-counter medications, vitamins, diet supplements, natural remedies, and herbal preparations that you take. Include the exact name of the prescription, dosage, frequency that it is taken, and the name of the physician who prescribed it.
* Keep this list in your purse or wallet and show it to your health care provider during an office visit, emergency room visit, or upon admission to a hospital or skilled nursing facility. If you haven’t had a chance to prepare your medication list but need to visit the doctor or go to the emergency room, simply gather all the bottles of your medications/vitamins/herbal preparations, etc. and put them in one plastic bag. Your healthcare provider can use the bottles to list everything that you are currently taking.
* Always tell your doctor or nurse about any past allergic reactions. Know the name of the medication that caused the allergic reaction and describe the adverse symptoms that you experienced.
* Be sure that your healthcare provider reviews your medications. Transitions between home and the hospital are frequently times when details can be overlooked, especially if you have been prescribed new medications. Make sure all the healthcare professionals caring for you know your medical history and your medication schedule. When you leave the hospital, ask the nurse or physician to compare the list of the medications you were taking before you were admitted to your current list to ensure that nothing has been omitted. If there has been an omission, make sure it is correct. If any new medications have been prescribed, make sure you have the prescriptions to take with you.
* Try to use the same pharmacy. Fill as many prescriptions as possible at the same pharmacy or chain and use mail-order prescription service if available. Using the same pharmacy is especially important when you are trying out a medication for the first time because they will be better able to monitor any potential interactions between medications.
By following these suggestions, you can help make sure the medications that are prescribed for you are safe and accurate.
- Where can I find information about Tufts Health Plan Medicare Preferred Privacy Practices?
Tufts Health Plan Medicare Preferred takes the confidentiality of your personal health information very seriously.
In addition to complying with all applicable laws, we carefully handle your personal health information in accordance with our confidentiality policies and procedures. We’re committed to protecting your privacy in all settings.
The Notice of Privacy Practices provides detailed information about our privacy practices and your rights regarding your personal health information. It is available on our website and is included in the new member kit you received when you joined Tufts Health Plan Medicare Preferred.
You can view a copy of our Notice of Privacy Practices online here.
If you would like a copy of our Notice of Privacy Practices sent to you, just call our Customer Relations department at 1-800-701-9000 (TTY 1-800-208-9562). Representatives are available 7 days a week, 8:00 a.m - 8:00 p.m. from Oct 1 - Feb 14. After hours and on holidays, please leave a message and a representative will return your call the next business day.
- Will I need to submit a Form MA 1099- HC (Healthcare) with my annual tax return?
No, if you are a member of one of the following plans – Tufts Medicare Preferred HMO or Tufts Medicare Preferred Supplement plans, you are not required to submit the Form MA 1099-HC. People with Medicare Part A are automatically deemed to meet the Massachusetts minimum coverage requirements and therefore are not required to file a Form MA 1099-HC. Therefore, we will not mail a 1099-HC form to you.
- What if my prescription drugs cannot be filled?
Your Medicare Rights
If your pharmacist cannot fill your prescription drugs you have the right to request a coverage determination from Tufts Health Plan Medicare Preferred. This request includes the right to request a special type of coverage determination called an “exception” if you believe:
- You have been prescribed a drug that is not on your Plan’s list of covered drugs. The list of covered drugs is called a formulary and a drug not on our formulary is called a non-formulary drug;
- You believe one of the Plan’s coverage rules should not apply to you for medical reasons. Coverage rules include: requiring prior authorization by the plan before the drug is covered, quantity limits for dosage and or length of time on a drug, and/or or step therapy requirements asking you to try another drug to treat your medical condition before the Plan covers the drug prescribed by your physician; or
- You need to take a drug in a cost sharing tier that you think is too high and you want the plan to cover the drug at a lower cost sharing tier.
Step 1: What You Need to do to Request Coverage
You can complete the request online by filling out our "Coverage Determination" request form or you can call the toll free number on the back of your membership card. You will need the following information in order to complete the form or telephone call:
- The prescription drug you believe you need. Include the dose and strength, if known.
- If you ask for an exception, your doctor or other prescriber will need to provide Tufts Health Plan Medicare Preferred with a statement explaining: why you need the non-formulary drug, why a coverage rule should not apply to you, or why an exception should be made to your cost sharing.
- The date your prescription was rejected at the pharmacy.
Tufts Health Plan Medicare Preferred will provide you with a written decision. If coverage is not approved, we will explain why coverage was denied and how to request an appeal call a "redetermination" if you disagree with our decision.
