This is a comprehensive plan in which you choose a primary care provider (PCP) who will coordinate your medical care within the HMO's network and provide referrals as needed. There are no benefits for health care outside of the New England network except for emergency and urgent care.
During personal travel outside of the New England network, you may need to pay for emergency or urgent care, and then apply for reimbursement from the plan.
For information about health care while traveling for business outside of the New England network, contact us at email@example.com.
In-Network (Using Tufts Health Care Providers)
There is no coverage outside of the network except for urgent care or emergencies.
|Preventive care||Covered in full|
|Annual physical||Covered in full|
|Office visit||$25 copay applies (copay does not apply toward deductible)|
|Routine vision exam||$25 copay applies; one visit every 12 months (copay does not apply toward deducible)|
|Emergency room||$150 copay applies (copay does not apply toward deductible)|
|Outpatient surgery||Deductible, then $250 copay applies|
|Inpatient hospital||Deductible, then $500 copay applies|
|Copayment maximum||Individual $2,500; family $5,000|
Low Cost Generic
High Cost Generic
|Retail (30-day supply)||$5||$20||$30||$50|
|Mail order (90-day supply)||$10||$40||$60||$150|
|Specialty drugs||Special pricing may apply.|
Tip: Consider enrolling in a health care FSA to pay for copays and other services not covered by the plan.