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Your Choice 3-Tier Hospital Tiering Effective January 1, 2014

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Your Choice 3-Tier Hospital Tiering Effective January 1, 2014 Your Choice 3-Tier Hospital Tiering Effective January 1, 2014 This is a listing of all Tufts Health Plan network hospitals and their tiering placement for the Your Choice 3-tier plan options. Tiered Provider Network: This plan includes the Tiered Provider Network called Your 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 Your Choice provider directory or visit the provider search tool attuftshealthplan.com and click on Find a Doctor to determine the tier of providers in the Your Choice Tiered Provider Network. If you need a paper copy of the provider directory, please contact Member Services. Massachusetts - East HOSPITAL TIER HOSPITAL TIER Anna Jaques Hospital 1 Massachusetts Eye and Ear Infirmary 1 Beth Israel Deaconess Hospital - Needham 1 Massachusetts General Hospital 3 Beth Israel Deaconess Medical Center 1 Merrimack Valley Hospital 1 Boston Medical Center 1 Metrowest Medical Center (Framingham or Leonard Morse) 1 Brigham and Women’s Hospital 3 Milton Hospital 1 Brockton Hospital 1 Morton Hospital and Medical Center 1 Cambridge Hospital (part of Cambridge Health Alliance) 3 Mount Auburn Hospital 1 Cape Cod Hospital 3 Nantucket Cottage Hospital 3 Carney Hospital 1 New England Baptist Hospital 1 Charlton Memorial Hospital 2 Newton-Wellesley Hospital 3 Children’s Hospital 3 North Shore Medical Center (Salem or Union campuses) 3 Dana-Farber Cancer Institute 2 Northeast Hospital Corp. 1 (Addison Gilbert or Beverly Hospitals) Emerson Hospital 3 Norwood Hospital 1 Falmouth Hospital 3 Quincy Medical Center 1 Faulkner Hospital 3 Saints Memorial Medical Center 1 Good Samaritan Medical Center 1 1 Hallmark Health Systems South Shore Hospital 3 (Lawrence Memorial or Melrose Wakefield Hospitals) St. Anne’s Hospital 1 Holy Family Hospital 1 St. Elizabeth’s Medical Center 1 Jordan Hospital 1 St. Luke’s Hospital 2 Lahey Clinic Hospital 1 Sturdy Memorial Hospital 1 Lawrence General Hospital 1 Tobey Hospital 2 Lowell General Hospital 1 Tufts Medical Center 1 Martha’s Vineyard Hospital 3 Winchester Hospital 1 continued on reverse For more information, contact the sales offices at: Watertown 800-208-8013 | Worcester 800-208-9545 Springfield 800-337-4447 | Providence 800-455-2012 tuftshealthplan.com 9/13 Massachusetts - Central New Hampshire HOSPITAL TIER HOSPITAL TIER Athol Memorial Hospital 1 Catholic Medical Center 2 Clinton Hospital 2 Elliot Hospital 2 Harrington Hospital 1 Exeter Hospital 2 HealthAlliance Hospital 2 Mary Hitchcock Memorial Hospital 2 Henry Heywood Hospital 1 Parkland Medical Center 2 Marlborough Hospital 2 Portsmouth Regional Hospital 2 Milford Regional Medical Center 1 Southern N.H. Regional Medical Center 2 Nashoba Valley Medical Center 1 St. Joseph Hospital 2 St. Vincent Hospital 1 UMass Memorial Medical Center 2 Rhode Island HOSPITAL TIER Massachusetts - West Kent County Hospital 2 HOSPITAL TIER Landmark Medical Center 2 Baystate Medical Center 1 Memorial Hospital of Rhode Island 2 Berkshire Medical Center 3 Miriam Hospital 2 Cooley Dickinson Hospital 2 Newport Hospital 2 Fairview Hospital 3 Rhode Island Hospital - 2 Including Hasbro Children’s Hospital Franklin Medical Center 1 Roger Williams Medical Center 2 Holyoke Hospital 3 South County Hospital 2 Mary Lane Hospital 1 St. Joseph’s Hospital 2 Mercy Medical Center 1 The Westerly Hospital 2 Noble Hospital 1 Women and Infants Hospital 2 North Adams Regional Hospital 3 Wing Memorial Hospital 2 Vermont HOSPITAL TIER Southwestern Vermont Medical Center 2 TIER 1 Massachusetts Anna Jaques Hospital Merrimack Valley Hospital Athol Memorial Hospital Metrowest Medical Center (Framingham or Leonard Morse) Baystate Medical Center Milford Regional Medical Center Beth Israel Deaconess Hospital - Needham Milton Hospital Beth Israel Deaconess Medical Center Morton Hospital and Medical Center Boston Medical Center Mount Auburn Hospital Brockton Hospital Nashoba Valley Medical Center Carney Hospital New England Baptist Hospital Franklin Medical Center Noble Hospital Good Samaritan Medical Center Northeast Hospital Corp. (Addison Gilbert or Beverly Hospitals) Harrington Hospital Norwood Hospital Henry Heywood Hospital Quincy Medical Center Holy Family Hospital Saints Memorial Medical Center Jordan Hospital South Shore Hospital Lahey Clinic Hospital St. Anne’s Hospital Lawrence General Hospital St. Elizabeth’s Medical Center Lowell General Hospital St. Vincent Hospital Mary Lane Hospital Sturdy Memorial Hospital Massachusetts Eye and Ear Infirmary Tufts Medical Center Mercy Medical Center Winchester Hospital TIER 2 Massachusetts Charlton Memorial Hospital Marlborough Hospital Clinton Hospital St. Luke’s Hospital Cooley Dickinson Hospital Tobey Hospital Dana-Farber Cancer Institute UMass Memorial Medical Center HealthAlliance Hospital Wing Memorial Hospital New Hampshire Catholic Medical Center Parkland Medical Center Elliot Hospital Portsmouth Regional Hospital Exeter Hospital Southern N.H. Regional Medical Center Mary Hitchcock Memorial Hospital St. Joseph Hospital TIER 2 Rhode Island Kent County Hospital Roger Williams Medical Center Landmark Medical Center South County Hospital Memorial Hospital of Rhode Island St. Joseph’s Hospital Miriam Hospital The Westerly Hospital Newport Hospital Women and Infants Hospital Rhode Island Hospital - Including Hasbro Children’s Hospital Vermont Southwestern Vermont Medical Center TIER 3 Massachusetts Berkshire Medical Center Hallmark Health Systems Brigham and Women’s Hospital (Lawrence Memorial or Melrose Wakefield Hospitals) Cambridge Hospital (part of Cambridge Health Alliance) Holyoke Hospital Cape Cod Hospital Martha’s Vineyard Hospital Children’s Hospital Massachusetts General Hospital Emerson Hospital Nantucket Cottage Hospital Fairview Hospital Newton-Wellesley Hospital Falmouth Hospital North Adams Regional Hospital Faulkner Hospital North Shore Medical Center (Salem or Union campuses).
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