Step 2: What You Need to do if Your Request is Denied?
If you disagree with our decision, you can file a redetermination request or an “appeal” by completing our redetermination request form online or you can call the toll free number on the back of your membership card.
H2256_2012_137 CMS Approved (01/04/2012)
- What is a Tufts Medicare Preferred HMO plan Organization Determination?
An organization determination is our initial decision about whether we will provide the medical care or service you request, or pay for a service you have received. If our initial decision is to deny your request, you may appeal the decision. When we make an "organization determination," we are giving our interpretation of how the benefits and services that are covered for members of the Plan apply to your specific situation. Please refer to your EOC for additional details.
Learn more about filing an appeal or coverage determination in Chapter 9, section 1-9 and a grievance in Chapter 9, section 10 of your EOC (Chapter 7 for HMO No Rx Plans).
- How do I contact the Medicare Beneficiary Ombudsman office?
To learn more about how to contact the Medicare Beneficiary Ombudsman office, visit http://www.medicare.gov/navigation/help-and-support/ombudsman.aspx
- When do I receive information about changes to my benefits or costs for the upcoming year?
Each September, members are mailed an Annual Notice of Change (ANOC) letter and Evidence of Coverage (EOC) booklet that contains details about your benefit and cost information for the upcoming year. For example, the last ANOC/EOC was mailed in September for delivery to you no later than September 30th, and contained information for the following plan year. Please make a note to look for these documents in the mail in September.
- Can I apply for an exception if my drug requires prior authorization, quantity limits or step therapy?
Some covered drugs may have additional requirements or limits on coverage known as Utilization Management. These requirements and limits may include:
Prior Authorization: Tufts Medicare Preferred HMO requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Tufts Medicare Preferred HMO before you fill your prescriptions. If you don't get approval, Tufts Medicare Preferred HMO may not cover the drug.
Quantity Limits: For certain drugs, Tufts Medicare Preferred HMO limits the amount of the drug that Tufts Medicare Preferred HMO will cover. For example, Tufts Medicare Preferred HMO provides 30 tablets per prescription for zolpidem. This may be in addition to a standard one month or three month supply.
Step Therapy: In some cases, Tufts Medicare Preferred HMO requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Tufts Medicare Preferred HMO may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Tufts Medicare Preferred HMO will then cover Drug B.
You can ask Tufts Medicare Preferred HMO to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.
* You can ask us to cover your drug even if it is not on our formulary.
* You can ask us to waive coverage restrictions or limits on your drug. For example,for certain drugs, Tufts Medicare Preferred HMO may limit the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more.
* You can ask us to provide a higher level of coverage for your drug. If your drug is contained in tier 2, tier 3, or tier 4, you can ask us to cover it at a lower cost-sharing tier applicable to your brand or generic drug. This would lower your share of the cost for the drug.
* If your brand drug is in Tier 4: Non-preferred Brand Drugs, you can ask us to cover it at the cost-sharing amount for Tier 3: Preferred Brand Drugs. This would lower your share of the cost for the drug.
* If your generic drug is in Tier 3: Preferred Brand Drugs, you can ask us to cover it at a lower the cost-sharing amount for T-2: Non-preferred Generic Drugs or T-1: Preferred Generic Drugs. This would lower your share of the cost for the drug.
* If your generic drug is in Tier 2: Non-preferred Generic Drugs, you can ask us to cover it at the cost-sharing amount for Tier 1: Preferred Generic Drugs. This would lower your share of the cost for the drug.
* We cannot change the cost-sharing tier for any drug in Tier 5: Specialty Tier Drugs.
Please note, if we grant your request to cover a drug that is not on our formulary, we cannot provide a higher level of coverage for the drug.
Tufts Medicare Preferred HMO will only approve your request for a tier exception if all alternative drugs approved for treating your condition on lower-tiers have not been effective in treating your condition and/or would cause you to have adverse medical effects.
When you are requesting a formulary, tiering, or utilization restriction exception, you should submit a statement from your physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescribing physician's supporting statement. You can request an expedited (faster) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get your prescribing physician's supporting statement.
H2256_2013_337 CMS Pending Approval 3/12/2013
- Information About a CVS Caremark Mailing
CVS Caremark is notifying affected Tufts Health Plan Medicare Preferred Plan members that due to a programming error, letters intended for approximately 3,500 plan members were sent to incorrect addresses in late January and early February. CVS Caremark is the pharmacy benefits manager for the plan. The personal information in the letter included a member’s name, the name of a medication prescribed, and a general description of the types of conditions that the medication is used to treat. No other information was included in any of the letters, and there is no evidence that any of this information was used improperly. After reports were received concerning the issue in early February, the programming error was promptly corrected.
