2026 Tufts Medicare Preferred
PPO Rx Plan
- Prescription Drug Coverage Included
- $100 Annual Wellness Allowance
Tier 1 Drug Costs
Deductible
Preferred Retail Pharmacy
Non-preferred Retail Pharmacy
Tier 2 Drug Costs
Deductible
Preferred Retail Pharmacy
Non-preferred Retail Pharmacy
Tier 3 Drug Costs
Deductible
Preferred Retail Pharmacy
Non-preferred Retail Pharmacy
Tier 4 Drug Costs
Deductible
Preferred Retail Pharmacy
Non-preferred Retail Pharmacy
Tier 5 Drug Costs
Deductible
Preferred Retail Pharmacy
Non-preferred Retail Pharmacy
Tier 6 Drug Costs
Deductible
Preferred Retail Pharmacy
Non-preferred Retail Pharmacy
Catastrophic Coverage Stage
Once you've spent $2,100 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: $35/month (Other Part B Drugs: up to 20% coinsurance in-network/45% coinsurance out-of-network)
Part D: Your copay for covered insulin will not exceed $35 or 25% of the total cost per 30-day supply regardless of the drug tier. Your actual copay may be lower depending on the drug tier and total cost of the insulin drug. Please refer to your Evidence of Coverage for more details.
Out-of-Pocket Maximum
$6,750 for in-network costs; $10,100 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.
Annual Physical Visit
Your Annual Physical visit will cost you $0 per visit in-network or out-of-network. You are covered for one Annual Physical each plan year.
Annual Wellness Visit
Your Annual Wellness Visit will cost you $0 per visit in-network or out-of-network. You are covered for one Annual Wellness each plan year.
Primary Care Provider (PCP)
$0 per visit in-network; $80 per visit out-of-network.
Specialist Copay
$65 per visit in-network; $80 per visit out-of-network.
Routine Vision Exam
$0 per visit in-network; $80 per visit out-of-network. You are covered for one Annual Routine Vision exam each plan year.
Routine Hearing Exam
$0 per visit in-network; $80 per visit out-of-network. You are covered for one Annual Routine Hearing exam each plan year.
Laboratory Services
$0 per day in-network; 45% of cost out-of-network. Copay will not apply in addition to office visit or urgent care copay. Prior Authorization may be required for in-network services.
X-Rays
$30 per day in-network; 45% of cost out-of-network. Copay will not apply in addition to office visit or urgent care copay. Prior Authorization may be required for in-network services.
Diagnostic Procedures
$30 per day in-network; 45% of cost out-of-network. Copay will not apply in addition to office visit or urgent care copay. Prior Authorization may be required for in-network services.
Diagnostic Radiology Services
Ultrasounds: $100 per day in-network; Others: $300 per day in-network. These services generally include computed tomography (CT) and magnetic resonance imaging (MRI). Out-of-network: 45% of cost. Prior Authorization may be required for in-network services.
Outpatient Surgery
In-network: Colonoscopies: $0; Other outpatient surgeries (Ambulatory Surgical Center, ASC): $290 per day; Other outpatient surgeries (Non-ASC): $390 per day - for Outpatient Services in-network.
Out-of-network: 45% of the cost. Prior Authorization may be required for in-network services.
Physical, Occupational, and Speech Therapy
$30 per visit in-network; 45% 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. Prior authorization may be required for in-network services.
Outpatient Observation Services
$390 per stay in-network; 45% of cost out-of-network. Copay is waived if admitted inpatient within 1 day for the same condition. Prior authorization may be required.
Cardiovascular Screening
$0 per visit in-network or 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; 45% of cost out-of-network ($0 for prostate cancer screening). These screenings are aimed at detecting cancer before symptoms appear, when treatment is more effective.
Urgent Care
$50 per visit in-network or out-of-network. Urgently needed services are provided to treat a non-emergency, unforeseen medical illness, injury, or condition that requires immediate medical care. Urgent care copayment is NOT waived if admitted inpatient within 1 day.
Emergency Room Visits
Emergency Room visits cost $130 per visit worldwide, and there is no limit to the number of visits in a plan year. Copay is waived if admitted to observation or inpatient within 1 day for the same condition, and applicable observation or inpatient copay will apply.
Inpatient Hospital Coverage
In-Network: Days 1-6: $450 per day, $0 per day after day 6
Out-of-Network: 45% of cost.
Prior Authorization may be required for in-network services.
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.
Acupuncture
$20 per visit in-network; $45 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. Additional acupuncture services are eligible for reimbursement under your Wellness Allowance.
Telehealth
In-network: Medicare-covered services plus additional telehealth services. $0 copay for e-visits, virtual check-ins, and remote patient monitoring with your Primary Care Provider (PCP) or Specialist; for all other telehealth visits, copay and other requirements are the same as the corresponding in-person visit.
Out-of-network: Medicare-covered services only. Additional telehealth services not covered. Cost share is the same as corresponding in-person visit cost share.
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 TruHearing, Inc. formulary and must be purchased through TruHearing, Inc.: $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.
Over the Counter (OTC)
$20 per calendar quarter. Members receive an OTC card loaded quarterly with credit to use towards covered OTC items at participating retailers and plan approved online stores. Unused quarterly balances do not rollover. You may also purchase OTC hearing aids using your OTC benefits.
Eyewear Benefit
Not Covered
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 $100 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. Also included are alternative therapies, massage therapy, fitness tracking devices (one per year), and heart rate monitors.
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, Hampshire or Worcester counties.