Tufts Medicare Preferred HMO Prime Rx Plus (HMO)
Available to residents of Essex County, MA for 2026. Contract H2256, plan 001, segment 1.
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- Plan health benefits
- Benefits in plain text
- Rx cost-sharing for all pharmacies and tiers
- Other plans in Essex County
- Plan website
- Browse the Tufts Medicare Preferred HMO Prime Rx Plus (HMO) formulary
Plan details
| Monthly premium (Part C + D) | $255.00 |
|---|---|
| — medical (Part C) part | $187.00 |
| — drug (Part D) part | $68.00? |
| Monthly premium with full Extra Help (LIS) | $219.20?drug (Part D) part $32.20; Extra Help does not cover the medical (Part C) premium |
| Part B premium reduction (giveback) | None |
| Health plan deductible (in-network) | None |
| In-network out-of-pocket maximum | $3,850.00? |
| Drug deductible | $0.00 |
| Drug out-of-pocket threshold | $2,100.00 |
| Plan type | HMO? |
| Contract / plan | H2256-001-1 |
| Offered by | Tufts Health Plan |
| Parent organization | Point32Health, Inc. |
| Formulary drugs | 3,529 |
| Formulary exception tier | 4? |
| Pharmacy search | www.thpmp.org/hmo-pharmacies |
| Member services | (877)218-4835TTY 711 |
CMS star ratings
- Overall
- 4 out of 5 stars for Overall
- Health plan (Part C)
- 4 out of 5 stars for Health plan (Part C)
- Drug plan (Part D)
- 4.5 out of 5 stars for Drug plan (Part D)
Published per contract — every plan under contract H2256 shares this rating.
Plan health benefits
| Service | In-network |
|---|---|
| Doctor visits | |
| Primary care doctor | $10 copay |
| Specialist | $15 copay(referral required) |
| Other health care professional | $10–$20 copay(referral required) |
| Additional telehealth services | $0–$75 copay(authorization and referral required) |
| Preventive care | |
| Medicare-covered preventive services | $0 copay |
| Annual physical exam | $0 copay |
| Kidney disease education | $0 copay |
| Glaucoma screening | $0 copay |
| Diabetes self-management training | $0 copay |
| Diagnostic tests, labs and imaging | |
| Diagnostic tests and procedures | $0–$30 copay(authorization required) |
| Lab services | $0–$30 copay(authorization required) |
| Diagnostic radiology (e.g. MRI, CT) | 20% coinsurance(authorization required) |
| Therapeutic radiology | $0 copay(authorization required) |
| Outpatient x-rays | $0–$30 copay(authorization required) |
| Emergency and urgent care | |
| Emergency room | $110 copay |
| Urgent care | $30 copay |
| Worldwide emergency coverage | $110 copay |
| Worldwide urgent care | $30 copay |
| Worldwide emergency transportation | $150 copay |
| Hospital care | |
| Inpatient hospital stay | $200 per stay(authorization required) |
| Outpatient hospital services | $0–$75 copay(authorization and referral required) |
| Outpatient observation | $75 copay(authorization required) |
| Ambulatory surgical center | $0–$75 copay(authorization and referral required) |
| Outpatient blood services | $0 copay |
| Skilled nursing and home health | |
| Skilled nursing facility | $20 per day for days 1–20; $0 per day for days 21–100(authorization required) |
| Home health care | $0 copay(authorization and referral required) |
| Kidney dialysis | 20% coinsurance |
| Rehabilitation | |
| Occupational therapy | $15 copay(authorization and referral required) |
| Physical therapy and speech-language therapy | $15 copay(authorization and referral required) |
| Cardiac rehabilitation | $0 copay(authorization and referral required) |
| Pulmonary rehabilitation | $0 copay(authorization and referral required) |
| Mental health and substance use | |
| Inpatient psychiatric hospital stay | $200 per stay |
| Outpatient mental health, individual session | $0–$10 copay |
| Outpatient mental health, group session | $0–$10 copay |
| Psychiatrist, individual session | $0–$10 copay |
| Psychiatrist, group session | $0–$10 copay |
| Partial hospitalization | $0 copay |
| Intensive outpatient program | $0 copay |
| Outpatient substance use, individual session | $10 copay |
| Outpatient substance use, group session | $10 copay |
| Opioid treatment program | $15 copay |
| Ambulance and transportation | |
| Ground ambulance | $150 copay(authorization required) |
| Air ambulance | $150 copay(authorization required) |
| Transportation to plan-approved locations | $0 copay |
| Medical equipment and supplies | |
| Durable medical equipment (e.g. wheelchairs, oxygen) | 10% coinsurance(authorization required) |
| Prosthetics (e.g. braces, artificial limbs) | 10% coinsurance(authorization required) |
| Medical supplies | 0%–10% coinsurance(authorization required) |
| Diabetes supplies | $0 copay(authorization required) |
| Diabetic therapeutic shoes or inserts | $0 copay(authorization required) |
| Chiropractic, acupuncture and foot care | |
| Chiropractic (Medicare-covered) | $15 copay(authorization and referral required) |
| Routine chiropractic care | Not covered |
| Acupuncture | $0 copay |
| Foot exams and treatment (Medicare-covered) | $15 copay(referral required) |
| Routine foot care | Not covered |
| Dental? | |
| Medicare-covered dental services | $15 copay(authorization and referral required) |
| Oral exams | Not covered |
| Cleanings | Not covered |
| Fluoride treatment | Not covered |
| Dental x-rays | Not covered |
| Other diagnostic dental services | Not covered |
| Other preventive dental services | Not covered |
| Restorative services (fillings, crowns) | Not covered |
