This is a comprehensive plan in which you choose a primary care provider (or 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 firstname.lastname@example.org.
In-Network (Using Tufts Healthcare 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 per visit|
|Routine Vision Exam||$25 per visit, 1 visit every 12 months|
|Emergency Room||$150 per visit (waived if admitted)|
|Day Surgery||$250 per admission|
|Inpatient Hospital||$500 per admission|
|Out-of-Pocket 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.