Tufts Health Extend. Member Handbook

Transcription

1 2014 Tufts Health Extend Member Handbook This health plan meets Minimum Creditable Coverage standards and will satisfy the individual mandate that you have health insurance. Please see page 6 for additional information. Effective Date: October 2014 Issue Date: October 2014

2 Welcome! A great health plan at a great price With Tufts Health Plan Network Health, you get more from your health plan. Since 1997, we have partnered with a Network of Primary Care Providers (PCPs), Hospitals, and other Providers across Massachusetts to bring our Members access to highquality health care. By joining Tufts Health Extend you have access to thousands of great doctors and Specialists across the state, friendly and helpful Member Services Team representatives, and great service. We want you to get the most out of your membership. To help you understand what you need to know about your health plan, we have capitalized important words and terms throughout this Member Handbook. You will find definitions for each of these terms starting on page 40. Keep this handbook it has all the information you need to make the most of your Tufts Health Extend membership. Contact us: (TTY: , for people with partial or total hearing loss) Mail: 101 Station Landing, Fourth Floor, Medford, MA Translation services are available in 200 languages. Website: Network-Health.org Tufts Health Extend Member website: Network-Health.org/Extend Tufts Health Plan Network Health s Member Services Team hours: A Member Services Team representative can help you with any questions you may have. Call us at , Monday through Friday, from 8 a.m. to 5 p.m. 24/7 NurseLine: Talk to a caring and supportive health professional 24 hours a day, seven days a week, at no cost about any medical and behavioral health (mental health and/or substance abuse) issues and questions. 888-MY-RN-LINE ( ) TTY: Visit us on the web! Visit Network-Health.org to: Find a Primary Care Provider (PCP), Specialist, or health center near you Find a Behavioral Health Provider near you Order your free Tufts Health Extend EXTRAS Sign up for Network Health Member Connect, our online self-service tool, and: Choose or change your PCP Check if your PCP or other doctor needs to get Prior Authorization before you get a service Check the status of a Prior Authorization Order a new Tufts Health Plan Network Health Member ID Card Update your contact information 2014 Tufts Health Public Plans, Inc. Get important information, such as: How you can file a Grievance or request an Appeal How you have the right to request an External Review if we deny an Appeal, as well as your other rights and responsibilities How we make sure you get the best care possible (Quality Management and Improvement Program) How we make sure you get the right care in the right place (Utilization Management). Note: We never reward our staff for denying care. How we use information your Providers give us to decide what services you need to make you better or keep you healthy (Utilization Review) How we may collect, use, and release information about you and your health your Protected Health Information (PHI) according to our privacy policy And much more! Your Dependents Your family, including children up to age 26 or disabled children regardless of age, may also qualify for health insurance coverage under the plan. Call us at for more information. You can also call the Health Connector for plan-related questions at (TTY: ), Monday through Friday, from 8 a.m. to 6 p.m. If you move If you move or change your phone number, don t forget to update your contact information. You must call the Health Connector and us to update your address and phone number in order to ensure you continue to receive your benefits. You should also put the last names of all Tufts Health Extend Members in your household on your mailbox. The post office may not deliver mail from the Health Connector or us to someone whose name is not listed on the mailbox. To update your contact information, please call: The Health Connector at (TTY: ), Monday through Friday, from 8 a.m. to 6 p.m., and Tufts Health Plan Network Health at (TTY: ), Monday through Friday, from 8 a.m. to 5 p.m. Also, let the Health Connector know about any changes in your income, family size, employment status, and disability status, if you become pregnant, or if you have additional health insurance. Translation services If you have questions, need this document translated, need someone to read this or other printed information to you, or want to learn more about any of our free EXTRAS or Covered Services, call us at , Monday through Friday, from 8 a.m. to 5 p.m. We offer translation services in 200 languages. All translation services are free to Members. Members with partial or total hearing loss should call our TTY line at for help.

3 Table of contents Your Evidence of Coverage 6 Minimum creditable coverage and mandatory health insurance requirement Your Member ID Card 6 Getting the care you need 6 Service Area information Access to Covered Services In an Emergency Post-stabilization Care Services Urgent Care situations Hospital services When you re away from home Tufts Health Plan Network Health Providers 9 Your Primary Care Provider (PCP) Specialists Seeing an Out-of-network provider Communication between Providers Getting a second opinion 11 Continuity of Care 11 New Members Existing Members Prior Authorization 12 Standard Prior Authorizations Concurrent review Prior Authorization approvals and denials Adverse Determination Premiums 13 Co-payments 13 Medical Co-payments Pharmacy Co-payments Covered Services 14 Services we cover If you get a bill for a Covered Service Services not covered Covered medications and pharmacy 19 Pharmacy program Step therapy program Specialty pharmacy program Quality Management 21 Utilization Management 21 Experimental and/or investigational drugs and procedures

4 Care Management 22 Health and wellness support Disease management programs Care coordination Integrated care management Tufts Health Extend EXTRAS 26 FREE rewards for healthy behaviors FREE Weight Watchers registration (plus $50 back on program costs) Acupuncture reimbursement Fitness reimbursement FREE rewards that keep your family safe FREE rewards and help with your health care needs Coverage 30 Effective Coverage Date Disenrollment Protecting your benefits 31 Your rights 31 Advance Directives Your rights for privacy practices Additional information available to you Your responsibilities 33 How to resolve concerns with Tufts Health Plan Network Health 33 When you have additional insurance 37 Coordination of Benefits Subrogation Motor vehicle accidents and/or work-related injury/illness Member cooperation Our responsibilities 38 Notice of Privacy Policy Multicultural Health Care Privacy Protection Policy Glossary 40 Benefit and Co-payment Summaries 45 Plan Type I Plan Type II Plan Type III A great health plan at a great price Keep this handbook it has all the information you need to make the most of your Tufts Health Extend membership. If you have any questions, please call us at Members with partial or total hearing loss should call our TTY line at for assistance.

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6 Your Evidence of Coverage This Member Handbook, the Benefit and Co-payment Summary for each Plan Type at the end of this handbook, your Preferred Drug List, and any amendments we may send you make up your Evidence of Coverage. These documents are a contract between you and us. By signing and returning your enrollment application to the Health Connector, and having Tufts Health Extend as your health plan, you applied for coverage from us. You also agree to all the terms and conditions the Health Connector sets forth and to the terms and conditions of this handbook. This handbook explains your rights, benefits, and responsibilities as a Tufts Health Extend Member. It also explains our responsibilities to you. If there are any major plan changes, we ll notify you by mail 60 days before the changes go into effect. Only an authorized officer of Tufts Health Plan Network Health can change this Member Handbook, and only in writing. No other action, including any exception we make on a case-by-case basis, changes this Member Handbook. Minimum creditable coverage and mandatory health insurance requirement The Massachusetts Health Care Reform Law requires that Massachusetts residents, 18 years of age and older, must have health coverage that meets the Minimum Creditable Coverage standards that the Health Connector sets, unless waived from the health insurance requirement based on affordability or individual hardship. For more information, call the Health Connector at 877-MA-ENROLL ( ) or visit the Health Connector s website at MAhealthconnector.org. This health plan meets Minimum Creditable Coverage standards as part of the Massachusetts Health Care Reform Law. If you enroll in this plan, you will satisfy the statutory requirement that you have health insurance meeting these standards. Your Member ID Card Each person in your family with Tufts Health Extend will get a Tufts Health Extend Member ID Card. Your Member ID Card has important information about you and your benefits and also tells Providers and pharmacists that you are a Member of Tufts Health Extend. When you get the card(s), please check the information carefully to make sure all of it is correct. If you have any questions or concerns about your Member ID Card, if you lose it, or if you never receive it, call our Member Services Team at , Monday through Friday, from 8 a.m. to 5 p.m. Getting the care you need Service Area information Tufts Health Plan Network Health has developed a Network of Providers to make sure you get access to Covered Services. We serve Tufts Health Extend Members in most counties in the state of Massachusetts. For a complete listing of our Providers, please visit Network-Health.org. For more information about where we offer Tufts Health Extend, call our Member Services Team at , Monday through Friday, from 8 a.m. to 5 p.m. Access to Covered Services Access to Covered Services is how fast you should be able to get the care you need. Nonurgent Symptomatic Care is care you get when you re sick or hurt. Nonsymptomatic Care, also called Preventive Care, is care you get when you re well. Your Providers must give you the care you ask for within the following time frames: THIS DISCLOSURE IS FOR MINIMUM CREDITABLE COVERAGE STANDARDS. BECAUSE THESE STANDARDS MAY CHANGE, REVIEW YOUR HEALTH PLAN MATERIAL EACH YEAR TO DETERMINE WHETHER YOUR PLAN MEETS THE LATEST STANDARDS. 6 For any questions, please call Tufts Health Plan Network Health at (TTY: ). You can also visit us at Network-Health.org. We re also available 24 hours a day, seven days a week, for behavioral health issues and questions.

7 Medical services Emergency care: Immediately Urgent Care: Within 48 hours of your asking for an appointment Primary Care: Nonurgent Symptomatic Care: Within 10 Days of your asking for an appointment Routine, Nonsymptomatic Care: Within 45 Days of your asking for an appointment Specialty care: Nonurgent Symptomatic Care: Within 30 Days of your asking for an appointment Routine, Nonsymptomatic Care: Within 60 Days of your asking for an appointment Behavioral Health (mental health and/or substance abuse) services Emergency care: Immediately Urgent Care: Within 48 hours of your asking for an appointment Emergency Services Program (ESP): Immediately Other services: Within 14 calendar days of your asking for an appointment If you re having any difficulty getting an appointment with or seeing your Provider, please call us at , Monday through Friday, from 8 a.m. to 5 p.m. In an Emergency An Emergency is when you believe your life or health is in danger or would be if you don t get immediate care. If you believe that you are in a medical emergency situation, take immediate action: Call 911 or go to the nearest emergency room right away. For Behavioral Health Emergencies, call 911 or your local Emergency Services Program (ESP) Provider, or go to the nearest emergency room right away. ESPs provide behavioral health crisis assessment, intervention, and stabilization services 24 hours a day, seven days a week, 365 days a year. Please call us at or use the Find a Doctor, Hospital, or Pharmacy tool at Network-Health.org for a complete list of emergency rooms in Massachusetts. To find the closest ESP Provider to you, call the statewide directory of behavioral health ESPs in Massachusetts at Make sure to: Bring your Tufts Health Extend Member ID Card with you Tell your Primary Care Provider (PCP) and, if applicable, your Behavioral Health Provider about your Emergency within 48 hours in order to get any necessary follow-up care You don t need approval from your Provider to get emergency care. You can get emergency care 24 hours a day, seven days a week, wherever you are, even when you re traveling. We also cover emergency-related ambulance transportation and Post-stabilization Care Services, which are care to help you get better after an Emergency. A Provider will examine and treat your emergency health needs before sending you home or moving you to another Hospital, if necessary. Examples of medical Emergencies: Chest pain Bleeding that won t stop Broken bones Seizures or convulsions Dizziness or fainting Poisoning or drug overdose Serious accidents Sudden confusion Severe burns Severe headaches Shortness of breath Vomiting that won t stop Examples of Behavioral Health (mental health and/or substance abuse) Emergencies: Violent feelings toward yourself or others Hallucinations For Health Connector plan-related questions, please call the Health Connector s customer service center at (TTY: ), Monday through Friday, from 8 a.m. to 6 p.m. 7

8 Post-stabilization Care Services Post-stabilization Care Services include Inpatient Services, additional tests, or outpatient care that help you get better and maintain your health after an Emergency. Tufts Health Extend Members can get Post-stabilization Care Services at Hospitals and all health care centers that provide emergency services. Please call or use the Find a Doctor, Hospital, or Pharmacy tool at Network-Health.org for a complete list of emergency rooms in Massachusetts and ESP Providers in Massachusetts. You can also call the statewide directory of behavioral health ESPs at to find the closest ESP to you. Urgent Care situations An Urgent Care situation is when you have a health problem that needs attention right away but you don t believe you re having an Emergency. You may experience a health problem that is serious but doesn t put your life in danger or risk permanent damage to your health. Examples would be when you have flu-like symptoms that are getting worse or when you have a cough or cold that is not getting better. Your PCP or, if applicable, your Behavioral Health Provider can usually address these health problems. In urgent situations, call your PCP or Behavioral Health Provider. You can contact any of your Providers offices 24 hours a day, seven days a week. If appropriate, make an appointment to visit your Provider. Your Provider must see you within 48 hours of your request for an Urgent Care appointment. If your condition gets worse before your PCP or Behavioral Health Provider sees you, call 911 or go to the emergency room. If you have a behavioral health concern, you may also call your local ESP Provider. Hospital services If you need hospital services for something that isn t an Emergency, please ask your Provider to help you get these services. If you need hospital services for an Emergency, don t wait. Call 911 or go to the nearest emergency room right away. For Behavioral Health Emergencies, call 911 or your local Emergency Services Program (ESP) Provider, or go to the nearest emergency room right away. When you re away from home If you re traveling and need emergency care, go to the nearest emergency room. If you need Urgent Care, call your PCP s office and follow your Provider s directions. For other routine health care issues, call your PCP. For routine behavioral health issues, call your Behavioral Health Provider. If you re outside of Tufts Health Plan Network Health s Service Area, we ll only cover emergency care, Post-stabilization Care Services, or Urgent Care. We won t cover: Nonemergency tests or treatment that your PCP asked for but that you decided to get outside of our Service Area Routine or follow-up care that can wait until you return to our Service Area, such as physical exams, flu shots, stitch removal, and Behavioral Health counseling Care that you knew you were going to get before you left our Service Area, such as elective surgery A Provider may ask you to pay for care you get outside of Tufts Health Plan Network Health s Service Area at the time of service. If you re asked to pay for emergency care, Post-stabilization Care Services, or Urgent Care that you get outside of our Service Area, you should show your Tufts Health Extend Member ID Card. The Provider shouldn t ask you to pay. If you do pay for any of these services, you may ask us to reimburse you. You may also call our Member Services Team at for help with any bills that you may get from a Provider. Note: Dependents who are full-time out-of-state students between 18 and 26 years of age don t need Prior Authorization to see an Out-of-network provider for any Covered Service, except for nonemergency inpatient Hospital stays. 8 For any questions, please call Tufts Health Plan Network Health at (TTY: ). You can also visit us at Network-Health.org. We re also available 24 hours a day, seven days a week, for behavioral health issues and questions.

9 Tufts Health Plan Network Health Providers For the most up-to-date information about Providers, such as a Provider s address, phone number, hours of operation, handicap accessibility, and languages spoken, visit our website at Network-Health.org and use the Find a Doctor, Hospital, or Pharmacy tool. We list the following types of Providers: Primary care sites Primary Care Providers (PCPs) Hospitals Specialty Providers Behavioral Health (mental health and/or substance abuse)providers The listing also includes all Tufts Health Extend pharmacies, facilities, ancillary Providers, hospital emergency services, ESP Providers for Behavioral Health, and Durable Medical Equipment suppliers. You can also call our Member Services Team at , Monday through Friday, from 8 a.m. to 5 p.m., to get this information. Other types of information we can give you include information about a Provider s professional qualifications, the names of any medical or professional school(s) attended, where a residency or training took place, malpractice information, and, for doctors, their board certification status. Your Primary Care Provider (PCP) A PCP is the Provider who manages your care. You can choose a doctor or a nurse practitioner as your PCP. As a Tufts Health Extend Member, you and your Dependents must have a PCP. You can choose a different PCP for each Member. To find a Tufts Health Extend PCP and to find out where the PCP s office is located, use the Find a Doctor, Hospital, or Pharmacy tool at Network-Health.org. You can also call us at to help you find a PCP. Your PCP is the Provider you should call for any kind of health care need, unless you re having an Emergency. You can call your PCP s office 24 hours a day, seven days a week. If your PCP is not available, somebody else will be able to help you. If you have problems contacting your Provider or if you have any questions, please call our Member Services Team, Monday through Friday, from 8 a.m. to 5 p.m. We re also available 24 hours a day, seven days a week, for medical and behavioral health issues and questions at Your PCP can: Give you regular checkups and health screenings, including Behavioral Health screenings Make sure you get the health care you need Arrange necessary tests, laboratory procedures, or hospital visits Keep your medical records Recommend Specialists, when necessary Provide information on Covered Services that need Prior Authorization (permission) or Referrals before you get treatment Write prescriptions, when necessary Help you get Behavioral Health services, when necessary PCP assignment If you don t choose a PCP within 15 Days of joining Tufts Health Plan Network Health, we ll choose one we think is right for you. We ll also choose a PCP for you if the PCP you chose is not available. We ll send you a letter letting you know the name and contact information of the PCP that we have on file for you and any of your Dependents. Changing your PCP You can switch your PCP up to two times during a Benefit Year (July 1 December 31) for any reason. Just call us at or visit Network-Health.org. Once you change your PCP, you will get a PCP confirmation notice from us verifying the change was made. Getting care after office hours Talk to your PCP to find out about getting care after normal business hours. Some PCPs have longer office hours. If you need Urgent Care after regular business hours, call your PCP s office. PCPs have covering Providers who work after hours. If you have any problems seeing your PCP or any other Provider, please call us at , Monday through Friday, from 8 a.m. to 5 p.m. For Health Connector plan-related questions, please call the Health Connector s customer service center at (TTY: ), Monday through Friday, from 8 a.m. to 6 p.m. 9

10 You can also get free health support from our 24/7 NurseLine to help you stay healthy 24 hours a day, seven days a week. Call 888-MY-RN-LINE ( ), TTY: , anytime. You can get help in many languages. Remember, the 24/7 NurseLine doesn t replace your PCP. Specialists Specialists are Providers who have extra training and who focus on one kind of care or on one part of the body. Sometimes you may need to visit a Specialist, such as a cardiologist (heart doctor), dermatologist (skin doctor), or ophthalmologist (eye doctor), or, for Behavioral Health services, a psychologist, psychiatrist, or social worker. You can visit most Specialists without Prior Authorization as long as the Specialist is a Preferred In-network Specialist (although you may still need a referral from your PCP see the following section). To find a Tufts Health Extend Specialist, talk to your PCP. You can also call or visit Network-Health.org and use the Find a Doctor, Hospital, or Pharmacy tool to search for a Specialist. You should discuss your need to see a Specialist with your PCP first and then call the Specialist to make an appointment. If the Specialist your PCP wants to send you to is a Nonpreferred In-network Specialist or an Out-of-network Specialist, your PCP will need to ask us for Prior Authorization before sending you to see this Specialist. We may approve your PCP s request, deny the request, or ask your PCP to make a different Prior Authorization request. By using the Find a Doctor, Hospital, or Pharmacy tool at Network-Health.org, you can check to see which Providers need Prior Authorization, or you can call us at to get this information. Remember, if we don t give written approval for you to see a Nonpreferred In-network or Out-of-network Specialist, we won t cover the services. If you still choose to get the services, you ll be responsible for payment. For more information about Prior Authorization, please see page 12 in this Member Handbook. Referrals for specialty services Some Tufts Health Extend Members may need their PCPs to give them a Referral for certain specialty services. A Referral is a notification from your PCP to us that you can get care from a different Provider. A Referral is different from a Prior Authorization because it does not require our approval. The Referral helps your PCP better guide the care and services you get from the doctors you see. These services include: Professional services, like a visit to a Specialist Outpatient hospital visits Surgical day care Your first evaluation for: Speech Therapy Occupational therapy Physical therapy If your PCP needs to give a Referral for these services, your Member ID Card will say PCP Referral Required. You should not be billed for any of these services if you get them from an In-network Provider. You won t need PCP Referrals for any outpatient Behavioral Health, emergency care services, Post-stabilization Care Services, Tufts Health Extend contracted Family-planning Services Provider, or any OB/GYN services. Seeing an Out-of-network provider Your Provider must ask us for and get Prior Authorization before you see an Out-of-network provider. You may ask your Provider to ask for the Prior Authorization or call our Member Services Team at , Monday through Friday, from 8 a.m. to 5 p.m. You can see an Out-of-network provider if: A participating In-network Provider is unavailable because of location A delay in seeing a participating In-network Provider, other than a member-related delay, would result in interrupted access to Medically Necessary services There isn t a participating In-network Provider with the qualifications and expertise that you need to get and stay better 10 For any questions, please call Tufts Health Plan Network Health at (TTY: ). You can also visit us at Network-Health.org. We re also available 24 hours a day, seven days a week, for behavioral health issues and questions.

