Welcome! 2023 Tufts Medicare Preferred Access PPO Plan
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Welcome! 2023 Tufts Medicare Preferred Access PPO Plan
Table of Contents
Table of Contents . . . . . . . . . . . . . . . . . . . . . . 3
What to Do First . . . . . . . . . . . . . . . . . . . . . . 4
How Your PPO Plan Works . . . . . . . . . . . . . . . . 8
How to Get Care . . . . . . . . . . . . . . . . . . . . . . 11
Using Your Prescription Drug Plan . . . . . . . . . . . 12
Exciting Benefits That Help You Save . . . . . . . . . . 14
Get Member-Only Discounts With
Your Preferred Extras . . . . . . . . . . . . . . . . . . . 16
Dental Coverage to Smile About . . . . . . . . . . . . 22
2023 Benefits Overview . . . . . . . . . . . . . . . . . .30
Notice of Privacy Practices . . . . . . . . . . . . . . . .34
Forms . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38
Thank you for choosing us! Get the answers you need.
Whether you're looking for information about medical benefits,
drug coverage, seeing a specialist, choosing a doctor, or finding
You made a great choice. Your Tufts Medicare Preferred Access PPO plan the right form or document, you can call Member Services at
brings the best of care and coverage together to make health care simpler 1-866-623-0172 (TTY: 711) or get the answers you need on
and less stressful. By providing you access to any doctor or hospital, our our website:
commitment is to provide the best health care coverage possible.
Because nothing is more important than your health. thpmp.org
2 Member Services: 1-866-623-0172 (TTY: 711) thpmp.org 3
What to Do First Select a PCP to support your health (optional)
A primary care provider (PCP) makes sure you get the care that is right for you
and can help you avoid unnecessary expenses such as duplicate tests or higher
out-of-network costs. This is especially helpful if you see multiple specialists. As
Tell us about any special situations a member of the Access PPO plan, you do not have to choose a network PCP,
We want your transition to your new plan to be easy. If you are currently however, we strongly encourage you to choose a PCP and let us know who you
undergoing treatment for a condition or have any upcoming appointments, call chose. To select a PCP, log in to your secure online member account (see left) or
Member Services at 1-866-623-0172 (TTY: 711) as soon as possible. Special call Member Services at 1-866-623-0172 (TTY: 711).
situations to let us know about include if you have a scheduled surgery or
hospitalization, need to see a specific specialist or psychiatrist, use a program to Schedule your physical
help pay for prescription drugs, are currently working with a Care Manager, or live
Seeing your doctor for a physical each year is one of the most important ways
in a nursing home.
to stay healthy. We encourage you to schedule a physical annually. You pay $0
in-network for a physical exam every calendar year. For complete physical exam
Activate your secure online account coverage details, see your Evidence of Coverage (EOC) booklet on our website at
Your secure online account is the easiest way to get the most out of your plan: thpmp.org/documents.
• 24/7 online access—Check your claims and referrals anytime For an easy way to get more from your next appointment, use the Doctor Visit
Book to remember your questions, review your medications, and more. Find it on
• Go paperless—Get documents electronically instead of by mail
our website at thpmp.org/doctor-visit-book.
Creating a secure account only takes a few minutes. Sign up today! Once you
receive your ID card, go to thpmp.org/registration to set up your account.
Note: For the best experience, use a desktop computer to register—some
features may not be accessible from a mobile device. For more details on how
to navigate your secure online account, view our more comprehensive guide at
thpmp.org/account-guide.
To activate your online account, follow these simple steps:
1. Visit thpmp.org/registration.
2. On the registration page, enter your member ID number (found on your
member ID card), and your date of birth.
3. Answer security questions so we can verify your identity.
4. Enter your email address and password, enter your mobile phone number
(optional), choose your three security questions, and choose your site key
image and security phrase.
5. Make your selections for eDelivery. If you would like to view your plan
documents electronically instead of receiving them by mail, make sure you
select “Electronic” for each option.
More on our website:
thpmp.org 5
4 Member Services: 1-866-623-0172 (TTY: 711)
Check your medications Fill out and return your health survey
If you take medications, check to see how each one is covered. Some drugs We will contact you about filling out the Health Risk Assessment survey during
on our Formulary (drug list) have special requirements. See page 13 for more your first month as a member of the Tufts Medicare Preferred Access PPO plan.
details. If a drug you take is not covered, you may be able to get a temporary This survey takes less than 15 minutes and helps us to understand your health
supply until your doctor can determine if another prescription would meet history so we know how our care management or health programs may be able
your needs. For more information, use the online Formulary drug search on our to help you.
website at thpmp.org/drug-coverage, see your Evidence of Coverage (EOC)
booklet on our website at thpmp.org/documents, or call Member Services at Use your ID card
1-866-623-0172 (TTY: 711).
You will receive your Tufts Health Plan ID card by mail.
Remember to always bring your ID card to your doctor
$0 monthly premium appointments and to the pharmacy. If you haven’t already
Because you have a $0 monthly premium, you will not receive a premium bill each received your ID card, you should receive it soon.
month unless you owe a late enrollment penalty.1
Give someone permission to talk about your benefits for you
Did you know if your spouse or family member calls us, we can't answer any
questions about your coverage because of HIPAA (Health Insurance Portability and
Accountability Act)? But you can give someone the ability to discuss your benefits
on your behalf with the Designated Representative Form on page 39. Return your
completed form and supporting legal documentation (if applicable) to us via fax
or via mail.
Your completed form can be mailed to:
Tufts Health Plan
Attention: Member Services
PO Box 494
Canton, MA 02021-0494
You may also fax your completed form to:
1-617-927-9405
Member Services
6 1-866-623-0172 (TTY: 711)
thpmp.org 7
How Your PPO Plan Works
You’re protected by an out-of-pocket maximum
Your plan has an out-of-pocket maximum that limits how much you spend on
medical costs in a year. Your in-network maximum out-of-pocket amount is $6,700.
This is the most you would have to pay for covered medical services received in-
network in 2023. Your plan pays 100% of the in-network costs of covered medical
benefits after you reach the maximum out-of-pocket amount.
Note: Services received out-of-network do not apply towards your $6,700 in-
network maximum out-of-pocket amount. See page 30 for the maximum out-of-
pocket amount that applies to combined in- and out-of-network services.
Access any doctor or hospital
With your Tufts Medicare Preferred Access PPO plan, you have the freedom to
access any doctor or hospital in- or out-of-network within the United States and
its territories—and you don’t need referrals. In-network doctors and services have
a lower cost share than out-of-network doctors. Seeing doctors inside the PPO
network will help you to save on health care costs. For details on which doctors are
in-network, visit thpmp.org/doctor.
