Granite Premier Choice Tiering Effective January 1, 2016

This is a listing of all Tufts Health Freedom Plan network and their tiering placement for the Granite Premier Choice plan options.

Tiered Provider Network: This plan includes the Tiered Provider Network called Granite Premier Choice. In this plan members may pay different levels of copayments, coinsurance, and/or deductibles depending on their plan design and the tier of the provider delivering a covered service or supply. This plan may make changes to a provider’s benefit tier annually. Please consult the Granite Premier Choice provider directory or visit the provider Massachusettssearch tool at thfp.com - East and click on Find a Doctor to determine the tier of providers in the Granite Premier Choice Tiered Provider Network. If you need a paper copy of the provider directory, please contact Member Services. New Hampshire Maine

HOSPITAL TIER HOSPITAL TIER

Alice Peck Day Hospital 2 Maine Medical Center 2 Androscoggin Valley Hospital 2 Southern Maine Medical Center 2 Catholic Medical Center 1 York Hospital 2 Cheshire Medical Center 1 Concord Hospital 1 Rhode Island Cottage Hospital 2 HOSPITAL TIER Dartmouth Hitchcock Memorial Hospital 1 Kent County Hospital 2 Elliot Hospital 2 Memorial Hospital of RI 2 Exeter Hospital 1 Miriam Hospital 2 Franklin Regional Hospital 1 Newport Hospital 2 Frisbie Memorial Hospital 2 Landmark Medical Center 2 Huggins Hospital 2 Rhode Island Hospital 2 Lakes Region General Hospital 1 Roger Williams Hospital 2 Littleton Regional Hospital 1 South County Hospital 2 Memorial Hospital 1 St. Joseph Hospital (Providence) 2 Monadnock Community Hospital 2 The Westerly Hospital 2 New London Hospital 2 Women and Infants Hospital 2 Parkland Medical Center 2 Portsmouth Regional Hospital 2 Vermont Southern N.H. Medical Center 1 Speare Memorial Hospital 2 HOSPITAL TIER

St. Joseph Hospital (Nashua) 2 Brattleboro Memorial Hospital 2 Upper Connecticut Valley Hospital 2 Mount Ascutney Hospital 2 Valley Regional Hospital 2 Southwestern Vermont Medical Center 2 Weeks Medical Center 2 Wentworth-Douglass General Hospital 2 continued on reverse

For more information, contact your sales office: 603.228.7450

thfp.com

02/16

HOSPITAL TIER HOSPITAL TIER

Anna Jaques Hospital 2 Lahey Clinic Hospital 2 Athol Hospital 2 Lawrence General Hospital 2 Baystate Franklin Medical Center 2 2 Baystate Mary Lane Hospital 2 Marlborough Hospital 2 Baystate Medical Center 2 Martha's Vineyard hospital 2 Baystate Noble Hospital 2 Massachusetts Eye & Ear Infirmary 2 Baystate Wing Memorial Hospital 2 Massachusetts General Hospital 1 Berkshire Medical Center 2 Mercy Medical Center 2 Beth Israel Deaconess Medical Center - Plymouth 2 Metrowest Medical Center 2 Beth Israel Deaconess Medical Center Boston 2 Milford Regional Medical Center 2 Beth Israel Deaconess Medical Center Needham 2 Morton Hospital and Medical Center 2 Beth Isreal Deaconess Medical Center - Milton 2 2 Boston Children's Hospital 2 Cottage Hospital 2 2 Nashoba Valley Medical Center 2 Brigham & Women's Faulkner Hospital 2 New England Baptist Hospital 2 Brigham and Women's Hospital 1 Newton-Wellesley Hospital 2 (Signature) 2 North Shore Medical Center (Salem Hospital) 2 Cambridge Health Alliance 2 North Shore Medical Center (Union Hospital) 2 Northeast Hospital Corp (Addison Gilbert 2 2 Hospital) 2 Northeast Hospital Corp (Beverly Hospital) 2 Charlton Memorial Hospital 2 2 Clinton Hospital 2 2 Cooley Dickinson Hospital 2 St. Anne's Hospital 2 Dana-Farber Cancer Institute 2 St. Elizabeth's Medical Center 2 2 St. Luke's Hospital 2 Fairview Hospital 2 St. Vincent Hospital 2 2 Sturdy Memorial Hospital 2 Good Samaritan Medical Center 2 Tobey Hospital (SouthCoast) 2 Hallmark Lawrence Memorial Hosp 2 2 Hallmark Melrose Wakefield Hospital 2 UMass Memorial Medical Center 2 Harrington Hospital 2 2 HealthAlliance Hospital 2 Heywood Hospital 2 Holy Family Hospital 2 Holy Family Hospital at Merrimack Valley Hospital 2 2