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Frequently Asked Questions

What is an ANOC?

The Annual Notice of Change (ANOC) is a personalized letter sent to all members that highlights any changes to their benefits and costs for the upcoming year. The format of the letter is determined by the Centers for Medicare and Medicaid Services (CMS) to ensure that Medicare Advantage plan members receive complete and accurate information about their coverage.

Information contained in the ANOC includes:

  • Your premium for the upcoming year
  • Any changes to the cost or coverage of your medical benefits
  • Any new medical benefits that will be part of your coverage in the upcoming year or non-Medicare benefits removed for the upcoming year
  • Any changes to the cost of prescriptions in your prescription drug benefit (if you are enrolled in a prescription drug plan)
  • Any changes to the drugs covered in your prescription drug benefit

What is an EOC?

If you are renewing into the same plan, you will receive along with your ANOC, a copy of the Evidence of Coverage (EOC) for the plan you are enrolled in. The EOC provides a detailed description of the benefits and costs for your plan. It also explains your rights as a member and how to use your coverage for medical care or prescription drug. Information contained in the EOC includes:

  • Important phone numbers and resources
  • A medical benefits chart that explains what is covered and what you pay
  • How to use your prescription drug coverage and the cost of your prescription drugs (if you are in a prescription drug plan)
  • Your rights and responsibilities
  • What to do if you have a problem or complaint
  • The EOC is available here. (Note: the ANOC is a personalized letter with member specific information and therefore not available on our website. The EOC’s on our Web site are for our individual plans.)

If you have any questions, just call our Customer Relations department at 1-800-701-9000 (TTY 1-800-208-9562). Representatives are available 7 days a week, 8:00 a.m. - 8:00 p.m. from Oct 15 - Feb 14. After hours and on holidays, please leave a message and a representative will return your call the next business day.

What is a referral and why do I need one?

Referrals are an important part of an HMO plan because they help your doctor keep track of the care you receive and ensure that the care is right for you. When you join an HMO plan, you select a doctor to be your Primary Care Physician (PCP). Your PCP will provide your routine care, preventive care, and treatment for common illnesses.

Your PCP is also responsible for coordinating or overseeing your care. An important part of coordinating your care is when your PCP “refers” you to a specialist for services he/she isn’t able to provide. Your PCP works with a team of specialists in a variety of areas so when you're referred to a specialist, he/she is recommending you see a doctor whose opinion your PCP trusts and feels is qualified to diagnose your specific condition.

Your PCP and the specialist will communicate to ensure you receive the care you need. Having one doctor who oversees all of the care you receive is one of the many advantages of being a member of an HMO plan. The intent of coordinated care and our HMO plan is simple; one team working together to help you stay healthy.

What value is the referral process to me and how do I start the process? 

One doctor (your PCP) oversees your care and collaborates with a team of specialists to help you get the care you need. Your PCP knows your medical history and will be involved in coordinating all aspects of your care.

Your PCP will refer you to the specialist within his/her referral circle who will best meet your needs. Your PCP will communicate with your specialist to ensure you receive the care that is right for you.

The Referral Process In 3 Easy Steps Step One:

  1. Discuss your medical condition or concerns with your PCP. Your PCP may consult with his/her medical group on the best course of action.
  2. Your PCP refers you to a specialist in his/her referral circle and sends your referral information to the specialist.
  3. Call the specialist’s office to make an appointment.

Helpful Things To Know About Referrals

You Do Not Need An Actual Referral Slip When your PCP issues a referral to see a specialist, he/she will send the specialist the referral information. If for any reason, you arrive at your specialist appointment after receiving a referral confirmation from your PCP and are told your referral is not there, ask the specialist’s office to contact your PCP’s office to send the referral while you wait.

Always Check With Your PCP Before Seeing A Specialist

Sometimes a specialist will recommend you see another specialist. Always check with your PCP before seeing a specialist because your PCP needs to issue the referral. A specialist isn’t able to refer you to another specialist.

By issuing all the referrals, your PCP is able to oversee the care you receive and help you see the specialist that is right for you. Your PCP has a team of specialists called a “referral circle.” Your doctor’s referral circle includes designated specialists, hospitals, skilled nursing facilities, durable medical equipment providers, and other selected providers. Your PCP’s referral circle represents the specialists and facilities your PCP has selected to work with in his/her area.

How do I receive a reimbursement for joining a fitness club?

Staying fit can help keep you healthy. Our fitness club reimbursement is part of our commitment to helping you lead an active lifestyle. All Tufts Medicare Preferred HMO members are eligible to receive up to $150 per calendar year toward club membership fees and/or exercise classes by enrolling with a qualified health club or fitness facility.

To Receive Your Wellness Allowance, complete the fitness benefit form, found here. You can also contact Customer Relations at the number below and ask to have a Wellness Allowance Form sent to you.

Make a photocopy of your health club or fitness facility agreement that includes the name and address of the club/facility, your name, and the dates of your membership or exercise classes.

Make a photocopy of one of the following:

  • Dated, paid receipt with club/facility’s name preprinted on the receipt, and amount paid
  • Front and back of cancelled check written to club/facility
  • Credit card statement or receipt identifying club/facility Photocopies must be on 8.5" x 11" paper. Multiple receipts may be included on one page.
  • Mail the form, photocopies of your health club or fitness facility agreement, and paid receipts or statements to:

    Tufts Attn: Wellness Allowance
    P.O. Box 9183
    ​Watertown, MA 02472

We encourage you to keep copies of all the paperwork you send to us. We are not able to return photocopies.

If you have any questions, just call our Customer Relations department at 1-800-701-9000 (TTY 1-800-208-9562). Representatives are available 7 days a week, 8:00 a.m. - 8:00 p.m. from Oct 1 - Feb 14. After hours and on holidays, please leave a message and a representative will return your call the next business day.

Does my health club or fitness facility qualify for the Wellness Allowance?

Qualified health clubs and fitness facilities provide cardiovascular and strength-training exercise equipment on site. Examples of qualified fitness facilities and health clubs include:

  • Traditional health clubs & community fitness centers
  • YMCA’s, YWCA’s & Jewish Community Centers with a fitness facility on site
  • Tufts Health Plan Medicare Preferred network of fitness centers in Massachusetts; Curves®; & Fitness Together

If you join a health club or fitness facility that meets the above requirements, you are eligible to receive up to $150 per calendar year toward club membership fees and/or exercise classes.

If you have any questions, call Tufts Health Plan Medicare Preferred Customer Relations at 1-800-701-9000, (TTY 1-800-208-9562). Representatives are available 7 days a week, 8:00 a.m. - 8:00 p.m. from Oct 1 - Feb 14. After hours and on holidays, please leave a message and a representative will return your call the next business day. 

How do I appoint a representative and authorize them to act on my behalf?

Every individual enrolled in a Tufts Health Plan Medicare Preferred plan has the right to appoint an individual to act as their representative in connection with a claim or asserted right under title XViii (18) of the Social Security act (the “act”) and related provisions of title Xi (11) of the act.

You can authorize this individual to make any request; to present or to elicit evidence; to obtain appeals information; and to receive any notice in connection with an appeal, wholly in your stead. It is important to understand that personal medical information related to your appeal may be disclosed to the representative that you indicate in the appointment of representative forms.

You may appoint a representative using either of the two forms below:

CMS Appointment of Representative Form

Tufts Medicare Preferred Appointment of Representative (AOR) Form

What is EFT and how do I sign up?

EFT stands for Electronic Funds Transfer. When you sign up for EFT, your monthly premium payment is automatically deducted from your checking or savings account each month and transferred to Tufts Health Plan Medicare Preferred. EFT allows you to make payments without writing checks or having to pay for postage.

The benefits of EFT: 

  • Plan premium payments will not be late or lost
  • Your plan premium is paid even when you are away from home or on vacation
  • You save postage costs and spend less time writing checks
  • It is a safe, easy, and convenient way to make timely payments
  • There is no charge to use the EFT payment option

Can anyone sign up?

As long as you are a current member and have no outstanding balance on your account, you can sign up for EFT.  