More on our website:
thpmp.org 9
8 Member Services: 1-866-623-0172 (TTY: 711)
You share the cost of your benefits
In most cases, when you use a medical service (such as seeing your doctor or a
How to Get Care
hospital stay) or fill a prescription, you pay a copay or coinsurance. A copay is a set
amount that covers a portion of the service or drug cost. For example, you might
pay $30 for X-rays or $10 for a prescription drug. Coinsurance is a percentage of During regular office hours
the cost you pay when you receive certain services. For a list of what you pay for Call your PCP or healthcare provider to get a checkup, make an appointment, and
medical services and prescription drugs, see the chart starting on page 32. ask general questions about your health.
Care Managers are available to help you After regular office hours
Our Care Management team is available to help you navigate the health care For non-emergency situations when your PCP’s or healthcare provider's office is
system. Care Managers work closely with your doctor and can help you if you closed, call your PCP or healthcare provider and a physician on call will help you.
get sick, have an injury, or are looking for ways to stay healthy. From helping you
understand your medications to planning a recovery process before a surgery, In an emergency
your Care Manager is there to support you. They can also help you prevent return
If you believe your health is in serious danger, call 911 or go to the nearest
trips to the hospital and answer any questions or concerns you might have. For
emergency room or hospital. You do not need to get approval from your PCP or
more information about working with a Care Manager, call Member Services at
healthcare provider if you have a medical emergency.
1-866-623-0172 (TTY: 711).
If your health is not in serious danger but you need medical care right away, call
your PCP or healthcare provider. If you are unable to see your PCP or healthcare
provider, you are covered for urgent care provided by any doctor. You do not need
approval from your PCP or healthcare provider for urgent care, but whenever
possible, you should see your PCP or healthcare provider.
When traveling
Find what you need on our website You are covered anywhere in the world for emergency or urgent care. You can be
Whether you're looking for information about medical benefits, drug coverage, outside our service area for up to six consecutive months and still be covered for
choosing a doctor, or finding the right form or document, get the answers you emergency or urgent care. Our plan cannot cover a prescription drug purchased
need on our website. outside of the United States and its territories.
You can see any doctor, but seeing a doctor in our network will help you to
thpmp.org/members save on costs. Remember to schedule routine care before or after your travel
plans. If you receive emergency or urgent care when traveling, you may need
to pay out of pocket. Simply save your receipts and call Member Services at
Benefit information Dentist search
Find complete benefit, out-of-pocket costs, The most up-to-date list of dentists in the 1-866-623-0172 (TTY: 711) for reimbursement details.2
and plan information in your Evidence of Dominion Dental PPO Network.
Coverage (EOC).
Article library
Drug search Extensive list of articles that explain how your
View or search the list of all the drugs we cover plan works.
by using the Formulary on our website.
Video library
Doctor search Short videos that explain how to use your plan.
The most up-to-date list of doctors in
our network.
More on our website:
thpmp.org 11
10 Member Services: 1-866-623-0172 (TTY: 711)
Using Your Prescription Generic drugs can help you save money
Generic drugs have the same active-ingredient formula as a brand name drug
Drug Plan and can help save you money. Generic drugs are rated by the Food and Drug
Administration to be as safe and effective as brand name drugs. If you take brand
name drugs, ask your provider if there are generic versions that are right for you.
Look up your drugs Does your drug have a special requirement?
It’s a good idea to look up your prescription drugs to make sure they're covered, find out
The Formulary will tell you if a drug has special requirements, such as:
what tier they're on, and see if your drugs have any special requirements. The Formulary
(drug list) lists all the drugs we cover alphabetically and by medical condition so they’re • Prior Authorization (PA)—Some drugs require you or your provider to request
easy to find. You can find the Formulary on our website at thpmp.org/drug-coverage. special permission from Tufts Health Plan before you fill your prescription.
• Step Therapy (STPA)—Some drugs require you to try a less expensive drug
What if your drug isn’t listed? first. Medications with step therapy have at least one comparable medication
If your drug is not listed on the Formulary, you may be able to get a temporary that you must try first.
supply in certain circumstances. This gives you time to talk to your doctor and see if • Quantity Limit (QL)—For quality and safety reasons, certain drugs have a limit
another prescription would meet your needs. Temporary supplies for new members on the amount you can get at one time. For example, a medication may have a
are generally a 30-day supply, and available one time only during the first 90 days of limit of 30 pills in 30 days.
your membership. For details on receiving a temporary supply, see Chapter 5 of your Find a complete list of special requirements in your Formulary, available at
Evidence of Coverage (EOC) booklet available at thpmp.org/documents or call Member thpmp.org/2023-ppo-formulary. If your drug has a special requirement, you or
Services at 1-866-623-0172 (TTY: 711). your provider may need to take extra steps in order for your drug to be covered.
Call Member Services at 1-866-623-0172 (TTY: 711) for details on what you can do
What is a tier? to get coverage for the drug. You can also ask Tufts Health Plan to remove a special
Every drug in the Formulary has a tier number. You’ll find the tier number listed next to requirement by requesting an exception. Your EOC includes information on how to
each drug. The tier number determines the cost of the drug. In general, the lower the request an exception. Special requirements are not able to be removed in all cases,
tier, the lower your cost for the drug. Plus, if the retail amount for a drug is lower than but each exception request is considered.
your copay, you pay the lower amount.
Use mail order and save
Save by using preferred pharmacies Mail order service delivers medications that you refill each month right to your
home. You may be able to save up to $49 by using mail order for a 90-day supply of
An easy way to save on your prescription drug costs is by using preferred pharmacies.
prescription medications (depending on the tier your drug is on). If you are ready
With a preferred pharmacy, you pay as low as $0 for Tier 1 and $4 for Tier 2 drugs. The
to sign up, you can register online, by mail, or by phone:
chart on page 33 provides more details on copay information. With 595 preferred
pharmacies in our network, including national chains such as CVS Pharmacy®, Walmart, • Online: Visit OptumRx.com.
and Stop & Shop, it's easy to use a preferred pharmacy and save on your prescription • By mail: Complete the Mail Order Form on page 41 or at
costs.3 To find preferred pharmacies near you, use our pharmacy search tool at thpmp.org/rx-mail-form. You should receive your order in approximately
thpmp.org/ppo-pharmacies. If two weeks.
you need to transfer a current • By phone: 1-800-460-0322
Cost using a non-preferred Cost using a preferred
prescription to a preferred pharmacy (30-day supply) pharmacy (30-day supply)
Have your Tufts Health Plan member ID number, prescription number(s), and
pharmacy, simply call the preferred
Tier 1 Drugs $14 $0
credit card information ready whenever you call. For more complete information,
pharmacy of your choice and ask
see Chapter 5 of your Evidence of Coverage (EOC) booklet available at
them to transfer your prescription.
Tier 2 Drugs $19 $4 thpmp.org/documents.