11 Note: Dependents who are full-time out-of-state students between 18 and 26 years of age don t need Prior Authorization to see an Out-of-network provider for any Covered Service, except for nonemergency inpatient Hospital stays. Communication between Providers It s a good idea for Providers to share information about your care with other Providers. When more than one Provider is involved in your care, the sharing helps them communicate and coordinate the services that you get, which leads to better quality of care. You must give Providers permission to share your information. Your doctor or therapist can talk with you more about which Provider(s) should receive the information, and answer any questions you have before getting your permission. Getting a second opinion Tufts Health Extend Members can get a second opinion from a different Provider about a medical or behavioral health (mental health and/or substance abuse)condition, or proposed treatment and care plan. You can get a second opinion about a medical issue or concern from an In-network Provider without Prior Authorization. If you want to get a second opinion about a behavioral health issue or concern, we may need to give Prior Authorization. You can see the most up-to-date list of our In-network Providers at Network-Health.org. Please call us at for help or for more information about picking a Provider to see for the second opinion. Continuity of Care New Members* If you are a new Tufts Health Plan Network Health Member, we ll make sure any care you are currently getting continues to go as smoothly as possible. To ensure Continuity of Care, we may be able to cover some health services, including Behavioral Health (mental health and/or substance abuse) services, from a provider who isn t part of our Network. If: You are in the second or third trimester of your pregnancy, you can keep seeing your current OB/GYN (even if Out-of-network) through delivery and a follow-up checkup within six weeks of delivery. Your second trimester begins at the start of the fourth month of pregnancy based on your expected delivery date You are getting ongoing covered treatment or management of chronic issues (like dialysis, home health, chemotherapy, and/or radiation), including previously authorized services or Covered Services, you can continue to get care for up to 30 days You are seeing your Primary Care Provider (PCP), you can continue to get care for up to 30 days You are terminally ill, you can continue to get care while you are sick Existing Members* If your PCP or another Provider is disenrolled from our Network for reasons not related to quality of care or Fraud, we ll make every effort to tell you at least 30 Days before the disenrollment, and we may be able to provide coverage. If: Your Provider is your PCP, for up to 31 Days; or up to 90 if the Provider, including a PCP, is actively treating a chronic or acute medical condition or until that Provider completes the active treatment, whichever comes first You are in the second or third trimester of your pregnancy, you can keep seeing your current OB/GYN (even if Out-of-network) through delivery and a follow-up checkup within six weeks of delivery. Your second trimester begins at the start of the fourth month of pregnancy based on your expected delivery date. You are terminally ill, you can continue to get care while you are sick * We will allow you to get continued treatment by an Out-of-network provider only if the provider agrees to our terms related to reimbursement, quality, Referrals, and additional Tufts Health Extend policies and procedures. For Health Connector plan-related questions, please call the Health Connector s customer service center at (TTY: ), Monday through Friday, from 8 a.m. to 6 p.m. 11

12 Prior Authorization Your Primary Care Provider (PCP) will work with your other Providers to make sure you get the care you need. For certain services, your PCP will need to ask us for Prior Authorization before sending you to get those services. For more information about which services need Prior Authorization, please see your Plan Type s Benefit and Co-payment Summary section starting on page 45 of this Member Handbook. Preferred In-network Providers are Providers you can see without your PCP or other Providers asking for Prior Authorization. Nonpreferred In-network Providers and Out-ofnetwork providers need Prior Authorization from us before you can see them. Your PCP will ask us for Prior Authorization when you need a service or need to get care from a Provider or at a location that requires prior approval. For these requests, we ll decide if the service is Medically Necessary and if we have a qualified In-network Provider who can provide the service instead. If we don t have an In-network Provider who can treat your health condition, we ll authorize an Out-of-network provider for you. For the most up-to-date listing of our In-network Providers, visit Network-Health.org. You don t need Prior Authorization for emergency health care, Post-stabilization Care Services, Family-planning Services, and the first 12 in-network outpatient Behavioral Health (mental health and/or substance abuse) or medical specialty (e.g., orthopedist, neurologist, oncologist) visits. You can get emergency services from any emergency care provider and Family-planning Services from any Tufts Health Extend-contracted Family-planning Services Provider. If you become a Tufts Health Plan Network Health Member by changing from another health plan, and you had already begun treatment (such as ongoing maternity care) with a provider who does not contract with us, we ll review that treatment and may approve your continued treatment by the same provider. Please see the section Continuity of Care earlier on page 11. Note: Dependents who are full-time out-of-state students between 18 and 26 years of age don t need Prior Authorization to see an Out-of-network provider for any Covered Service, except for nonemergency inpatient Hospital stays. Standard Prior Authorizations We ll make an initial decision about a Prior Authorization within two business days of obtaining all needed information. We ll let your Provider requesting the services know within 24 hours of our decision. We ll let you know in writing of our decision within one business day if we deny Authorization, and within two business days if we approve Authorization. If we don t give Prior Authorization before you see a Provider or have a procedure that requires one, you may be responsible for paying for the services you get. Concurrent review A concurrent review is a review we do when you re in a Hospital, during an inpatient stay or while you re getting treated, to decide what you should do next. We make concurrent review decisions within one business day of getting all necessary information from your Provider. Necessary information includes the results of any face-to-face clinical evaluation or second opinion. If we approve a longer stay or extra services, we ll let your Provider know within one business day and send written or electronic confirmation to you and your Provider within one business day thereafter. The notification will include the number of extended calendar days or the next review date, the new total number of calendar days or services we ve approved, and the date of admission or start of services. If we deny a longer stay or additional services, we ll let your Provider know within one business day and send written or electronic confirmation of this Adverse Determination to you and your Provider within one business day thereafter. You can continue getting the service at no cost to you until we let you know of our concurrent review decision. 12 For any questions, please call Tufts Health Plan Network Health at (TTY: ). You can also visit us at Network-Health.org. We re also available 24 hours a day, seven days a week, for behavioral health issues and questions.

13 Prior Authorization approvals and denials Once we review the request for services, we ll tell your Provider and/or you or your Authorized Representative, if you identify one, our decision. If we authorize the services, we ll send your Provider an authorization letter that will state the services we agree to cover. The Provider giving the services must have this authorization letter before you can get any services requiring an Authorization. Your Provider will ask us for additional Authorization if you need any services beyond what we authorized. If we approve the request for additional services, we ll send your Provider another authorization letter. If we don t authorize any of the services requested, authorize only some of the services requested, or don t authorize the full amount, duration, or scope of services requested, we ll send you, your Authorized Representative, and your Provider a denial letter. We won t pay for any unauthorized services. We ll also send you, your Authorized Representative, and your Provider a notice if we decide to reduce, put off, or stop providing previously authorized services. If you disagree with any of these decisions, you can request a Standard Internal Appeal. For details on requesting a Standard Internal Appeal, please see the How to resolve concerns with Tufts Health Plan Network Health section on page 33. Adverse Determination An Adverse Determination is when we decide not to authorize a service. Written notice of an Adverse Determination We ll tell you in writing of an Adverse Determination and include a clinical explanation for our decision. We will: Identify specific information we used Discuss your symptoms or condition, diagnosis, and the specific reasons why the evidence your Provider sent us fails to meet the relevant medical review criteria Specify alternate treatment options that we do cover Reference and include applicable clinical practice guidelines and review criteria Tell you or your Authorized Representative how to request a Standard Internal Appeal or an Expedited Internal Appeal Reconsideration of an Adverse Determination We ll give the Provider treating you the chance to ask us to reconsider an Adverse Determination involving an initial determination or a concurrent review. The reconsideration process will occur within one business day of our getting the request. A clinical reviewer will conduct the reconsideration and talk to your Provider. If we don t reverse our Adverse Determination, you or your Authorized Representative or your Provider may use the appeals process described starting on page 34. You don t have to ask us to reconsider an Adverse Determination before requesting a Standard Internal Appeal or Expedited Internal Appeal. Premiums Some Tufts Health Extend Plan Types require you to pay a Premium for you and any of your Dependents health insurance coverage. A Premium is a weekly amount you pay the Health Connector to get your plan benefits. This amount is deducted directly from your weekly unemployment benefit check for you and any of your Dependents. If the Premium isn t deducted directly from your check, then the Health Connector will invoice you for the amount owed. We are not responsible for paying the Health Connector any Premiums that you owe. Please note, children 19 years of age and under, disabled individuals, and pregnant women are exempt from paying Premiums. You may apply for a hardship waiver if you can t afford to pay your share of the premium amount. To qualify for this waiver, you must meet certain income requirements. To learn more, contact the Health Connector at (TTY: ), Monday through Friday, from 8 a.m. to 6 p.m. Co-payments You re responsible for paying all of the Co-payments listed in your Plan Type s Benefit and Co-payment Summary starting on page 45 of this Member Handbook. If you can t afford the Co-payment when you get a service, tell your Provider. You should never go without care you need because you can t afford the Co-payment. For Health Connector plan-related questions, please call the Health Connector s customer service center at (TTY: ), Monday through Friday, from 8 a.m. to 6 p.m. 13

14 If you don t pay the Co-payment at the time of your visit, you ll still owe the money to the Provider. The Provider may use a legal method to collect the money from you. We are not responsible for paying the Provider the Co-payment that you owe. American Indians and Alaskan Natives do not need to pay Co-payments for services received through the Indian Health Service. American Indians and Alaskan Natives who make less than 300% of the Federal Poverty Level never pay Co-payments regardless of where a service is received. Medical Co-payments (Plan Type II and III Members only) A Medical Co-payment is a fixed amount you may have to pay for Covered Services other than pharmacy services. You will need to pay a Co-payment for Covered Services, such as doctors visits, high-cost imaging (MRIs, PET, CT scans), emergency room visits, and care you get in the Hospital. These services that require Co-payments count toward your yearly Medical Co-payment Cap. Once you ve been charged the maximum in Medical Co-payments in a Benefit Year (January 1 December 31), you no longer have to pay Medical Co-payments until the next Benefit Year. This is called a Medical Co-payment Cap. We ll send you a letter telling you that you reached your Medical Co-payment Cap and that you don t have to pay any more Medical Co-payments until the beginning of the next Benefit Year. Co-payment Caps are listed in your Plan Type s Benefit and Co-payment Summary starting on page 45 of this Member Handbook. You can t be charged additional Medical Co-payments for the rest of the year unless your Tufts Health Extend Plan Type changes from Plan Type II to Plan Type III. If your Plan Type changes, you will have to start making Medical Co-payments again, even if you had reached your Medical Co-payment Cap in your previous Plan Type. We ll apply the Medical Co-payments you ve already paid to your new Plan Type s Medical Co-payment Cap amount. Pharmacy Co-payments (Plan Type I, II, and III Members) A Pharmacy Co-payment is a fixed amount you must pay for a covered pharmacy service. There is a yearly Co-payment Cap (or limit on what you will be charged) for pharmacy services. Please see your Plan Type s Benefit and Co-payment Summary starting on page 45 of this Member Handbook for your specific Plan Type Co-payments and Co-payment Caps. Once you ve been charged the maximum in Pharmacy Co-payments in a Benefit Year (January 1 December 31), you no longer have to pay Pharmacy Co-payments until the next Benefit Year. This is called a Pharmacy Co-payment Cap. We ll send you a letter telling you that you reached your Pharmacy Co-payment Cap and that you don t have to pay any more Pharmacy Co-payments until the beginning of the next Benefit Year. You can t be charged additional Pharmacy Co-payments for the rest of the year unless your Tufts Health Extend Plan Type changes. If your Plan Type changes, you may have to start making Pharmacy Co-payments again, even if you had reached your Pharmacy Co-payment Cap. We ll apply the Pharmacy Co-payments you have already paid to your new Plan Type s Pharmacy Co-payment Cap amount. Please note: Tufts Health Extend Members who are or become pregnant are excluded from paying Pharmacy Co-payments during the duration of their pregnancy. You will first need to notify the Health Connector at , and us by calling Be sure to tell your pharmacist that you are excluded from paying Co-payments when you drop off your prescriptions. Covered Services We cover the Medically Necessary Covered Services listed in this handbook. Services or service categories not specifically listed as covered are not covered under this agreement. The following section lists services we cover for Tufts Health Extend Members. We ll authorize, arrange, coordinate, and provide to Members all Medically Necessary Covered Services. The Covered Services for each of the Plan Types are listed in the Benefit and Co-payment Summary section starting on page 45 of this Member Handbook. Check the summary 14 For any questions, please call Tufts Health Plan Network Health at (TTY: ). You can also visit us at Network-Health.org. We re also available 24 hours a day, seven days a week, for behavioral health issues and questions.

15 for your Plan Type and for a list of services covered and other limitations, including Prior Authorization requirements for Tufts Health Extend Members. If you have any questions, call us at We can give you more information about any of these Covered Services. Covered Services are only covered if they are Medically Necessary. Medically Necessary services are those Covered Services that we determine consistent with generally accepted principles of medical practice, meaning that they re the least intensive and most cost-effective available, and are: The most appropriate available supply or service for you based on potential benefits and harm to you Known to be effective in improving health outcomes based on scientific evidence, professional standards, and expert opinion In addition to any limitations in the Benefit and Co-payment Summary, we may limit, or require Prior Authorization for, Covered Services on the basis of Medical Necessity. Services we cover Preventive Care services for adults age 21 and older You should visit your Primary Care Provider (PCP) for Preventive Care, also known as Nonsymptomatic Care. Examples of covered Preventive Care for adults age 21 and older include: Checkups: every one to three years Blood pressure checks: at least every two years Cholesterol screening: every five years Pelvic exams and Pap smears (for women): the first Pap test and pelvic exam should happen three years after first sexual intercourse or by age 21 and continue every one to three years depending on risk factors Breast cancer screening (mammogram for women): every year after turning 40 Colorectal cancer screening: every 10 years, starting at age 50 Flu shot: every year Eye exams: once every 24 months Preventive Care and well-child care for all children It s important for children, teens, and young adults to see their PCP for regular checkups so they can stay healthy. Children who are under age 21 should see their PCP for checkups at least once every year, even if they are well. As part of a well-child checkup, your child s PCP will check your child s development, health, vision, dental health, hearing, behavioral health (mental health and/or substance abuse), and need for immunizations. We pay your child s PCP for well-child checkups, so make sure to schedule them. It is at these checkups that your child s PCP can find and treat small problems before they become big ones. The following are the ages to take a child for full physical exams and screenings: At one to two weeks At one month At two months At four months At six months At nine months At 12 months At 15 months At 18 months At ages 2 through 20, children should visit their PCP once a year Children should also visit their PCP any time you are concerned about a medical, emotional, or behavioral health need, even if it is not time for a regular checkup. Outpatient medical care Abortion services We cover abortion services you get from a Tufts Health Extend Provider. We must give Prior Authorization for an abortion from a provider who does not participate in our Network, unless the service is provided for a full-time out-of-state dependent student between 18 and 26 years of age. For Health Connector plan-related questions, please call the Health Connector s customer service center at (TTY: ), Monday through Friday, from 8 a.m. to 6 p.m. 15

16 Community health center visits and office visits We cover community health center and office visits to Tufts Health Extend Providers for Primary Care or for specialty services. We must give Prior Authorization for office visits to all Out-of-network providers and Nonpreferred In-network Providers, unless the service is provided for a full-time out-of-state dependent student between 18 and 26 years of age. Call us at to find out more. We cover community health center and office visits with/for: Your PCP Specialists Eye care (vision care) Outpatient surgery We cover surgical procedures performed in an outpatient surgical center or hospital operating room. Laboratory services We cover laboratory services (including blood tests, urinalyses, Pap smears, and throat cultures) that your Provider orders to diagnose, treat, and prevent disease and to maintain your health. Radiology services We cover radiology services, including X-rays, mammography, MRIs, PET, and CT scans. Some of these services MRIs, MRAs, CT scans, outpatient nuclear cardiology, and PET require Prior Authorization for In-network and Out-of-network providers. Call us at for more information. Inpatient medical care We cover 24-hour inpatient medical services delivered in a licensed hospital setting with Prior Authorization. Inpatient Behavioral Health (mental health and/or substance abuse) services We cover Medically Necessary 24-hour clinical intervention services for mental health and/or substance abuse diagnoses delivered in a licensed hospital setting. Outpatient Behavioral Health (mental health and/or substance abuse) services We cover Medically Necessary mental health and/or substance abuse services provided in a face-to-face encounter in an ambulatory care setting, including: Individual, group, and family counseling Medication visits Community crisis counseling Family and case consultation Diagnostic evaluation Psychological testing Narcotic treatment services Electroconvulsive therapy Rehabilitation services We must give Authorization for inpatient rehabilitation services. Cardiac rehabilitation We cover outpatient cardiac rehabilitation when Medically Necessary. Cardiac rehabilitation is the multidisciplinary treatment of people with documented cardiovascular disease. Home health care We cover certain home health services, including: Durable Medical Equipment Part-time or intermittent skilled nursing care Physical, occupational, and speech therapy Part-time or intermittent home health aide services Inpatient Skilled Nursing Facility We cover daily skilled nursing care in an inpatient setting for a maximum of 100 Days per Benefit Year (July 1 December 31) at a Skilled Nursing Facility when Medically Necessary and with Prior Authorization. The maximum number of days is in combination with inpatient rehabilitation hospital days. See next section. 16 For any questions, please call Tufts Health Plan Network Health at (TTY: ). You can also visit us at Network-Health.org. We re also available 24 hours a day, seven days a week, for behavioral health issues and questions.

