The Health Maintenance Organization (HMO) option allows members to choose a Primary Care Physician (PCP) from an extensive network of doctors which provide or authorize all of your care (except in an emergency or in certain cases of self-referral). Your PCP will be the primary liaison between you and any specialists you might see within the network. Tufts requires that you call your PCP first when seeking medical services, unless it is an emergency. As of 1/1/08, the following applies:
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Doctor's Office Visits
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$20 per visit
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$20 per visit
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Routine Physical Exams
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$20 per visit
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$20 per visit
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Well-child Care
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$20 per visit
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$20 per visit
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| Specialist Care, Consultations |
$20 per visit
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$20 per visit
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| OBGYN Visits |
$20 per visit
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$20 per visit
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| Prenatal and Postnatal Care |
$20 per visit
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$20 per visit
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| Labratory Tests, Including Pap Smear |
Covered in Full |
Covered in Full |
| Diagnostic X-Rays, Including Mammograms |
Covered in Full |
Covered in Full |
| Injections and Immunizations |
Covered in Full |
Covered in Full |
| Speech Therapy and Short Term Physical/Occupational Therapy |
$20 per visit
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$20 per visit
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| Annual Routine Eye Exams |
$20 per visit
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$20 per visit
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| Spinal Manipulation (12 visits per calendar year) |
$20 per visit
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$20 per visit
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| Allergy Shot |
$5 per visit |
$5 per visit |
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Day Surgery
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Covered in Full
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Covered in Full
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Acute Care and Maternity Care (for hospital services)
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150$ per admission
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150$ per admission
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| Physician's Care while Hospitalized |
Covered in Full
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Covered in Full
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| Surgery and Surgeon's services while Hospitalized |
Covered in Full
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Covered in Full
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| Newborn Care in Hospital |
Covered in Full
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Covered in Full
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| Anesthesia while Hospitalized |
Covered in Full
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Covered in Full
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| Medications while Hospitalized |
Covered in Full
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Covered in Full
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| Nursing Care while Hospitalized |
Covered in Full
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Covered in Full
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X-ray and Lab Services while Hospitalized
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Covered in Full
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Covered in Full
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| Intensive Care/Coronary Care while Hospitalized |
Covered in Full
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Covered in Full
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| Radiation Therapy while Hospitalized |
Covered in Full
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Covered in Full
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| Skilled Nursing and Skilled Nursing Facility(Up to 100 days per Calendar Year) |
Covered in Full
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Covered in Full
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Membership at Network Fitness Facilities
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Multiple discount options
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Multiple discount options
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| Weight Watchers Weight Management Program |
Discounted Membership |
Discounted Membership |
| Health Education (may require advanced payment) |
30% discount per program |
30% discount per program |
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Preventive for children
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100% for 2 visits/year for children through 12 years old
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Not Applicable
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Outpatient Care (up to 24 visits per calendar year)
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20$ per visit
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20$ per visit
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Inpatient Care (services provided through a designated facility program for up to 60 days per calendar year)
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$150 per admission
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$150 per admission
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Outpatient Care (Alcohol, Drug and Detoxification)
(Tufts Health Plan pays up to $500.00 per calendar year)
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$20 per visit |
$20 per visit |
| Inpatient Care (Services provided through a designated facility program for up to 30 days per calendar year) |
$150 per admission |
$150 per admission
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| In Doctor's Office |
$20 per visit
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$20 per visit
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In Emergency Room
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$100 per visit
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$100 per visit
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Other Services
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Durable Medical Equipment
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Plan pays 80% Member pays 20% ($5000 calendar year maximum)
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Plan pays 80% Member pays 20%($5000 calendar year maximum, then at unauthorized level)
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| Ambulance (when medically necessary) |
covered in full |
covered in full |
| Pediatric Dental |
covered for children under 12 (contact Tufts for more details) |
Not Covered |
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Deductible and Out-of pocket Maximum
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| Annual Deductible |
not applicable
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$400 for individual/$800 for family
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| Annual Out-of-Pocket Maximum |
not applicable |
$2000 individual/$4000 family
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| Annual In-Patient Copayment Maximum |
not applicable |
$600 individual |
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DeltaPremier is a great choice for employees who value access, flexibility and freedom of choice. Care is available from approximately 5,500 dentists (over 95 percent of practicing dentists in Massachusetts). |
DeltaCare II is a great choice for employees who value managed care and prevention. Employees choose a "primary care dentist" who directs and coordinates all primary and specialty care. Please note that the provider you choose is not guaranteed to stay in the plan during your enrollment, and therefore you may have to be flexible in choosing other providers. |
| Diagnostic |
100 percent coverage |
co-payment schedule* |
| Preventative |
100 percent coverage |
co-payment schedule* |
| Restorative |
80 percent coverage |
co-payment schedule* |
| Oral Surgery |
80 percent coverage |
There is a $1,000 per personal annual calendar year maximum |
| Periodontic |
80 percent coverage |
There is a $1,000 per personal annual calendar year maximum |
| Endodontics |
80 percent coverage |
There is a $1,000 per personal annual calendar year maximum |
| Prosthetic Maintenance |
80 percent coverage |
co-payment schedule* |
| Emergency Dental Care |
80 percent coverage |
co-payment schedule* |
| Major Restorative |
50 percent coverage |
co-payment schedule* |
| Prosthodontics |
50 percent coverage |
co-payment schedule* |
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$100 per individual, $300 per family |
None |
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$1,000 per person |
Unlimited except for endodontic, oral surgery, or periodontal services |
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Dependents are covered until age 19. |
Dependents are covered until age 19. |
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Full-time students are covered to age 23. |
Full-time students are covered to age 23 |
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Fourth Quarter Carry Forward Deductible. |
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Not covered |
Benefits based upon 24 months of active treatment. |
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*All services must be provided by a DeltaCare primary care dentist and are subject to the DeltaCare Patient co-payment schedule available from Human Resources or on the Delta Dental website at http://www.deltamass.com. Limited out-of-network benefit, subject to a $100 per person deductible applicable to all services.