12 Member Services: 1-866-623-0172 (TTY: 711) thpmp.org 13
Exciting Benefits That Hearing aid benefit can save you thousands
With your hearing aid benefit, you can choose from 5 levels of hearing aids—
Help You Save from Standard level to Premier—with copays ranging from $250 to $1,150 for
each hearing aid. You’re covered for up to 2 hearing aids per calendar year, 1
hearing aid per ear. You’re also covered for a $0 hearing aid evaluation once per
Make sure to take advantage of these great benefits that offer excellent savings calendar year. Hearing aids and $0 copay hearing aid evaluations are available
while helping you stay healthy! only from Hearing Care Solutions (HCS) providers. Schedule your evaluation
by calling an HCS representative at 1-866-344-7756. For more details, visit
hearingcaresolutions.com/tuftshealthplan.
Save on programs that help you stay healthy
Your Wellness Allowance and Weight Management reimbursement benefits help
you lead a healthy lifestyle and save:
You pay $0 for in-network health screenings
Getting regular screenings is one of the best ways to stay healthy. Screenings
• Wellness Allowance—You can get reimbursed up to $350 each calendar year help find illness or disease before you feel sick. You pay a $0 copay in-network for
toward fees you pay for membership in a qualified health or fitness club, many screenings, such as a physical exam, breast cancer screening, cholesterol
wellness programs, acupuncture, online instructional fitness classes or screening, glaucoma screening, prostate cancer screening, and many more. A
membership fees for online fitness subscriptions (such as Peloton), and much coinsurance or copay will apply if the screening is performed out-of-network. See
more.4 For details, visit thpmp.org/wellness-allowance. page 32 for out-of-network coverage details.
• $150 Weight Management reimbursement—Reach your weight loss goals with
up to $150 each calendar year toward the program fees of Weight Watchers®, Save on insulin
Jenny Craig®, or hospital-based weight loss programs!5 For details, see your
If you use insulin to manage your diabetes, you will be pleased to know that you
Evidence of Coverage (EOC) booklet available at thpmp.org/documents.
won’t pay more than $35 for a one-month (30-day) supply of insulin products
covered by our plan, no matter what cost-sharing tier it’s on, even if you haven’t
Get up to $150 toward eyewear paid your deductible.
You can get up to $150 toward the full retail price (not sale price) for eyeglasses
(prescription lenses, frames, or a combination of both) and/or contact lenses. Save $240 on over-the-counter (OTC) health items each year
Discounts cannot be combined. EyeMed Vision Care is the network provider we
With your Over-the-Counter benefit, you get up to $240 every calendar year ($60
use to provide your eyewear benefit. The EyeMed network includes more than
every calendar quarter) to spend on health-related items such as toothbrushes,
26,000 eye care providers, including national chains such as LensCrafters®, Pearle
aspirin, allergy relief items, adhesive bandages, sunscreen, and more! This benefit
Vision®, and Target® Optical. If you choose an EyeMed Vision Care participating
can only be used to purchase items from the catalog supplied by Medline or from
provider, your coverage will apply at the time of service. If the cost of eyewear is
Walmart.com. Your OTC card will arrive separately by your effective date. If you do
above $150, you will be responsible to pay for any remaining balance. If you use
not receive your new OTC card by your effective date, please call Member Services.
a non-participating provider, you wIll need to pay out of pocket and submit for
reimbursement. To submit for reimbursement, you will need to file a claim with There are four convenient ways to order items:
EyeMed Vision Care. Please see your Evidence of Coverage for details of how to • Online through Medline—Once your coverage begins, go to
submit a reimbursement request. For details, go to thpmp.org/eyewear-benefit. thpmp.org/order-otc, log in, and select the items you want to purchase.
• Online through Walmart.com— At checkout, select pay with card and enter
your OTC card number. Note: Shipping fees will apply and will not be covered
by your OTC card. To avoid fees, you can choose in-store pick-up.
• By phone—Call 1-833-569-2168 Mon–Fri, 8 a.m.–7 p.m. ET, and a Medline
representative will take your order.
• By mail—Fill out the mail order form included with the catalog.
Member Services
14 1-866-623-0172 (TTY: 711)
thpmp.org 15
Get Member-Only Discounts Well-balanced meal delivery program
With Your Preferred Extras
Nutrition plays a critical role in maintaining optimal health.
As a member of the Tufts Medicare Preferred Access PPO plan, you get exclusive
discounts in addition to your plan benefits to help you lead a healthy lifestyle. As one of the nation’s largest nutritional meal providers, Independent
Save on everything from health products to weight management, and a variety of Living Systems delivers 300,000 medically tailored meals a month. Meals
wellness programs. are prepared at USDA inspected and approved facilities, and menus
are created by chefs who work with registered, licensed dietitians
to provide nutritionally balanced meals that meet the needs of
a variety of diets. Home-delivered meals offer a convenient
and affordable way to recover from an illness or surgical
procedure, or to manage a chronic condition.
The Dinner Daily
• Get a 15% discount on home-delivered meals
through Independent Living Systems.
• To place an order, call 1-844-372-8631.
The Dinner Daily makes healthy, delicious dinners easy and
affordable by providing weekly dinner plans customized to your
food preferences, dietary needs, and the specials at your local
grocery store.
Get a 25% discount on any Dinner Daily subscription.
• The first two weeks are free to make it easy to try.
• To sign up, or for more information, visit
Nutritional counseling
thedinnerdaily.com/tmp.
• Use code “TMP25” when you sign up to
receive your discount.
Nutritional counseling provided by registered dietitians helps you learn how
to stay healthy through nutrition and weight management.6
• Save 25% on unlimited visits with Tufts Health Plan-registered
dietitians or licensed nutritionists.
• No referral is needed from your primary care provider.
• For a list of providers near you, call Member Services at
1-866-623-0172 (TTY: 711).
• To get the discount, show your Tufts Health Plan ID
card at time of payment.
Member Services
16 1-866-623-0172 (TTY: 711)
thpmp.org 17Fitness Together® Massage therapy and acupuncture 25%
Reconnect your body, mind, and spirit with massage therapy or acupuncture.
Fitness Together provides customized workout programs to help you
reach your fitness goals. With Fitness Together, you are paired with • Massage therapy—Save 25% on the provider’s usual fee, or pay $15 per 15
a personal trainer in a private setting and receive a workout plan minutes of massage therapy, whichever is less.
tailored to you. • Acupuncture—Save 25% on the provider’s usual fee.
• New customers pay no fitness evaluation fee.7 For a list of providers near you, call ChooseHealthy®8 customer service at
• New customers get 10% off the purchase price of any 1-877-335-2746. (Monday–Friday 8 a.m.–11 p.m.; Saturday 8 a.m.–5 p.m.)
personal training package.
• Existing customers get 10% off the purchase price
of personal training packages of 36 sessions
or greater.
Laser vision correction 15%
To get the discount, show your Tufts Health
Plan ID card when joining any participating Improve your vision without glasses or contact lenses with laser vision correction.