17 Inpatient Rehabilitation Hospital We cover daily rehabilitative services provided in an inpatient setting for a maximum of 100 Days per Benefit Year (January 1 December 31) at an inpatient Rehabilitation Hospital when Medically Necessary and with Prior Authorization. The maximum number of Days is in combination with Days at a Skilled Nursing Facility. See previous section. Short-term outpatient rehabilitation physical, speech, and occupational therapy We provide physical and occupational therapy coverage, with Prior Authorization, or in some cases Referrals, for evaluation and restorative short-term treatment you need to attain your highest level of independent functioning. Care is provided in the timeliest manner possible and when we determine that the therapy will result in significant, sustained measurable improvement of your condition. We also cover the diagnosis and treatment of speech, hearing, and language disorders when you get services from a registered therapist as part of a formal treatment plan for speech loss or impairment. In some cases, your PCP may need to give a Referral. We must give Prior Authorization for all rehabilitation therapy services, including ongoing treatment plans (maximum combined 20-visit limit for physical, occupational, and speech therapy unless we give Prior Authorization). Other benefits Durable Medical Euipment (DME) We cover certain DME. Coverage includes but is not limited to the rental or purchase of medical equipment, some replacement parts, and repairs, with Prior Authorization. Emergency transportation We cover ground ambulance services in an Emergency. We cover nonemergency ambulance transportation only when Medically Necessary and when we give Prior Authorization. We don t cover transportation to and from medical appointments. We cover Hospital-to-Hospital transfers, which don t need Prior Authorization. We don t cover emergency transportation by air without Prior Authorization. Family-planning Services We cover Family-planning Services. These services include family-planning medical and counseling services, follow-up health care, and education. Hospice We cover hospice care for terminally ill Members who agree with their Providers not to continue a curative treatment program. We cover a package of services, including nursing; medical and social services; provider care; counseling (for example, bereavement, dietary, spiritual); physical, occupational, and speech language therapies; homemaker/ home health aide services; medical supplies; drugs; biological supplies; short-term inpatient care services; and institutional care services. The 100-calendar-day limitation pertaining to care at a Skilled Nursing Facility and a Rehabilitation Hospital described on your Plan Type s Benefit and Co payment Summary does not apply to hospice services. Nutritional counseling We cover nutritional counseling when Medically Necessary. Organ transplant We cover human organ transplants, with Prior Authorization. Transplants must be nonexperimental surgical procedures provided within the Tufts Health Plan Network Health Provider Network. Coverage includes living and cadaver donors costs. We don t cover donor charges for Members who donate organs to nonmembers or recipients of transplants who aren t Tufts Health Plan Network Health members. We don t cover personal searches for solid organs or stem cell donation outside the organ bank. Orthotics We provide coverage for nondental braces and other mechanical or molded devices when Medically Necessary. We cover shoe inserts only for Members who have diabetes with Prior Authorization. For Health Connector plan-related questions, please call the Health Connector s customer service center at (TTY: ), Monday through Friday, from 8 a.m. to 6 p.m. 17

18 Oxygen and respiratory therapy equipment services We cover oxygen and respiratory therapy equipment, including ambulatory liquid oxygen systems and refills, aspirators, compressor-driven nebulizers, intermittent positive pressure breathers, oxygen, oxygen gas, oxygen generating devices, and oxygen-therapy equipment rental, with Prior Authorization. Podiatry We cover Medically Necessary nonroutine podiatry services for Members when a licensed in-network podiatrist performs the service. We cover routine foot care only for Members who have diabetes. Prenatal care We provide inpatient and outpatient maternity benefits with precertification of the pregnancy by a Tufts Health Extend Provider. If you re pregnant, call Tufts Health Plan Network Health and the Health Connector as soon as your pregnancy is confirmed to be sure you get the best care for you and your baby. Prosthetics We cover certain prosthetic devices, including evaluation, fabrication, fitting, and the provision of the prosthesis, with Prior Authorization. Supplies We cover prescribed, Medically Necessary disposable medical supplies used to treat a specific medical condition, with Prior Authorization. Vision care We cover routine eye exams for Members once every 24 months from ophthalmologists or optometrists who are part of our Network. We also cover one pair of eyeglasses once every 24 months. You can choose from the free frame selection, or, if you choose any other frame, we pay up to a maximum credit of $80 and you pay the difference. For all Plan Types, Members with diabetes are eligible for and encouraged to get yearly vision exams. If you get a bill for a Covered Service You shouldn t get a bill for any Covered Services unless you obtained nonemergency services from an Out-of network provider or Nonpreferred In-network Provider without Prior Authorization (this excludes Dependents between 18 and 26 years of age who are full-time, out-of-state students please see the section Prior Authorization on page 12 for more information). However, you may get a bill for Co-payments for some Covered Services. You will not be held responsible for paying for services that were not provided, including missed appointments. If you get a bill that you believe is a mistake, don t pay it, and call us at We can help. Services not covered Acupuncture (except to treat substance abuse) Biofeedback Chiropractic services Cosmetic services and procedures, unless required to restore bodily function or correct a functional physical impairment after an accidental injury, prior surgical procedure, or congenital/birth defect. (Prior Authorization is required. No benefits are provided solely for the purpose of making you look better, whether or not these services are meant to make you feel better about yourself or treat a mental condition.) Custodial care Diagnosis and treatment for infertility, including in-vitro fertilization and gamete intrafallopian transfer (GIFT) procedure Some types of Durable Medical Equipment (DME): Elevators Back-up equipment Whirlpool equipment, used for soothing/comfort Hospital-type beds requiring installation in a home Hygienic equipment that does not serve a primary medical purpose Nonmedical equipment otherwise available to Members that does not serve a primary medical purpose Bed lifters, not primarily medical Nonhospital beds and mattresses Hospital-type beds in full, queen, and king sizes 18 For any questions, please call Tufts Health Plan Network Health at (TTY: ). You can also visit us at Network-Health.org. We re also available 24 hours a day, seven days a week, for behavioral health issues and questions.

19 Cushions, pads, and pillows, except when Medically Necessary and we give Prior Authorization Pulse tachometers Educational testing and evaluations Exams a third party requires (e.g., physical, psychiatric, and psychological examinations or testing a third party such as an employer, court, or school requires) Experimental or investigational treatment Routine podiatry/foot care, except as noted on page 18 Gender reassignment surgery and any services, drugs, or supplies related to such surgery Hearing aids Laser eyesight correction or any other eye surgery to treat a condition that another treatment besides surgery can correct Out-of-network providers, unless we give Prior Authorization (except emergency services, which never need Prior Authorization)* Services from Nonpreferred In-network Providers, unless we give Prior Authorization (except emergency services, which never need Prior Authorization)* Personal comfort items, including air conditioners, air purifiers, chair lifts, dehumidifiers, radios, telephones, and televisions Reversal of voluntary sterilization Any service or supply that is not Medically Necessary A Provider s charge for shipping and handling, or copying of records Medications, devices, treatments, and procedures that have not been demonstrated to be medically effective Routine care, including routine prenatal care, when you re outside our Service Area* Services for which there would be no charge in the absence of insurance Special equipment you need for sports or job purposes Any dental services, except emergency dental care and oral surgery by a Provider as a result of an injury, accident, or other condition A service or supply, which is not covered by or at the direction of a Tufts Health Extend Provider, except for emergency services Gym or health club memberships Replacement of DME or prosthetics due to loss, intentional damage, or negligence Services for which we did not give required Prior Authorization * Dependents who are full-time out-of-state students between 18 and 26 years of age don t need Prior Authorization to see an Out-of-network provider for any Covered Service, except for nonemergency inpatient Hospital stays. Covered medications and pharmacy Pharmacy program We aim to provide high-quality, cost-effective options for drug therapy. We work with your Providers and pharmacists to make sure we cover the most important and useful drugs for a variety of conditions and diseases. We cover first-time prescriptions and refills. We also cover some over-the-counter (OTC) drugs if your doctor writes a prescription and it is filled at a pharmacy. Our pharmacy program doesn t cover all drugs and prescriptions. Some drugs must meet certain clinical guidelines before we can cover them. Your Provider must ask us for Prior Authorization before we ll cover one of these drugs. Please see the section Prior Authorization for drugs below for more information. Prior Authorization for drugs Some drugs always require Prior Authorization, which means your Provider must ask us for approval before we ll cover the drug. One of our clinicians will review this request. We ll cover the drug according to our clinical guidelines if: There is a medical reason you need the particular drug Depending on the drug, other drugs on the Preferred Drug List (PDL) have not worked If we don t approve the request for Prior Authorization, you or your Authorized Representative, if you identify one, can appeal the decision. For more information, please see the Grievances and Appeals sections starting on page 33. If you want more information about our pharmacy program, visit Network-Health.org or call us at For Health Connector plan-related questions, please call the Health Connector s customer service center at (TTY: ), Monday through Friday, from 8 a.m. to 6 p.m. 19

20 Preferred Drug List We use a Preferred Drug List (PDL) as our list of covered drugs. We update the PDL every three months. The PDL applies only to drugs you get at retail, mail-order, and specialty pharmacies, if covered under your Plan Type. The PDL doesn t apply to drugs you get if you re in the Hospital. For the most current PDL, call or visit Network-Health.org. Exclusions We don t cover certain drugs. If it is Medically Necessary for you to take a drug that we don t cover, your Provider must ask us for and get Prior Authorization before we ll cover the drug. One of our clinicians will review the request. If we don t approve the request for Prior Authorization, you or your Authorized Representative can appeal the decision. For more information, please see the Grievances and Appeals sections starting on page 33. If you want more information about our pharmacy program, call or visit Network-Health.org. We don t cover: Any drug products used for cosmetic purposes Contraceptive implants* Experimental and/or investigational drugs Immunization agents administered or dispensed at a pharmacy, except for the influenza virus vaccine for Members who are at least 18 years old, when given by a pharmacist between September 15 and March 31 at a participating pharmacy* Infertility agents Medical supplies* Mifepristone (Mifeprex)* Any drugs related to gender reassignment surgery, specifically including, but not limited to, presurgery and postsurgery hormone therapy * May be covered as a nonpharmacy benefit. Generic drugs Generic drugs have the same active ingredients and work the same as brand-name drugs. When generic drugs are available, we won t cover the brand-name drug without giving Prior Authorization. If you and your Provider feel a generic drug is not right for treating your health condition and that a brand-name drug is Medically Necessary, your Provider can ask us for Prior Authorization. One of our clinicians will then review the request. Please see the section Prior Authorization for drugs on page 19 for more information. If we don t approve the request for Prior Authorization, you or your Authorized Representative can appeal the decision. For more information, please see the Grievances and Appeals sections starting on page 33. If you want more information about our pharmacy program, visit Network-Health.org or call us at New-to-market drugs We review new drugs for safety and effectiveness before we add them to our Preferred Drug List (PDL). A Provider who feels a new-to-market drug is Medically Necessary for you before we ve reviewed it can submit a request for Prior Authorization. One of our clinicians will review this request. If we approve the request, we ll cover the drug according to our clinical guidelines. If we don t approve, you or your Authorized Representative can appeal the decision. For more information, please see the Grievances and Appeals sections starting on page 33. Quantity limits To make sure the drugs you take are safe and that you are getting the right amount, we may limit how much you can get at one time. Your Provider can ask us for Prior Authorization if you need more than we cover. One of our clinicians will review the request. We ll cover the drug according to our clinical guidelines if there is a medical reason you need this particular amount. If we don t approve the request for Prior Authorization, you or your Authorized Representative can appeal the decision. To learn more about appealing our decision, please see the Grievances and Appeals sections starting on page 33. If you want more information, visit Network-Health.org or call us at For any questions, please call Tufts Health Plan Network Health at (TTY: ). You can also visit us at Network-Health.org. We re also available 24 hours a day, seven days a week, for behavioral health issues and questions.

21 Step therapy program Step therapy means that before we pay for a certain second-level drug, you have to first try first-level drugs of that type. We cover some types of drugs only through our step therapy program. Our step therapy program requires you to try first-level drugs before we ll cover another drug of that type. If you and your Provider feel a certain drug isn t appropriate for treating your health condition, your Provider can ask us for Prior Authorization for the other drug. One of our clinicians will review the request and we ll cover the drug according to our clinical guidelines. Please see the section Prior Authorization for drugs on page 19 for more information. Specialty pharmacy program A specialty pharmacy may need to supply you with some drugs, such as injectable and intravenous (IV) drugs often used to treat chronic conditions like hepatitis C or multiple sclerosis. These types of drugs need additional expertise and support. Specialty pharmacies have knowledge in these areas. These pharmacies can give extra support to Members and Providers. CVS/caremark is our specialty pharmacy and it can provide you with these drugs. In addition to providing specific specialty drugs, CVS/caremark will: Deliver drugs to your home, Provider s office, or any delivery address you choose (except for a P.O. box) Answer your questions and offer help with your drugs Give you information, materials, and ongoing support to help you manage your health condition and take your drugs the right way Have staff pharmacists who can help you 24 hours a day, seven days a week Visit Network-Health.org for a list of drugs that CVS/caremark provides. These drugs aren t available at retail or mail-order pharmacies. Quality Management We are committed to delivering quality care that enables you to stay healthy, get better, or, if necessary, live with illness or disability. Our program is consistent with the Foundation for Accountability (FACCT) and the Institute of Medicine priority areas. Quality care refers to: Clinical quality Access to and utilization of care Coordination of care Member experience with care We conduct a yearly survey to evaluate your satisfaction with access to specialist services; Ancillary Services like lab tests, hospitalization services, Durable Medical Equipment (DME); and other Covered Services. If you have a concern about the quality of care you get from a Tufts Health Plan Network Health Provider or the services we provide, call us at Utilization Management Utilization Management (UM) is how we make sure you get the right care and services in the right place. We base all UM decisions on how appropriate the care is and your coverage. We don t reward Providers, UM clinical staff, or consultants for denying care. We don t offer Providers, UM clinical staff, or consultants any money or financial incentive that could discourage them from making a service available to you. If you have questions about UM or want more information on how we determine the care we authorize, please call us at (TTY: ), Monday through Friday, from 8 a.m. to 5 p.m. We can also give you information in different languages. We offer translation services in 200 languages free to Members, Monday through Friday, from 8 a.m. to 5 p.m. For Health Connector plan-related questions, please call the Health Connector s customer service center at (TTY: ), Monday through Friday, from 8 a.m. to 6 p.m. 21

22 Experimental and/or investigational drugs and procedures Experimental and/or investigational drugs and procedures are new kinds of treatment. We decide whether to cover new drugs and procedures based on scientific evidence and what doctors and other clinicians recommend. As new technologies come up, we have a process to consider whether or not to cover new (experimental) procedures, including clinical trials. Before we decide to cover new procedures, equipment, and prescription drugs, we look at how safe they are and how well these treatments work. Our medical management team, which our chief medical officer leads, makes all decisions on whether or not we cover experimental and/or investigational procedures, including clinical trials. If you have questions about our pharmacy program or benefits, please call us at Care Management Care Management is everything we do to help keep you well and improve your health. Our care management services include helping you make and keep appointments, getting you health information, and coordinating your care with your Providers. There are four types of Care Management: health and wellness support, disease management, care coordination (transition of care and Behavioral Health [mental health and/or substance abuse] services), and integrated care management, which includes complex care management and intensive clinical management (ICM). Care Management doesn t replace the care you get from your Primary Care Provider (PCP) or other Providers but helps support it. Please remember to continue to schedule regular and ongoing visits with your Providers. Our care managers work with your Providers to coordinate your care and make sure you get the care you need when you need it. To help us do this, be sure to return the Your Health Form we send you. Call us at , Monday through Friday, from 8 a.m. to 5 p.m., to speak to a member of our care management team or to talk to someone on our on-call service during nights and on the weekends. One of our care managers can help you fill out the form over the phone. Health and wellness support Health coaching We understand how important it is for you to feel in control of your health. Learning to take control of your health when you have a chronic health problem (such as diabetes or asthma) can feel overwhelming. Our free health coaching can help you feel good about the health care decisions you re making. Visit us at Network-Health.org or call our 24/7 NurseLine at 888-MY-RN-LINE ( ) to find out about personalized health coaching services. Our health coaches are specially trained health professionals available Monday through Saturday, from 8 a.m. to 9 p.m., to talk to you about your immediate or everyday health concerns. Health library Our online health library has valuable health information for you to access when it s convenient for you. We have easy-to-understand articles on thousands of health topics for you at Network-Health.org. Maternal and child health program We work closely with you and your Providers to make sure you get ongoing prenatal care if you re pregnant. We can also help coordinate care you need after you deliver, like the Visiting Nurse Association (VNA) or programs like the Early Intervention Partnership Program, if you qualify. For information about the benefits and services we offer pregnant Tufts Health Extend Members, see page /7 NurseLine We have a 24/7 NurseLine for help with your health questions, seven days a week. When you call 888-MY-RN-LINE ( ), you can talk with a caring and supportive health care professional at any hour and at no cost. Our 24/7 NurseLine is staffed by licensed health professionals. Staff can give you information and support on health care issues like symptoms, diagnoses, treatments, tests, test results, and procedures your Provider orders. Staff don t give medical advice. They aren t a replacement for your Provider. 22 For any questions, please call Tufts Health Plan Network Health at (TTY: ). You can also visit us at Network-Health.org. We re also available 24 hours a day, seven days a week, for behavioral health issues and questions.

