Tufts Medicare Preferred HMO Saver Rx (HMO)

Tufts Medicare Preferred HMO Saver Rx (HMO) H2256-028 Plan Details
5 out of 5 stars

Tufts Medicare Preferred HMO Saver Rx (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Tufts Associated HMO, Inc..
Plan ID: H2256-028.

$0.00
Monthly Premium

Tufts Medicare Preferred HMO Saver Rx (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Tufts Associated HMO, Inc..
Plan ID: H2256-028.

Tufts Medicare Preferred HMO Saver Rx (HMO) H2256-028 Plan Details
5 out of 5 stars

Tufts Medicare Preferred HMO Saver Rx (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Tufts Associated HMO, Inc..
Plan ID: H2256-028.

$0.00
Monthly Premium

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $250
Out of Pocket Max In-Network: $7550
Out-of-Network: N/A
Initial Coverage Limit $4430
Catastrophic Coverage Limit $7,050
Primary Care Doctor Visit
In-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $10.00
Specialty Doctor Visit
In-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $45.00
Referral Required for Doctor Specialty Visit
Inpatient Hospital Care
In-Network:

Acute Hospital Services:
$350.00 per day for days 1 to 5
$0.00 per day for days 6 to 90
Prior Authorization Required for Acute Hospital Services
Prior authorization required
Urgent Care
Copayment for Urgent Care $50.00

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $50.00
Emergency Room Visit
Copayment for Emergency Care $90.00
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours for the same condition

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $90.00
Copayment for Worldwide Emergency Transportation $350.00
Ambulance Transportation
In-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $350.00 per one-way trip

Air Ambulance:
Copayment for Air Ambulance Services $350.00 per one-way trip

Please see Evidence of Coverage for Prior Authorization rules
Prior authorization required

Health Care Services and Medical Supplies

Tufts Medicare Preferred HMO Saver Rx (HMO) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).

Coverage Cost
Chiropractic Services
In-Network:
Copayment for Medicare-covered Chiropractic Services $15.00
Copayment for Initial Chiropractic Evaluation $15.00
  • Initial Evaluation covered once per calendar year
Referral Required for Chiropractic Services
Diabetes Supplies, Training, Nutrition Therapy and Monitoring
In-Network:
Copayment for Medicare-covered Diabetic Supplies $0.00
Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0.00
Prior Authorization Required for Therapeutic Continuous Glucose Monitors
Diabetic Supplies and Services limited to those from specified manufacturers(Please see Evidence of Coverage)
Prior authorization required
Durable Medical Eqipment (DME)
In-Network:
Coinsurance for Medicare-covered Durable Medical Equipment 20%
Prior Authorization Required for Durable Medical Equipment
Prior authorization required
Diagnostic Tests, Lab and Radiology Services, and X-Rays
In-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $10.00 to $45.00
Copayment for Medicare-covered Lab Services $10.00 to $45.00
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $100.00 to $325.00
Copayment for Medicare-covered Therapeutic Radiological Services $60.00
Copayment for Medicare-covered X-Ray Services $10.00 to $45.00
Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services
Prior authorization required
Home Health Care
In-Network:
Copayment for Medicare-covered Home Health Services $0.00
Mental Health Inpatient Care
In-Network:

Psychiatric Hospital Services:
$350.00 per day for days 1 to 5
$0.00 per day for days 6 to 90
Mental Health Outpatient Care
In-Network:
Copayment for Medicare-covered Individual Sessions $0.00 to $25.00
Copayment for Medicare-covered Group Sessions $0.00 to $25.00
Referral Required for Outpatient Mental Health Services
Outpatient Services / Surgery
In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0.00 to $350.00
Prior Authorization Required for Outpatient Hospital Services
Referral Required for Outpatient Hospital Services

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services $0.00

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $0.00 to $350.00
Prior Authorization Required for Ambulatory Surgical Center Services
Referral Required for Ambulatory Surgical Center Services
Prior authorization required
Outpatient Substance Abuse Care
In-Network:
Copayment for Medicare-covered Individual Sessions $25.00
Copayment for Medicare-covered Group Sessions $25.00
Referral Required for Outpatient Substance Abuse Services
Over-the-counter (OTC) Items
In-Network:

Over-The-Counter (OTC) Items:
Maximum Plan Benefit of $50.00 every calendar quarter
Podiatry Services
In-Network:
Copayment for Medicare-Covered Podiatry Services $45.00
Referral Required for Podiatry Services
Skilled Nursing Facility Care
In-Network:

Skilled Nursing Facility Services:
$0.00 per day for days 1 to 20
$180.00 per day for days 21 to 44
$0.00 per day for days 45 to 100

Dental Benefits

The following dental services are covered from in-network providers.