How do I sign up?

  1. Download the EFT Form
  2. Fill out the EFT and mail it, along with a voided check to:

    Tufts Health Plan Medicare Preferred
    Attention: EFT Enrollment
    705 Mount Auburn Street, Mail Stop 69
    Watertown MA 02472 

We will contact you by mail when your application has been approved. Please continue to pay your monthly premium until we notify you that you are enrolled in the EFT program. Once you're signed up and receive your EFT invoice, your monthly plan premium payments will be automatically deducted from your checking or savings account. Just be sure to keep enough money in your account each month for the deduction

How do I know when the EFT amount has been deducted from my account?

A monthly invoice will be sent to all EFT members confirming the EFT transaction amount. In addition, your EFT deduction will be identified in your monthly bank statement as "Medicare Preferred".

Your monthly plan premium will be withdrawn from your account on the 9th of every month for the current month's plan premium. For example, the premium for the month of July will be withdrawn on July 9th. The withdrawal will occur on the following business day if the 9th falls on a Saturday, Sunday, or holiday. The withdrawal takes place on the 9th in order to allow for payment to be received by the invoice due date of the 15th.

For More Information For more information on signing up for EFT*, contact Customer Relations at 1-800-701-9000 (TTY 1-800-208-9562). Representatives are available 7 days a week, 8:00 a.m. - 8:00 p.m. from Oct 1 - Feb 14. After hours and on holidays, please leave a message and a representative will return your call the next business day.

 

* If you receive your benefits from a current or former employer, you are not eligible for EFT unless you pay your premium directly to Tufts Health Plan Medicare Preferred. If you are unsure, check with your benefits administrator before enrolling

Will I need to submit a Form MA 1099- HC with my annual tax return?

No, if you are a member of one of the following plans – Tufts Medicare Preferred HMO or Tufts Medicare Preferred Supplement plans, you are not required to submit the Form MA 1099-HC. People with Medicare Part A are automatically deemed to meet the Massachusetts minimum coverage requirements and therefore are not required to file a Form MA 1099-HC. Therefore, we will not mail a 1099-HC form to you.

How do I contact the Medicare Beneficiary Ombudsman office?

To learn more about how to contact the Medicare Beneficiary Ombudsman office, visit: http://www.medicare.gov/claims-and-appeals/medicare-rights/get-help/ombudsman.html 

Where can I find Tufts Health Plan Medicare Preferred Privacy Practices information?

Tufts Health Plan Medicare Preferred takes the confidentiality of your personal health information very seriously. In addition to complying with all applicable laws, we carefully handle your personal health information in accordance with our confidentiality policies and procedures. We’re committed to protecting your privacy in all settings.

The Notice of Privacy Practices provides detailed information about our privacy practices and your rights regarding your personal health information. It is available on our website and is included in the new member kit you received when you joined Tufts Health Plan Medicare Preferred.

You can view a copy of our Notice of Privacy Practices online here.

If you would like a copy of our Notice of Privacy Practices sent to you, just call our Customer Relations department at 1-800-701-9000 (TTY 1-800-208-9562).

Representatives are available 7 days a week, 8:00 a.m. - 8:00 p.m. from Oct 1 - Feb 14. After hours and on holidays, please leave a message and a representative will return your call the next business day.

What are my Rights and Responsibilities on Disenrollment?

Ending your membership in Tufts Medicare Preferred HMO or Supplement plans may be voluntary (your own choice) or involuntary (not your own choice).

You might leave our plan because you have decided that you want to leave. There are only certain times during the year, or certain situations, when you may voluntarily end your membership in the plan. Your Evidence of Coverage (EOC) document tells you when you can end your membership in the plan. The process for voluntarily ending your membership varies depending on what type of new coverage you are choosing. See your Evidence of Coverage (EOC) document for additional details. 

There are also limited situations where you do not choose to leave, but we are required to end your membership. Your Evidence of Coverage document tells you about situations when we must end your membership.

If you are leaving our plan, you must continue to get your medical care through our plan until your membership ends. If you leave a Tufts Medicare Preferred HMO plan, it may take time before your membership ends and your new Medicare coverage goes into effect. (See your Evidence of Coverage document for information on when your new coverage begins.) During this time, you must continue to get your medical care through our plan.

If we end your membership in our plan, we must tell you our reasons in writing for ending your membership. We must also explain how you can make a complaint about our decision to end your membership. You can also look in your Evidence of Coverage document for information about how to make a complaint.

When am I informed about changes to my benefits or costs for the upcoming year?

Each September, members are mailed an Annual Notice of Change (ANOC) letter and Evidence of Coverage (EOC) booklet that contains details about your benefit and cost information for the upcoming year.

For example, the last ANOC/EOC was mailed in September for delivery to you no later than September 30th, and contained information for the following plan year. Please make a note to look for these documents in the mail in September.

What is covered when I travel?

Knowing that your health plan will be there for you when you’re away from home is an important part of enjoying your next trip. Tufts Medicare Preferred HMO members have the peace of mind that comes with worldwide coverage for emergency and urgent care. Below is more detail of what is covered when you travel. Review the below detail and enjoy your trip!

What is covered when I travel?

Tufts Medicare Preferred HMO covers members for emergency and urgently needed care anywhere in the world. You can be outside of our service area for up to 6 consecutive months and still be covered for emergency and urgently needed care.

What is a medical emergency?

A medical emergency is when you believe your health is in serious danger. A medical emergency includes severe pain, a bad injury, sudden illness, or a medical condition that is quickly getting much worse.

If you have a medical emergency: Get medical help as quickly as possible. Call 911 for an ambulance or go to the nearest emergency room, hospital, or urgent care center. You do not need to get approval or a referral first from your Primary Care Physician (PCP). As soon as possible, you or someone else should call to tell us about your emergency (usually within 48 hours), because we need to follow up on your emergency care. The Customer Relations number is conveniently located on the back of your membership card.

What is urgently needed care? Urgently needed care is when you need medical care right away because of an illness, injury, or condition that you did not anticipate, but your health is not in serious danger. Or, because of your health situation, it isn’t reasonable for you to obtain medical care from a network provider, and you need to see someone outside of the network.

If you require urgently needed care: If you are outside of our service area and cannot get care from a network provider, our plan will cover urgently needed care that you get from any provider.

What if I don't have enough medication when I travel?

Below are some helpful Medication Travel Tips:

Requesting a vacation override

A vacation override allows you to bring a larger supply of your prescription medication with you when traveling out of the country or to a remote location. To request a vacation override, contact Customer Relations 5 business days before leaving for your trip with your prescription and pharmacy information.

Filling prescriptions when you travel

If you lose or run out of prescriptions when traveling, we will cover prescriptions that are filled at an out-of-network pharmacy if a network pharmacy is not available. (This applies to Tufts Medicare Preferred HMO members whose plan includes prescription drug coverage).

At a non-network pharmacy, you will have to pay the full cost (rather than paying just your copayment) when you fill the prescription. You can then ask us to reimburse you for our share of the cost by submitting a paper claim form. Just save your receipt and call Customer Relations to ask for a Prescription Claim Form. Mail the completed form with your receipt to the address on the form.

Be prepared

  • Check your supply of prescription drugs you take on a regular basis before leaving for a trip and if possible, take all the medication you need with you.
  • Bring copies of your prescriptions so you can fill them in the event you lose your medications.
  • Have a list of the generic names of your medications, especially when traveling overseas.
  • If you need an emergency refill, physicians or pharmacists will be more likely to recognize generic names.
  • Bring the name and telephone number of your doctor and pharmacy.

Protect your medications

  • Read the storage instructions on the prescription label or talk with your doctor if you’re not sure how to store your medications when traveling.
  • When traveling by plane, pack medications in your carry-on, not in checked luggage.
  • When traveling by car, remember not to leave your medications in the car, especially in warm weather, and never leave them in the trunk.

Airport security

  • The Transportation Security Administration Web site www.tsa.gov/travelers has helpful tips to get you through airport checkpoints quickly and securely, including which medications and supplies you can transport by plane.