23 Disease management programs We want to help you get the best health care possible. We use evidence-based practice guidelines (guidelines based on the best research) as a clinical basis for our disease management programs. These programs help you live as healthfully as possible and to feel your best. We have staff who are experts on many health topics, so we can connect you with information and community resources you can really use. For more information, please visit Network-Health.org or call us at We have disease management programs for the following conditions: Asthma There s a lot we can do to help keep asthma from keeping you down. Working with your Provider, we can help you avoid trips to the emergency room and live life to its fullest. With our free in-home asthma education program, we can even send a nurse to your home to help you get started. With the program, a visiting nurse can give you information and tools to help you understand asthma and its causes, triggers, and symptoms. A visiting nurse can also help you learn how to spot the warning signs of a flare-up (attack) before it happens, look for problems in your home that may make your asthma worse, talk with you about an asthma action plan, and take other steps to make sure you get any other services you might need. We stay in touch with our Members who have asthma. We may send you helpful information, such as information about controller and rescue medications and their appropriate use, to help you better manage your asthma. If you have asthma or think you have asthma, please contact our asthma program manager today at For more information about the benefits and services we offer our Members who have asthma, please see page 30. Diabetes Our diabetes program has staff members available to help you manage type 1, type 2, and gestational (when you re pregnant) diabetes. Diabetes supplies and lab work are Covered Services, including hemoglobin A1c and lipids tests and yearly dilated eye exams. One of our clinicians can arrange your health care with your PCP and any Specialists you may need to see. You also can use our behavioral health and social care management programs. If you need it, you can also take American Diabetes Association-approved diabetes classes. We stay in touch with our Members with diabetes. We may send you helpful information, such as notices that you need to have certain tests done and information on how you can better manage diabetes. Additionally, we may call to remind you about yearly lab work and PCP appointments. We also offer, when appropriate, diabetes education if you re homebound. We work with Neighborhood Diabetes, an approved vendor for diabetic supplies, and their representatives can: Give you a free meter Visit you at home and teach you about using your meter Teach you less painful ways to test your blood Teach you about regular foot and eye care Teach you healthy eating habits Deliver supplies to your home for free Make sure you always have testing supplies when you need them If you want to learn more, please call Neighborhood Diabetes at This program is free to Tufts Health Plan Network Health Members. For more information about the benefits and services we offer our Members who have diabetes, please see page 30. HIV/AIDS To support your care, we can help you identify and remove social barriers to appropriate care. We can also identify services that will benefit you. Help with quitting smoking Tufts Health Extend Members can get medications from their doctor and counseling to help quit smoking from the Massachusetts Tobacco Cessation & Prevention Program. For more information about quitting smoking, talk to your PCP. For free counseling over the phone, call our 24/7 NurseLine at 888-MY-RN-LINE ( ). For Health Connector plan-related questions, please call the Health Connector s customer service center at (TTY: ), Monday through Friday, from 8 a.m. to 6 p.m. 23

24 Care coordination Transition of care When you leave a 24-hour care facility (like a Skilled Nursing Facility, transitional care unit, Rehabilitation Hospital, or acute-care Hospital), our care managers will help you with a transition plan to make sure you get the care you need to keep getting better. Our care managers will work with ancillary Providers (like a Visiting Nurse Association and Durable Medical Equipment Providers) to make sure you get the services you need when you need them. Transition of care services also include: Teaching you about your condition and medication Teaching you about managing your disease and its stages, if necessary Giving you individual and integrated care Developing a plan to help you get and use the services you need Improving your overall health Your Provider can ask us to give you transition of care services by calling us at or visiting Network-Health.org. Behavioral Health (mental health and/or substance abuse) services We have different levels of Behavioral Health services, based on your need, what type and how many services you need, and/or any medical condition you may have. You can find a complete list of these services (including inpatient, outpatient, substance abuse disorder services, and diversionary services) in the Benefit and Co-payment Summary starting on page 45 of this Member Handbook. You don t need Prior Authorization for the first 12 In-network outpatient Behavioral Health or medical specialty visits each Benefit Year (January 1 December 31). You can find a list of Behavioral Health Providers at Network-Health.org. Tufts Health Plan Network Health s Behavioral Health care managers are licensed clinicians who can help you by: Monitoring your treatment Reviewing your need for ongoing care Participating with your health care team on discharge planning Giving you information about community-based services Together we can help make sure you get the best care. We ll work with you to help: Continue to improve you and your family s health Make sure you have timely and easy access to the appropriate level of Behavioral Health care Involve you in your treatment planning and recovery Make sure your care continues smoothly if you change Providers or plans Coordinate your care among your Providers If you need help finding a Behavioral Health Provider, please call us at If at any time you re having a Behavioral Health Emergency, call 911, go to your local emergency room, or call your local Emergency Services Program (ESP) Provider. For a list of emergency rooms and ESP Providers throughout the state, visit Network-Health.org or call To find the closest ESP Provider near you, call the statewide directory at Integrated care management To make sure you get the best possible care and results, we use an integrated care management model. This means that, when appropriate, our behavioral health, medical, and social care managers work closely with each other and with you to coordinate the care you need. Integrated care management can help if you have complex and/or specific medical needs and conditions. If you have a physical disability; a special health condition like a highrisk pregnancy, cancer, or HIV/AIDS; a behavioral health problem; or any other chronic health condition, you can: Get health information from a care manager Get help finding out what resources and benefits you can get Work with one of our care managers to coordinate your care with your Provider Our team of dedicated health care professionals includes nurse practitioners, nurses, Behavioral Health Providers, social care managers, and health advocates. This team understands how to work with you if you have special health care needs, and will make sure you get care in the right place at home, at a Provider s office, at a Hospital, in school, in person, or by phone to help you get and stay healthy. 24 For any questions, please call Tufts Health Plan Network Health at (TTY: ). You can also visit us at Network-Health.org. We re also available 24 hours a day, seven days a week, for behavioral health issues and questions.

25 This team will work with you to answer your questions, address your needs, develop a plan to get you feeling better, and monitor your health. Some care managers make home visits, explain how to manage a condition, and arrange for services and equipment. Other care managers may also help with any medical, behavioral, social, and financial needs. We provide four types of integrated care management services: Complex care management Behavioral health intensive clinical management (ICM) Social care management Clinical community outreach Complex Care Management Our complex care management program is for Members with hard-to-manage, unstable, and/or long-lasting medical conditions. Members in these programs get help from a team of dedicated health care professionals who can help them get and stay healthy. Members with the following conditions may benefit from complex care management: Multiple health conditions Intensive-care needs (newborn) Cancer HIV/AIDS Organ transplantation Severe disability or impairment Our care managers can give you valuable information and help coordinate your care. Call to talk to a care manager. Behavioral health (mental health and/or substance abuse) intensive clinical management (ICM) We can offer you behavioral health ICM if you: Have severe behavioral health issues Have three or more behavioral health inpatient hospital admissions during a 12-month period Have not accessed or cannot access community-based services Experience a catastrophic event Have a history of multiple hospitalizations Are newly diagnosed with a major mental illness Have special needs or cultural issues that require multiple agencies to coordinate service delivery Call us at if you want information or have questions about behavioral health ICM and how we determine the care we authorize. Social Care Management Our social care management team can help you with more than health care issues. Social care managers are here to support you with anything in your life that could affect your health, including getting health care. Social care managers can help you: Apply for food stamps Apply for benefits like Supplemental Security Income (SSI) and Social Security and Disability Insurance (SSDI) Coordinate services with the Department of Transitional Assistance (DTA) and/or the Social Security Office Locate emergency shelter Get community services in addition to services we provide Get information about programs that help pay for utilities (electricity or heat) Find disability support groups Coordinate transportation to medically necessary appointments, when appropriate and applicable Get counseling To get social care management services or for more information, call us at Clinical Community Outreach Our clinical community outreach program is a two- to six-week program that will help you become familiar and involved with the preventive health care services, health maintenance programs, and community resources that are available to you as a Tufts Health Plan Network Health Member. Our clinical community outreach team can: Connect you to our programs that help you with any medical needs and conditions Help you find a doctor Support you in getting help with food, transportation, or housing Make sure you know what benefits and EXTRAS you can get For Health Connector plan-related questions, please call the Health Connector s customer service center at (TTY: ), Monday through Friday, from 8 a.m. to 6 p.m. 25

26 We can work with you to help you move to another care management program if we think it s necessary. Call us at if you want more information or if you have questions about the clinical community outreach program. Tufts Health Extend EXTRAS To help you get and stay healthy, we reward you with Tufts Health Extend EXTRAS. Only current, eligible Tufts Health Extend Members can get EXTRAS. However, some restrictions may apply, and we reserve the right to stop giving an EXTRA at any time. FREE rewards for healthy behaviors Get a $55 health rewards card As part of good preventive health, you should see your doctor on a yearly basis. Tufts Health Extend Members who get their yearly checkup can earn a $55 health rewards card to use on health-related purchases at participating pharmacies, grocery stores, discount stores, and even the doctor s office for Co-payments. You can use the health rewards card for health-related items like contact lens solution, prescriptions, bandages, and/or first-aid supplies. How to get your health rewards card: 1. Schedule a yearly checkup with your doctor 2. Call or visit Network-Health.org to get the Tufts Health Extend Member Reward Form you need your doctor to sign for the reward 3. Fill out your information and bring the reward form to your yearly checkup 4. Have your doctor sign and date the form to show that the visit took place 5. Make a copy of the form to keep for yourself 6. Mail the completed form to Tufts Health Plan Network Health, Attn: Member Services Team, 101 Station Landing, Fourth Floor, Medford, MA Watch your mail for your health rewards card, which should come in four to six weeks. Note: You must be a Tufts Health Plan Network Health Member at the time of the doctor visit and when we process your Member Reward Form. The card is valid for three months from the date we send it to you. Members can get one health rewards card every 12 months. Help your kids earn a FREE gift card To help our young Members get and stay healthy, we reward their healthy choices with a choice of a gift card to a variety of places. Here s what you need to do: Get your child a yearly checkup (ages 3 to 19) and we ll send them a free $10 CVS gift card Get your child all recommended childhood immunizations and screenings* by age 2 and we ll send them a $25 CVS or Walgreens gift card. * The recommended childhood immunizations and screenings are four DTaP, three OPV/IPV, one MMR, four HiB, two hepatitis A, three hepatitis B, one VZV, four PCV, three Rota, the flu shot each year, and a blood lead screening. Your child s doctor will talk to you about the best time to get these immunizations. We ll also send you reminder cards in the mail around the time your child should get these immunizations. How to get these benefits: 1. Call or visit Network-Health.org to get the Tufts Health Extend Member Reward Form you need to give your child s doctor to fill out and sign for these rewards 2. Bring the form with you when you go to your child s doctor 3. Fill out your information and have your child s doctor sign the form 4. Make a copy of the form to keep for yourself 5. Mail the completed form to Tufts Health Plan Network Health, Attn: Member Services Team, 101 Station Landing, Fourth Floor, Medford, MA Watch your mail for your gift card, which should come in four to six weeks. Note: You must be a Tufts Health Plan Network Health Member at the time of the doctor visit and when we process your Member Reward Form. 26 For any questions, please call Tufts Health Plan Network Health at (TTY: ). You can also visit us at Network-Health.org. We re also available 24 hours a day, seven days a week, for behavioral health issues and questions.

27 FREE Weight Watchers registration (plus $50 back on program costs) Any Member age 19 or older can join Weight Watchers with no fee. Once you sign up, we ll reimburse you up to $50 every 12 months toward the cost of your weekly meetings. Too busy to attend meetings? Check out the Weight Watchers At Home Kit. You ll get $10 off when you order it, PLUS we reimburse you $50 of the cost of the kit. Remember, you should discuss any diet or exercise program with your Primary Care Provider (PCP) before you begin. How to get your reimbursement: 1. With your PCP s approval, sign up for Weight Watchers meetings or order an At Home Kit by calling Weight Watchers at Visit Network-Health.org or call to get the Tufts Health Extend Reimbursement Form 3. Make a copy of your receipt for your records 4. Mail the completed form and original receipt to Tufts Health Plan Network Health, Attn: Member Services Team, 101 Station Landing, Fourth Floor, Medford, MA Watch your mail for your reimbursement of up to $50, which should come in six to eight weeks. Note: You must be a Tufts Health Plan Network Health Member when you sign up for Weight Watchers or order the At Home Kit and when we process your Reimbursement Form. Members age 19 and older can get one $50 reimbursement every 12 months. Acupuncture reimbursement We know that maintaining your health and well-being sometimes requires a holistic approach, so we offer you up to $150 back on acupuncture services when you visit a licensed acupuncturist. How to get your reimbursement: 1. Visit any licensed acupuncturist 2. Make a copy of your acupuncture receipt; be sure it shows the acupuncturist s license number 3. Visit Network-Health.org or call to get the Tufts Health Extend Reimbursement Form 4. Fill out and mail the completed form and original receipt to Tufts Health Plan Network Health, Attn: Member Services Team, 101 Station Landing, Fourth Floor, Medford, MA Watch your mail for your reimbursement of up to $150, which should come in six to eight weeks. Note: You must be a Tufts Health Plan Network Health Member when you get acupuncture services and when we process your Reimbursement Form. Members can get up to a $150 reimbursement every 12 months. Fitness reimbursement We help you stay fit. After you ve been a gym member for three months or completed one of several types of fitness activities, we ll give you up to $50 back. While this benefit is available to all Members every 12 months, Members age 18 and younger must get a parent s permission to join a gym or participate in a fitness activity. Eligible fitness-related activities include, but are not limited to: Gym and health club memberships, including YMCAs and Jewish Community Centers (JCCs) Yoga, Pilates, and fitness classes Salsa and other types of dance classes Sports leagues, like soccer and basketball Martial arts classes, like karate and tai chi Please discuss any diet or exercise program with your PCP before you begin. How to get your reimbursement: 1. Visit Network-Health.org or call to get the Tufts Health Extend Reimbursement Form 2. Fill out the form and make a copy of it and of your receipt for your records 3. Mail the completed form and original receipt to Tufts Health Plan Network Health, Attn: Member Services Team, 101 Station Landing, Fourth Floor, Medford, MA Watch your mail for your reimbursement of up to $50, which should come in six to eight weeks. For Health Connector plan-related questions, please call the Health Connector s customer service center at (TTY: ), Monday through Friday, from 8 a.m. to 6 p.m. 27

28 Note: You must be a Tufts Health Plan Network Health Member when we process your Reimbursement Form. Members can get one $50 reimbursement every 12 months. FREE rewards that keep your family safe FREE bike helmets Get a FREE bike helmet for each Tufts Health Extend Member in your household. Bike helmets help to prevent injuries. We have helmets available for toddlers, kids, and adults. How to get this benefit: 1. Visit Network-Health.org to print out the Tufts Health Extend EXTRAS Form or to complete it online, or call to place your bike helmet order 2. Fill out the form and make a copy for yourself 3. Mail the original form to Tufts Health Plan Network Health, Attn: Member Services Team, 101 Station Landing, Fourth Floor, Medford, MA Watch your mail for your FREE bike helmet, which should come in four to six weeks. Note: You must be a Tufts Health Plan Network Health Member at the time you order your bike helmet(s) and when we process your EXTRAS Form. Each Member can get one bike helmet every 12 months. FREE home safety kits Protect your kids from the hidden dangers at home. We help keep your little ones secure by sending you a FREE home safety kit, recommended for kids up to age 6. The kit has doorknob covers, cabinet and drawer latches, and outlet plugs. 2. Fill out the form and make a copy for yourself 3. Mail the original form to Tufts Health Plan Network Health, Attn: Member Services Team, 101 Station Landing, Fourth Floor, Medford, MA Watch your mail for your FREE home safety kit, which should come in four to six weeks. Note: You must be a Tufts Health Plan Network Health Member at the time you order your home safety kit and when we process your EXTRAS Form. Each household can get one home safety kit every 12 months. FREE child ID kits We can help you keep your kids safe. We offer a FREE McGruff Safe Kids Identification Kit, which includes a fingerprinting tool, for each child who is a Tufts Health Plan Network Health Member. ID kits are recommended for children ages 3 to 8. How to get this benefit: 1. Visit Network-Health.org to print out the Tufts Health Extend EXTRAS Form or to complete it online, or call to place your child ID kit order 2. Fill out the form and make a copy for yourself 3. Mail the original form to Tufts Health Plan Network Health, Attn: Member Services Team, 101 Station Landing, Fourth Floor, Medford, MA Watch your mail for your FREE child ID kit, which should come in four to six weeks. Note: You must be a Tufts Health Plan Network Health Member at the time you order your child ID kit and when we process your EXTRAS Form. Each Member can get one child ID kit every 12 months. How to get this benefit: 1. Visit Network-Health.org to print out the Tufts Health Extend EXTRAS Form or to complete it online, or call to place your home safety kit order 28 For any questions, please call Tufts Health Plan Network Health at (TTY: ). You can also visit us at Network-Health.org. We re also available 24 hours a day, seven days a week, for behavioral health issues and questions.