Coverage Cost
Dental Care
In-Network:

Preventive Dental:
Copayment for Oral Exams $0.00
  • Maximum 2 visits every year
Copayment for Prophylaxis (Cleaning) $0.00
  • Maximum 2 visits every year
Copayment for Dental X-Rays $0.00
  • Maximum 2 visits every year
Maximum Plan Benefit of $1000.00 every year

Comprehensive Dental:
Copayment for Medicare-covered Benefits $45.00
Coinsurance for Diagnostic Services 0% to 50%
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Coinsurance for Restorative Services 50%
  • Maximum 1 visit every two years

Vision Benefits

The following vision services are covered from in-network providers.

Coverage Cost
Vision Benefits
In-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $45.00
Copayment for Routine Eye Exams $15.00
  • Maximum 1 Routine Eye Exam every year
Referral Required for Eye Exams

Eyewear:
Copayment for Medicare-Covered Benefits $0.00
Maximum Plan Allowance of $150.00 every year for all Non-Medicare covered eyewear

Hearing Benefits

The following hearing services are covered from in-network providers.

Coverage Cost
Hearing Benefits
In-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $45.00
Copayment for Routine Hearing Exams $45.00
  • Maximum 1 visit every year
Copayment for Fitting/Evaluation for Hearing Aid $0.00
  • Maximum 1 visit every year
Referral Required for Hearing Exams

Hearing Aids:
Copayment for Hearing Aids $250.00 to $1150.00
  • Maximum 2 Hearing Aids every year
$250 copayment for standard level hearing aid up to 1 per ear, per year $475 copayment for superior level hearing aid up to 1 per ear, per year $650 copayment for advanced level hearing aid up to 1 per ear, per year $850 copayment for advanced plus level hearing aid up to 1 per ear, per year $1150 copayment for premier level hearing aid up to 1 per ear, per year To access the hearing aid benefit, the member must use a Hearing Care Solutions provider

Preventive Services and Health/Wellness Education Programs

The following services are covered from in-network providers.

Coverage Cost
Preventive Services and Health/Wellness Education Programs
In-Network:
$0.00 copay for Medicare Covered Preventive Services:

Abdominal aortic aneurysm screening
Alcohol misuse screenings & counseling
Bone mass measurements (bone density)
Cardiovascular disease screenings
Cardiovascular disease (behavioral therapy)
Cervical & vaginal cancer screening
Colorectal cancer screenings
Depression screenings
Diabetes screenings
Diabetes self-management training
Glaucoma tests
Hepatitis B (HBV) infection screening
Hepatitis C screening test
HIV screening
Lung cancer screening
Mammograms (screening)
Nutrition therapy services
Obesity screenings & counseling
One-time Welcome to Medicare preventive visit
Prostate cancer screenings(PSA)
Sexually transmitted infections screening & counseling
Shots:
  • COVID-19 shots
  • Flu shots
  • Hepatitis B shots
  • Pneumococcal shots
  • Tobacco use cessation
    Yearly "Wellness" visit

    Prescription Drug Costs and Coverage

    The Tufts Medicare Preferred HMO Saver Rx (HMO) plan offers the following prescription drug coverage, with an annual drug deductible of $250 (excludes Tiers 1, 2 and 6) per year.

    Coverage
    Cost
    Coverage & Cost
    Annual Drug Deductible $250 (excludes Tiers 1, 2 and 6)
    Preferred Generic
    • Preferred retail $0.00
    • Standard retail $14.00
    • Standard mail order $0.00
    Generic
    • Preferred retail $4.00
    • Standard retail $19.00
    • Standard mail order $4.00
    Vaccines
    • Preferred retail $0.00
    • Standard retail $0.00
    Annual Drug Deductible $250 (excludes Tiers 1, 2 and 6)
    Preferred Generic
    • Preferred retail $0.00
    • Standard retail $28.00
    • Standard mail order $0.00
    Generic
    • Preferred retail $8.00
    • Standard retail $38.00
    • Standard mail order $8.00
    Vaccines
    • Preferred retail $0.00
    • Standard retail $0.00
    Annual Drug Deductible $250 (excludes Tiers 1, 2 and 6)
    Preferred Generic
    • Preferred retail $0.00
    • Standard retail $42.00
    • Standard mail order $0.00
    Generic
    • Preferred retail $12.00
    • Standard retail $57.00
    • Standard mail order $8.00
    Vaccines
    • Preferred retail $0.00
    • Standard retail $0.00