What if I need medical care when my primary care physician's office is closed?

Sometimes you may need to talk with your Primary Care Physician (PCP) or get medical care when your PCP’s office is closed. If you have a non-emergency situation and need to talk to your PCP after hours, you can call your PCP’s office at any time and there will be a physician on call to help you.

Hearing or speech-impaired members with TTY machines can call the Massachusetts Relay Association at 1-800-439-0183 (TTY 1-800-439-2370) for assistance contacting your PCP after hours.

If you have a medical emergency, get help as quickly as possible by calling 911 for an ambulance or by going to the nearest emergency room, hospital, or urgent care center.

You do not need to call your PCP’s office first when you have a medical emergency.

A medical emergency is when you believe your health is in serious danger and can include severe pain, a bad injury, a sudden illness, or a medical condition that is quickly getting much worse.

Where can I find additional information about my plan's service area, conditions/limitation and out-of-network coverage?

Please refer to the Evidence of Coverage Document for your plan for more information about the plan service area, conditions/limitations and out-of-network coverage.
 

What are the Tufts Medicare Preferred HMO plan Quality Assurance Policies and Procedures?

Utilization Management

To help monitor quality of care and manage health care costs, Tufts Health Plan Medicare Preferred conducts utilization management activities for all its members. The goal of utilization management is to be sure the care for which members receive coverage is medically necessary, covered by Tufts Health Plan Medicare Preferred and provided by a qualified provider. Utilization management may be conducted in several ways, including preauthorization review, concurrent review (while you are receiving care), and retrospective review (after care has been provided). Tufts Medicare Preferred HMO also includes case management services for medically complex situations in which the member is likely to require extensive coordination of services.

Medication Therapy Management (MTM)

We offer medication therapy management programs at no additional cost for members who have multiple medical conditions, who are taking many prescription drugs, or who have high drug costs. These programs were developed for us by a team of pharmacists and doctors. We use these medication therapy management programs to help us provide better coverage for our members. For example, these programs help us make sure that our members are using appropriate drugs to treat their medical conditions and help us identify possible medication errors. We offer medication therapy management programs for members that meet specific criteria. We may contact members who qualify for these programs. You may decide not to participate but it is recommended that you take full advantage of this covered service if you are selected. Remember, you do not need to pay anything extra to participate.

Click here for more information on medication therapy management.

If you are selected to join a medication therapy management program, we will send you information about the specific program, including information about how to access the program. For additional information, please contact Tufts Medicare Preferred.

What is a Tufts Medicare Preferred HMO plan Organization Determination?

An organization determination is our initial decision about whether we will provide the medical care or service you request, or pay for a service you have received. If our initial decision is to deny your request, you may appeal the decision. When we make an "organization determination," we are giving our interpretation of how the benefits and services that are covered for members of the Plan apply to your specific situation. Please refer to your EOC for additional details.

Learn more about filing an appeal or coverage determination in Chapter 9, section 1-9 and a grievance in Chapter 9, section 10 of your EOC (Chapter 7 for HMO No Rx Plans).

Where can I find a copy of Tufts Health Plan Medicare Preferred's Privacy Notice? 

You can view our Privacy Notice here.

What are the Medicare enrollment dates?

Please consult the important Medicare enrollment dates below for the times during the calendar year that you are able to enroll.

Important: If you are enrolled in a Medicare Advantage Plan, PACE Plan, or Medicare Part D Plan, enrollment in Tufts Health Plan Medicare Preferred will result in disenrollment from your current plan.

  • October 15 through December 7 is the Annual Election Period for Medicare Advantage plans and Prescription Drug Plans (PDPs). During this time period, anyone wishing to join a Medicare Advantage plan or a Prescription Drug Plan, or switch to a different plan, may do so. The change in coverage requested during this period will begin on January 1 of the next year.
     
  • January 1 – February 14 of each year is the Annual Disenrollment Period (Not applicable to PDP). During this period, anyone already enrolled in a Medicare Advantage Plan can switch to Original Medicare. If you choose to switch to Original Medicare during this period, you can also enroll in a separate Medicare prescription drug plan at the same time.
     
  • Special Election Period. Anyone who qualifies for extra help or moves in/out of the plan’s service area may join or switch Medicare Advantage plans. Other circumstances may also qualify as a Special Election Period

Important Note:

When you first become eligible for Medicare, you can enroll three months before your 65th birthday, the month of your 65th birthday, and three months after your 65th birthday. In case you are disabled, you can apply for Medicare benefits at any time provided you have been eligible for Social Security disability benefits.

If you have retiree health care coverage through an employer, the enrollment rules are different. Call the employer or their benefits administrator for information.

If You Are Thinking About Switching Plans, We Can Help

  • Our Customer Relations team knows how our plans work and can answer your questions
     
  • Call us at 1-800-701-9000 (TTY 1-800-208-9562) Monday – Friday, 8:00 a.m.– 8:00 p.m. (From October 15 – February 14, representatives are available 7 days a week, 8:00 a.m. – 8:00 p.m.) After hours and on holidays, please leave a message and a representative will return your call on the next business day.
     
  • There are only certain times during the year when you can switch plans. See above for enrollment period information.

Remember, you do not need to make a change to your plan. You will automatically be a member in the same plan for the next plan year, unless you decide to make a change.

Please note: If you receive your benefits from a current or former employer, please contact your benefits administrator regarding plan options and enrollment information.

Things To Consider When Choosing A Plan:

  • What you can afford
     
  • Your health and your age
     
  • How often you use health services
     
  • What is most important to you; lower monthly payments or lower copays

 

How much are my copays for medical, hospital and other benefits with my Tufts Medicare Preferred HMO plan?

Every Medicare Advantage Plan is required to include a document called a "Summary of Benefits" in your enrollment kit.  We've provided an easy to use index below to help you find copays, deductibles and coverage information on each benefit covered under our Tufts Medicare Preferred HMO plans.  When the government created this document, they numbered every benefit category in a specific order and labeled them as items 1 through 31.  This was designed to help consumers compare coverage not only within Tufts Medicare Preferred HMO product lines (Basic, Value and Prime) but our competitors as well.

Each column in the "Summary of Benefits" represents a specific product line offered by Tufts Medicare Preferred HMO - Basic, Value or Prime. Each row represents a specific benefit covered by our products including medical, hospital, prescription and wellness benefits. Please use this index to find the copays, cost sharing and coverage information on each benefit covered in each of our Tufts Medicare Preferred HMO plans. Click here for a copy of the HMO Summary of Benefits.

Who do I call to report Fraud, Waste, and Abuse?

Click here for information about Tufts Health Plan's Fraud, Waste and Abuse Hotline. 

How can I find out more about other member's experiences with Tufts Health Plan Medicare Preferred's Prescription Coverage?

Interested in learning more about the aggregate number of appeals, grievances and exceptions filed with Tufts Health Plan Medicare Preferred? Call Customer Relations for a copy of our Tufts Medicare Preferred HMO Appeals and Grievances Report. 

What is a Tufts Medicare Preferred HMO plan Coverage Determination?

When we make a coverage determination, we are making a decision whether or not to provide or pay for a Part D drug and what your share of the cost is for the drug. Coverage determinations include exceptions requests. You have the right to ask us for an "exception" if you believe you need a drug that is not on our list of covered drugs (formulary) or believe you should get a drug at a lower co-payment. If you request an exception, your physician must provide a statement to support your request.

You must contact us if you would like to request a coverage determination (including an exception). You cannot request an appeal if we have not issued a coverage determination.

You, your physician, or your appointed representative may file a coverage determination, including an exception, by either faxing, calling, filling out a form online, or writing to us. For requests received outside normal business hours, we have pharmacists on-call for processing requests for Part D pharmacy coverage.

By fax:

1–617-673-0956. Faxed requests can be sent 24-hours a day, 7 days a week. Faxes are checked routinely during business hours and by the on-call pharmacist during off hours, weekends and on holidays for requests for Part D pharmacy coverage.