29 FREE rewards and help with your health care needs Our clinicians can help you with your health needs. Call to speak with a clinician. If you are pregnant We give our pregnant Members help during and after a pregnancy to make sure you have as healthy a pregnancy and baby as possible. Get FREE childbirth, newborn, and breastfeeding classes up to $150 reimbursement during each pregnancy Get a $10 CVS gift card after your second visit to a Women, Infants, and Children (WIC) office during your pregnancy Get help choosing a doctor for your baby Call us at as soon as you know you are pregnant to find out about these benefits. How to get your childbirth class reimbursement: 1. Visit Network-Health.org or call to get the Tufts Health Extend Reimbursement Form 2. Fill out the information on the form 3. Make a copy of the form for yourself 4. Mail the completed form to Tufts Health Plan Network Health, Attn: Member Services Team, 101 Station Landing, Fourth Floor, Medford, MA Watch your mail for your reimbursement of up to $150, which should come in six to eight weeks. Note: You must be a Tufts Health Plan Network Health Member when we process your Reimbursement Form. Members can get one reimbursement of up to $150 during each pregnancy. How to get the $10 gift card: 1. Call us at to tell us your due date, and we ll send you the Tufts Health Extend Member Reward Form 3. Make a copy of the signed form for yourself 4. Mail the completed form to Tufts Health Plan Network Health, Attn: Member Services Team, 101 Station Landing, Fourth Floor, Medford, MA Watch your mail for your $10 gift card, which should come in four to six weeks. Note: You must be a Tufts Health Plan Network Health Member when you visit WIC and when we process your Member Reward Form. Members can get one $10 gift card during each pregnancy. After having a baby Get a $10 CVS gift card if you visit your OB/GYN for a postpartum visit between 21 and 56 days after you have your baby Get a FREE breast pump (if you re eligible) Call as soon as you have your baby to get these benefits. How to get the $10 gift card: 1. Call to tell us when you had your baby, and we ll send you the Tufts Health Extend Member Reward Form to fill out. Please make sure to visit your PCP, OB/GYN, or other pregnancy care Provider between 21 and 56 days after having your baby. 2. Fill out the form and have your PCP, OB/GYN, or other pregnancy care Provider sign it 3. Make a copy of the form for yourself 4. Mail the completed form to Tufts Health Plan Network Health, Attn: Member Services Team, 101 Station Landing, Fourth Floor, Medford, MA Watch your mail for your $10 gift card, which should come in four to six weeks. Note: You must be a Tufts Health Plan Network Health Member when you have your postpartum visit and when we process your Member Reward Form. Members can get one $10 gift card after each pregnancy. 2. Fill out the information on the form. Have a WIC representative sign the form at each of your visits. For Health Connector plan-related questions, please call the Health Connector s customer service center at (TTY: ), Monday through Friday, from 8 a.m. to 6 p.m. 29

30 How to get the FREE breast pump: Call after your 28 th week of pregnancy or after you have your baby to see if you are eligible. If you have asthma Get a $10 CVS gift card for filling out an asthma action plan with your PCP Get information on asthma by calling us at or by visiting Network-Health.org How to get the $10 gift card: 1. Visit Network-Health.org or call to get an asthma action plan and the Tufts Health Extend Member Reward Form 2. Visit your PCP and fill out the asthma action plan together 3. Have your PCP also fill out the reward form 4. Have your PCP sign the asthma action plan and the reward form 5. Make a copy of the plan and the reward form for yourself 6. Mail the completed asthma action plan and the reward form to Tufts Health Plan Network Health, Attn: Member Services Team, 101 Station Landing, Fourth Floor, Medford, MA Watch your mail for your $10 gift card, which should come in four to six weeks. Note: You must be a Tufts Health Plan Network Health Member when you fill out the asthma action plan and when we process your Member Reward Form. Members can get one $10 gift card every 12 months. If you have diabetes Get a $25 health rewards card for getting an eye exam, two blood sugar (HbA1c) tests, a protein test, and a blood cholesterol test every 12 months Take a free nutrition class about diabetes Get information on diabetes by calling or by visiting Network-Health.org How to get the $25 health rewards card: 1. Call and ask to speak to a diabetes clinician. We ll send you the Tufts Health Extend Member Reward Form with a list of screenings to complete in a calendar year. Getting these screenings will help you manage your diabetes. You can also get the Member Reward Form at Network-Health.org. 2. Visit your PCP, complete the tests, and fill out the form 3. Have your PCP sign the form 4. Make a copy of the form for yourself 5. Mail the completed form to Tufts Health Plan Network Health, Attn: Member Services Team, 101 Station Landing, Fourth Floor, Medford, MA Watch your mail for your $25 health rewards card, which should come in four to six weeks. Note: You must be a Tufts Health Plan Network Health Member when you get the five screenings and when we process your Member Reward Form. Members can get one $25 health rewards card every 12 months for completing the five screenings. Coverage Your eligibility in the plan is determined by the Health Connector. If you or any of your Dependents are covered by any other health insurance, such as MassHealth, Commonwealth Care, Medicare, or any commercial insurance, your eligibility may be affected. Please call the Health Connector at , Monday through Friday, from 8 a.m. to 6 p.m., for all eligibility-related questions. Effective Coverage Date Your Effective Coverage Date is the date you become a Member of Tufts Health Extend and are eligible to get Covered Services from Tufts Health Extend Providers. Your coverage will start at 12:01 a.m., effective on the date assigned by the Health Connector. 30 For any questions, please call Tufts Health Plan Network Health at (TTY: ). You can also visit us at Network-Health.org. We re also available 24 hours a day, seven days a week, for behavioral health issues and questions.

31 Disenrollment The Health Connector will provide us with information about member disenrollment. Note: We will never request a Member s disenrollment due to a negative change in health, or because of the Member s use of medical services, diminished mental capacity, or uncooperative behavior resulting from special needs. When you re disenrolled from the plan, we will continue to provide Covered Services to you through 11:59 p.m. on the last day of your coverage. Your coverage is over seven days after the week-ending date of your final unemployment insurance payment. Protecting your benefits Help reduce health care Fraud and abuse, and protect everyone. Member and Provider Fraud or abuse include: You lending your Member ID Card to someone else You getting prescriptions in an improper way Your doctors billing us for services you didn t get To report potential health care Fraud or abuse, or if you have questions, please call us at or [email protected]. We don t need your name or Member information. You can also call our confidential hotline at or send an anonymous letter to us at: Tufts Health Plan Network Health Attn: Fraud and Abuse 101 Station Landing, Fourth Floor Medford, MA Your rights As a Tufts Health Plan Network Health Member, you have the right to: Be treated with respect and dignity by all Providers, regardless of your race, ethnicity, creed, religious belief, sexual orientation, or source of payment for care Get Medically Necessary treatment, including emergency care Get the delivery of services in a culturally competent manner Make decisions about your medical care Get information about us and our services, Primary Care Providers (PCPs), Specialists, other Providers, and your rights and responsibilities Have a candid discussion of appropriate or Medically Necessary treatment options for your condition(s) regardless of cost or benefit coverage Work with your PCP, Specialists, and other Providers to make decisions about your health care Accept or refuse medical or surgical treatment Call your PCP s and/or Behavioral Health (mental health and/or substance abuse) Provider s office 24 hours a day, seven days a week Expect that your health care records are private, and that we abide by all laws regarding confidentiality of patient records and personal information, in recognition of your right to privacy Get a second opinion for proposed treatments and care File a Grievance to express dissatisfaction with your Providers and the quality of care or services you get Appeal a denial or Adverse Determination we make for your care or services Be free from any form of restraint or seclusion used as a means of coercion, discipline, or retaliation Ask for more information or explanation on anything included in this Member Handbook, either orally or in writing Ask for a duplicate copy of this Member Handbook at any time Get written notice of any significant and final changes to our Provider Network, including but not limited to PCP, Specialist, Hospital, and facility terminations that affect you Get copies of your medical records, and ask that we amend or correct the records, if necessary Get the services listed in the Benefit and Co-payment Summary starting on page 45 of this Member Handbook Make recommendations about our member rights and responsibilities policy Get this Member Handbook and other Tufts Health Plan Network Health information translated into your preferred language or in your preferred format For Health Connector plan-related questions, please call the Health Connector s customer service center at (TTY: ), Monday through Friday, from 8 a.m. to 6 p.m. 31

32 Advance Directives Advance Directives are written instructions, sometimes called a living will or durable power of attorney, for health care. Advance Directives are recognized under Massachusetts law and relate to getting health care when a person isn t capable of making a decision. If you re no longer able to make decisions about your health care, having an Advance Directive in place can help. These written instructions will tell your Providers how to treat you if you aren t able to make your own health care decisions. In Massachusetts, if you re at least 18 years old and of sound mind, you can make decisions for yourself. You may also choose someone as your health care agent or health care proxy. Your health care agent or proxy can make health care decisions for you in the event that your Providers determine you re unable to make your own decisions. As a Tufts Health Plan Network Health Member, you have certain rights that relate to an Advance Directive. To choose a health care agent or proxy, you must fill out a Health Care Proxy Form, available from your Provider or Tufts Health Plan Network Health. Please call us at to request a copy. You can also request a Health Care Proxy Form from the Commonwealth of Massachusetts. Write to the address below and send a self-addressed and stamped envelope to: Commonwealth of Massachusetts Executive Office of Elder Affairs 1 Ashburton Place, Room 517 Boston, MA With Advance Directives, you also have the right to: Make decisions about your medical care Get the same level of care, and be free from any form of discrimination, whether or not you have an Advance Directive Get written information about your Provider s Advance Directive policies Have your Advance Directive in your medical record Your rights for privacy practices You have the right to: Ask us in writing to restrict use or disclosure of your Protected Health Information (PHI). We may not be able to comply with all requests. Ask us in writing to communicate your PHI to you in the way or at the location of your choice. We must comply with any reasonable request. Inspect and copy your PHI. If we decline your request, you can appeal our decision. Request changes, corrections, or deletions to your PHI that you believe are incorrect or incomplete. We may not be able to comply with all requests. Request an accounting of certain PHI disclosures, excluding disclosures made more than six years before the date of your request. If you request an accounting more than once during any 12-month period, fees may apply. Get a paper copy of this notice at any time. Request further information or file a complaint by contacting our privacy officer. You may also file a written complaint regarding your privacy rights with the director of the Office for Civil Rights of the U.S. Department of Health and Human Services. Our privacy officer will provide you with the correct address for the director. We won t retaliate against you if you file a complaint with us or the Office of Civil Rights. For details or to find out how to exercise your rights, visit Network-Health.org, call (TTY: ), or contact: Tufts Health Plan Network Health Attn: Privacy Officer 101 Station Landing, Fourth Floor Medford, MA [email protected] Our Providers will comply with state law concerning Advance Directives. We also educate staff members and people they interact with in the community about Advance Directives. 32 For any questions, please call Tufts Health Plan Network Health at (TTY: ). You can also visit us at Network-Health.org. We re also available 24 hours a day, seven days a week, for behavioral health issues and questions.

33 Additional information available to you You can learn about other Members experience with Tufts Health Plan Network Health by calling us at Types of available information include: Tufts Health Extend voluntary and involuntary disenrollment rates A list of sources of independently published information assessing Members satisfaction and evaluating the quality of health care services we offer The percentage of Providers who voluntarily and involuntarily ended contracts with us during the previous calendar year, and the three most common reasons for voluntary and involuntary Provider disenrollment The percentage of premium revenue we spend for health care services our Members got during the most recent year for which information is available A summary report on Appeals, including the number of Appeals filed, the number of Appeals approved internally, the number of Appeals denied internally, and the number of Appeals withdrawn before resolution You can also get information about us from the Massachusetts Board of Registration in Medicine at massmedboard.org, which may be able to give you information about Providers licensed to practice in Massachusetts. Your responsibilities As a Tufts Health Plan Network Health Member, you have the responsibility to: Treat all Providers with respect and dignity Keep appointments, be on time, or call if you ll be late or need to cancel an appointment Give us, your Primary Care Provider (PCP), Specialists, and other Providers complete and correct information about your medical history, medicine you take, and other matters about your health Ask for more information from your PCP and other Providers if you don t understand what they tell you Participate with your PCP, Specialists, and other Providers to understand and help develop plans and goals to improve your health Follow plans and instructions for care that you ve agreed to with your Providers Understand that refusing treatment may have serious effects on your health Contact your PCP or Behavioral Health (mental health and/or substance abuse) Provider within 48 hours of visiting the emergency room for follow-up care Change your PCP or Behavioral Health Provider if you aren t happy with your current care Voice your concerns and complaints clearly Tell us if you have access to any other insurance Tell us if you suspect potential Fraud or abuse Tell us and the Health Connector about any address, phone, or PCP changes Tell us if you re pregnant How to resolve concerns with Tufts Health Plan Network Health Inquiries An Inquiry is any question or request that you may have about our operations. As a Tufts Health Plan Network Health Member, you have the right to make an Inquiry at any time. We ll resolve your Inquiries immediately or, at the latest, within two business days of the day we get it. We ll let you know the resolution the day we resolve your Inquiry. Grievances A Grievance is an expression of dissatisfaction you or your Authorized Representative (someone you have authorized in writing to act on your behalf), if you identify one, make about any action or inaction by us other than an Adverse Determination. As a Tufts Health Plan Network Health Member, you or your Authorized Representative have the right to file a Grievance with us. You may file a Grievance up to 180 Days after the action or inaction that is of concern to you. You may file a Grievance for any reason, including: If you re dissatisfied with the quality of care or services you get If one of your Providers or one of our employees is rude to you If you believe one of your Providers or one of our employees did not respect your rights For Health Connector plan-related questions, please call the Health Connector s customer service center at (TTY: ), Monday through Friday, from 8 a.m. to 6 p.m. 33

34 If you disagree with our decision to extend the time frame for making an Authorization or a Standard Internal Appeal or Expedited Internal Appeal decision If you disagree with our decision not to expedite a Standard Internal Appeal request Your Authorized Representative can file a Grievance for you. You can appoint an Authorized Representative by sending us a signed Tufts Health Plan Network Health Authorized Representative Form. You can get a form by calling our Member Services Team or our grievance coordinator at , Monday through Friday, from 8 a.m. to 5 p.m. You can also find this form at Network-Health.org. If we don t get your signed Tufts Health Plan Network Health Authorized Representative Form within 30 Days of someone other than you filing a Grievance on your behalf, we ll dismiss the Grievance. How to file a Grievance You or your Authorized Representative may file a Grievance in the following ways: Telephone call us at , Monday through Friday, from 8 a.m. to 5 p.m. TTY/TTD people with hearing loss can call our TTY line at , Monday through Friday, from 8 a.m. to 5 p.m. Mail mail a Grievance to Tufts Health Plan Network Health, Attn: Grievance Coordinator, 101 Station Landing, Fourth Floor, Medford, MA a Grievance via the Contact us section of our website at Network-Health.org Fax fax a Grievance to us at In person visit our office at 101 Station Landing (Medford, MA), Monday through Friday, from 8 a.m. to 5 p.m. Once you file a Grievance, we will: Tell you and your Authorized Representative that we got your Grievance by sending you a written notice within one business day Look into and resolve your Grievance within 30 Days from when we get your Grievance Ask to extend the time frame by mutual written agreement if we need more information. The additional time will not be more than 30 Days. Tell you and your Authorized Representative in writing of the outcome of your Grievance, which will include the information we considered and explain our decision Provide interpreter services, if necessary Appeals As a Tufts Health Extend Member, you or your Authorized Representative have the right to request a Standard Internal Appeal if you disagree with any Adverse Determination. How to request a Standard Internal Appeal You or your Authorized Representative may request a Standard Internal Appeal within 180 Days of an Adverse Determination in the following ways: Telephone call us at , Monday through Friday, from 8 a.m. to 5 p.m. TTY/TTD people with hearing loss can call our TTY line at , Monday through Friday, from 8 a.m. to 5 p.m. Mail request a Standard Internal Appeal by mail, by sending a copy of the notice of Adverse Determination and any additional information about the Standard Internal Appeal to us at Tufts Health Plan Network Health, Attn: Appeals Specialist, 101 Station Landing, Fourth Floor, Medford, MA request a Standard Internal Appeal by via the Contact us section of our website at Network-Health.org Fax request a Standard Internal Appeal by faxing us at In person visit our office at 101 Station Landing (Medford, MA.), Monday through Friday, from 8 a.m. to 5 p.m. Although you have 180 Days to request a Standard Internal Appeal, we encourage you to act as soon as possible. We ll let you know we got your Standard Internal Appeal request by sending you a written notice within one business day, or 48 hours, whichever is less. 34 For any questions, please call Tufts Health Plan Network Health at (TTY: ). You can also visit us at Network-Health.org. We re also available 24 hours a day, seven days a week, for behavioral health issues and questions.

