2024 Tufts Medicare Preferred
HMO Prime Rx Plus
- $0 Medical Deductible
- Prescription Drug Coverage Included
- $150 Annual Wellness Allowance
- $150 Annual Eyewear Benefit
Tier 1 - Preferred Generic Drugs
Copays (30-day Retail / 90-day Mail Order)
Deductible
Tier 2 - Generic Drugs
Copays (30-day Retail / 90-day Mail Order)
Deductible
Tier 3 - Preferred Brand Drugs
Copays (30-day Retail / 90-day Mail Order)
Deductible
Tier 4 - Non-Preferred Drugs
Copays (30-day Retail / 90-day Mail Order)
Deductible
Tier 5 - Specialty Drugs
Copays (30-day Retail / 90-day Mail Order)
Deductible
Tier 6 - Vaccines
Copays (30-day Retail / 90-day Mail Order)
Deductible
Coverage Gap Stage - Generic
Once you and your plan have spent $5,030 on covered drugs combined, you're in the Coverage Gap Stage where the 30 day supply costs are: $2 for Tier 1, $4 for Tier 2, $0 for Tier 6 vaccine drugs, no more than $35 for covered insulin drugs, and 25% of the cost for Part D generic drugs, plus a portion of the dispensing fee for Tiers 3-5.
Coverage Gap Stage - Brand Name
Once you and your plan have spent $5,030 on covered drugs combined, you're in the Coverage Gap Stage where the 30 day supply costs are: $2 for Tier 1, $4 for Tier 2, $0 for Tier 6 vaccine drugs, no more than $35 for covered insulin drugs, and 25% of the cost for Part D generic drugs, plus a portion of the dispensing fee for Tiers 3-5.
Catastrophic Coverage Stage - Generic
Once you've spent $8,000 in out-of-pocket prescription costs you are in the Catastrophic Coverage Stage. If you reach the Catastrophic Coverage Stage, you pay nothing for covered Part D drugs and for excluded drugs that are covered under our enhanced benefit.
Catastrophic Coverage Stage - Brand Name
Once you've spent $8,000 in out-of-pocket prescription costs you are in the Catastrophic Coverage Stage. If you reach the Catastrophic Coverage Stage, you pay nothing for covered Part D drugs and for excluded drugs that are covered under our enhanced benefit.
Covered Insulin Drugs
Part B: $0
Part D: Your copay for covered insulin will not exceed $35 per 30-day supply regardless of the drug tier. This means that your copay is the Tier 1, Tier 2, Tier 3, or Tier 4 copay, or $35 per 30-day supply, whichever is lower.
Out-of-Pocket Maximum
Your Annual Out-of-Pocket Maximum is $3,650. This is the most you will pay in a plan year for covered medical expenses.
Physical and Wellness Visit
Your Annual Physical, or Wellness Visit, will cost you $0. You are covered for one Annual Physical and one Wellness Visit each plan year.
Primary Care Provider (PCP)
$10 per Primary Care Physician (PCP) visit
Specialist Copay
$15 per Specialist visit
Routine Vision Exam
Your Annual Routine Vision exam will cost $15. You are covered for one Annual Routine Vision exam each plan year.
Routine Hearing Exam
Your Annual Routine Hearing Exam will cost $0. You are covered for one Annual Routine Hearing Exam each plan year.
Laboratory Services
$0 per day for Lab Services, including certain blood, urinalysis and tissue tests. Prior Authorization may be required.
X-Rays
$0 per day. Prior Authorization may be required.
Diagnostic Procedures
$0 per day. Prior Authorization may be required.
Diagnostic Radiology Services
20% of cost, up to $75 per day. These services generally include computed tomography (CT) magnetic resonance imaging (MRI) and ultrasound. Prior Authorization may be required.
Outpatient Surgery
Colonoscopies: $0; All Other Outpatient Surgeries: $75 per day - for Outpatient Services, medical procedures or tests administered at a medical facility that don't require an overnight stay. Prior Authorization may be required.
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. Referral from your Primary Care Provider (PCP) is required.
Cardiovascular Screening
$0 per visit. These screenings and tests help detect conditions that can lead to a heart attack or stroke.
Cancer Screening (Colorectal, Prostate, Breast)
$0 per visit. These screenings are aimed at detecting cancer before symptoms appear, when treatment is more effective.
Urgent Care
$30 per visit. Urgently needed services are provided to treat a non-emergency, unforeseen medical illness, injury, or condition that requires immediate medical care but, given your circumstances, it is not possible, or it is unreasonable, to obtain services from network providers.
Emergency Room Visits
Emergency Room visits cost $110 per visit, and there is no limit to the number of visits in a plan year.
Inpatient Hospital Coverage
You will pay $200 per inpatient hospital stay, up to a $400 annual maximum. Prior Authorization may be required.
Ambulance Rides and Services
$90 per one-way trip for medically necessary Ambulance Services. Prior authorization may be required for non-emergency transportation. Includes worldwide emergency transportation coverage.
Calendar Year Maximum
With Dental Option Added: $1,000 per calendar year
Individual Annual Deductible
With Dental Option Added: $0
Periodic Oral Evaluation
With Dental Option Added: $0. Covers two per year.
Comprehensive Oral Exam
With Dental Option Added: $0. Covers one every 36 months.
Intra Oral Bitewing X-ray (X-rays of Crowns of Teeth)
With Dental Option Added: $0. Covers two per year.
Intra Oral X-ray - Entire Mouth (Panoramic & Full Mouth)
With Dental Option Added: 20% of total cost. Includes panoramic or full mouth series. Covers one every 60 months.
Single Tooth X-ray Images
With Dental Option Added: 20% of total cost. Covered as needed.
Silver Fillings and White Fillings
With Dental Option Added: 20% of total cost. Covers one every 24 months per surface, per tooth.
Periodontal Cleaning
With Dental Option Added: 20% of total cost. Covers one every 6 months following active periodontal therapy; not to be combined with regular cleanings.
Telehealth
Cost varies by service. Medicare-covered services plus additional telehealth services. $0 copay for e-visits, virtual visits, and remote patient monitoring with your Primary Care Provider (PCP) or Specialist; For all other telehealth visits, copay is the same as corresponding in-person visit copay.
Acupuncture
$20 per visit. 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. Referral is required from your Primary Care Provider (PCP). Additional acupuncture services are eligible for reimbursement under your Wellness Allowance.
Over the Counter (OTC)
Not Included
Hearing Aid Benefit
You are eligible for up to 2 covered hearing aids per year, 1 aid per ear. To be covered, the hearing aids must be on the Hearing Care Solutions formulary and must be purchased through Hearing Care Solutions: $250 copay for Standard level hearing aid; $475 copay for Superior level hearing aid; $650 copay for Advanced level hearing aid; $850 copay for Advanced Plus level hearing aid; $1,150 copay for Premier level hearing aid
Eyewear Benefit
$150 per year to use at a participating EyeMed provider or $90 per year at a non-participating provider.
Weight Management Programs
$150 reimbursement per year for fees related to weight management programs like WeightWatchers and hospital based programs.
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.
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.
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.
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.
The service areas for this plan are: Barnstable, Bristol, Essex, Middlesex, Norfolk, Plymouth, Suffolk, Hampden or Hampshire Counties.