By phone: Call Customer Relations at 1-800-701-9000 (TTY 1-800-208-9562). For prescription drug related questions, please call Monday to Friday from 8:00 a.m.- 8:00p.m (Representatives are available 7 days a week, 8:00 a.m - 8:00 p.m from Oct.1 - Feb.14). After hours, weekends and on holidays, please leave us a message. The confidential voice mail box is checked routinely by our on-call pharmacist to address requests for Part D pharmacy coverage.

Online:

Go to tuftsmedicarepreferred.org/coverage for details on submitting a Coverage Determination online, or go right to the form by clicking here. By mail: Write to us at: Attn: Pharmacy Utilization Management Department Tufts Health Plan Medicare Preferred 705 Mt. Auburn Street Watertown, MA 02472 For more information: Learn more about filing an appeal or coverage determination in Chapter 9, section 1-9 and a grievance in Chapter 9, section 10 of your EOC (Chapter 7 for HMO No Rx Plans).

How do I file a coverage determination, including an exception?

You, your physician or your appointed representative may file a coverage determination by calling Customer Relations at 1-800-701-9000 (TTY 1-800-208-9562). Representatives are available Monday - Friday, 8:00 a.m. - 8:00 p.m. (Representatives are available 7 days a week, 8:00 a.m. - 8:00 p.m. from Oct 1 - Feb 14).

After hours and on holidays, please leave a message and a representative will return your call the next business day, or by writing to:

Attn: Pharmacy Utilization Management Department
Tufts Health Plan Medicare Preferred
705 Mt. Auburn Street
Watertown, MA 02472

Or by fax to: 1-617-673-0956.

If you are requesting a formulary or tiering exception, your physician must provide a statement to support your request. Your physician can submit the request using our Universal Pharmacy Form (found here) or the Medicare Part D Coverage Determination Request Form (found here).

The form asks your physician for information regarding your diagnosis, what other drug(s), if any, has been prescribed for the diagnosis and why it has not worked, and other questions. Your physician should send the completed form to:

Attn: Pharmacy Utilization Management Department
Tufts Health Plan Medicare Preferred
705 Mt. Auburn Street Watertown, MA 02472

Or by fax to: 1-617-673-0956.

Your physician can also provide an oral supporting statement by calling Customer Relations at 1-800-701-9000 (TTY 1-800-208-9562) Representatives are available Monday - Friday, 8:00 a.m. - 8:00 p.m. (Representatives are available 7 days a week, 8:00 a.m - 8:00 p.m. from Oct 1 - Feb 14).

Learn more about filing an appeal or coverage determination in Chapter 9, section 1-9 and a grievance in Chapter 9, section 10 of your EOC.

How do I find additional information about coverage determinations?

Learn more about filing an appeal or coverage determination in Chapter 9, section 1-9 and a grievance in Chapter 9, section 10 of your EOC (Chapter 7 for HMO No Rx Plans).

Find a copy of your HMO Plan Evidence of Coverage document here.

If you have questions about any of these processes, or if you want to inquire about the status of a coverage determination request, you, your physician or your appointed representative may contact us at 1-800-701-9000 (TTY 1-800-208-9562).

Representatives are available Monday - Friday, 8:00 a.m. - 8:00 p.m. (Representatives are available 7 days a week, 8:00 a.m - 8:00 p.m. from Oct 1 - Feb 14). After hours and on holidays, please leave a message and a representative will return your call the next business day.

What is a Tufts Medicare Preferred HMO plan Organization Determination?

An organization determination is our initial decision about whether we will provide the medical care or service you request, or pay for a service you have received. If our initial decision is to deny your request, you may appeal the decision.

When we make an "organization determination," we are giving our interpretation of how the benefits and services that are covered for members of the Plan apply to your specific situation. Please refer to your EOC for additional details.

Learn more about filing an appeal or coverage determination in Chapter 9, section 1-9 and a grievance in Chapter 9, section 10 of your EOC (Chapter 7 for HMO No Rx Plans).

How can I help prevent medication errors?

Prescriptions are medications that treat illness and help maintain your health. However, if taken improperly, they could seriously jeopardize your well being. This is especially true during times of transition or change, such as if you see a physician who does not know your medical history, if you are transported to an emergency room, or if you are released from a hospital or skilled nursing facility.

Here are some easy ways to stay safe and reduce or eliminate medication mishaps: 

  • Make a list of all prescription drugs, over-the-counter medications, vitamins, diet supplements, natural remedies, and herbal preparations that you take. Include the exact name of the prescription, dosage, frequency that it is taken, and the name of the physician who prescribed it. 
  • Keep this list in your purse or wallet and show it to your health care provider during an office visit, emergency room visit, or upon admission to a hospital or skilled nursing facility. If you haven’t had a chance to prepare your medication list but need to visit the doctor or go to the emergency room, simply gather all the bottles of your medications/vitamins/herbal preparations, etc. and put them in one plastic bag. Your healthcare provider can use the bottles to list everything that you are currently taking.
  • Always tell your doctor or nurse about any past allergic reactions. Know the name of the medication that caused the allergic reaction and describe the adverse symptoms that you experienced.
  • Be sure that your healthcare provider reviews your medications. Transitions between home and the hospital are frequently times when details can be overlooked, especially if you have been prescribed new medications. Make sure all the healthcare professionals caring for you know your medical history and your medication schedule. When you leave the hospital, ask the nurse or physician to compare the list of the medications you were taking before you were admitted to your current list to ensure that nothing has been omitted. If there has been an omission, make sure it is correct. If any new medications have been prescribed, make sure you have the prescriptions to take with you.
  • Try to use the same pharmacy. Fill as many prescriptions as possible at the same pharmacy or chain and use mail-order prescription service if available. Using the same pharmacy is especially important when you are trying out a medication for the first time because they will be better able to monitor any potential interactions between medications.

By following these suggestions, you can help make sure the medications that are prescribed for you are safe and accurate.

What if my prescription drugs cannot be filled?

Your Medicare Rights If your pharmacist cannot fill your prescription drugs, you have the right to request a coverage determination from Tufts Health Plan Medicare Preferred. This request includes the right to request a special type of coverage determination called an “exception” if you believe:

  • You have been prescribed a drug that is not on your Plan’s list of covered drugs. The list of covered drugs is called a formulary and a drug not on our formulary is called a non-formulary drug
  • One of the Plan’s coverage rules should not apply to you for medical reasons. Coverage rules include: requiring prior authorization by the plan before the drug is covered, quantity limits for dosage and or length of time on a drug, and/or or step therapy requirements asking you to try another drug to treat your medical condition before the Plan covers the drug prescribed by your physician
  • You need to take a drug in a cost sharing tier that you think is too high and you want the plan to cover the drug at a lower cost sharing tier.

Step 1: What You Need to do to Request Coverage

You can complete the request online by filling out our "Coverage Determination" request form or you can call the toll free number on the back of your membership card. You will need the following information in order to complete the form or telephone call:

  • The prescription drug you believe you need. Include the dose and strength, if known.
  • If you ask for an exception, your doctor or other prescriber will need to provide Tufts Health Plan Medicare Preferred with a statement explaining: why you need the non-formulary drug, why a coverage rule should not apply to you, or why an exception should be made to your cost sharing.
  • The date your prescription was rejected at the pharmacy.

Tufts Health Plan Medicare Preferred will provide you with a written decision. If coverage is not approved, we will explain why coverage was denied and how to request an appeal call a "redetermination" if you disagree with our decision.

Print and Mail-in a Coverage Determination form

Complete Request for Coverage Determination Online

Step 2: What You Need to do if Your Request is Denied?

If you disagree with our decision, you can file a redetermination request or an “appeal” by completing our redetermination request form online or you can call the toll free number on the back of your membership card.

Print and Mail-in a Redetermination (Appeals) form

Complete Request for Redetermination (Appeals) Online

Where can I find information about using my prescription drug plan?

Visit our Medicare Part D explanation and coverage stages content for more information on how Medicare Part D works. You also search for your specific prescription drugs and their costs on our plans using our Drug Search tool.