35 Other people who can request an Appeal for you Your Authorized Representative can request an Appeal for you. You need to tell us in writing if your Authorized Representative will request an Appeal for you. You can appoint an Authorized Representative by sending us a signed Tufts Health Plan Network Health Authorized Representative Form. You can get a form by calling our Member Services Team or our appeals specialists at , Monday through Friday, from 8 a.m. to 5 p.m. You can also find this form at Network-Health.org. Note: If someone tries to request an Appeal, including an Expedited Internal Appeal, for you and you did not already send us an Authorized Representative Form for that person, we ll tell you in writing that a request has been made and will send you a copy of the Authorized Representative Form to sign and return to us. We will take no further action until we get the signed Authorized Representative Form. If you don t send the form, we ll dismiss the request, unless it is an Expedited Internal Appeal requested by a Provider. Continuation of services during the Appeal process If you ve been getting a Covered Service and we stop covering the service, we ll continue the disputed coverage at our expense through the end of the Appeal process, as long as you or your Authorized Representative request the Appeal in a timely manner. Ongoing coverage or service includes only medical services that, at the time they began, were authorized by us. Standard Internal Appeal time frames We ll review and make a decision about your Standard Internal Appeal request within 30 Days* from the date we get your request. Reviewing medical records as part of the Standard Internal Appeal You may send us written comments, documents, or other information relating to your Standard Internal Appeal. If we need to review additional medical records, the Standard Internal Appeal period of 30 Days begins when you or your Authorized Representative send us a signed authorization for release of medical records and treatment information, as required. If you don t provide this authorization within 30 Days of our getting the Standard Internal Appeal request, we may issue a decision on the Standard Internal Appeal without reviewing some or all of the medical records. You have the right to review your case file, which includes information like medical records and other documents and records we considered during the Appeal process. Expedited (fast) Internal Appeal If a Provider thinks that our standard time frame of 30 Days could seriously harm your life, health, or ability to get back to maximum function, or if it will cause you severe pain that can t be adequately managed without the requested service, then you or your Authorized Representative may request an Expedited Internal Appeal. You or your Authorized Representative may request an Expedited Internal Appeal from us orally, in writing, or in person, rather than requesting a Standard Internal Appeal. You or your Authorized Representative may also request an expedited external review from the Health Connector at the same time you request an Expedited Internal Appeal. For more information, please see the sections on expedited external reviews starting on page 36. There are three situations when we may review a Standard Internal Appeal in a fast manner, and each situation has a certain time requirement in which we must decide the Standard Internal Appeal: When you re a patient in a Hospital, we must issue a decision before you re discharged from the Hospital. When a Provider tells us in writing that a delay in getting the requested service or supply would result in risk of substantial harm to you, we must issue a decision within 72 hours. If you re terminally ill, we must review your Grievance or Standard Internal Appeal within five days, unless the request is for urgently needed services, in which case we must issue a decision within 72 hours. We ll issue a decision within 48 hours*, or in less time for Durable Medical Equipment (DME), when the Provider specifies a reasonable time. If the Expedited Internal Appeal upholds the denial of coverage or treatment regarding terminal illness, we ll allow you or your Authorized Representative to request a conference. We ll schedule the conference within 10 business days of getting a request. The conference will be held within five business days of the request if the treating Provider determines, after consulting with a Tufts Health Plan Network Health medical director, that the effectiveness of the proposed treatment or For Health Connector plan-related questions, please call the Health Connector s customer service center at (TTY: ), Monday through Friday, from 8 a.m. to 6 p.m. 35

36 supplies, or any alternative treatment or supplies, would be greatly reduced if not provided at the earliest possible date. You and/or your Authorized Representative can attend the conference. * Any Standard Internal Appeal not properly acted on by us within the time limits specified will be decided in your favor. Time limits include any extensions made by mutual written agreement between you or your Authorized Representative and us. Written notice of Appeal decisions We will tell you our Appeal decisions in writing. For Adverse Determinations, this notice will include a clinical explanation for the decision, and will: Give specific information upon which we based an Adverse Determination Discuss your symptoms or condition, diagnosis, and the specific reasons why the evidence submitted doesn t meet the relevant medical review criteria Specify alternate treatment options we cover Reference and include applicable clinical practice guidelines and review criteria Let you or your Authorized Representative know your options to further appeal our decision, including procedures for requesting an External Review and an Expedited External Review Reconsideration of a Standard Internal Appeal If you re unhappy with our decision about your Standard Internal Appeal, you or your Authorized Representative may ask for a Reconsideration of our decision. You can also waive your right to a Reconsideration and request an External Review directly from the Office of Patient Protection (OPP). You or your Authorized Representative must request a Reconsideration within 30 Days of our denial of your Internal Appeal. When you or your Authorized Representative asks for a Reconsideration, we must agree in writing to a new time period for review, but it won t be more than 30 Days from our agreement to review the Standard Internal Appeal decision. If we deny your reconsideration, you may request an External Review from the OPP. The time period for requesting an External Review begins on the date you get our Reconsideration decision. External Review If you get a Final Adverse Determination from us, you have the opportunity to request an External Review from the Office of Patient Protection (OPP). You or your Authorized Representative are responsible for starting the External Review process. We ll enclose an External Review Form any time we issue a Final Adverse Determination. To start the review, send the required form to the OPP within four months of getting our final decision. If you ve been getting a Covered Service and we end coverage of the service, the disputed coverage will continue at our expense through the end of the Appeal process, as long as you request an External Review within the second business day of getting your Final Adverse Determination. If the External Review Agency decides you should keep getting the service because there could be substantial harm to you if the service ends, we ll keep covering the service until the External Review is decided, no matter what the final External Review decision is. The External Review Agency will screen all requests for External Reviews to see if they: Meet the requirements of the External Review Form Don t involve a service or benefit we specify in this Member Handbook that we exclude from coverage Result from our issuing a Final Adverse Determination. You won t need a Final Adverse Determination from us if we fail to act within the timelines for the Standard Internal Appeal If your case is eligible for External Review, you ll get a written decision from the External Review Agency within 45 business days. Expedited (fast) External Reviews You may request an Expedited External Review if your Provider tells the OPP in writing that a delay in providing the care would result in a serious threat to your health. Expedited External Reviews are resolved within four business days from when the External Review Agency gets the referral. You or your Authorized Representative may request an Expedited External Review at the same time you request an Expedited Internal Appeal from Tufts Health Plan Network Health. 36 For any questions, please call Tufts Health Plan Network Health at (TTY: ). You can also visit us at Network-Health.org. We re also available 24 hours a day, seven days a week, for behavioral health issues and questions.

37 When your External Review involves a decision by us to end a previously authorized service If the External Review involves ending ongoing coverage of services, you may apply to the OPP to keep getting the services during the External Review. You need to make the request before the end of the second business day after you get our Final Adverse Determination. If the External Review Agency decides you should keep getting the service because there could be substantial harm to you if the service ends, we ll keep covering the service until the External Review is decided, no matter what the final External Review decision is. How to Contact the Health Connector If you have questions about your rights as a Member or questions about the External Review process, you can contact the OPP at or by fax at , or visit the OPP s website at mass.gov/hpc/opp. Questions or concerns? If you have questions or concerns about the Grievance and/or Appeal process, please call our Member Services Team at (TTY: ), Monday through Friday, from 8 a.m. to 5 p.m. When you have additional insurance You must tell us if you have any other health insurance coverage in addition to Tufts Health Extend. You must also let us know when there are any changes in your additional insurance coverage. The types of additional insurance you might have include: Coverage from an employer s group health insurance for employees or retirees, either for yourself or your spouse Coverage under Workers Compensation because of a job-related illness or injury Coverage from MassHealth, Commonwealth Care, Medicare, or commercial insurance Coverage for an accident where no-fault insurance or liability insurance is involved Coverage you have through veteran s benefits We re the payer of last resort for medical services involving Coordination of Benefits and third-party liability or Subrogation. Please see the following sections for more information. Coordination of Benefits When you have other health insurance coverage, we work with your other insurance to coordinate your Tufts Health Extend benefits. The way we work with the other companies depends on your situation. This process is called Coordination of Benefits. Through this Coordination of Benefits, you ll often get your health insurance coverage as usual through us. If you have other health insurance, our coverage will always be secondary when the other plan provides you with health care coverage, unless the law states something different. In other situations, such as for care we don t cover, another insurer other than us may be able to cover you. If you have additional health insurance, please call us at to find out how payment will be handled. If you have comprehensive health insurance with another health plan, including MassHealth or Medicare Part B, you can t get benefits. If you fit this category, the Health Connector will disenroll you from Tufts Health Plan Network Health. The Health Connector will notify you about your disenrollment. Subrogation If another person s action or omission injures you, your Tufts Health Extend benefits will be subrogated. Subrogation means that we may use your right to recover money from the person(s) who caused the injury or from any insurance company or other party. If another person or party is, or may be, liable to pay for services related to your illness or injury that we paid for or provided, we ll subrogate and succeed to all your rights to recover against such person or party 100% of the value of services we pay for or provide. Your Provider should submit all claims incurred as a result of any Subrogation case before any settlement. We may deny Claims for services rendered before a settlement that your Provider doesn t submit before that settlement is reached. In the event another party reimburses any medical expense we pay for, we are entitled to recover from you 100% of the amount you got for such services from us. Attorney s fees and/or expenses you incur won t reduce the amount you must pay back to us. For Health Connector plan-related questions, please call the Health Connector s customer service center at (TTY: ), Monday through Friday, from 8 a.m. to 6 p.m. 37

38 To enforce our Subrogation rights under this Member Handbook, we ll have the right to take legal action, with or without your consent, against any party to recover the value of services we provide or cover for which that party is, or may be, liable. Nothing in this Member Handbook may be interpreted to limit our right to use any means provided by law to enforce our rights to Subrogation under this plan. We need you to follow all requirements for Prior Authorization even when third-party liability exists. Authorization isn t a guarantee of payment. Motor vehicle accidents and/or work-related injury/illness If you re in a motor vehicle accident, you must use all of your auto insurance carrier s medical coverage, including Personal Injury Protection (PIP) and/or medical payment coverage, before we ll consider paying for any of your expenses. You must send us any explanation of payment or denial letters from an auto insurance carrier for us to consider paying a Claim that your Provider sends to us. In the case of a work-related injury or illness, the Workers Compensation carrier will be responsible for those expenses first. You must send to us any explanation of payment or denial letters from the Workers Compensation carrier for us to consider paying a Claim that your Provider sends us. Member cooperation As a Tufts Health Extend Member, you agree to cooperate with us in using our Coordination of Benefits and Subrogation rights. This means you must complete and sign all necessary documents to help us use our rights, and you must notify us before settling any claim arising out of injuries you sustained by any liable party for which we have provided coverage. You must not do anything that might limit our right to full reimbursement. These provisions apply, even if you re a minor. We ask that you: Give us all information and documents we ask for Sign any documents we think are necessary to protect our rights Promptly assign us any money you get for services that we ve provided or paid for Promptly let us know of any possible Coordination of Benefits or Subrogation potential You also must agree to do nothing to prejudice or interfere with our rights to Coordination of Benefits or Subrogation. If you aren t willing to help us, you ll be liable to us for any expenses we may incur, including reasonable attorneys fees, in enforcing our rights under this plan. Nothing in this Member Handbook may be interpreted to limit our right to use any means provided by law to enforce our rights to Coordination of Benefits or Subrogation under this plan. Our responsibilities We are required by law to maintain the privacy of your individually identifiable health information, known as Protected Health Information (PHI), across our organization, including oral, written, and electronic PHI. We ensure the privacy of your PHI in a number of ways. For example, employees don t discuss your PHI in public areas. We monitor breaches of security. We keep any paper PHI in secure spaces. We must follow the terms of this notice (or any revised notice) when using or disclosing your PHI. We may revise this notice at any time. If we do, changes will apply to your entire PHI that we maintain, and we ll make a copy of the revised notice available at Network-Health.org or upon request. Notice of Privacy Policy We re committed to protecting your rights and privacy. Our Notice of Privacy Policy describes how we may use and disclose your PHI, and how you can access this information. Please review this section carefully. You can also read the Notice of Privacy Practices at Network-Health.org, or get another copy by calling Uses and disclosures of your PHI that don t require your authorization We may use and disclose your PHI without your written authorization for the following purposes, or as otherwise permitted or required by law: Treatment to help Providers provide, coordinate, or manage your care. For example, we may share your PHI with another Provider to coordinate a Prior Authorization. Payment to help us, or other health plans and Providers with whom you have or had a relationship, get payment of Premiums for your health coverage, and meet our responsibility to provide your benefits 38 For any questions, please call Tufts Health Plan Network Health at (TTY: ). You can also visit us at Network-Health.org. We re also available 24 hours a day, seven days a week, for behavioral health issues and questions.

39 Health care operations to help us, or other health plans and Providers with whom you have or had a relationship, improve the quality and cost effectiveness of the care we deliver Disclosure to the Health Connector to operate, monitor, audit, and administer benefits, or to report suspected Member and/or Provider Fraud Public health to prevent or control disease, injury, or disability; to report child abuse or neglect; to report information about a product or activity under the jurisdiction of the U.S. Food and Drug Administration; and if authorized by law, to notify a person about any exposure to a communicable disease Health oversight to respond to a health oversight agency responsible for ensuring compliance with the rules of government benefit programs, such as Medicare or Medicaid, or other regulatory programs for which health information is necessary for determining compliance Legal proceedings to respond to a legal order or other lawful process in a judicial or administrative proceeding Law enforcement to respond to the police or other law enforcement officials as required by law or to be in compliance with a court order or other process authorized by law Health or safety to prevent or lessen a serious and imminent threat to the health or safety of an individual or the public Specialized government functions to respond to units of the government with special functions, such as the U.S. military or the U.S. Department of State Legal compliance to comply with applicable federal or state laws and regulations Workers Compensation to comply with Workers Compensation laws Outreach activities to engage in a face-to-face encounter initiated by you; to give you free EXTRAS or to communicate with you about our benefits or services relating to your treatment, Care Management or coordination, or alternative treatments, therapies, Providers, or health care settings Uses and disclosures of your PHI that require your written authorization We won t use and disclose your PHI without your written approval for the following purposes, and as otherwise allowed or required by law: Marketing activities we must get written authorization to use your PHI in any and all marketing activities, except in a face-to-face encounter or to give you a promotional gift Your highly confidential information we won t release your PHI relating to alcohol and/or drug abuse treatment, HIV/AIDS, sexually transmitted diseases, genetic testing, pregnancy termination, child abuse, abuse of an adult with a disability, psychotherapy notes, certain mental health or social work communications, or sexual assault counselor communications, except as required or permitted by law You may change your mind and tell us you no longer approve of our using and disclosing your PHI at any time by writing to us. This exclusion won t apply to information you ve already released. Multicultural Health Care Privacy Protection Policy There will be times when we may ask you about your race, ethnicity, and language preference. We collect this information so that we can better understand your cultural needs, and to: Understand the demographics (the data of a population) of our Members Measure and report any existing differences in health care or services provided Deal with any differences through appropriate outreach and Member initiatives We ll use the data we collect to plan and manage outreach materials, design intervention programs, and tell Providers about your language needs. Providers can use this information to help design programs that help improve your health and give you better care. Your answers will not change your health insurance benefits in any way. The information you give us is collected, stored, protected, and used only as allowed by our internal policies. These internal policies tell us when we can and can t use race, ethnicity, and language data. They also describe how we tell Members about privacy protections. You will be told of our policies for use and protection of race, ethnicity, and language data at the time we ask you for this information. For Health Connector plan-related questions, please call the Health Connector s customer service center at (TTY: ), Monday through Friday, from 8 a.m. to 6 p.m. 39

40 Access to the data is managed by Tufts Health Plan Network Health s information security access controls policies and will be given only to those Tufts Health Plan Network Health staff whose jobs need to have access to this information. We will not share this data with any unauthorized user or third party. Termination of this data is also managed by the same information security access controls policies. To get a copy of our Multicultural Health Care Privacy Protection Policy, please call us at Glossary An Advance Directive is a decision, based on a review of information you provide to us or our designated utilization review organization, to deny, reduce, modify, or end an admission, continued inpatient stay, experimental/ investigational service, or any other services, for failing to meet the requirements for coverage, based on Medical Necessity, appropriateness of health care setting, and level of care or effectiveness. An Adverse Determination is a decision, based on a review of information you provide to us or our designated utilization review organization, to deny, reduce, modify, or end an admission, continued inpatient stay, experimental/ investigational service, or any other services, for failing to meet the requirements for coverage, based on Medical Necessity, appropriateness of health care setting, and level of care or effectiveness. Ancillary Services are tests, procedures, imaging, and support services (such as lab tests and radiology services) you get in a health care setting that help your Provider diagnose and/or treat your condition. Appeal see Standard Internal Appeal or Expedited Internal Appeal. Authorization see Prior Authorization. Authorized Representative is someone you authorize in writing to act on your behalf regarding a specific Grievance, Appeal, or External Review. If you re unable to pick an Authorized Representative, your Provider, a guardian, conservator, or holder of a power of attorney may be your Authorized Representative. You can give your Authorized Representative a standing authorization to act on your behalf if you make this request in writing. This standing authorization will remain in effect until you cancel it. If you re a minor and you re able by law to consent to a medical procedure, you may appeal our denial of the medical procedure without permission from a parent or guardian. In that case, you can also pick an Authorized Representative without permission from a parent or guardian. Authorized Representative Form is a legal document that tells us you have given someone written permission to act on your behalf as described above. Behavioral Health (mental health and/or substance abuse) services include visits, consultations, counseling, screenings, and assessments for mental health and/or substance abuse, as well as inpatient, outpatient, detoxification, and diversionary services. The Benefit and Co-payment Summary is the section included at the end of this Member Handbook to provide a general description of your Tufts Health Extend Plan Type s Covered Services. It lists benefits, Co-payment amounts if any, and any limits on the benefits your policy covers. A Benefit Year is the 12-month period from January 1 to December 31. Care Management is how we regularly evaluate, coordinate, and help you with your medical, behavioral health and/ or social care health needs. Through Care Management, we do our best to make sure you can get high-quality, costeffective, and appropriate care; get information about disease prevention and wellness; and get and stay healthy. A Claim is a bill your Provider sends us to ask us to pay for services you get. Continuity of Care is how we make sure you keep getting the care you need when your doctor is no longer in our Network, or when you first become a Member and you were getting care from another doctor who is not in our Network. Coordination of Benefits is how we get money from other sources to pay for your health care needs when you have coverage from more than one insurer. A Co-payment is a fixed amount you may have to pay for a covered pharmacy or medical service. See also Medical Co-payment and Pharmacy Co-payment. A Co-payment Cap is a limit on the amount of Co-payments you can be charged each Benefit Year (January 1 December 31). 40 For any questions, please call Tufts Health Plan Network Health at (TTY: ). You can also visit us at Network-Health.org. We re also available 24 hours a day, seven days a week, for behavioral health issues and questions.