Fitness Together location. For more • Get 15% off the retail price, or 5% off the promotional price of LASIK and PRK laser
information about Fitness Together, visit vision correction.9
fitnesstogether.com.
• To find a location near you and to obtain a discount authorization, call 1-877-5LASER6.
Hearing aids 63%
Ompractice 40% Discount is available on a wide selection of hearing aid choices from major
manufacturers up to 63% below retail.10
With Ompractice, you can access live, online yoga and meditation classes led by an • 3-year supply of batteries at no charge (up to 64 cells per ear, per year for non-
instructor to practice yoga from the comfort and privacy of your own home. Ompractice rechargeable devices).
utilizes two-way video so you can participate in group classes, and receive feedback and • 1 year of follow-up care at no charge, with the original provider.11
support from your teacher.
• 3-year comprehensive warranty, including loss, damage, and repairs.
In addition, you may be able to use your annual Wellness Allowance to submit for
• 60-day hearing aid evaluation period.
possible reimbursement of your membership fees. For full details of your annual
Wellness Allowance, please see your Evidence of Coverage (EOC) available at • Complete hearing aid evaluation at no charge.
thpmp.org/documents. • 12-month, interest-free financing available to qualified applicants.
• Sign up for Ompractice for $14.99/month. For details on this discount, or to schedule your comprehensive hearing
• Or sign up for an annual subscription for $129.00 (40% off the regular monthly rate). exam, call Hearing Care Solutions at 1-866-344-7756. For more details, visit
hearingcaresolutions.com/tuftshealthplan.
• For more information or to sign up, go to ompractice.com/thpmp.
18 Member Services: 1-866-623-0172 (TTY: 711) thpmp.org 19Cambridge Health Alliance Center for
Mindfulness and Compassion 15% Be Safer at Home 25%
Mindfulness and compassion training can help reduce stress and improve Be Safer At Home (BSAH) offers members substantially discounted rates on the
your overall well-being. Save 15% on the Cambridge Health Alliance Center for installation and monthly fees of a Personal Emergency Response System (PERS). A PERS
Mindfulness and Compassion (CMC) 8-week Mindfulness-Based Stress Reduction unit allows you to live the independent lifestyle you want by providing a resource that is
and Mindful Self-Compassion courses.12 always there to respond to emergency calls.
For more information and to register, visit chacmc.org/courses. If you have • Get a 25% discount (or more) on the installation and monthly fees of a Personal
questions, please email cmc@challiance.org or call 1-617-591-6132. To get your Emergency Response System.
discount, use access code “TMP15” during the registration process.
• To learn more about BSAH, visit BeSaferatHome.com. To receive the discounted rates
and to schedule a FREE consultation, contact Be Safer At Home at 1-866-513-7377
and provide code “TUFTSMP.”
Home Instead® Senior Care $100
Home Instead Senior Care provides a wide range of non-medical support services LifeCycle Transitions 20%
to enable you to live safely and comfortably wherever you call home—whether it’s
the home you have lived in for decades, the home of a child, an assisted living
community, or a nursing home. Trained CAREGivers® help with meal preparation, If you have chronic health problems, LifeCycle Transitions can help you stay well at home
bathing, grooming, dressing, incontinence care, mobility assistance, or transition to a new location.
transportation, housework, and medication regimen support. Home Instead
provides support services in hospice settings and following discharge from • Get a 20% discount for services such as relocation and downsizing, help addressing a
the hospital or rehab. CAREGivers® provide meaningful companionship, distressed home, cleaning, hoarding assistance, and more.
engagement, and supervision if needed due to an Alzheimer’s or • For details on discounts, and to order services, call LifeCycle Transitions at
dementia diagnosis. Home Instead’s services are customized to 1-877-273-7810 and use reference code “LCTTHPMP.”
meet the needs of each individual. Service hours generally range
• For more information on services, go to LifeCycleTransitions.com.
from a few hours per week to 24 hours per day.
• Get a one-time $100 credit toward charges for services
at participating offices. To get the discount, show
your Tufts Health Plan member ID card during your
consultation.
• Get a free home safety inspection once you
have contracted for services with Home
Instead Senior Care. For even more health and wellness content, like
healthy recipes, tips on staying active, managing
• For more information, please common conditions, and maintaining health, visit:
visit HomeInstead.com or call
thpmp.org/healthy-living
1-888-580-6676.
20 Member Services: 1-866-623-0172 (TTY: 711) thpmp.org 21Access PPO
Dental Coverage to Smile About Benefit
Preventive and Diagnostic Services
(Embedded coverage)
Routine cleaning, scaling, and polishing of teeth
$0
Two per calendar year.
Dental coverage is included with your plan! Periodic oral evaluation
$0
Your $1,000 dental benefit includes a $0 copay for preventive visits and 50% Two per calendar year.
coinsurance for fillings, simple extractions, bridges, crowns, dentures, and more. Bitewing X-ray images
X-rays of the crowns of the teeth. Completed when oral $0
conditions indicate need. Two per calendar year.
You have access to hundreds of dentists Comprehensive oral exam
$0
The dental network is provided by Dominion National. To use your dental coverage, Once every 36 months.
you can see any licensed dentist, but may pay higher costs for services provided Basic Services
by dentists not participating in the Dominion PPO Network. Dominion National
Emergency oral evaluation problem focused exams
provides you with access to hundreds of participating dentists.13 50%
Once every 12 months.
To view the list of participating dentists in the Dominion PPO Network, go to Minor treatment for pain relief
Only if no services other than exam and X-rays were 50%
thpmp.org/dentist.
performed on the same date of service.
X-ray image of the entire mouth
50%
You will get an ID card in the mail (Panoramic image) Once every 60 months.
You will receive a Dominion National ID card by mail to use for your dental X-ray image of the entire mouth
50%
(Full mouth series) Once every 60 months.
coverage. If you don’t receive your card within 3 weeks of joining the plan, call
Single tooth X-ray images
Member Services at 1-866-623-0172 (TTY: 711). As needed.
50%
Periodontal cleaning
Once every 6 months following active periodontal therapy, 50%
not to be combined with regular cleanings.
Restorative Services
Silver fillings and white fillings (front teeth)
50%
Once every 24 months per surface per tooth.
Silver fillings and white fillings (back teeth)
Covered only for single surfaces. Once every 24 months
per surface, per tooth. White fillings on back teeth (teeth
behind canines) will be processed as a silver filling and the 50%
patient is responsible up to the allowed amount. A pre-
treatment estimate is recommended prior to receiving
treatment.
Scaling and root planing
50%
Once in 24 months, per quadrant.
Scaling in presence of generalized moderate/severe
gingival inflammation
Check out 50%
Once per 24 months after oral evaluation and in lieu of a
the FAQs and covered prophylaxis (routine dental cleaning).