Can I apply for an exception if my drug requires Prior Authorization, Step Therapy, has a Quantity Limit, or is Non-formulary? 

Some covered drugs may have additional requirements or limits on coverage known as Utilization Management. These requirements and limits may include:

Prior Authorization: Tufts Medicare Preferred HMO requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Tufts Medicare Preferred HMO before you fill your prescriptions. If you don't get approval, Tufts Medicare Preferred HMO may not cover the drug.

Quantity Limits: For certain drugs, Tufts Medicare Preferred HMO limits the amount of the drug that Tufts Medicare Preferred HMO will cover. For example, Tufts Medicare Preferred HMO provides 30 tablets per prescription for zolpidem. This may be in addition to a standard one month or three month supply.

Step Therapy: In some cases, Tufts Medicare Preferred HMO requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Tufts Medicare Preferred HMO may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Tufts Medicare Preferred HMO will then cover Drug B.

You can ask Tufts Medicare Preferred HMO to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make: 

  • You can ask us to cover your drug even if it is not on our formulary.
  • You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Tufts Medicare Preferred HMO may limit the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more.
  • You can ask us to provide a higher level of coverage for your drug. If your drug is contained in tier 2, tier 3, or tier 4, you can ask us to cover it at a lower cost-sharing tier applicable to your brand or generic drug. This would lower your share of the cost for the drug.
  • If your brand drug is in Tier 4: Non-preferred Brand Drugs, you can ask us to cover it at the cost-sharing amount for Tier 3: Preferred Brand Drugs. This would lower your share of the cost for the drug.
  • If your generic drug is in Tier 3: Preferred Brand Drugs, you can ask us to cover it at a lower the cost-sharing amount for T-2: Non-preferred Generic Drugs or T-1: Preferred Generic Drugs. This would lower your share of the cost for the drug.
  • If your generic drug is in Tier 2: Non-preferred Generic Drugs, you can ask us to cover it at the cost-sharing amount for Tier 1: Preferred Generic Drugs. This would lower your share of the cost for the drug.
  • We cannot change the cost-sharing tier for any drug in Tier 5: Specialty Tier Drugs.

Please note, if we grant your request to cover a drug that is not on our formulary, we cannot provide a higher level of coverage for the drug.

Tufts Medicare Preferred HMO will only approve your request for a tier exception if all alternative drugs approved for treating your condition on lower-tiers have not been effective in treating your condition and/or would cause you to have adverse medical effects.

When you are requesting a formulary, tiering, or utilization restriction exception, you should submit a statement from your physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescribing physician's supporting statement. You can request an expedited (faster) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get your prescribing physician's supporting statement.

Where can I find additional information on my plan's prescription drug quality assurance?

Your plan's Evidence of Coverage (EOC) document can provide you with additional information on plan's prescription drug quality assurance.

What if I need extra help lowering my Medicare Prescription Drug Plan costs? 

If you qualify for extra help with your Medicare Prescription Drug Plan costs, your premium and drug costs will be lower. When you join a plan offered by Tufts Health Plan Medicare Preferred, Medicare will tell us how much extra help you are receiving and we will then let you know the amount you will pay.

To view the low income subsidy for your plan and count please see our HMO Premium Changes for Low Income Subsidy page here

Please Note: The premiums listed on this page do not include any Part B premium the member may have to pay. The premiums listed on this page are for both medical services and prescription drug or Part D benefits only. 

Beneficiaries interested in qualifying for extra help with Medicare Prescription Drug Plan costs should call:

The Social Security Administration at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY/TDD users should call 1-800-325-0778; 1-800-MEDICARE (1-800-633-4227). TTY/TDD users should call 1-877-486-2048 (24 hours a day/7 days a week); or Your State Medicaid Office.
 

Does my medication require prior authorization?

Some medications may require prior authorization. This form is used to request coverage for medications that require prior authorization, step therapy exceptions, quantity limit exceptions, tier exceptions and coverage of non-formulary or new-to-market drugs. Your physician must be involved in filling out this form since he or she will need to provide information regarding the medical necessity of your request.

The Universal Pharmacy Form can be found here.

The alternative Coverage Determination Request form can be found here.

Does Tufts Health Plan Medicare Preferred make Changes and/or Updates to the Formulary throughout the year?

Tufts Health Plan Medicare Preferred may add or remove drugs from our formulary during the year. The cover page of the posted formulary PDFs include the last date the document was updated. For questions call Customer Relations.

What happens if I'm unaware of changes or updates to our Formulary?

The 2015 Prescription Drug Transition Process document can answer the following questions:

  • What if your drug is no longer covered?
  • What if your drug is excluded from coverage?
  • What if you just joined Tufts Medicare Preferred and did not know that your drug was not covered?
  • What if your drug requires Prior Authorization?
  • What if your drug is part of a Step Therapy program?

View the Drug Transition Process Document here: Prescription Drug Transition Process

What If I'm out-of-network and run out of my prescription?

Our Pharmacy Finder gives you a complete list of our network pharmacies - that means all of the pharmacies that have agreed to fill covered prescriptions for our plan members. In most cases, your prescriptions are covered only if they are filled at the plan's network pharmacies (retail or mail-order). Tufts Health Plan Medicare Preferred has contracts with Pharmacies that equal or exceed requirements for pharmacy access in your area.

If you are traveling within the U.S., but outside of the Plan's service area and you become ill or if you lose or run out of your prescription drugs, we will cover prescriptions that are filled at an out-of-network pharmacy if you follow all other coverage rules identified within your Evidence of Coverage. In this situation, you will have to pay the full cost (rather than paying just your copayment) when you fill the prescription. You can ask us to reimburse you for our share of the cost by submitting a paper claim form.

There may be other times you can get your prescription covered if you go to an out-of-network pharmacy. We will cover your prescription at an out-of-network pharmacy if at least one of the following applies:

  • If you are unable to get a covered drug in a timely manner within our service area because there are no network pharmacies within a reasonable driving distance that provide 24-hour service.
  • If you are trying to fill a covered prescription drug that is not regularly stocked at an eligible network retail or mail order pharmacy (these drugs include orphan drugs or other specialty pharmaceuticals).

Before you fill your prescription in either of these situations, call Customer Relations to see if there is a network pharmacy in your area where you can fill your prescription. If you do go to an out-of-network pharmacy for the reasons listed above, you will have to pay the full cost (rather than just paying your copayment) when you fill your prescription. You can ask us to reimburse you for our share of the cost by submitting a claim form.

To view a list of in-network pharmacies please reference the HMO Provider Directory.

What if I need to request coverage for Prescriptions? (Universal Pharmacy Form) 

This form is used to request coverage for medications that require prior authorization, step therapy exceptions, quantity limit exceptions, tier exceptions and coverage of non-formulary or new-to-market drugs. Your prescriber must be involved in filling out this form since he or she will need to provide information regarding the medical necessity of your request.

Universal Pharmacy Form 

Coverage Determination Request Form 

What is the Tufts Medicare Preferred HMO plan Appeals Policy?

If Tufts Health Plan Medicare Preferred has denied your request for coverage, you have the right to ask us for a redetermination (appeal) of our decision. You have 60 days from the date of our Notice of Denial of Medicare Prescription Drug Coverage to ask for a redetermination.

By fax:

1-617-972-9516

By phone:

Call Customer Relations at 1-800-701-9000 (TTY 1-800-208-9562) Monday to Friday from 8:00 a.m.- 8:00 p.m. (Representatives are available 7 days a week, 8:00 a.m. - 8:00 p.m. from Oct.1 - Feb.14). After hours, weekends and on holidays, please leave us a message. Online: Click here for details on submitting an appeal online, or go right to the form by clicking here

By mail:

Write to us at:

Attn: Appeals & Grievances
Tufts Health Plan Medicare Preferred
705 Mt. Auburn Street
Watertown, MA 02472

For more information: Learn more about filing an appeal or coverage determination in Chapter 9, section 1-9 and a grievance in Chapter 9, section 10 of your EOC (Chapter 7 for HMO No Rx Plans).

