TSS - Tufts Health Insurance Plan- Quality Tiered Plan

Tufts Health Insurance Plan- Quality Tiered Plan

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First Published  :Mon Dec 01 19:35:39 GMT 2014
Last Modified  :Tue Sep 10 13:24:20 GMT 2019
Last Published  :Tue Sep 10 13:24:20 GMT 2019
Summary :  Reference for benefits eligible employees who have inquiries about the Tufts Health Insurance options, specifically the Quality Tiered Plan. Audience: Benefits Eligible Employees & Dependents


Primary Information

    AccessTufts 2019 Benefits Information

    Health Insurance – Quality Tiered Plan

    Eligible employees and their family members may elect health benefits and choose from 3 health coverage options, at 3 different coverage levels (individual, 2-person, family). All options are administered by Tufts Health Plan.  You can view a side-by-side comparison of the health coverage options at the following link:  

    The Quality Tiered Health Plan is designed for employees who are interested in using and knowing which providers are providing the most efficient care. Employees can use the entire Tufts Health Plan Preferred Provider Option (PPO) network, but when you utilize “TU Preferred” providers, your co-payments are lower. Since this is a Preferred Provider Organization (PPO) type of health plan, you have the freedom to see any provider – in or out of the Tufts Health Plan network – without required referrals.This plan also includes a value-based pharmacy option with no copayment on medications for certain chronic conditions.  Go to https://tuftshealthplan.com/tufts-university for more information.

    All hospitals and the affiliated doctors in Tufts Health Plan’s network have been assigned a “Tier” based on their quality and cost. To help keep your health care affordable, we have partnered with certain providers to give you the option of getting high-quality care at a lower cost. You pay the lowest out-of-pocket costs when you receive services from Tier 1 providers.
    • TIER 1—“TU Preferred” providers: There is not an annual deductible and office visit copayments for a PCP or Specialist are $15
    • TIER 2—“In-Network” providers: There is an annual deductible which applies to certain services and office visit copayments for a PCP or Specialist are $25
    • TIER 3—“Out-of-Network”: A higher annual deductible and you will pay 20% coinsurance once deductible is met for services (the Plan pays 80% of the remaining bill).
    Note that you are not “locked” into a Tier. If you are in this plan, you (and your family members) can decide to use Tier 1, Tier 2, or Tier 3 providers each and every time you need care. For example, you can use  a Primary Care Provider (PCP) who is a TU Preferred provider and that your specialist is a Tier 2 provider. The choice is yours. Depending on what tier you select for each service, the corresponding cost share will apply.  Note that in most cases the individual provider at a Tier 1 hospital would also be Tier 1 however there are always exceptions.  To confirm the provider's Tier, please to go to https://tuftshealthplan.com/microsites/tufts-university/network or call THP.

    Members of this plan also have a value-based pharmacy benefit - see attached pamphlet , bottom of page 1 for more information.

    Certain medications offered at no copayment for treatment of five specific common chronic conditions (diabetes, asthma and chronic obstructive pulmonary disease (COPD), coronary artery disease (high blood pressure and high cholesterol), depression, and heart failure). 
    All of the hospitals in the Tufts Health Plan network meet our quality standards. All hospitals in MA and RI are included in the Tufts Health Plan network.  As part of our National Committee for Quality Assurance (NCQA) accreditation and our own quality initiatives, Tufts Health Plan is committed to contracting with a network of high- performing hospitals. The quality of the network hospitals is reviewed periodically through Tuft’s Health Plan’s  re- credentialing process and quality assurance programs. Tiering will be updated on an annual basis to reflect changes in hospital quality or cost based on the measures used by the Tufts Health Plan Clinical Review Team.

    Preferred Hospitals List

    A list of “TU Preferred” (Tier 1) Hospitals can be accessed at the following link: TU Preferred” (Tier 1) Hospitals
    To find out which Hospitals are considered Tier 2, please contact Tufts Health Plan at (844) 516-5790.

    Visit the Tufts University/Tufts Health Plan micro-site which provides a wealth of information.  Or specifically for Prescription information, click here.

    Eligibility-If you do not enroll within 31 days of the date you are first eligible, you will not be able to enroll until the next annual open enrollment, unless you experience a Qualified Status Change. See Change in Benefits Election after Change in Life Status (Qualified Status Changes)
    All active, regular employees at the University are eligible, provided that you are an exempt or non-exempt employee regularly scheduled to work 17.5 hours or more a week, with a minimum 90 days employment period. 
    or faculty member with at least a half time (as determined by the academic department), two- semester appointment
    See pages 5-8 of the Summary Plan Description for Benefits Eligible Employees for full Eligibility information for Staff, Faculty, Dependents, and Retirees. See also Aging Out at 26 - Dependents with Disabilities.  Please note that children of domestic partners can be added to plans.

    The Quality Tiered plan is not available to employees who reside outside of MA, RI, or NH. See Employees Who Live Outside of THP Service Area for more information about the options for those employees. If an individual experiences difficulty in finding a provider in the area and isn't given a choice, check Modify a Person to ensure their current address is correct.

    Provider Contact Information
    For information on Physician selection, Health plan coverage, or claims contact Tufts Health Plan.

    Group Number 

    For most employees, the group number of Quality Tiered Plan is 48347-000.  

    Identification Cards
    • New members and their dependents receive individual ID Cards within ten days of enrollment
    • If a Subscriber adds a dependent, a new ID card is sent for that dependent
    • Members who change plan type (Quality, Traditional, Value) will receive updated ID cards with updated group numbers
    • If a Subscriber and /or dependents move groups (Active to COBRA or Retiree), new ID cards are sent with new group numbers
    • Members don't need a physical ID card to use benefits. Providers can confirm coverage contacting THP Provider Services at 888-884-2404 with the member's SSN or Subscriber Id #.
    • Subscribers may request additional ID cards by contacting THP Member Services by phone 884-516-5790 or online via the secure member portal.
    • Members have the option to download the Tufts Health Plan Mobile App, which allows them to access a virtual ID card, check claims and cost-sharing responsibility, offers a provider search tool, and view costs and benefits.
    • Open Enrollment: New ID cards are not re-issued every plan year, unless a new member is added (only the new addition will receive a card) or there is change to plan type (Quality, Traditional, Value).  2019 Open Enrollment:  ID cards for new members were mailed on 12/20/18.

    For all of our health plan options, Tufts Health Plan contracts with CVS Caremark as the Pharmacy Benefit Manager. For members seeking long term prescriptions, known as maintenance medications, these must be purchased at either a CVS Pharmacy or through the CVS Caremark mail order program for a 90 day supply.   For short term medication, 30 day supply, those may be filled at any pharmacy
    Members of the Quality Tiered and Value plans also have a value-based pharmacy benefit - see attached pamphlet , bottom of page 1 for more information
    Certain medications offered at no copayment for treatment of five specific common chronic conditions (diabetes, asthma and chronic obstructive pulmonary disease (COPD), coronary artery disease (high blood pressure and high cholesterol), depression, and heart failure). 

    Tufts Health Plan
    (844) 516-5790

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