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Benefit and co-payment summary for Plan Type II

Note: Tufts Health Forward is ending. Enroll in a new plan by January 23, 2015, to ensure you stay covered. Learn more about your health plan options.

COVERED SERVICES

CO-PAYMENTS

BENEFIT LIMIT

OUTPATIENT MEDICAL CARE

Abortion Services

$50 co-payment

Community Health Center Visits
• Primary Care Provider (PCP)
• Specialist



$10 co-payment
$18 co-payment

Office Visits
• PCP
• Specialist
• Eye Care (vision care)


$10 co-payment
$18 co-payment
$10 co-payment


Coverage for routine eye exams for members once every 24 months (once every 12 months for diabetics) from network ophthalmologists or optometrists. One pair of eyeglasses once every 24 months is also covered; choose from free frame selection, or choose any other frame with up to a maximum credit of $80.

Diabetic Specialty Care

$10 co-payment

Co-payment is for services diabetic members get from a specialist (other than routine services a podiatrist provides; see Podiatry).

Outpatient Surgery
(outpatient hospital/ambulatory surgery centers)


$50 co-payment

Laboratory Services

No co-payment

Radiology Services

No co-payment

Prior authorization required for some services

High-cost Imaging Services
(MRI, CT, PET)

$30 co-payment

Prior authorization required

INPATIENT MEDICAL CARE

Inpatient Medical Care
Room and Board (includes deliveries/surgeries/radiology services/labs)


$50 co-payment

Co-payments waived if transferred from another inpatient unit
Inpatient medical care covered according to medical necessity and subject to prior authorization

PHARMACY

Medication via Retail/Specialty Pharmacy
(1-month supply)

$10 generic drugs and select over-the-counter medications
(Tier 1)

$20 preferred brand-name drugs
(Tier 2)

$40 nonpreferred brand-name drugs
(Tier 3)

1-month supply
Co-payments are for first-time prescriptions and refills.
Select over-the-counter medications may be covered with a prescription.
Supplies for diabetes and asthma are covered and don’t have a co-payment.

Medication via Mail
(3-month supply)

$20 generic drugs and select over-the-counter medications
(Tier 1)

$40 preferred brand-name drugs
(Tier 2)

$120 nonpreferred brand-name drugs
(Tier 3)

3-month supply
Co-payments are for first-time prescriptions and refills.
Select over-the-counter medications may be covered with a prescription.
Supplies for diabetes and asthma are covered and don’t have a co-payment.

EMERGENCY CARE

Emergency Care

$50 co-payment

Co-payment waived if admitted to a hospital's inpatient unit

MENTAL HEALTH AND/OR SUBSTANCE ABUSE

Inpatient Mental Health and/or Substance Abuse

$50 co-payment

Inpatient mental health and/or substance abuse services covered according to medical necessity and subject to prior authorization
Co-payment waived if transferred from another inpatient unit

Outpatient Mental Health and/or Substance Abuse

Methadone Treatment (dosing, counseling, labs)

$10 co-payment


No co-payment

After 12 visits per benefit year,Click for Definition prior authorization required

No co-payments for methadone-related services

REHABILITATION SERVICES

Cardiac Rehabilitation

No co-payment

Requires prior authorization

Home Health Care

No co-payment

Requires prior authorization

Inpatient Skilled Nursing Facility (SNF)

No co-payment

Maximum of 100 calendar days total per benefit year Click for Definition at either (or at a combination of) an inpatient skilled nursing facility or an inpatient rehabilitation hospital
Co-payment waived if transferred from another inpatient unit

Inpatient Rehabilitation Hospital or Chronic Disease Hospital

$50 co-payment

Short-term Outpatient Rehabilitation

$10 co-payment

Maximum of 20 sessions (combined) of physical therapy, occupational therapy, and speech therapy with prior authorization; additional sessions require medical review and prior authorization

Physical/Occupational/Speech Therapy

$10 co-payment

OTHER BENEFITS

Ground Ambulance

No co-payment

Emergency transport only; nonemergency transport covered if medically necessary and with prior authorization

Durable Medical Equipment (DME)

No co-payment

May require prior authorization; your provider should check

Supplies

No co-payment

Prosthetics

No co-payment

Requires prior authorization

Oxygen and Respiratory Therapy Equipment

No co-payment

Requires prior authorization

Hospice

No co-payment

Requires prior authorization

Orthotics

No co-payment

Requires prior authorization; shoe inserts for diabetics only

Podiatry

$10 co-payment (nonroutine diabetic)
$18 co-payment (nondiabetic)
$5 co-payment

Medically necessary nonroutine foot care covered


Routine foot care services for diabetics only

Vision

$10 co-payment (optometrist)
$18 co-payment (ophthalmologist)

Coverage for routine eye exams for members once every 24 months (once every 12 months for diabetics) from network ophthalmologists or optometrists. One pair of eyeglasses once every 24 months is also covered; choose from free frame selection, or choose any other frame with up to a maximum credit of $80.

Wellness
• Family Planning
• Nutrition Counseling
• Prenatal Care
• Nurse Midwife


No co-payment
No co-payment
No co-payment
No co-payment


Does not require prior authorization
Requires prior authorization
Does not require prior authorization
Does not require prior authorization

CO-PAYMENT MAXIMUMS

Yearly Co-payment Maximum per Benefit Year per Member

Pharmacy
All other co-payments

$400
$600

For more information on services and co-payments, check our Tufts Health Forward Member Handbook, or call us at 888-257-1985 (TTY: 888-391-5535), Monday through Friday, 8 a.m. to 5 p.m. We're happy to help.

888-257-1985
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