What is the Tufts Medicare Preferred HMO plan Grievance Policy?

You can view the Tufts Medicare Preferred HMO Grievance Policy online here.

How do I file a grievance or appeal about my Tufts Medicare Preferred HMO plan?

You, your physician or your appointed representative (find the Authorization of Representative form here) may file a grievance or appeal by calling Customer Relations at 1-800-701-9000 (TTY 1-800-208-9562). Representatives are available Monday - Friday, 8:00 a.m. - 8:00 p.m. (Representatives are available 7 days a week, 8:00 a.m. - 8:00 p.m. from Oct 1 - Feb 14).

After hours and on holidays, please leave a message and a representative will return your call the next business day, or by writing to:

Attn: Appeals & Grievance Department
Tufts Health Plan Medicare Preferred
705 Mt. Auburn Street Watertown, MA 02472

Or by fax to:

1-617-972-9516

Learn more about filing an appeal or coverage determination in Chapter 9, section 1-9 and a grievance in Chapter 9, section 10 of your EOC (Chapter 7 for HMO No Rx Plans).

How do I find additional information about my Tufts Medicare Preferred HMO plan grievance or appeal?

Please see your Evidence of Coverage:

Complaints about Medical Services and Benefits: Complaints about Prescription Drug Benefits of your Evidence of Coverage (EOC) for more information on our grievance and appeals process.

Find your copy of the HMO Plan Evidence of Coverage document here.

If you have questions about this process, or if you want to inquire about the status of a grievance or appeal request, you, your physician or your appointed representative may contact us at 1-800-701-9000 (TTY 1-800-208-9562). Representatives are available Monday - Friday, 8:00 a.m. - 8:00 p.m. (Representatives are available 7 days a week, 8:00 a.m. - 8:00 p.m. from Oct 1 - Feb 14).

After hours and on holidays, please leave a message and a representative will return your call the next business day. Learn more about filing an appeal or coverage determination in Chapter 9, section 1-9 and a grievance in Chapter 9, section 10 of your EOC (Chapter 7 for HMO No Rx Plans).

What do I do if I have a complaint concerning a Tufts Medicare Preferred HMO plan?

Tufts Health Plan Medicare Preferred is dedicated to providing its members with comprehensive health care coverage. However, there may be times when you have concerns or problems related to your coverage or care. In these instances, you have the right to make formal complaints to Tufts Health Plan Medicare Preferred. If you make a complaint, we must be fair in how we handle it, and you cannot be disenrolled or penalized in any way.

There are two types of formal complaints you can make. They are appeals and grievances. In this document, we explain the differences between the two types of complaints and provide a high-level description of the processes for each. Learn more about filing an appeal or coverage determination in Chapter 9, section 1-9 and a grievance in Chapter 9, section 10 of your EOC (Chapter 7 for HMO No Rx Plans).

Where can I view the Tufts Health Plan Medicare Preferred website's legal, security, and privacy practices?

To view the Tufts Health Plan Medicare Preferred website's legal, security, and privacy practices, please click here.

How can I make a complaint about my Medicare plan directly to Medicare online?

You can make a complaint about your Medicare plan directly to Medicare online by clicking here.

How can I use my Prescription Drug Plan?

Four helpful things for Tufts Health Plan Senior Care Options members with a prescription drug plan to know:

1. How To Find Your Drug On Our Formulary (Drug List)

A “Formulary” is a list of drugs that our plan covers. To find out if a drug that is prescribed to you is covered:

  • Look up the name of the drug in the Formulary by using the index.
  • A tier number will be listed next to each drug.
  • The tier number determines the relative cost of the drug.

You can view the most current version of our formulary on the plan documents page of our website. A printed copy is mailed to you each year. You can also call Customer Relations for assistance.

2. What To Know About Generic Drugs

  • Generic drugs generally cost less than brand name drugs. One reason why is because unlike makers of brand name drugs, generic drug manufacturers don’t need to spend as much money on research, development or advertising.
  • Generic drugs are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand name drugs.
  • A generic drug has the same active-ingredient formula as a brand name drug.
  • Make sure to talk to your doctor to see if generic drugs are right for you.

3. Mail Order Offers Convenience

Mail order service is for medications that you refill each month for conditions such as diabetes, high blood pressure, or asthma. These medications are often called “maintenance medications”.

  • Mail order is the most convenient way to get the medication you refill each month mailed directly to your home.
  • When you use mail order you have the option of ordering a 30, 60, or 90-day supply of your drug.
  • There is no cost for using mail order.

How To Sign Up For Mail Order:

Signing up for mail order is easy and can be done quickly over the phone by calling FastStart by Caremark. There are no forms to fill out, just call FastStart toll-free at 1-866-281-0629. Before calling make sure you have the following items ready:

  • Tufts Health Plan Senior Care Options ID card (you will need information from the card)
  • Prescription drug names
  • Physician name and phone number
  • Shipping address

A FastStart representative will call your doctor to get your prescription(s) set up for mail service. Once your prescription(s) are set up, you can refill them by phone 24 hours a day, 7 days a week.

4. Where To Find More Information About Your Prescription Drug Coverage

Each of our plans has an Evidence of Coverage (EOC) booklet that describes the benefits. Each EOC booklet contains a chapter that explains the prescription drug benefit for that plan including how to use your prescription drug coverage (if you are in a prescription drug plan). Each year an EOC booklet is mailed to you. The EOCs are also available on the plan documents page of our website. If you have any questions about your prescription drug coverage you can always call Customer Relations.

Customer Relations Can Answer Your Questions

If you have any questions, just call Customer Relations at 1-855-670-5934 (TTY 855-670-5936). Representatives are available Monday – Friday, 8:00 a.m. – 8:00 p.m. (From October 1 – February 14, representatives are available 7 days a week, 8:00 a.m. – 8:00 p.m.).

Can I apply for an exception if my drug requires prior authorization, quantity limits or step therapy? 

ome covered drugs may have additional requirements or limits on coverage known as Utilization Management. These requirements and limits may include:

Prior Authorization: Tufts Health Plan Senior Care Options requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Tufts Health Plan Senior Care Options before you fill your prescriptions. If you don't get approval, Tufts Health Plan Senior Care Options may not cover the drug.

Quantity Limits: For certain drugs, Tufts Health Plan Senior Care Options limits the amount of the drug that Tufts Health Plan Senior Care Options will cover. For example, Tufts Health Plan Senior Care Options provides 30 tablets per prescription for zolpidem. This may be in addition to a standard one month or three month supply.

Step Therapy: In some cases, Tufts Health Plan Senior Care Options requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Tufts Health Plan Senior Care Options may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Tufts Health Plan Senior Care Options will then cover Drug B.

You can ask Tufts Health Plan Senior Care Options to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make:

  • You can ask us to cover your drug even if it is not on our formulary.
  • You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Tufts Health Plan Senior Care Options may limit the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more.

When you are requesting a formulary or utilization restriction exception, you should submit a statement from your physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescribing physician's supporting statement. You can request an expedited (faster) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get your prescribing physician's supporting statement.

Are my prescriptions covered?

Tufts Health Plan Senior Care Options uses a Formulary to list the prescription drugs that we cover. We provided the following search tools to help you find which tier your drug will be covered under.

Drug Search Tufts Health Plan

Senior Care Options (HMO SNP) Formulary

Is my Pharmacy in the Tufts Health Plan Senior Care Options network?

We have contracts with over 850 pharmacies within our pharmacy network. The link below provides a list of our participating pharmacies. This directory is updated annually, however this does not guarantee that the pharmacy is still in the network. Contact Customer Relations at 1-855-670-5934 with additional questions.

SCO Provider and Pharmacy Directory

Does Tufts Health Plan Senior Care Options make changes and/or updates to the Formulary throughout the year?

Tufts Health Plan Senior Care Options may add or remove drugs from our formulary during the year. The cover page of the posted formulary PDFs include the last date the document was updated. For questions call Customer Relations at 1-855-670-5934 (TTY 855-670-5936). Representatives are available Monday – Friday, 8:00 a.m. – 8:00 p.m. (From October 1 – February 14, representatives are available 7 days a week, 8:00 a.m. – 8:00 p.m.).