41 Covered Services are the services and supplies Tufts Health Extend covers. The Benefit and Co-payment Summary we include in this Member Handbook includes all of your Covered Services and supplies. Day means a calendar day, unless business day is specified. A Dependent is the spouse or child of the person who primarily qualifies for the plan. Such person(s) must qualify for dependent status under the Internal Revenue Code. Diabetic Specialty Care is care a Specialist provides to treat diabetes. Durable Medical Equipment (DME) is equipment that can stand repeated use, is primarily used to serve a medical purpose, generally is not useful to a person in the absence of illness or injury, and is appropriate for use in the home. Effective Coverage Date means the date on which you become a Member of Tufts Health Extend and are eligible to get Covered Services from Tufts Health Extend Providers. An Emergency is a medical or behavioral health (mental health and/or substance abuse) condition with such serious symptoms, including such severe pain, that a person with an average knowledge of health and medicine could realistically expect that not getting medical attention right away would result in the health of the Member (or in the case of a pregnant woman, the health of the woman and/ or her unborn child) being put in serious danger. This danger could include serious damage to bodily function or a serious problem with any body organ or part; or, in the case of a pregnant woman who is having contractions, if there isn t enough time to safely transfer to another hospital before delivery, or if that transfer could be harmful to the health of the woman or her unborn child. Emergency Services Program (ESP) Providers are treatment centers that provide Behavioral Health (mental health and/or substance abuse) emergency services 24 hours a day, seven days a week, per Massachusetts state requirements. Evidence-based means there is clinical proof that this treatment option is an appropriate way to help you. Evidence of Coverage (EOC), also referred to as the Member Handbook, is this document developed by Tufts Health Plan Network Health and filed with the Health Connector, which details the Covered Services you get with Tufts Health Extend. It is our agreement with you and includes any riders, amendments, or other documents that add to the details of Covered Services. An Expedited (fast) Internal Appeal is an oral or written request for a fast review of an Adverse Determination when your life, health, or ability to attain, maintain, or regain maximum function will be at risk if we follow our standard time frames when reviewing your request. We will review Expedited Internal Appeals and make a decision about a request within 72 hours. An Expedited External Review is a request for a quick resolution to an External Review involving immediate and urgently needed services. You may request an Expedited External Review at the same time you request an Expedited Internal Appeal from Tufts Health Plan Network Health. External Review is a request for an External Review Agency to review Tufts Health Plan Network Health s final Standard Internal Appeal decision. An External Review Agency is an accredited company under contract with the Office of Patient Protection and separate from Tufts Health Plan Network Health that looks at decisions made by Tufts Health Plan Network Health about a member s coverage. Providers who work at the designated External Review Agency review all appropriate medical records according to objective, evidence-based medical standards to make a final decision about a Member s Final Adverse Determination. Family-planning Services include birth control methods, exams, counseling, education, pregnancy testing, follow- up health care, and some lab tests. Federal Poverty Level (FPL) is the income standard that the federal government issues yearly and is used by the Health Connector along with other criteria to determine eligibility. Final Adverse Determination is an Adverse Determination made after you have exhausted all remedies available through Tufts Health Plan Network Health s formal Appeal process. For Health Connector plan-related questions, please call the Health Connector s customer service center at (TTY: ), Monday through Friday, from 8 a.m. to 6 p.m. 41

42 Fraud is when someone dishonestly gets services or payment for services but doesn t have a right to them. An example of Fraud is Members lending their Tufts Health Extend Member ID Cards to other people so they can get health care or pharmacy services. A Grievance is any expression of dissatisfaction by you or your Authorized Representative, if you identify one, about any action or inaction by Tufts Health Plan Network Health other than an Adverse Determination. Reasons to file Grievances may include, but aren t limited to, the quality of care or services provided, rudeness on the part of a Provider or employee of Tufts Health Plan Network Health, failure to respect your rights, a disagreement you may have with our decision not to approve a request to speed up a Standard Internal Appeal, a disagreement with our request to extend the time frame for resolving an authorization decision or an Appeal, and the retroactive ending of coverage due to fraud. A Hospital is any licensed facility that provides medical and surgical care for patients who have acute illnesses or injuries and that the American Hospital Association (AHA) lists as a Hospital or the Joint Commission accredits. In-network refers to a Provider that Tufts Health Plan Network Health contracts with to provide Covered Services to Members. Inpatient Services are services that need at least one overnight stay in a hospital setting. This generally applies to services you get in licensed facilities, such as Hospitals and Skilled Nursing Facilities. An Inquiry is any question or request you have for us. A Medical Co-payment is a fixed amount you may have to pay for a Covered Service other than pharmacy. Medically Necessary or Medical Necessity describe services that are, within reason, intended to prevent, diagnose, stop the worsening of, improve, correct, or cure conditions that endanger your life, cause suffering or pain, cause physical deformity or malfunction, may cause or worsen a disability, or that could result in making you very sick. They are services for which there is no other medical service or site of service that could give you the same result, that is available and suitable for you, and that is more conservative or less costly. Medically Necessary services must be of a quality that meets professionally recognized standards of health care, and must be validated by records including evidence of such Medical Necessity and quality. A Member is anyone enrolled in Tufts Health Extend by choice or by assignment by the Health Connector. Your Member Handbook is this document. It details Covered Services you get with Tufts Health Extend. It is our agreement with you and includes any riders, amendments, or other documents that add to the details of Covered Services. A Tufts Health Extend Member Identification Card (ID Card) is the card that identifies you as a Member of Tufts Health Extend. Your Member ID Card includes your name and your Member identification number, and must be shown to Providers before you get services. Member Premium Contribution (Premium) is the weekly financial contribution that some Tufts Health Extend Members pay for the plan. Member Services Team is the team at Tufts Health Plan Network Health that handles all of your questions about policies, procedures, requests, and concerns. You can reach our Member Services Team at For people with partial or total hearing loss, you can reach our Member Services Team at our TTY line: We are available Monday through Friday, from 8 a.m. to 5 p.m. Network or Provider Network is the collective group of Providers who have contracted with Tufts Health Plan Network Health to provide Covered Services. Nonpreferred In-network Providers are Providers you can t see unless we give Prior Authorization. If you see a Nonpreferred In-network Provider without Prior Authorization, we may not cover the cost. Nonsymptomatic Care is care not associated with any visible health signs. Examples include well visits and physical examinations. See also Preventive Care. Nonurgent Symptomatic Care is care associated with visible health signs and symptoms but not requiring immediate health attention. Examples include visits for recurrent headaches or fatigue. Our Notice of Privacy Policy tells you about how we may use and disclose your Protected Health Information (PHI). We include our Notice of Privacy Policy in this Member Handbook. 42 For any questions, please call Tufts Health Plan Network Health at (TTY: ). You can also visit us at Network-Health.org. We re also available 24 hours a day, seven days a week, for behavioral health issues and questions.

43 24/7 NurseLine is our help line for health questions, available 24 hours a day, seven days a week. When you call our 24/7 NurseLine at 888-MY-RN-LINE ( ), you can talk with a caring and supportive health care professional at any hour and at no cost. Staff can give you information and support on health care issues like symptoms, diagnoses, and test results, as well as treatments, tests, and procedures your Provider has ordered. 24/7 NurseLine staff don t give medical advice or replace your Provider. Out-of-network refers to a provider we don t contract with to provide Covered Services to Members. Outpatient Medical Care refers to the services provided in a Provider s office, a day surgery or ambulatory care unit, an emergency room or outpatient clinic, or other location. Outpatient services include all services that aren t Inpatient Services. A Pharmacy Co-payment is a fixed amount you will be asked to pay for a covered pharmacy service. Plan Type refers to a scope of medical services, other benefits, or both that are available to eligible individuals who meet specific plan eligibility criteria. Plan Types consist of Plan Type I, Plan Type II, and Plan Type III. Post-stabilization Care Services are covered services that help you get better and stay healthy after an emergency health condition. You can get Post -stabilization Care Services at Hospitals and all health care centers that provide emergency services. Preferred In-network Providers are Providers you can see without your Primary Care Provider (PCP) first asking for Prior Authorization. Premium see Member Premium Contribution. Preventive Care includes a variety of services for adults, women, and children, such as annual physicals, blood pressure screenings, immunizations, behavioral assessments for children, and many other services to help keep you from getting sick. Primary Care is the arrangement of coordinated, comprehensive, medical services you get during a first visit with a Provider and at any time after. Primary Care involves an initial medical history intake, medical diagnosis and treatment, Behavioral Health screenings, communication of information about illness prevention, health maintenance, and Authorizations. A Primary Care Provider (PCP) is the individual Provider or team you selected, or to whom we assign you, to provide and coordinate all of your health care needs. PCPs who are doctors must practice one of the following specialties: family practice, internal medicine, general practice, adolescent and pediatric medicine, or obstetrics/gynecology (for women only). PCPs must be board-certified or eligible for board certification in their area of specialty. You may also choose a nurse practitioner as a PCP if the nurse practitioner is a participating Provider in our Network. PCPs for people with disabilities and people with HIV/AIDS may include practitioners in other specialties. Prior Authorization is a process that determines if you need a specific health care service or where you can get a specific health care service. Tufts Health Plan Network Health must authorize certain types of services and Providers before you can get the service or see the Provider. We take into account the benefit, any benefit limits, the Provider s Network status, and other factors as we make our decision. Protected Health Information (PHI) is any information (oral or written) about your past, present, or future physical or mental health or condition; or about your health care; or payment for your health care. PHI includes any individually identifiable health information, which includes any health information that a person could use to identify you. A Provider is an appropriately credentialed and licensed individual, facility, agency, institution, organization, or other entity that has an agreement with Tufts Health Plan Network Health, or its subcontractor, to deliver the Covered Services under this contract. Quality Management is the process we use to monitor and improve the quality of care our Members get. A Referral is notification from your Primary Care Provider (PCP) to us that you can get care from a different Provider. A Reconsideration of a Standard Internal Appeal is a request by you or your Authorized Representative, if you identify one, for us to review our Standard Internal Appeal decision a second time. We will review and make a decision about a Reconsideration of a Standard Internal Appeal request within 30 Days of the date we get the request. A Rehabilitation Hospital is a facility licensed to provide therapeutic services to help patients restore function after an illness or injury. These facilities provide occupational, physical, and Speech Therapy and skilled nursing care services. For Health Connector plan-related questions, please call the Health Connector s customer service center at (TTY: ), Monday through Friday, from 8 a.m. to 6 p.m. 43

44 Service Area is the geographical area within which Tufts Health Plan Network Health has developed a Network of Providers to provide adequate access to Covered Services and is authorized by the Health Connector to enroll Members. Skilled Nursing Facility is a licensed inpatient facility that provides skilled nursing to Members who don t require or no longer require the services of an acute-care Hospital. A Specialist is a doctor who is trained to provide specialty medical services. Examples include cardiologists (heart doctors), obstetricians (doctors who take care of pregnant women), and dermatologists (skin doctors), or, for Behavioral Health (mental health and/or substance abuse) services, psychologists, psychiatrists, or social workers. Speech Therapy refers to the evaluation and treatment of speech, language, voice, hearing, and fluency disorders. A Standard Internal Appeal is an oral or written request for Tufts Health Plan Network Health to review any Adverse Determination. We will review and make a decision about a Standard Internal Appeal request within 30 calendar days of the date we get the request. Urgent Care includes services that aren t emergency or routine. Utilization Management is our constant process of reviewing and evaluating the care you get to make sure that it is appropriate and what you need. Utilization Review is our process of looking at information from doctors and other clinicians to help us decide what services you need to get better or to stay healthy. Our formal review methods help us monitor the use of or evaluate the clinical necessity, appropriateness, or efficiency of Covered Services, procedures, or settings. The review methods may include but aren t limited to ambulatory review, prospective review, second opinion, certification, concurrent review, Care Management, discharge planning, or retrospective review. Workers Compensation is insurance coverage employers maintain under state and federal law to cover employees injuries and illnesses under certain conditions. Your Health Form is a series of questions we ask Members so that we can get their most up-to-date health information. Subrogation is the procedure under which Tufts Health Plan Network Health can recover the full or partial cost of benefits paid from a third person or entity, such as an insurer. 44 For any questions, please call Tufts Health Plan Network Health at (TTY: ). You can also visit us at Network-Health.org. We re also available 24 hours a day, seven days a week, for behavioral health issues and questions.

45 Tufts Health Extend Benefit and Co-payment Summary Plan Type I This Benefit and Co-payment Summary gives you information about your Tufts Health Extend benefits. For some of these benefits, you will have to pay a Co-payment. Some services have limits. Other services have yearly Co-payment Caps. Note: You don t have to pay a Co-payment for Preventive Care services such as physical examinations, Family-planning Services, health screenings, or vaccinations. For a complete listing of the types of Preventive Care services covered, please visit the U.S. Preventive Services Task Force website: uspreventiveservicestaskforce.org/uspstf/uspsabrecs.htm. A Benefit Year runs from January 1 through December 31. The services that you can get and the fees for those services are different depending on your Plan Type. To see which Plan Type you have, check your Tufts Health Plan Network Health Member ID card, or call Make sure you review the services you re eligible for under the Benefit and Co-payment Summary for your Plan Type. You re responsible for paying the Co-payment amounts listed in this Benefit and Co-payment Summary. If you can t afford the Co-payment at the time you get the service, tell your Provider. You should never go without services that you need because you can t afford the Co-payment. If you don t pay the Co-payment at the time of your visit, you will still owe the money to the Provider. The Provider may use a legal method to collect the money from you. Tufts Health Plan Network Health won t pay the Provider for the Co-payment that you owe. This summary gives you a general understanding of your benefits. If you want more information about your benefits, see the Covered Services section of this Member Handbook. This Member Handbook also has a list of services not covered. You must go to Providers (doctors, hospitals, and other health care professionals) who are part of the Tufts Health Extend Provider Network to get services. For Primary Care, you must see the Primary Care Provider (PCP) you chose or were assigned to. If you need help choosing or changing your PCP, checking on your assigned PCP, or locating a Network Provider, call or visit Network-Health.org. If you want to see providers who aren t part of the Tufts Health Extend Provider Network, we must give Prior Authorization.* The Tufts Health Extend Provider Network can change at any time. Always check with Tufts Health Plan Network Health for the most up-to-date information. If you have questions about your Tufts Health Extend benefits, call (TTY: ), Monday through Friday, from 8 a.m. to 5 p.m. All nonemergency Out-of-network visits need Prior Authorization.* * Dependents who are full-time out-of-state students between 18 and 26 years of age don t need Prior Authorization for any Covered Service, except for nonemergency inpatient Hospital stays. For Health Connector plan-related questions, please call the Health Connector s customer service center at (TTY: ), Monday through Friday, from 8 a.m. to 6 p.m. 45

46 Plan Type I COVERED SERVICES CO-PAYMENTS BENEFIT LIMIT OUTPATIENT MEDICAL CARE Abortion Services Community Health Center Visits Primary Care Provider (PCP) Specialist Office Visits Primary Care Provider (PCP) Specialist Outpatient Surgery (outpatient hospital/ambulatory surgery centers) Laboratory Services Coverage for routine eye exams for Members once every 24 months (once every 12 months for diabetics) from Network ophthalmologists or optometrists. One pair of eyeglasses once every 24 months is also covered; choose from free frame selection, or choose any other frame for up to a maximum credit of $80. Radiology Services Prior Authorization required for some services High-cost Imaging Services (MRI, CT, PET) Requires Prior Authorization INPATIENT MEDICAL CARE Inpatient Medical Care Room and Board (includes deliveries/surgery/radiology services/labs) PHARMACY Pharmacy Medication via Pharmacy (1-month supply) $1 generic drugs and over-the-counter (Tier 1) $3.65 preferred brand-name drugs (Tier 2) $3.65 nonpreferred brand-name drugs (Tier 3) Inpatient medical care covered according to Medical Necessity and subject to Prior Authorization 1-month supply Co-payments are for first-time prescriptions and refills Select over-the-counter medications may be covered with a prescription Supplies for diabetes and asthma are covered with a prescription and don t have a Co-payment Medication via Mail (3-month supply) Contraceptives EMERGENCY CARE Emergency Care $1 generic drugs and select over-the-counter medications (Tier 1) $3.65 preferred brand-name drugs (Tier 2) $3.65 nonpreferred brand-name drugs (Tier 3) 3-month supply Co-payments are for first-time prescriptions and refills Select over-the-counter medications may be covered with a prescription Supplies for diabetes are covered and don t have a Co-payment MENTAL HEALTH AND/OR SUBSTANCE ABUSE Inpatient Mental Health and/or Substance Abuse Outpatient Mental Health and/or Substance Abuse Methadone Treatment (dosing, counseling, labs) REHABILITATION SERVICES Inpatient mental health and/or substance abuse services covered according to Medical Necessity and subject to Prior Authorization After 12 visits per Benefit Year (January 1 December 31), Prior Authorization required Cardiac Rehabilitation Requires Prior Authorization Home Health Care Requires Prior Authorization Inpatient Skilled Nursing Facility Inpatient Rehabilitation Hospital or Chronic Disease Hospital Maximum of 100 calendar days total per Benefit Year (January 1 December 31) at either (or at a combination of) inpatient Skilled Nursing Facility or inpatient Rehabilitation Hospital; requires Prior Authorization Short-term Outpatient Rehabilitation Requires Prior Authorization Physical/Occupational/Speech Therapy Requires Prior Authorization 46 For any questions, please call Tufts Health Plan Network Health at (TTY: ). You can also visit us at Network-Health.org. We re also available 24 hours a day, seven days a week, for behavioral health issues and questions.