There was no other specific information, such as financial account numbers or insurance identifiers, in any of the letters that could be used for identity theft or other financial harm.
CVS Caremark has sent a notice to the recipients of the incorrectly addressed letters asking them to mail the letter back if it is still in their possession or to confirm they have already destroyed the letter.
CVS Caremark sincerely apologizes for any inconvenience or concern this incident may have caused.
Tufts Health Plan Medicare Preferred members with questions regarding this matter should call CVS Caremark at their toll-free number, 877-878-5377. Representatives are available 24 hours a day, 7 days a week. TTY users should call 866-236-1069.
- What is an ANOC?
The Annual Notice of Change (ANOC) is a personalized letter sent to all members that highlights any changes to their benefits and costs for the upcoming year. The format of the letter is determined by the Centers for Medicare and Medicaid Services (CMS) to ensure that Medicare Advantage plan members receive complete and accurate information about their coverage. Information contained in the ANOC includes:
- Your premium for the upcoming year
- Any changes to the cost or coverage of your medical benefits
- Any new medical benefits that will be part of your coverage in the upcoming year or non-Medicare benefits removed for the upcoming year
- Any changes to the cost of prescriptions in your prescription drug benefit (if you are enrolled in a prescription drug plan)
- Any changes to the drugs covered in your prescription drug benefit
- What is an EOC?
If you are renewing into the same plan, you will receive along with your ANOC, a copy of the Evidence of Coverage (EOC) for the plan you are enrolled in. The EOC provides a detailed description of the benefits and costs for your plan. It also explains your rights as a member and how to use your coverage for medical care or prescription drug. Information contained in the EOC includes:
- Important phone numbers and resources
- A medical benefits chart that explains what is covered and what you pay
- How to use your prescription drug coverage and the cost of your prescription drugs (if you are in a prescription drug plan)
- Your rights and responsibilities
- What to do if you have a problem or complaint
The EOC is available here.
(Note: the ANOC is a personalized letter with member specific information and therefore not available on our website. The EOC’s on our Web site are for our individual plans.)
If you have any questions, just call our Customer Relations department at 1-800-701-9000 (TTY 1-800-208-9562). Representatives are available 7 days a week, 8:00 a.m - 8:00 p.m. from Oct 15 - Feb 14. After hours and on holidays, please leave a message and a representative will return your call the next business day.
- What is a referral and why do I need one?
Referrals are an important part of an HMO plan because they help your doctor keep track of the care you receive and ensure that the care is right for you.
When you join an HMO plan, you select a doctor to be your Primary Care Physician (PCP). Your PCP will provide your routine care, preventive care, and treatment for common illnesses. Your PCP is also responsible for coordinating or overseeing your care.
An important part of coordinating your care is when your PCP “refers” you to a specialist for services he/she isn’t able to provide. Your PCP works with a team of specialists in a variety of areas. When your PCP refers you to a specialist, he/she is recommending you see a doctor whose opinion your PCP trusts and who your PCP feels is qualified to diagnose your specific condition. Your PCP and the specialist will communicate to ensure you receive the care you need.
Having one doctor who oversees all of the care you receive is one of the many advantages of being a member of an HMO plan. The intent of coordinated care and our HMO plan is simple; one team working together to help you stay healthy.
- Helpful Things To Know About Referrals
You Do Not Need An Actual Referral Slip
When your PCP issues a referral to see a specialist, he/she will send the specialist the referral information. If for any reason, you arrive at your specialist appointment after receiving a referral confirmation from your PCP and are told your referral is not there, ask the specialist’s office to contact your PCP’s office to send the referral while you wait.
Always Check With Your PCP Before Seeing A Specialist
Sometimes a specialist will recommend you see another specialist. Always check with your PCP before seeing a specialist because your PCP needs to issue the referral. A specialist isn’t able to refer you to another specialist. By issuing all the referrals, your PCP is able to oversee the care you receive and help you see the specialist that is right for you.
Your PCP has a team of specialists called a “referral circle.”
Your doctor’s referral circle includes designated specialists, hospitals, skilled nursing facilities, durable medical equipment providers, and other selected providers. Your PCP’s referral circle represents the specialists and facilities your PCP has selected to work with in his/her area.