What happens if I am unaware of changes or updates to the Formulary?

The Prescription Drug Transition Process document can answer the following questions:

  • What if your drug is no longer covered?
  • What if your drug is excluded from coverage?
  • What if you just joined Tufts Health Plan Senior Care Options and did not know that your drug was not covered?
  • What if your drug requires Prior Authorization?
  • What if your drug is part of a Step Therapy program?

Drug Transition Document

Does Tufts Health Plan Senior Care Options have a program to help members manage their medications? 

We have programs that can help our members with special situations. For example, some members have several complex medical conditions or they may need to take many drugs at the same time, or they could have very high drug costs.

These programs are voluntary and free to members. A team of pharmacists and doctors developed the programs for us. The programs can help make sure that our members are using the drugs that work best to treat their medical conditions and help us identify possible medication errors.

One program is called a Medication Therapy Management (MTM) program. Some members who take several medications for different medical conditions may qualify. A pharmacist or other health professional will give you a comprehensive review of all your medications.

Learn more about Medication Therapy Management.

What if I need to request coverage for Prescriptions? (Universal Pharmacy Form)

This form is used to request coverage for medications that require prior authorization or exceptions for non-covered drugs. Your physician must be involved in filling out this form since he or she will need to provide information regarding the medical necessity of your request.

Universal Pharmacy Form Coverage Determination Form

What if my prescription drugs cannot be filled?

Your Rights

If your pharmacist cannot fill your prescription drugs you have the right to request a coverage determination from Tufts Health Plan Senior Care Options. This request includes the right to request a special type of coverage determination called an “exception” if you believe:

  1. You have been prescribed a drug that is not on your Plan’s list of covered drugs. The list of covered drugs is called a formulary and a drug not on our formulary is called a non-formulary drug;
  2. You believe one of the Plan’s coverage rules should not apply to you for medical reasons. Coverage rules include: requiring prior authorization by the plan before the drug is covered, quantity limits for dosage and or length of time on a drug, and/or or step therapy requirements asking you to try another drug to treat your medical condition before the Plan covers the drug prescribed by your physician.

Step 1: What You Need to do to Request Coverage

You can complete the request online by filling out our "Coverage Determination" request form or you can call the toll free number on the back of your membership card. You will need the following information in order to complete the form or telephone call:

  • The prescription drug you believe you need. Include the dose and strength, if known.
  • If you ask for an exception, your doctor or other prescriber will need to provide Tufts Health Plan Senior Care Options with a statement explaining: why you need the non-formulary drug, why a coverage rule should not apply to you, or why an exception should be made.
  • The date your prescription was rejected at the pharmacy.

Tufts Health Plan Senior Care Options will provide you with a written decision. If coverage is not approved, we will explain why coverage was denied and how to request an appeal call a "redetermination" if you disagree with our decision. Print and Mail-in a Coverage Determination form Complete Request for Coverage Determination Online

Step 2: What You Need to do if Your Request is Denied?

If you disagree with our decision, you can file a redetermination request or an “appeal” by completing our redetermination request form online or you can call the toll free number on the back of your membership card.

Print and Mail-in a Redetermination (Appeals) form

Complete Request for Redetermination (Appeals) Online

How can I find out more about other member’s experiences with Tufts Health Plan Senior Care Options’ Prescription Coverage? 

Interested in learning more about the aggregate number of appeals, grievances and exceptions filed with Tufts Health Plan Senior Care Options?

Call Customer Relations at 1-855-670-5934 (TTY 855-670-5936) for a copy of our Tufts Health Plan Senior Care Options Appeals and Grievances Report. 

What is an Organization Determination?

An organization determination is our initial decision about whether we will cover the medical care or service you request, or pay for a service you have received. If our initial decision is to deny your request, you may appeal the decision. When we make an "organization determination," we are giving our interpretation of how the benefits and services that are covered for members of the Plan apply to your specific situation. Please refer to your EOC for additional details.

Learn more about organization determination in Chapter 8, section 1-9 of your EOC.

What is Coverage Determination?

When we make a coverage determination, we are making a decision whether or not to cover or pay for a Part D drug. Coverage determinations include exceptions requests. You have the right to ask us for an "exception" if you believe you need a drug that is not on our list of covered drugs (formulary). If you request an exception, your physician must provide a statement to support your request.

You must contact us if you would like to request a coverage determination (including an exception). You cannot request an appeal if we have not issued a coverage determination.

You, your physician, or your appointed representative may file a coverage determination, including an exception, by either faxing, calling, filling out a form online, or writing to us. For requests received outside normal business hours, we have clinicians on-call for processing requests for Part D pharmacy coverage.

By fax:

1–617-673-0956

Faxed requests can be sent 24-hours a day, 7 days a week. Faxes are checked routinely during business hours and by the on-call nurse during off hours for requests for Part D pharmacy coverage.

By phone:

Call Customer Relations at 1-855-670-5934 (TTY 855-670-5936). For prescription drug related questions only, call 7 days a week 8:00 a.m.-8:00p.m. After hours and on holidays, please leave a message. The voice mail boxes are checked routinely on weekends and holidays by the on-call nurse to address requests for Part D pharmacy coverage.

Online:

Go to Online Coverage Determination for details on submitting a Coverage Determination online, or go right to the form by clicking here.

By mail:

Write to us at:

Attn: Pharmacy Utilization Management Department
Tufts Health Plan
705 Mt. Auburn Street
Watertown, MA 02472

For more information:

Learn more about filing a coverage determination in Chapter 8, section 1-9 of your EOC.

How do you file a coverage determination, including an exception?

You, your physician or your appointed representative may file a coverage determination by calling Customer Relations at 1-855-670-5934 (TTY 855-670-5936). Representatives are available Monday - Friday, 8:00 a.m. - 8:00 p.m. (Representatives are available 7 days a week, 8:00 a.m. - 8:00 p.m. from Oct 1 - Feb 14), or by writing to:

Attn: Pharmacy Utilization Management Department
Tufts Health Plan
705 Mt. Auburn Street
Watertown, MA 02472

Or by fax to:

1-617-673-0956.

If you are requesting a formulary exception, your physician must provide a statement to support your request. Your physician can submit the request using our Universal Pharmacy Form (found here) or the Medicare Part D Coverage Determination Request Form (found here). The form asks your physician for information regarding your diagnosis, what other drug(s), if any, has been prescribed for the diagnosis and why it has not worked, and other questions. Your physician should send the completed form to:

Attn: Pharmacy Utilization Management Department
Tufts Health Plan
705 Mt. Auburn Street
Watertown, MA 02472

Or by fax to:

1-617-673-0956.

Your physician can also provide an oral supporting statement by calling Customer Relations at 1-855-670-5934 (TTY: 855-670-5936). Representatives are available Monday - Friday, 8:00 a.m. - 8:00 p.m. (Representatives are available 7 days a week, 8:00 a.m. - 8:00 p.m. from Oct 1 - Feb 14).

Learn more about filing a coverage determination in Chapter 8, section 1-9 of your EOC.
 

How do you find additional information about coverage determinations?

Learn more about filing a coverage determination in Chapter 8, section 1-9 of your EOC.

Find a copy of your Senior Care Options (HMO SNP) Plan Evidence of Coverage document here.

If you have questions about any of this processes, or if you want to inquire about the status of a coverage determination request, you, your physician or your appointed representative may contact us at 1-855-670-5934 (TTY 855-670-5936).
Representatives are available Monday - Friday, 8:00 a.m. - 8:00 p.m. (Representatives are available 7 days a week, 8:00 a.m. - 8:00 p.m. from Oct 1 - Feb 14). 

How do I file a grievance or appeal?

You, your physician or your appointed representative (find the Authorization of Representative form here) may file a grievance or appeal by calling Customer Relations at 1-855-670-5934 (TTY 1-855-670-5936) Representatives are available Monday - Friday, 8:00 a.m. - 8:00 p.m. (Representatives are available 7 days a week, 8:00 a.m. - 8:00 p.m. from Oct 1 - Feb 14).