Glossary on Full mouth debridement
50%
pages 26–29 Once per lifetime.
to learn more Simple extractions
50%
about your Once per tooth.
dental coverage.
22 Member Services: 1-866-623-0172 (TTY: 711) thpmp.org 23Access PPO Access PPO
Benefit (Embedded coverage) Benefit (Embedded coverage)
Major Services Fixed bridges
(A pre-treatment estimate is recommended for all major services, prior to receiving Once per 84 months. Note: A back-of-mouth fixed bridge
treatment. See page 26 for details on pre-treatment estimates.) and a removable denture are not covered in the same arch
50%
within 84 months; if a denture in the same arch as the fixed
Protective restorations bridge was covered within 84 months, there will be no
50% benefit for the fixed bridge.
Once per tooth.
Adjunctive Services (provided in conjunction with the primary treatment) Temporary partial dentures
Once per 84 months to replace any of the six upper or
Local anesthesia and inhalation of nitrous oxide lower front teeth, but only if the temporary partial dentures 50%
(sometimes known as laughing gas) are installed immediately following the loss of teeth during
Local anesthesia and inhalation of nitrous oxide/analgesia, the period of healing.
50%
anxiolysis are provided in conjunction with covered oral
surgery or periodontal surgery and are integral to the Major Restorative (Recommend pre-treatment estimate prior to service to confirm
primary treatment. tooth has a good prognosis)
Oral Surgery Inlays
50%
Once per tooth per 84 months.
Surgical extractions
50% Crowns and onlays-initial placement
Once per tooth.
When teeth cannot be restored with regular fillings due
Periodontics to fracture or decay, once per 84 months per tooth.
50%
Periodontal surgery Implants, implant crowns, implant prosthetics, and
One surgical procedure per lifetime; gingivectomy or 50% implant supporting structures (such as connectors) are not
gingivoplasty and osseous surgery covered as needed. covered.
Recement/reaffix of crowns and onlays
Bone grafts and guided tissue regeneration 50%
50% Once per tooth per 12 months.
Once per lifetime.
Post and core or crown buildup
Endodontics When needed to retain a crown on a tooth with excessive
50%
breakdown due to decay and/or fractures. Once per tooth
Root canal treatment
50% every 84 months.
Once per tooth per lifetime.
Retreatment root canal therapy
Once per tooth per lifetime after 24 months of initial root 50%
canal therapy.
Apicoectomy
50%
Covered as needed.
Maintenance for Dentures and Fixed Bridges (Prosthetic Maintenance)
Bridge or denture repair
50%
Once every 24 months per bridge or denture.
Tissue conditioning
50%
One treatment per denture every 84 months.
Adding teeth to existing partial or full dentures
50%
Once per tooth, per denture, per 24 months.
Rebase or reline of dentures
50%
Once per denture every 24 months.
Fixed and Removable Dentures/Bridges (Prosthodontics)
Dentures
50%
Complete or partial dentures: one per arch per 84 months.
More on our website:
thpmp.org 25
24 Member Services: 1-866-623-0172 (TTY: 711)What is the difference between silver fillings and white fillings?
Fillings can be performed using either composite (tooth-colored/white) or
amalgam (metal/silver) restorative materials. If a tooth-colored filling is submitted
for a back tooth, the coverage provided will be for a comparable metal filling.
You and your dentist may still choose a white filling, but you will be responsible
for the difference in cost between the white and silver fillings. If you would like a
better estimate of your payment, we urge you to ask your dentist to submit a pre-
treatment estimate.
Dental benefit FAQs
Which services are part of a routine checkup? What is bone grafting and guided tissue regeneration?
Services include a cleaning, periodic oral evaluation, and sometimes bitewing Bone grafting and guided tissue regeneration are two separate but related
X-rays. A comprehensive oral exam only occurs for a new patient or to procedures that your dentist can use to save natural teeth from failing due to the
evaluate an issue. loss of healthy tissue from gum disease. By regenerating the lost bone and tissues
surrounding a tooth, these restored structures will create the protective, strong
How can I determine whether a dental service will be covered and what the foundation a tooth needs to remain healthy long-term.
cost will be?
How do I know which types of crowns are covered with my plan?
We recommend asking your dentist to submit a pre-treatment estimate to
Dominion National before your treatment begins. The dentist can submit the exact Crowns can be manufactured from a variety of materials, such as high noble
services or procedures they plan to provide in your treatment plan and Dominion metals, base metals, porcelain fused to metal (PFM), and ceramic compounds. Your
National will respond with confirmation of whether the service will be covered and dental plan covers crowns manufactured with porcelain fused to predominantly
the estimated out-of-pocket cost you will be expected to pay. base metal. You and your dentist may still choose a crown made from more costly
materials, but you will be responsible for the difference in cost between the
• The pre-treatment estimate will be reviewed, and an estimate statement predominantly base metal crown and the crown of your choosing. If you would like
will be issued to you or the provider. The statement will include details of a better estimate of your payment, we urge you to ask your dentist to submit a
the services that will be covered by your plan along with your estimated pre-treatment estimate.
responsibility and potential payment to the dental office.
• The pre-treatment estimate is based on eligibility and benefits available at the
time it is processed. A pre-treatment estimate is not required to obtain care.
• A pre-treatment estimate is not a guarantee of payment. The claim for services
performed will be based on eligibility and available benefits at the time it is
submitted for payment. Other procedures performed, especially in the same
area/quadrant/tooth, could affect the actual claim determination/payment.
What is the difference between simple extractions and surgical extractions?
A simple dental extraction is the procedure of removing teeth that are visible and
easily accessible. In contrast, surgical dental extraction often involves an incision
to get access to the tooth to be removed.
What is the difference between an inlay and an onlay?
Inlays and onlays use the same materials as crowns and they both serve the same
function, but they cover different areas of the tooth when there is tooth decay.
The difference between an onlay and an inlay is that an onlay will treat the cusp,
whereas an inlay only restores the area between the cusps.
26 Member Services: 1-866-623-0172 (TTY: 711) thpmp.org 27Maximum allowable charge/Allowed amount (MAC) Quadrants Tissue conditioning
Amount that is negotiated with providers in the Dominion Quadrants mean the four parts of Tissue conditioning is an effort to restore the health of the
National dental network. This is the maximum allowed your mouth. Your dentist sections tissues of the denture foundation area prior to denture
amount you can be charged for a service. For services the interior of your mouth into four treatment.
with coinsurance, the amount you pay is calculated by parts for reference when providing
multiplying the coinsurance rate with the MAC. treatment. The split is between the
front teeth, split into upper right,
For more information
Onlays
upper left, lower right, lower left. For more information on dental coverage, go to
An onlay is a treatment, like an inlay, which restores the
thpmp.org/dental, see your 2023 Evidence of Coverage
cusp(s) of the tooth. The cusp (or cusps) of the tooth refer Rebase denture
(EOC) at thpmp.org/documents, or call Member Services at
to the angled topmost surface of the tooth. Canine teeth Rebasing may be recommended
1-866-623-0172 (TTY: 711).
have a single cusp, while bicuspids have two and molars when the teeth of your denture are
may have four or five. still in good condition and have not worn out in comparison
Dental Glossary Periodic oral exam to the denture base material. Rebasing is the process of
Apicoectomy Exam performed by a dentist as part of a routine checkup. replacing the entire acrylic denture base providing a stable
The removal of inflamed gum tissue and the end of the denture without replacing the denture teeth.