47 COVERED SERVICES CO-PAYMENTS BENEFIT LIMIT OTHER BENEFITS Ground Ambulance Emergency transport only; nonemergency transport covered if Medically Necessary and with Prior Authorization Durable Medical Equipment (DME) Supplies Prosthetics Oxygen and Respiratory Therapy Equipment Via Pharmacy Plan Type I Requires Prior Authorization Doesn t require Prior Authorization Requires Prior Authorization Requires Prior Authorization Hospice Requires Prior Authorization Orthotics (Diabetes only) Requires Prior Authorization; shoe inserts for diabetics only Podiatry Medically Necessary nonroutine foot care covered Routine foot care services for diabetics only Vision Coverage for routine eye exams for members once every 24 months (once every 12 months for diabetics) from Network ophthalmologists or optometrists. One pair of eyeglasses once every 24 months is also covered; choose from free frame selection, or choose any other frame for up to a maximum credit of $80. Wellness Family Planning Nutritional Counseling Prenatal Care Nurse Midwife Doesn t require Prior Authorization Requires Prior Authorization Doesn t require Prior Authorization Doesn t require Prior Authorization CO-PAYMENT MAXIMUMS Yearly Co-payment Maximum per Benefit Year per Member Pharmacy $250 Members excluded from paying Pharmacy Co-payments You don t need to pay a Co-payment for your prescription drugs if: You re pregnant or during the 60 Days after the month your pregnancy ended You re a patient in a nursing facility; chronic-disease, acute, or Rehabilitation Hospital; or intermediate care facility for the mentally disabled You re receiving hospice care You re obtaining family-planning supplies You have already met the Co-payment Cap for the current Benefit Year (January 1 December 31), unless your eligibility changes from Plan Type I to Plan Type II or III Be sure to tell the pharmacist if you re excluded from Co-payments when you drop off your prescriptions especially if you re pregnant. Services not covered Please see page 18 of this Member Handbook for the list of services not covered. For Health Connector plan-related questions, please call the Health Connector s customer service center at (TTY: ), Monday through Friday, from 8 a.m. to 6 p.m. 47

48 Tufts Health Extend Benefit and Co-payment Summary Plan Type II This Benefit and Co-payment Summary gives you information about your Tufts Health Extend benefits. For some of these benefits, you will have to pay a Co-payment. Some services have limits. Other services have yearly Co-payment Caps. Note: You don t have to pay a Co-payment for Preventive Care services such as physical examinations, Family-planning Services, health screenings, or vaccinations. For a complete listing of the types of Preventive Care services covered, please visit the U.S. Preventive Services Task Force website: uspreventiveservicestaskforce.org/uspstf/uspsabrecs.htm. A Benefit Year runs from January 1 through December 31. The services that you can get and the fees for those services are different depending on your Plan Type. To see which Plan Type you have, check your Tufts Health Plan Network Health Member ID card, or call Make sure you review the services you re eligible for under the Benefit and Co-payment Summary for your Plan Type. You re responsible for paying the Co-payment amounts listed in this Benefit and Co-payment Summary. If you can t afford the Co-payment at the time you get the service, tell your Provider. You should never go without services that you need because you can t afford the Co-payment. If you don t pay the Co-payment at the time of your visit, you will still owe the money to the Provider. The Provider may use a legal method to collect the money from you. Tufts Health Plan Network Health won t pay the Provider for the Co-payment that you owe. This summary gives you a general understanding of your benefits. If you want more information about your benefits, see the Covered Services section of this Member Handbook. This Member Handbook also has a list of services not covered. You must go to Providers (doctors, hospitals, and other health care professionals) who are part of the Tufts Health Extend Provider Network to get services. For Primary Care, you must see the Primary Care Provider (PCP) you chose or were assigned to. If you need help choosing or changing your PCP, checking on your assigned PCP, or locating a Network Provider, call or visit Network-Health.org. If you want to see providers who aren t part of the Tufts Health Extend Provider Network, we must give Prior Authorization.* The Tufts Health Extend Provider Network can change at any time. Always check with Tufts Health Plan Network Health for the most up-to-date information. If you have questions about your Tufts Health Extend benefits, call (TTY: ), Monday through Friday, from 8 a.m. to 5 p.m. All nonemergency Out-of-network visits need Prior Authorization.* * Dependents who are full-time out-of-state students between 18 and 26 years of age don t need Prior Authorization for any Covered Service, except for nonemergency inpatient Hospital stays. 48 For any questions, please call Tufts Health Plan Network Health at (TTY: ). You can also visit us at Network-Health.org. We re also available 24 hours a day, seven days a week, for behavioral health issues and questions.

49 Plan Type II COVERED SERVICES CO-PAYMENTS BENEFIT LIMIT OUTPATIENT MEDICAL CARE Abortion Services Community Health Center Visits Primary Care Provider (PCP) Specialist Office Visits Primary Care Provider (PCP) Specialist Outpatient Surgery (outpatient hospital/ambulatory surgery centers) $50 Co-payment $10 Co-payment $18 Co-payment $10 Co-payment $18 Co-payment $50 Co-payment Coverage for routine eye exams for Members once every 24 months (once every 12 months for diabetics) from Network ophthalmologists or optometrists. One pair of eyeglasses once every 24 months is also covered; choose from free frame selection, or choose any other frame for up to a maximum credit of $80. Laboratory Services Radiology Services Prior Authorization required for some services High-cost Imaging Services (MRI, CT, PET) $30 Co-payment Requires Prior Authorization INPATIENT MEDICAL CARE Inpatient Medical Care Room and Board (includes deliveries/surgery/radiology services/labs) $50 Co-payment Co-payments waived if transferred from another inpatient unit Inpatient medical care covered according to Medical Necessity and subject to Prior Authorization PHARMACY Pharmacy Medication via Pharmacy (1-month supply) $10 generic drugs and select over-the-counter medications (Tier 1) $20 preferred brand-name drugs (Tier 2) $40 nonpreferred brand-name drugs (Tier 3) 1-month supply Co-payments are for first-time prescriptions and refills Select over-the-counter medications may be covered with a prescription Supplies for diabetes and asthma are covered and don t have a Co-payment Medication via Mail (3-month supply) Contraceptives EMERGENCY CARE Emergency Care $20 generic drugs and select over-the-counter medications (Tier 1) $40 preferred brand-name drugs (Tier 2) $120 nonpreferred brand-name drugs (Tier 3) $50 Co-payment MENTAL HEALTH AND/OR SUBSTANCE ABUSE Inpatient Mental Health and/or Substance Abuse 3-month supply Co-payments are for first-time prescriptions and refills Select over-the-counter medications may be covered with a prescription Supplies for diabetes are covered and don t have a Co-payment $50 Co-payment Inpatient mental health and/or substance abuse services covered according to Medical Necessity and subject to Prior Authorization Co-payment waived if transferred from another inpatient unit Outpatient Mental Health and/or Substance Abuse Methadone Treatment (dosing, counseling, labs) $10 Co-payment After 12 visits per Benefit Year, (January 1 December 31) Prior Authorization required For Health Connector plan-related questions, please call the Health Connector s customer service center at (TTY: ), Monday through Friday, from 8 a.m. to 6 p.m. 49

50 Plan Type II COVERED SERVICES CO-PAYMENTS BENEFIT LIMIT REHABILITATION SERVICES Cardiac Rehabilitation Requires Prior Authorization Home Health Care Requires Prior Authorization Inpatient Skilled Nursing Facility Inpatient Rehabilitation Hospital or Chronic Disease Hospital Short-term Outpatient Rehabilitation Physical/Occupational/Speech Therapy $50 Co-payment Maximum of 100 calendar days total per Benefit Year (January 1 December 31) at either (or at a combination of) inpatient Skilled Nursing Facility or inpatient Rehabilitation Hospital; requires Prior Authorization Co-payment waived if transferred from another inpatient unit $10 Co-payment Requires Prior Authorization OTHER BENEFITS Ground Ambulance Emergency transport only; nonemergency transport covered if Medically Necessary and with Prior Authorization Durable Medical Equipment (DME) Supplies Prosthetics Oxygen and Respiratory Therapy Equipment Via Pharmacy Requires Prior Authorization Doesn t require Prior Authorization Requires Prior Authorization Requires Prior Authorization Hospice Requires Prior Authorization Orthotics (Diabetes Only) Requires Prior Authorization; shoe inserts for diabetics only Podiatry Vision Wellness Family Planning Nutritional Counseling Prenatal Care Nurse Midwife CO-PAYMENT MAXIMUM Yearly Co-payment Maximum per Benefit Year per Member $5 Co-payment (routine diabetics) $18 Co-payment (nonroutine diabetics/ nondiabetics) $10 Co-payment (optometrist) $18 Co-payment (ophthalmologist) Medical Pharmacy Routine foot care services for diabetics only Medically Necessary nonroutine foot care covered Coverage for routine eye exams for Members once every 24 months (once every 12 months for diabetics) from Network ophthalmologists or optometrists. One pair of eyeglasses once every 24 months is also covered; choose from free frame selection, or choose any other frame for up to a maximum credit of $80. Doesn t require Prior Authorization Requires Prior Authorization Doesn t require Prior Authorization Doesn t require Prior Authorization $750 $ For any questions, please call Tufts Health Plan Network Health at (TTY: ). You can also visit us at Network-Health.org. We re also available 24 hours a day, seven days a week, for behavioral health issues and questions.

51 Members excluded from paying Pharmacy Co-payments You don t need to pay a Co-payment for your prescription drugs if: You re pregnant or during the 60 Days after the month your pregnancy ended You re a patient in a nursing facility; chronic-disease, acute, or Rehabilitation Hospital; or intermediate care facility for the mentally disabled You re receiving hospice care You re obtaining family-planning supplies You have already met the Co-payment Cap for the current Benefit Year (January 1 December 31), unless your Plan Type changes from Plan Type II to Plan Type III Be sure to tell the pharmacist if you re excluded from Co-payments when you drop off your prescriptions especially if you re pregnant. Members excluded from paying Medical Co-payments You don t need to pay a Co-payment for all other services if you have already met the Co-payment Cap for the current Benefit Year (January 1 December 31), unless your eligibility changes from Plan Type II to Plan Type III. If your Plan Type changes, we will apply any Medical Co-payments you have already paid to your new Plan Type s Co-payment Cap amount. Services not covered Please see page 18 of this Member Handbook for the list of services not covered. For Health Connector plan-related questions, please call the Health Connector s customer service center at (TTY: ), Monday through Friday, from 8 a.m. to 6 p.m. 51

52 Tufts Health Forward Benefit and Co-payment Summary Plan Type III This Benefit and Co-payment Summary gives you information about your Tufts Health Extend benefits. For some of these benefits, you will have to pay a Co-payment. Some services have limits. Other services have yearly Co-payment Caps. Note: You don t have to pay a Co-payment for Preventive Care services such as physical examinations, Family-planning Services, health screenings, or vaccinations. For a complete listing of the types of Preventive Care services covered, please visit the U.S. Preventive Services Task Force website: uspreventiveservicestaskforce.org/uspstf/uspsabrecs.htm. A Benefit Year runs from January 1 through December 31. The services that you can get and the fees for those services are different depending on your Plan Type. To see which Plan Type you have, check your Tufts Health Plan Network Health Member ID card, or call Make sure you review the services you re eligible for under the Benefit and Co-payment Summary for your Plan Type. You re responsible for paying the Co-payment amounts listed in this Benefit and Co-payment Summary. If you can t afford the Co-payment at the time you get the service, tell your Provider. You should never go without services that you need because you can t afford the Co-payment. If you don t pay the Co-payment at the time of your visit, you will still owe the money to the Provider. The Provider may use a legal method to collect the money from you. Tufts Health Plan Network Health won t pay the Provider for the Co-payment that you owe. This summary gives you a general understanding of your benefits. If you want more information about your benefits, see the Covered Services section of this Member Handbook. This Member Handbook also has a list of services not covered. You must go to Providers (doctors, hospitals, and other health care professionals) who are part of the Tufts Health Extend Provider Network to get services. For Primary Care, you must see the Primary Care Provider (PCP) you chose or were assigned to. If you need help choosing or changing your PCP, checking on your assigned PCP, or locating a Network Provider, call or visit Network-Health.org. If you want to see providers who aren t part of the Tufts Health Extend Provider Network, we must give Prior Authorization.* The Tufts Health Extend Provider Network can change at any time. Always check with Tufts Health Plan Network Health for the most up-to-date information. If you have questions about your Tufts Health Extend benefits, call (TTY: ), Monday through Friday, from 8 a.m. to 5 p.m. All nonemergency Out-of-network visits need Prior Authorization.* * Dependents who are full-time out-of-state students between 18 and 26 years of age don t need Prior Authorization for any Covered Service, except for nonemergency inpatient Hospital stays. 52 For any questions, please call Tufts Health Plan Network Health at (TTY: ). You can also visit us at Network-Health.org. We re also available 24 hours a day, seven days a week, for behavioral health issues and questions.

53 Plan Type III COVERED SERVICES CO-PAYMENTS BENEFIT LIMIT OUTPATIENT MEDICAL CARE Abortion Services Community Health Center Visits Primary Care Provider (PCP) Specialist Office Visits Primary Care Provider (PCP) Specialist Outpatient Surgery (outpatient hospital/ambulatory surgery centers) $100 Co-payment $15 Co-payment $22 Co-payment $15 Co-payment $22 Co-payment $125 Co-payment Coverage for routine eye exams for Members once every 24 months (once every 12 months for diabetics) from Network ophthalmologists or optometrists. One pair of eyeglasses once every 24 months is also covered; choose from free frame selection, or choose any other frame for up to a maximum credit of $80 Laboratory Services Radiology Services Prior Authorization required for some services High-cost Imaging Services (MRI, CT, PET) $60 Co-payment Requires Prior Authorization INPATIENT MEDICAL CARE Inpatient Medical Care Room and Board (includes deliveries/surgery/radiology services/labs) PHARMACY Pharmacy Medication via Pharmacy (1-month supply) Medication via Mail (3-month supply) Contraceptives EMERGENCY CARE $250 Co-payment Co-payments waived if transferred from another $12.50 generic drugs and select over-the-counter medications (Tier 1) $25 preferred brand-name drugs (Tier 2) $50 nonpreferred brand-name drugs (Tier 3) $25 generic drugs and select over-the-counter medications (Tier 1) $50 preferred brand-name drugs (Tier 2) $150 nonpreferred brand-name drugs (Tier 3) inpatient unit Inpatient medical care covered according to Medical Necessity and subject to Prior Authorization 1-month supply Co-payments are for first-time prescriptions and refills Select over-the-counter medications may be covered with a prescription Supplies for diabetes and asthma are covered with no Co-payment 3-month supply Co-payments are for first-time prescriptions and refills Select over-the-counter medications may be covered with a prescription Supplies for diabetes are covered with no Co-payment Emergency Care $100 Co-payment Co-payment waived if transferred from inpatient MENTAL HEALTH AND/OR SUBSTANCE ABUSE Inpatient Mental Health and/or Substance Abuse unit of a Hospital $250 Co-payment Inpatient mental health and substance abuse services covered according to Medical Necessity and subject to Prior Authorization Co-payment waived if transferred from another inpatient unit Outpatient Mental Health and/or Substance Abuse Methadone Treatment (dosing, counseling, labs) $15 Co-payment After 12 visits per Benefit Year (January 1 December 31), Prior Authorization required For Health Connector plan-related questions, please call the Health Connector s customer service center at (TTY: ), Monday through Friday, from 8 a.m. to 6 p.m. 53

54 Plan Type III COVERED SERVICES CO-PAYMENTS BENEFIT LIMIT REHABILITATION SERVICES Cardiac Rehabilitation Requires Prior Authorization Home Health Care Requires Prior Authorization Inpatient Skilled Nursing Facility (SNF) Inpatient Rehabilitation Hospital or Chronic Disease Hospital Short-term Outpatient Rehabilitation Physical/Occupational/Speech Therapy Maximum of 100 calendar days total per Benefit Year $250 Co-payment (January 1 December 31) at either (or at a combination of) inpatient Skilled Nursing Facility or inpatient Rehabilitation Hospital; requires Prior Authorization Co-payment waived if transferred from another inpatient unit $20 Co-payment Requires Prior Authorization OTHER BENEFITS Ground Ambulance Emergency transport only; nonemergency transport covered if Medically Necessary and with Prior Authorization Durable Medical Equipment (DME) Supplies Prosthetics Oxygen and Respiratory Therapy Equipment Via Pharmacy 10% of cost 10% of cost 10% of cost 10% of cost Requires Prior Authorization Doesn t require Prior Authorization Requires Prior Authorization Requires Prior Authorization Hospice Requires Prior Authorization Orthotics (Diabetes Only) Requires Prior Authorization; shoe inserts for diabetics only Podiatry Vision Wellness Family Planning Nutritional Counseling Prenatal Care Nurse Midwife CO-PAYMENT MAXIMUM Yearly Co-payment Maximum per Benefit Year per Member $10 Co-payment (routine diabetics) $22 Co-payment (nonroutine diabetics/ nondiabetics) $20 Co-payment (optometrist) $22 Co-payment (ophthalmologist) Medical Pharmacy Routine foot care services for diabetics only Medically Necessary nonroutine foot care covered Coverage for routine eye exams for members once every 24 months (once every 12 months for diabetics) from Network ophthalmologists or optometrists. One pair of eyeglasses once every 24 months is also covered; choose from free frame selection, or choose any other frame for up to a maximum credit of $80. Doesn t require Prior Authorization Requires Prior Authorization Doesn t require Prior Authorization Doesn t require Prior Authorization $1,500 $ For any questions, please call Tufts Health Plan Network Health at (TTY: ). You can also visit us at Network-Health.org. We re also available 24 hours a day, seven days a week, for behavioral health issues and questions.

55 Members excluded from paying Pharmacy Co-payments You don t need to pay a Co-payment for your prescription drugs if: You re pregnant or during the 60 Days after the month your pregnancy ended You re a patient in a nursing facility; chronic-disease, acute, or Rehabilitation Hospital; or intermediate care facility for the mentally disabled You re receiving hospice care You re obtaining family-planning supplies Your Plan Type changes from Plan Type III to Plan Type I or Plan Type II and you have already met the new Plan Type s Co-payment Cap for the current Benefit Year (January 1 December 31) Be sure to tell the pharmacist if you re excluded from Co-payments when you drop off your prescriptions especially if you re pregnant. Members excluded from paying Medical Co-payments You don t need to pay a Co-payment for all other services if: You have already met the Co-payment Cap for the current Benefit Year (January 1 December 31) Your Plan Type changes from Plan Type III to Plan Type II and you have already met the new Plan Type s Co-payment Cap for the current Benefit Year (January 1 December 31) Services not covered Please see page 18 of this Member Handbook for the list of services not covered. For Health Connector plan-related questions, please call the Health Connector s customer service center at (TTY: ), Monday through Friday, from 8 a.m. to 6 p.m. 55

56 56 For any questions, please call Tufts Health Plan Network Health at (TTY: ). You can also visit us at Network-Health.org. We re also available 24 hours a day, seven days a week, for behavioral health issues and questions.