2023 Tufts Medicare Preferred
Access (PPO) Plan
- $0 Medical Deductible
- Prescription Drug Coverage Included
- $350 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
In 2023, once you and your plan have spent $4,660 on covered drugs combined, you're in the Coverage Gap Stage where the 30 day supply costs: $0 for Tier 6 drugs and 25% of the cost for Part D generic drugs, plus a portion of the dispensing fee for Tiers 1-5.
Coverage Gap Stage - Brand Name
In 2023, once you and your plan have spent $4,660 on covered drugs combined, you're in the Coverage Gap Stage where the 30 day supply costs: $0 for Tier 6 drugs and 25% of the cost for Part D brand name drugs, plus a portion of the dispensing fee for Tiers 1-5.
Catastrophic Coverage Stage - Generic
In 2023, once you've spent $7,400 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 $4.15 per prescription.
Catastrophic Coverage Stage - Brand Name
In 2023, once you've spent $7,400 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 $10.35 per prescription.
Out-of-Pocket Maximum
$6,700 for in-network providers; $10,000 for a combination of in and out-of-network costs. 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 per visit in-network; 40% coinsurance out-of-network. You are allowed one Annual Physical and one Wellness Visit each plan year.
Primary Care Provider (PCP)
$0 per visit in-network; $20 per visit out-of-network per Primary Care Physician (PCP) visit
Specialist Copay
$45 per visit in-network; $65 per visit out-of-network per Specialist visit
Routine Vision Exam
$0 per visit in-network; $65 per visit out-of-network. You are allowed one Annual Routine Vision exam each plan year.
Routine Hearing Exam
$0 per visit in-network; $65 per visit out-of-network. You are allowed one Annual Routine Hearing exam each plan year.
Laboratory Services
$0 per service per day in-network; 40% of cost per service per day out-of-network. Copay will not apply in addition to office visit or urgent care copay.
X-Rays
$30 per day in-network; 40% of cost per day out-of-network
Diagnostic Procedures
$30 per day in-network; 40% of cost per day out-of-network
Diagnostic Radiology Services
Ultrasounds: $100 per day; Others: $200 per day for other services. These services generally include computed tomography (CT) and magnetic resonance imaging (MRI). Out-of-network: 40% of cost.
Outpatient Surgery
In-network: Colonoscopies: $0; Others (ASC): $290 per day; Others (Non-ASC): $390 - for Outpatient Services
Out-of-network: 40% of the cost
Physical, Occupational, and Speech Therapy
$40 per visit in-network; 40% of cost out-of-network. 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.
Cardiovascular Screening
$0 per visit in-network; 40% coinsurance out-of-network. These screenings and tests help detect conditions that can lead to a heart attack or stroke.
Cancer Screening (Colorectal, Prostate, Breast)
$0 per service in-network; 40% coinsurance out-of-network. These screenings are aimed at detecting cancer before symptoms appear, when treatment is more effective.
Urgent Care
$45 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.
Emergency Room Visits
Emergency Room visits cost $90 per visit, and there is no limit to the number of visits in a plan year.
Inpatient Hospital Coverage
In-Network: Days 1-5: $400 per day, $0 per day after day 5
Out-of-Network: 40% coinsurance
Ambulance Rides and Services
$350 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
Included with Plan: $1,000 per calendar year
Individual Annual Deductible
Included with Plan: $0
Periodic Oral Evaluation
Included with Plan: $0. Covers two per calendar year.
Comprehensive Oral Exam
Included with Plan: $0. Covers one every 36 months.
Intra Oral Bitewing X-ray (X-rays of Crowns of Teeth)
Included with Plan: $0. Covers two per calendar year.
Intra Oral X-ray - Entire Mouth (Panoramic & Full Mouth)
Included with Plan: 50% of total cost. Includes panoramic or full mouth series. Covers one every 60 months.
Single Tooth X-ray Images
Included with Plan: 50% of total cost. Covered as needed.
Silver Fillings and White Fillings
Included with Plan: 50% of total cost. Covers one every 24 months per surface, per tooth; White filings on posterior teeth will be processed as a silver filling and the patient is responsible for up to the contracted fee.
Periodontal Cleaning
Included with Plan: 50% of total cost. Covers one every 6 months following active periodontal therapy; not to be combined with regular cleanings.
Telehealth
In-network: Medicare-covered services plus additional telehealth services. $0 copay for e-visits and virtual check-ins; for all other telehealth visits, copay is the same as corresponding in-person visit copay
Out-of-network: Medicare-covered services only. Additional telehealth services not covered. Cost share is the same as corresponding in-person visit cost share.
Acupuncture
$20 per visit in-network; $65 per visit out-of-network. 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.
Over the Counter (OTC)
$60 per calendar quarter to spend on Medicare approved health-related items.
Hearing Aid Benefit
Up to 2 aids per year 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 towards eyewear purchased from any provider.
Weight Management Programs
$150 reimbursement per year for fees related to weight management programs like WeightWatchers, Jenny Craig and hospital-based programs.
Wellness Allowance
$350 reimbursement per year for fees related to qualified health clubs, participation in instructional fitness classes, participation in online instructional fitness classes or membership fees for online fitness subscriptions, such as Peloton, nutritional counseling, memory fitness activities, wellness programs, additional acupuncture services beyond Medicare coverage, and more.
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.
A PPO plan provides you the freedom to access any doctor and hospital, and you don't need referrals. A PPO plan is a good option if you travel often or want to keep a doctor that is outside of the network. Seeing doctors inside the network will generally have lower costs for services than seeing a doctor outside of the network.
The service area for this plan are: Bristol, Essex, Middlesex, Norfolk, Plymouth, Suffolk, Hampden, or Worcester counties.