You may also file a grievance or appeal by writing to:

Attn: Appeals & Grievance Department
Tufts Health Plan
705 Mt. Auburn Street
Watertown, MA 02472

Or by fax to:

1-617-972-9405 or 1-617-972-9487.

You may pursue a MassHealth Board of Hearings (BOH) review, in addition to, or instead of, filing a standard or expedited appeal with Tufts Health Plan Senior Care Options.  If you choose to pursue an external appeal, you must submit your written hearing request to BOH within 30 calendar days from the date of mailing of the Tufts Health Plan Senior Care Options notice to deny coverage for your services.

The Tufts Health Plan Senior Care Options Appeals and Grievances Department may assist you with this process. Hearing requests should be sent to:

Executive Office of Health and Human Services 
Board of Hearings 
Office of Medicaid
100 Hancock Street, 6th floor
Quincy, MA 02171

Or by fax to:

1-617-847-1204

Learn more about filing an appeal in Chapter 8, section 1-9 and a grievance in Chapter 8, section 11 of your EOC. Also, to learn more about filing an appeal with MassHealth please review Chapter 8, section 12 of your EOC.

How do you find additional information about your Tufts Health Plan Senior Care Options plan grievance or appeal?

Please see your Evidence of Coverage: Complaints about Medical Services and Benefits: Complaints about Prescription Drug Benefits of your Evidence of Coverage (EOC) for more information on our grievance and appeals process.

Find your copy of the Tufts Health Plan Senior Care Options (HMO SNP) Plan Evidence of Coverage document here.

If you have questions about this process, or if you want to inquire about the status of a grievance or appeal request, you, your physician or your appointed representative may contact us at 1-855-670-5934 (TTY 1-855-670-5936). Representatives are available Monday - Friday, 8:00 a.m. - 8:00 p.m. (Representatives are available 7 days a week, 8:00 a.m. - 8:00 p.m. from Oct 1 - Feb 14).

Learn more about filing an appeal in Chapter 8, section 1-9 and a grievance in Chapter 9, section 11 of your EOC. Also, to learn more about filing an appeal with MassHealth please review Chapter 9, section 12 of your EOC.

How do I appoint a representative to help with a claim and authorize them to act on my behalf?

Every individual enrolled in a Tufts Health Plan Senior Care Options plan has the right to appoint an individual to act as their representative in connection with a claim or asserted right under title XViii (18) of the Social Security act (the “act”) and related provisions of title Xi (11) of the act.

You can authorize this individual to make any request; to present or to elicit evidence; to obtain appeals information; and to receive any notice in connection with an appeal, wholly in your stead. It is important to understand that personal medical information related to your appeal may be disclosed to the representative that you indicate on the Appointment of Representative form.

Where do I send this form?

Send this form to the same location where you are sending (or have already sent) an appeal if you are filing an appeal, grievance if you are filing a grievance, initial determination or decision if you are requesting an initial determination or decision..

Attn: Appeals & Grievance Department
Tufts Health Plan
705 Mt. Auburn Street
Watertown, MA 02472

Or by fax to: 1-617-972-9405 or 1-617-972-9487.

How do I find out how many grievances, appeals, and exceptions have been filed with the Tufts Health Plan Senior Care Options?

To find out how many grievances, appeals, and exceptions have been filed with the Tufts Health Plan Senior Care Options you may contact us at 1-855-670-5934 (TTY 1-855-670-5936). Representatives are available Monday - Friday, 8:00 a.m. - 8:00 p.m. (Representatives are available 7 days a week, 8:00 a.m. - 8:00 p.m. from Oct 1 - Feb 14).

What are your Rights and Responsibilities on Disenrollment?

Ending your membership in Tufts Health Plan Senior Care Options may be voluntary (your own choice) or involuntary (not your own choice):

  • Your Evidence of Coverage (EOC) document tells you when you can end your membership in the plan.
  • There are also limited situations where you do not choose to leave, but we are required to end your membership. The process for Involuntary Disenrollment requests must be preapproved; the plan must present a detailed explanation and all applicable documentation to the MassHealth SCO Operations Unit. Your Evidence of Coverage document tells you about situations when we must end your membership.

If you are leaving our plan, you must continue to get your medical care through our plan until your membership ends. If you leave the Tufts Health Plan Senior Care Options plan, it may take time before your membership ends and your new coverage goes into effect. (See your Evidence of Coverage document for information on when your new coverage begins.) During this time, you must continue to get your medical care through our plan.

If we end your membership in our plan, we must tell you our reasons in writing for ending your membership. We must also explain how you can make a complaint about our decision to end your membership. You can also look in your Evidence of Coverage document for information about how to make a complaint.

What are the Quality Assurance Policies and Procedures?

Utilization Management

To help monitor quality of care and manage health care costs, Tufts Health Plan Senior Care Options conducts utilization management activities for all its members. The goal of utilization management is to be sure the care for which members receive coverage is medically necessary, covered by Tufts Health Plan Senior Care Options and provided by a qualified provider. Utilization management may be conducted in several ways, including preauthorization review, concurrent review (while you are receiving care), and retrospective review (after care has been provided). Tufts Health Plan Senior Care Options also includes case management services for medically complex situations in which the member is likely to require extensive coordination of services.
 
Medication Therapy Management (MTM)

We offer medication therapy management programs at no additional cost for HMO SNP (Medicare and Medicaid) members who have multiple medical conditions, who are taking many prescription drugs, or who have high drug costs. These programs were developed for us by a team of pharmacists and doctors. We use these medication therapy management programs to help us provide better coverage for our members. For example, these programs help us make sure that our members are using appropriate drugs to treat their medical conditions and help us identify possible medication errors. We offer medication therapy management programs for members that meet specific criteria. We may contact members who qualify for these programs. You may decide not to participate but it is recommended that you take full advantage of this covered service if you are selected. Remember, you do not need to pay anything extra to participate.

Click here for more information on medication therapy management.

If you are selected to join a medication therapy management program, we will send you information about the specific program, including information about how to access the program. For additional information, please contact Tufts Health Plan Senior Care Options Customer Relations at 1-855-670-5934
(TTY 1-855-670-5936). Representatives are available Monday - Friday, 8:00 a.m. - 8:00 p.m. (from Oct 1 - Feb 14 representatives are available 7 days a week, 8:00 a.m. - 8:00 p.m.).

Where can I find additional information on benefits, service area, conditions/limitations and out-of-network coverage?

Please refer to the Evidence of Coverage for more information about:

  • Benefits
  • Plan service area 
  • Conditions/limitations 
  • Out-of-network coverage 

Where can I find information on appeals/grievances, prescription drug quality assurance, contract termination and disenrollment?

Please refer to your Evidence of Coverage document for more information on: 

  • Coverage Determination
  • Appeals and Grievances and Coverage Determination
  • Prescription drug quality assurance 
  • Potential for contract termination 
  • Disenrollment rights and responsibilities 

How can I contact Tufts Health Plan Senior Care Options?

Phone Numbers

If you are interested in becoming a member of a plan offered by Tufts Health Plan Senior Care Options call:

1- 855-670-5927 (1-855-670-5940 TTY)

Our representatives are available Monday - Friday, 8:00 a.m. - 8:00 p.m. (from Oct 1 - Feb 14 representatives are available 7 days a week, 8:00 a.m - 8:00 p.m.). After hours and on holidays, please leave a message and a representative will return your call the next business day.

If you are already a member call, our Customer Relations department:

1- 855-670-5934 (1-855-670-5936 TTY)

Our representatives are available Monday - Friday, 8:00 a.m. - 8:00 p.m. (from Oct 1 - Feb 14 representatives are available 7 days a week, 8:00 a.m - 8:00 p.m.).

Mailing Address:

Tufts Health Plan Senior Care Options
705 Mt. Auburn Street
Watertown, MA 02472-1508

Fax:

To fax completed enrollment forms: 1-617-673-0785