2022 Tufts Medicare Preferred HMO Prime Rx

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5-Star Plan

Five Stars
Premium

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Per Month
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$0
Medical Deductible
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$10 per visit
Doctor Copay
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$15 per visit
Specialist Copay
Dental Coverage Option
2022 Tufts Health Plan Medicare Preferred Dental Option
Monthly Dental Premium
Deductible for Diagnostic and Preventive Services
$0
Maximum benefit per year
$1,000

Drug Copays and Deductibles

Tier Type Copays
(30-day Retail / 90-day Mail Order)
Deductible

Tier 1

Preferred Generic Drugs
$4
/
$8
$0

Tier 2

Generic Drugs
$8
/
$16
$0

Tier 3

Preferred Brand Drugs
$45
/
$90
$0

Tier 4

Non-Preferred Drugs
$100
/
$300
$0

Tier 5

Specialty Drugs
33% of cost
/
N/A
$0

Tier 6

Vaccines
$0
/
N/A
$0

Enroll Now Compare to Other Plans

About the Plan

This is a Medicare Advantage plan, also known as Medicare Part C. It provides you with all of your Medicare Part A and B benefits, as well as additional coverage not included in Parts A and B. By paying a monthly premium, you gain consistent co-payments and deductibles and a yearly out-of-pocket spending maximum. Medicare Part D prescription drug coverage is also included as a part of this plan. 

You must continue to pay your Medicare Part B premium. If you receive Social Security, Railroad Retirement Board (RRB) benefits, or Civil Service benefits, your Medicare Part B (Medical Insurance) premium is already automatically deducted from your benefit payment. 

What is an HMO plan?

An HMO plan requires you to choose a Primary Care Physician (PCP) who provides all of your routine treatment for common ailments and illnesses, while also coordinating your overall care. In most cases your PCP will work with a Referral Circle to coordinate your care. A Referral Circle is a network of specialists your PCP has selected to work with due to their expertise in their respective fields. This means that in most cases, you will not have access to the entire Tufts Medicare Preferred HMO network, except in emergency or urgent care situations, or for out-of-area renal dialysis. When your PCP can’t treat a specific illness or condition he or she will refer you to a specialist within this referral circle who can. Your specialists will communicate with your PCP to ensure you receive the right care at the right time.


What does RX mean?

Rx is an abbreviation for a drug prescription. Plans with "Rx" in their names include prescription drug coverage, plans with "No Rx" in their names do not.  


Massachusetts Plan Service Area

To join a Tufts Medicare Preferred HMO Prime Rx plan, you must live in Barnstable, Bristol, Essex, Middlesex, Norfolk, Plymouth, Suffolk, Hampden, Worcester, or Hampshire Counties.

Medical Coverage

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Out-of-Pocket Maximum

Your Annual Out-of-Pocket Maximum is $3,450. This is the most you will pay in a plan year for covered medical expenses.

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Physical and Wellness Visit

Your Annual Physical, or Wellness Visit, will cost $0. You are allowed one Annual Physical and one Wellness Visit each plan year.

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Routine Vision Exam

Your Annual Routine Vision exam will cost $15. You are allowed one Annual Routine Vision exam each plan year.

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Routine Hearing Exam

Your Annual Routine Hearing Exam will cost $15. You are allowed one Annual Routine Hearing Exam each plan year.

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Laboratory Services

$0 per visit. Lab Services, including certain blood, urinalysis and tissue tests are covered at no cost to you.

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X-Rays

$0 per visit.

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Diagnostic Procedures

$0 per visit.

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Diagnostic Radiology Services

20% of cost, up to $75 per day. These services generally include computed tomography (CT) magnetic resonance imaging (MRI) and ultrasound.

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Outpatient Surgery

Colonoscopies: $0; Others: $100 per day for Outpatient Services, medical procedures or tests administered at a medical facility that don't require an overnight stay.

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Physical, Occupational, and Speech Therapy

$15 per visit. Physical Therapy often helps in recovering from surgery or injury and can help manage long-term health issues like arthritis. Occupational Therapy helps develop, recover, and improve the skills needed for daily living and working after an injury or disability. Speech Therapy generally helps manage speech, language, communication and swallowing disorders.

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Cardiovascular Screening

$0 per visit. These screenings and tests help detect conditions that can lead to a heart attack or stroke.

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Cancer Screening (Colorectal, Prostate, Breast)

$0 per visit. These screenings are aimed at detecting cancer before symptoms appear, when treatment is more effective.

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Urgent Care

PCP: $10 per visit; Specialists: $15 per visit. Urgently needed care covers you when you need immediate medical care due to an unanticipated illness, injury, or condition but your health is not in serious danger.

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Emergency Room Visits

Emergency Room visits cost $110 per visit, and there is no limit to the number of visits in a plan year. 

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Inpatient Hospital Coverage

You will pay $300 per inpatient hospital stay, up to a $900 annual maximum.

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Ambulance Rides and Services

$125 per one-way trip for medically necessary Ambulance Services. This cost applies on a per day basis, regardless of the number of ambulance trips made. PA may be required for non-emergency transportation.

Benefits

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Embedded Dental Benefit

Not Covered.

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Acupuncture

Covers up to 12 visits in 90 days for members with chronic lower back pain. 8 additional visits covered for those demonstrating an improvement. No more than 20 visits administered annually.

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Hearing Aid Benefit

Not Covered.

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Eyewear Benefit

$150 per year to use at a participating EyeMed provider or $90 per year at a non-participating provider.

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Weight Management Programs

$150 reimbursement per year for fees related to weight management programs like WeightWatchers, Jenny Craig and hospital based programs.

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Wellness Allowance

Choose how to stay fit with up to a $150 reimbursement for fees you pay toward joining a health club, fitness class (such as aerobics, Pilates, Tai Chi, or yoga), nutritional counseling sessions and other wellness programs like memory fitness activities.

Drug Coverage

prescriptions

Coverage Gap Stage - Generic

In 2022, once you and your plan have spent $4,430 on covered drugs combined, you're in the Coverage Gap Stage. You are responsible for 25% of the cost of generic drugs.

prescriptions

Coverage Gap Stage - Brand Name

In 2022, once you and your plan have spent $4,430 on covered drugs combined, you're in the Coverage Gap Stage and are responsible for 25% of the cost for Part D brand name drugs, plus a portion of the dispensing fee.

prescriptions

Catastrophic Coverage Stage - Generic

In 2022, once you've spent $7,050 in out-of-pocket prescription costs you are in the Catastrophic Coverage Stage; generic prescriptions will cost the greater of 5% of the prescription price or $3.95 per prescription.

prescriptions

Catastrophic Coverage Stage - Brand Name

In 2022, once you've spent $7,050 in out-of-pocket prescription costs you are in the Catastrophic Coverage Stage; brand name prescriptions will cost the greater of 5% of the prescription price or $9.85 per prescription.