Periodontal cleaning
tooth's root, while leaving the top of the tooth in place. Reline denture
Like a regular teeth cleaning, periodontal maintenance
Bitewing X-rays removes tartar buildup from the teeth. Unlike a normal, A denture reline is a simple procedure to reshape the
Provides details of the upper and lower teeth in one area preventive cleaning, periodontal maintenance is a treatment underside of a denture so that it fits more comfortably
of the mouth. Each bitewing shows a tooth from its crown prescribed to combat periodontal (gum) disease. It involves on the user's gums. Relining is periodically necessary as
(the exposed surface) to the level of the supporting bone. both scaling and root planing, meaning tartar must be dentures lose their grip in the mouth.
Many dentists include bitewing X-rays as part of routine removed from deep between the teeth and gums. Retreatment root canal therapy
diagnostic care. Root canal retreatment is the removal of the previous
Periodontal surgery
Bone grafting Consists of three different potential surgeries. Your dentist crown and packing material left by a prior root canal, the
Bone grafting is a surgical procedure that uses transplanted will determine which one is needed. The three different cleansing of the canals, and the re-packing and re-crowning
bone to replace missing or damaged bone in your mouth. If surgeries could be: of the tooth.
you’re getting a dental implant, you may also need a bone Root canal
• Gingivectomy—The surgical removal of gum tissue.
graft because it provides additional support. The bone graft A root canal is performed when the endodontist removes
A gingivectomy is necessary when the gums have
is performed first, and you’ll need to wait 3 to 4 months the infected pulp and nerve in the root of the tooth, cleans
pulled away from the teeth creating deep pockets.
for it to heal before getting the implant. Please note that the inside of the root canal, then fills and seals the space.
The pockets make it hard to clean away plaque
implants are not covered with your dental plan. After completing a root canal your dentist will place a crown
and calculus.
Comprehensive oral exam on the tooth to protect and restore it to its original function.
• Gingivoplasty—The surgical reshaping of gum tissue
Performed by a dentist when evaluating a patient. Applies Scaling and root planing
around the teeth.
to new patients or established patients who have had Scaling and root planing is when your dentist removes all
change in health or have been absent from treatment for • Osseous surgery—Removes diseased gum tissue and the plaque and tartar above and below the gumline, making
three or more years. bone from infected sites within the mouth and stops sure to clean all the way down to the bottom of the tooth.
periodontal disease from getting worse.
Front teeth Scaling in presence of generalized moderate/severe
Includes canines and all teeth in front of canines. Posterior/back teeth gingival inflammation
Includes any teeth behind the canines but does not include The removal of plaque and stains from above and below the
Full mouth debridement
the canine teeth. gumline when there is generalized gum inflammation. This
The removal of plaque and tartar that interfere with the
ability of the dentist to perform an oral examination. This is Protective restorations procedure is for patients who have swollen, inflamed gums
the most extensive cleaning procedure. The placement of a restorative material to protect a tooth and bleeding on probing. This procedure is performed on
and/or surrounding tissue. This procedure may be used the entire mouth rather than just one quadrant. It is also a
Guided tissue regeneration
to relieve pain, promote healing, and prevent further higher degree of cleaning for patients with more advanced
Guided tissue regeneration is a procedure designed to
deterioration. periodontal disease.
remove infected soft tissue in your mouth, while stimulating
the regrowth of healthy gum tissue. Single tooth X-rays
Also sometimes referred to as a "periapical X-ray" a single
Inlays
tooth X-ray is one that captures the whole tooth. It shows
A dental inlay is a pre-molded restorative filling fitted into
everything from the crown (chewing surface) to the root
the grooves of your tooth. It restores cavities that are
(below the gum line).
centered in your tooth instead of along the outer edges
or "cusps."
28 Member Services: 1-866-623-0172 (TTY: 711) thpmp.org 292023 Benefits Overview
This is a quick reference guide to some of the more commonly used services. For
more complete plan benefit information, see your Evidence of Coverage (EOC),
available at thpmp.org/documents. Please note: Costs may differ if you receive
your benefits from a current or former employer.
The Basics
Medical Deductible No medical deductible
Annual Out-of-Pocket
$6,700 in-network ($10,000 combined in- and out-of-network)
Maximum14
30 Member Services: 1-866-623-0172 (TTY: 711) thpmp.org 31The Basics Access PPO (In-network) Access PPO (Out-of-network) Additional Benefits Access PPO (In-network) Access PPO (Out-of-network)
Doctor Office Visits $350 per calendar year toward fitness club membership, instruction-
Wellness Allowance al fitness classes, and more.
Primary Care Physician $0 per visit $20 per visit
Specialist $45 per visit $65 per visit $150 per calendar year reimbursement toward program fees for
Weight Management Programs weight loss programs such as Weight Watchers®, Jenny Craig®, or
Medicare-covered services plus additional telehealth services. $0 hospital-based weight loss programs.
copay for e-visits and virtual check-ins; for all other telehealth visits, Embedded Supplemental Dental
Telehealth
copay is the same as corresponding in-person visit copay. Additional Benefits13
telehealth services not covered out-of-network.15 For complete coverage details $0 deductible, $0 for preventive services, 50% coinsurance for basic
dental services, 50% coinsurance for major services, up to a calendar
Preventive Care and limitations, see your Evidence year maximum of $1,000.
of Coverage (EOC) available at
Annual Physical $0 per visit 40% coinsurance thpmp.org/documents.
Cancer Screening (Colorectal,
$0 per service 40% coinsurance Over-the-Counter (OTC) Benefit17 $60 per calendar quarter to spend on Medicare-approved health-
Prostate, Breast) related items.
Vision and Hearing
Acupuncture18 $20 per visit $65 per visit
Annual Routine Vision Exam $0 $65
Annual Eyewear Benefit $150 per calendar year toward eyewear purchased from any provider.
$0 (through Hearing Care
Annual Routine Hearing Exam $65
Solutions provider) Rx Drug Coverage Access PPO
Up to 2 aids per calendar year, 1 per year. $250 copay for Standard
level, $475 copay for Superior level, $650 copay for Advanced level, Deductible $0 for Tiers 1–2 and 6; $150 for Tiers 3–5
Hearing Aids
$850 copay for Advanced Plus level, $1,150 copay for Premier level.