| Endodontics (root canals) | Not covered |
| Periodontics (gum disease) | Not covered |
| Dentures and other removable prosthodontics | Not covered |
| Maxillofacial prosthetics | Not covered |
| Implants | Not covered |
| Bridges and other fixed prosthodontics | Not covered |
| Oral and maxillofacial surgery | Not covered |
| Orthodontics | Not covered |
| Adjunctive general services | Not covered |
| Vision? | |
| Eye exam (Medicare-covered) | $15 copay(referral required) |
| Routine eye exam | $15 copay(referral required, limits apply) |
| Eyewear after cataract surgery (Medicare-covered) | $0 copay(limits apply) |
| Eyewear plan limit | $150 plan limit every year |
| Contact lenses | $0 copay(limits apply) |
| Eyeglasses (frames and lenses) | $0 copay(limits apply) |
| Eyeglass lenses | $0 copay(limits apply) |
| Eyeglass frames | $0 copay(limits apply) |
| Eyewear upgrades | $0 copay(limits apply) |
| Hearing? | |
| Hearing exam (Medicare-covered) | $15 copay |
| Routine hearing exam | $0 copay(limits apply) |
| Hearing aid fitting and evaluation | $0 copay(limits apply) |
| Hearing aids (all types) | $250–$1,150 copay(limits apply) |
| Hearing aids, inner ear | Not covered |
| Hearing aids, outer ear | Not covered |
| Hearing aids, over the ear | Not covered |
| Medicare Part B drugs | |
| Part B insulin | $0 copay(authorization required, step therapy may apply) |
| Chemotherapy and radiation drugs | $0 copay(authorization required, step therapy may apply) |
| Other Part B drugs | $0 copay(authorization required, step therapy may apply) |
| Other extra benefits? | |
| Over-the-counter (OTC) allowance | Not covered |
| Meals after a hospital stay or for a chronic condition | Not covered |
| Fitness benefit | $0 copay(limits apply) |
| Health education | $0 copay(limits apply) |
| Nutritional / dietary benefit | $0 copay(limits apply) |
| Extra smoking and tobacco cessation counseling | Not covered |
| Enhanced disease management | Not covered |
| Telemonitoring | Not covered |
| Remote access technologies (web/phone, nurse line) | Not covered |
| Home and bathroom safety devices | $0 copay(limits apply) |
| Counseling services | Not covered |
| In-home safety assessment | $0 copay(limits apply) |
| Personal emergency response system (PERS) | Not covered |
| Medical nutrition therapy | $0 copay(limits apply) |
| Post-discharge in-home medication reconciliation | Not covered |
| Re-admission prevention | Not covered |
| Wigs for hair loss from chemotherapy | $0 copay(limits apply) |
| Weight management programs | $0 copay(limits apply) |
| Alternative therapies | $0 copay(limits apply) |
| Therapeutic massage | $0 copay(limits apply) |
| Adult day health services | Not covered |
| Home-based palliative care | Not covered |
| In-home support services | Not covered |
| Support for caregivers | Not covered |
In-network cost-sharing as the plan filed it with CMS (CMS plan benefit package (PBP) files, CY2026). A range means the cost depends on the service or setting. Rows the filing does not state are left out rather than guessed. Contact the plan for the full Evidence of Coverage.
Drug tiers — preferred pharmacy, initial coverage
| Tier | Cost-sharing |
|---|---|
| Tier 1 | $2.00 |
| Tier 2 | $4.00 |
| Tier 3 | 20% |
| Tier 4 | 40% |
| Tier 5 | 33% |
| Tier 6 | $0.00 |
Rx cost-sharing by coverage phase
| Tier | 30-day supply | 90-day supply | ||||
|---|---|---|---|---|---|---|
| Preferred | Standard | Mail Order | Preferred | Standard | Mail Order | |
| Initial coverage phase | ||||||
| Tier 1: Preferred Generic | $2.00 | $2.00 | $2.00 | $6.00 | $6.00 | $4.00 |
| Tier 2: Generic | $4.00 | $4.00 | $4.00 | $12.00 | $12.00 | $8.00 |
| Tier 3: Preferred Brand | 20% | 20% | 20% | 20% | 20% | 20% |
| Tier 4: Non-Preferred Drug | 40% | 40% | 40% | 40% | 40% | 40% |
| Tier 5: Specialty Tier | 33% | 33% | 33% | n/a | n/a | n/a |
| Tier 6: Select Care Drugs | $0.00 | $0.00 | n/a | $0.00 | $0.00 | n/a |
| Catastrophic coverage phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 2: Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 3: Preferred Brand | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 4: Non-Preferred Drug | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 5: Specialty Tier | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 6: Select Care Drugs | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
Also available in 1 other MA county
Benefits in plain text
Tufts Medicare Preferred HMO Prime Rx Plus (HMO) (H2256-001-1) is a 2026 HMO Medicare Advantage plan offered by Tufts Health Plan, available to residents of Essex County, MA.
The monthly premium is $255.00 (Part C and Part D together).
With full Extra Help (the Low-Income Subsidy), the total monthly premium is $219.20.
There is no in-network deductible for health services.
Its in-network out-of-pocket maximum is $3,850.00.
The drug deductible is $0.00.
The plan's formulary lists 3,529 drugs.
At a preferred pharmacy in the initial coverage phase, a 30-day supply costs tier 1: $2.00; tier 2: $4.00; tier 3: 20%; tier 4: 40%; tier 5: 33%; tier 6: $0.00.
CMS gives the plan's contract (H2256) an overall rating of 4 out of 5 stars.
Email a copy of the plan benefit details
Plan facts come from the CMS quarterly prescription drug plan public use files; the premium split, Extra Help premium, MOOP and plan type from the CMS Landscape file; the Part B giveback and health benefits from the CMS plan benefit package (PBP) files.