Tufts Medicare Preferred HMO Saver Rx (HMO) H2256-028-000 is a 2021 Medicare Advantage plan with drug coverage provided by Tufts Health Plan.

In terms of networks, this plan is a Local HMO. HMO plans require you to choose an in-network primary care doctor who coordinates your care with other healthcare providers in your network. With HMOs, you must generally seek care in-network. If you seek care outside of the plan’s network, the plan will only cover emergency or urgent care in most cases. Local HMOs cover only a small service area or part of the country. If you want to have costs covered out of network, you may want to look for PPOs in your county. Meanwhile, if you need a wider area of coverage, you may want to look at Regional PPO plans specifically.

When it comes to cost-sharing, you’ll want to consider both monthly costs and out-of-pocket costs. This plan has a monthly premium of $0.00, which covers both the health and drug portions of the plan.

Since this plan has a zero-dollar Premium, you can enroll at no monthly cost. Please keep in mind zero-Premium Medicare plans typically have more out-of-pocket costs than higher Premium plans. So, if you tend to spend a lot out-of-pocket in a year, make sure to check out other plans as well.

The drug plan portion of this plan provides Enhanced Alternative (EA) benefits, which are benefits that exceed the required standard.

When it comes to out-of-pocket costs for drugs, this plan has a Part D drug Deductible of $250.00 and an Initial Coverage Limit of $4130. Each drug tier may be subject to different cost-sharing in each coverage phase, so keep that in mind when considering out-of-pocket costs. Check out the drug formulary below for more information, or reach out to a licensed Medicare agent for help using the call number on this page. Alternatively, if you know what plan you want, you can enroll online yourself using our site as well.


Plan Basics
Contract Year 2021
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID H2256-028-000
Plan Organization Tufts Health Plan
Plan Type Local HMO
Plan Name Tufts Medicare Preferred HMO Saver Rx (HMO)
Plan Organization Type Local CCP
Drugs Covered Yes
Doctors Choice Plan Doctors for Most Services
Benefit Type Enhanced Alternative
Special Needs Plan No
Overall Star Rating 5
Plan Cost Sharing
Premium $0.00
Total Premium (Includes Part B) $135.50
Monthly Part C Premium $0.00
Monthly Part D Basic Premium $0.00
Monthly Part D Supplemental Premium $0.00
Monthly Part D Total Premium $0.00
Monthly Part D Premium Full Assistance $0.00
Monthly Part D Premium 75% Assistance $0.00
Monthly Part D Premium 50% Assistance $0.00
Monthly Part D Premium 25% Assistance $0.00
Part D Drug Deductible $250.00
Annual Drug Deductible $250.00
Tiers Excluded From Deductible 1
Part D Initial Coverage Limit $4130.00
Part D Catastrophic Coverage Threshold $6550.00
Maximum Out-of-Pocket Limit for Parts A & B (MOOP) $7550.00
Gap Coverage No

Medicare Advantage Plan Health Benefits


Additional Benefits And/or Reduced Cost-sharing For Enrollees With Certain Health Conditions?
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network - - Yes, contact plan for further details
Comprehensive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diagnostic services Yes - No No 0-50% coinsurance
Endodontics No - - - Not covered
Extractions No - - - Not covered
Non-routine services No - - - Not covered
Periodontics No - - - Not covered
Prosthodontics, other oral/maxillofacial surgery, other services No - - - Not covered
Restorative services Yes - No No 50% coinsurance
Diagnostic Procedures/lab Services/imaging
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diagnostic radiology services (e.g., MRI) - - Yes No $100-325 copay
Diagnostic tests and procedures - - Yes No $10-45 copay
Lab services - - Yes No $10-45 copay
Outpatient x-rays - - Yes No $10-45 copay
Doctor Visits
Service Cap Network Auth. Req. Ref. Req. Cost Share
Primary - - - - $10 copay per visit
Specialist - - No Yes $45 copay per visit
Emergency Care/Urgent Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
Emergency - - - - $90 copay per visit (always covered)
Urgent care - - - - $10-45 copay per visit (always covered)
Foot Care (podiatry Services)
Service Cap Network Auth. Req. Ref. Req. Cost Share
Foot exams and treatment - - No Yes $45 copay
Routine foot care - - - - Not covered
Ground Ambulance
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $350 copay
Health Plan Deductible
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $0
Hearing
Service Cap Network Auth. Req. Ref. Req. Cost Share
Fitting/evaluation Yes - No Yes $0 copay
Hearing aids Yes - No No $250-1,150 copay
Hearing exam - - No Yes $45 copay
Inpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - Yes No $350 per day for days 1 through 5$0 per day for days 6 through 90
Maximum Out-of-pocket Enrollee Responsibility (does Not Include Prescription Drugs)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $7,550 In-network
Medical Equipment/supplies
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diabetes supplies - - No - $0 copay
Durable medical equipment (e.g., wheelchairs, oxygen) - - Yes - 20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs) - - Yes - 20% coinsurance per item
Medicare Part B Drugs
Service Cap Network Auth. Req. Ref. Req. Cost Share
Chemotherapy - - Yes - 20% coinsurance
Other Part B drugs - - Yes - 20% coinsurance
Mental Health Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Inpatient hospital - psychiatric - - No No $315 per day for days 1 through 5$0 per day for days 6 through 90
Outpatient group therapy visit - - No Yes $0-25 copay
Outpatient group therapy visit with a psychiatrist - - No Yes $0-25 copay
Outpatient individual therapy visit - - No Yes $0-25 copay
Outpatient individual therapy visit with a psychiatrist - - No Yes $0-25 copay
Optional Supplemental Benefits
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - Yes
Other Health Plan Deductibles?
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network - - No
Outpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - Yes Yes $0-350 copay per visit
Preventive Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - No No $0 copay
Preventive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Cleaning Yes - No No $0 copay
Dental x-ray(s) Yes - No No $0 copay
Fluoride treatment No - - - Not covered
Oral exam Yes - No No $0 copay
Rehabilitation Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Occupational therapy visit - - No Yes $0-40 copay
Physical therapy and speech and language therapy visit - - No Yes $0-40 copay
Skilled Nursing Facility
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - No No $0 per day for days 1 through 20$160 per day for days 21 through 44$0 per day for days 45 through 100
Transportation
Service Cap Network Auth. Req. Ref. Req. Cost Share
No - No No $40 copay
Vision
Service Cap Network Auth. Req. Ref. Req. Cost Share
Contact lenses Yes - No No $0 copay
Eyeglass frames Yes - No No $0 copay
Eyeglass lenses Yes - No No $0 copay
Eyeglasses (frames and lenses) Yes - No No $0 copay
Other No - - - Not covered
Routine eye exam Yes - No Yes $15 copay
Upgrades - - - - Not covered
Wellness Programs (e.g., Fitness, Nursing Hotline)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - No No Covered

Medicare Plan Packages


Package #1
Category Cost Sharing Type Cost Share
Comprehensive dental Monthly Premium $17.00
Plan Drug Info
Formulary Link Drug Formulary Directory
Official Medicare Contact
Medicare Phone 1-800-MEDICARE (1-800-633-4227)
Medicare TTY User 1-877-486-2048

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