Through Hearing Care Solutions. Copays 30-day retail supply 90-day mail order supply
Outpatient and Lab Services
$0 ($14 at a non-preferred phar-
Tier 1: Preferred Generic19 $0
Outpatient Services/Surgery Colonoscopies: $0; Other macy)
including services at hospital Services (ASC): $290 per $4 ($19 at a non-preferred phar-
40% coinsurance Tier 2: Generic19 $8
outpatient facilities and ambulatory day; Other Services (non- macy)
surgical centers (ASC) ASC): $390 per day
Tier 3: Preferred Brand $47 $94
Rehabilitation Therapy16 $40 per visit 40% coinsurance
Mental Health and Substance Tier 4: Non-Preferred Drug $100 $300
$25 per visit 40% coinsurance
Abuse Services
Outpatient Diagnostic Labs $0 40% coinsurance Tier 5: Specialty Tier 30% N/A
Ultrasound: $100 per day;
Diagnostic Radiology Services 40% coinsurance Tier 6: Vaccines $0 N/A
Others: $200 per day
Emergency Services Insulin $35 $70
Emergency Room $90 per visit After your total prescription drug costs reach $4,660, and until your
Urgent Care $45 per visit payments reach $7,400, you pay: 25% coinsurance for Part D ge-
Coverage Gap Stage
neric drugs; 25% coinsurance of costs for Part D brand drugs plus a
Ambulance Services $350 per one-way trip (also referred to as the 'Donut Hole')
portion of the dispensing fee20; $0 copay for covered Tier 6 vaccine
Note: Amounts determined by Medicare
Inpatient Care drugs obtained through a retail pharmacy; $35 per month (30-day
supply) copay for select insulin drugs.
Days 1–5: $400 per day, $0 After the coverage gap, when your payments for the year are greater
Inpatient Hospital Coverage 40% coinsurance
per day after day 5 than $7,400, you pay the greater of 5% per prescription or $4.15 per
Catastrophic Coverage Stage prescription for Part D generic drugs/$10.35 per prescription for Part
Note: Amounts determined by Medicare D brand drugs; $0 copay for covered Tier 6 vaccine drugs obtained
through a retail pharmacy; no more than $35 per month (30-day sup-
ply) copay for select insulin drugs.
32 Member Services: 1-866-623-0172 (TTY: 711) thpmp.org 33Notice of Privacy Practices
• Seeking accreditation by independent organizations, such as the National Committee for Quality Assurance.
• Engaging in wellness programs, preventive health, early detection, disease management, health risk assessment
participation initiatives, case management, and coordination of care programs, including sending preventive health
service reminders.
This notice describes how health information about you may be used and disclosed, and how you • Providing you with information about a health-related product or service included in your plan of benefits.
can get access to this information. Please review it carefully. • Using information for underwriting, establishing premium rates and determining cost sharing amounts, as well as
administration of reinsurance policies. (Tufts Health Plan will not use or disclose any genetic information it might
Tufts Health Plan values your privacy rights and is committed to safeguarding your demographic, medical, and financial otherwise receive for underwriting purposes.)
information we may receive or collect when providing services to you. The information we collect includes protected health
• Facilitating transition of care from and to other insurers, health plans or third-party administrators.
information (“PHI”) and personal information (“PI”). PHI is information that relates to your physical or behavioral health
condition, your health care, or the payment for your health care. PI includes information like your name and Social Security • Communicating with you about your eligibility for public programs, such as Medicare.
number. PHI and PI are referred to as “information” elsewhere in this notice. • Other general administrative activities, including data and information systems management, risk management,
We may obtain your information from a number of sources, such as through your enrollment in a plan or from doctors auditing, business planning, and detection of fraud and other unlawful conduct.
and hospitals who submit claim forms containing your information so that we may pay them for services they provided to
you. We are required by law to maintain the privacy of your information. To support this, Tufts Health Plan has privacy and For Treatment
security policies for safeguarding, using, and disclosing information in compliance with applicable state and federal laws.
Tufts Health Plan may use and disclose your information for health care providers (doctors, dentists, pharmacies, hospitals,
All employees must complete annual privacy and security training, and access to your information is limited to employees
and other caregivers) to treat you. Examples include:
who require it to do their job. Tufts Health Plan also requires its business partners who assist with administering health care
coverage to you on our behalf to protect your information in accordance with applicable laws. • Our care managers providing your information to a home health care agency to make sure you get the services you
need after discharge from a hospital.
Tufts Health Plan is required to provide you with notice of our legal duties and privacy practices with respect to your
information, and to follow the duties and practices described in the notice currently in effect. We may change the terms of • Quality improvement programs, safety initiatives, and clinical reminders sent to your primary care provider.
this notice at any time and apply the new notice to any information we already maintain. If we make an important change to • Disclosing a list of medications you’ve received using your Tufts Health Plan coverage to alert your treating providers
our notice, we will publish the updated notice on our website at thpmp.org. about any medications prescribed to you by other providers and help minimize potential adverse drug interactions.
How We Use And Disclose Your Information • Receiving your test results from labs you use, from your providers, or directly from you, using the results to develop
In order to administer your health care coverage, including paying for your health care services, we need to use and disclose tools to improve your overall health, and sharing the results with providers involved in your care.
your information in a number of ways. Tufts Health Plan maintains and enforces company policies governing the use and
disclosure of information, including only using or disclosing the minimum amount of information necessary for the intended For Other Permitted or Required Purposes
purpose. The following are examples of the types of uses and disclosures we are permitted or required by federal law to
The following are examples of the additional types of uses and disclosures Tufts Health Plan is permitted or required by law
make without your written authorization. Where state or other federal laws offer you greater privacy protections, we will
to make without your written authorization:
follow the more stringent requirements.
• To you, your family, and others involved in your care when you are unavailable to communicate (such as during an
For Payment emergency), when you are present prior to the disclosure and agree to it, or when the information is clearly relevant to
Tufts Health Plan may use or disclose your information for payment purposes to administer your health benefits, which may their involvement in your health care or payment for health care.
involve obtaining premiums, determination of eligibility, claims payment, and coordination of benefits. Examples include: • Sharing eligibility information and copayment, coinsurance, and deductible information for dependents with
• Paying claims that were submitted to us by physicians and hospitals. the subscriber of the health plan in order to facilitate management of health costs and Internal Revenue Service
verification.
• Providing information to a third party to administer an employee- or employer-funded account, such as a Flexible
Spending Account (“FSA”) or Health Reimbursement Account (“HRA”), or another benefit plan, such as a dental • To your Personal Representative (including parents or guardians of a minor, so long as that information is not further
benefits plan. restricted by applicable state or federal laws) or to an individual you have previously indicated is your Designated
Representative or is authorized to receive your information. Information related to any care a minor may receive
• Performing medical necessity reviews.
without parental consent remains confidential unless the minor authorizes disclosure.
• Sharing information with third parties for Insurance Liability Recovery (“ILR”) or subrogation purposes.
• To our business partners and affiliates. Tufts Health Plan may contract with other organizations to provide services on
For Health Care Operations our behalf. In these cases, Tufts Health Plan will enter into an agreement with the organization explicitly outlining the
requirements associated with the protection, use, and disclosure of your information. The following corporate affiliates
Tufts Health Plan may use or disclose your information for operational purposes, such as care management, customer
of Tufts Health Plan designate themselves as a single affiliated covered entity and may share your information among
service, coordination of care, or quality improvement. Examples include:
them: Harvard Pilgrim Health Care, Inc., Harvard Pilgrim Health Care of New England, Inc., HPHC Insurance Company,
• Assessing and improving the quality of service, care and outcomes for our members. Inc., Tufts Associated Health Maintenance Organization, Inc., Tufts Health Public Plans, Inc., Tufts Insurance Company,
• Learning how to improve our services through internal and external surveys. CarePartners of Connecticut, Inc., and Point32Health Services, Inc. Group Health Plan.
• Reviewing the qualifications and performance of physicians. • To your plan sponsor, when sharing information used for enrollment, plan renewal, or plan administration purposes.
This is your employer or the employer of your subscriber if you are enrolled through an employer. When sharing detailed
• Evaluating the performance of our staff, such as reviewing our customer service phone conversations with you.
34 Member Services: 1-866-623-0172 (TTY: 711) thpmp.org 35information, your plan sponsor must certify that they will protect the privacy and security of your information and that Access Your Information and Receive a Copy
the information will not be used for employment decisions.
You have the right to access, inspect, and obtain a copy of your information maintained by Tufts Health Plan (with certain
• To government entities, such as the Centers for Medicare & Medicaid Services, the Health Connector, HealthSourceRI, exceptions). We have the right to charge a reasonable fee for the cost of producing and mailing copies of your information.
or MassHealth, if you are enrolled in a government-funded plan.
Amend Your Information
• To provide information for health research to improve the health of our members and the community in certain
circumstances, such as when an Institutional Review Board or Privacy Board approves a research proposal with You have the right to request we amend your information if you believe it is incorrect or incomplete. We may deny your
protocols to protect your privacy, or for purposes preparatory to research. request in certain circumstances, such as when we did not create the information. For example, if a provider submits medical
information to Tufts Health Plan that you believe is incorrect, the provider will need to amend that information.
• To comply with laws and regulations, such as those related to workers’ compensation programs.
• For public health activities, such as assisting public health authorities with disease prevention or control and pandemic
Receive an Accounting of Disclosures
response efforts. You have the right to request an accounting of those instances in which we disclosed your information, except for
disclosures made for treatment, payment, or health care operations, or for other permitted or required purposes. Your
• To report suspected cases of abuse, neglect, or domestic violence.
request must be limited to disclosures in the six years prior to the request. If you request an accounting more than once in a
• For health oversight activities, such as audits, inspections, and licensure or disciplinary actions. For example, Tufts 12-month period, we may charge you a reasonable fee.
Health Plan may submit information to government agencies such as the U.S. Department of Health and Human
Services or a state insurance department to demonstrate its compliance with state and federal laws. Receive a Copy of this Notice of Privacy Practices
• For judicial and administrative proceedings, such as responses to court orders, subpoenas, or discovery requests. You have the right to receive a paper copy of this notice from us at any time upon request.
• For law enforcement purposes, such as to help identify or locate a victim, suspect, or missing person. Be Notified of a Breach
• Disclosures to coroners, medical examiners, and funeral directors about decedents. Tufts Health Plan may also You have the right to be notified if there is a breach of your unsecured information by us or our business partners. We will
disclose information about a decedent to a person who was involved in their care or payment for care, or to the person provide you written notice via mail, unless we do not have up-to-date contact information for you. In these cases we will
with legal authority to act on behalf of the decedent’s estate. notify you by a substitute method, such as posting the notice on our public website. You may exercise any of your privacy
• To organ procurement organizations for cadaveric organ, eye, or tissue donation purposes, only after your prior rights described above by contacting Member Services at the phone number listed on your Tufts Health Plan ID card. In
authorization. some cases, we may require you to submit a written request. Tufts Health Plan will not require you to waive your rights as a
condition of the provision of treatment, payment, enrollment in a health plan, or eligibility for benefits.
• To prevent a serious threat to your health or safety, or that of another person.
• For specialized government functions, such as national security and intelligence activities.
Whom To Contact With Questions Or Complaints
• Disclosures by employees for whistleblower purposes.
If you believe your privacy rights have been violated or you would like more information, you may send a question or
Other than the permitted or required uses and disclosures described above, Tufts Health Plan will only use and disclose complaint to:
your information with your written authorization. For example, we require your authorization if we intend to sell your
Privacy Officer
information, use or disclose your information for marketing or fundraising purposes, or, in most cases, use or disclose your
Point32Health
psychotherapy notes.
1 Wellness Way
You may give us written authorization to use or disclose your information to any individual or organization for any purpose Canton, MA 02021
by submitting a completed authorization form. The form can be found at thpmp.org, or you may obtain a copy by calling
Or, you may call our Compliance Hotline at 1-877-824-7123 or Member Services at the phone number listed on your Tufts
Member Services at the phone number listed on your Tufts Health Plan ID card.
Health Plan ID card. You also have the right to submit a complaint to the Secretary of the Department of Health and Human
You may revoke such an authorization at any time in writing, except to the extent we have already made a use or disclosure Services. You can find more information at hhs.gov/ocr.
based on a previously executed authorization.
Tufts Health Plan will not take retaliatory action against you for filing a complaint.
THIS NOTICE IS EFFECTIVE SEPTEMBER 1, 2022.
Your Rights With Respect To Your Information
Visit us online
The following are examples of your rights under federal law with respect to your information. You may also be entitled to
additional rights under state law. thpmp.org
Request a Restriction
You have the right to request we restrict the way we use and disclose your information for treatment, payment, or health
care operations to individuals involved in your care or for notification purposes, including asking that we not share your
information for health research purposes. We are not, however, required by law to agree to your request.
Request Confidential Communications
You have the right to request we send communications to you at an address of your choice or that we communicate with
Tufts Health Plan includes Tufts Associated Health Maintenance Organization, Inc., Tufts Health Public Plans, Inc., Total Health Plan,
you by alternative means. For example, you may ask us to mail your information to an address that is different than your Inc., Tufts Benefit Administrators, Inc., Tufts Insurance Company, TAHP Brokerage Corporation, Point32Health Services, Inc. Group
subscriber’s address. We will accommodate reasonable requests. Health Plan, and self-funded plans administered by these entities.
36 Member Services: 1-866-623-0172 (TTY: 711) thpmp.org 37You can also read
