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Helpful Information about Medicare Advantage Plans
This page contains additional information about your health coverage. Please select from the topics below.
If you qualify for extra help with your Medicare Prescription Drug Plan costs, your premium and drug costs will be lower. When you join Tufts Health Plan Medicare Preferred, Medicare will tell us how much extra help you are getting. Then, we will let you know the amount you will pay. The premiums listed do not include any Part B premium the member may have to pay. The premiums listed 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:
Universal Pharmacy Form This form is used to request coverage for medications that require prior authorization, for exceptions for non-covered drugs, or for tier exceptions. 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. Your physician can also directly access this form on the Tufts Health Plan provider website.
Tufts Medicare Preferred PDP is dedicated to providing its members with prescription drug 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 Medicare Preferred PDP. 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.
PDP Appeals
PDP Grievances For more detailed information about appeals and grievances information for both Medicare Advantage and Part D prescription drug benefits, please see your Evidence of Coverage booklet that you receive as a Tufts Medicare Preferred PDP member, or call Customer Relations at 1-800-978-2222 (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 Nov 15 – Mar 1.) After hours and on holidays, please leave a message and a representative will return your call the next business day. HMO/PDP Quality Assurance Policies and Procedures Utilization Management To help monitor quality of care and manage health care costs, Tufts 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 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 also provides case management services for medically complex situations in which the member is likely to require extensive coordination of services. Medication Therapy Management 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. 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. HMO/PDP Coverage Determination What is a coverage determination? Whenever you ask for a Part D prescription drug benefit, the first step is called requesting a 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. For Prescription drug related questions only, call 7 days a week 8:00 a.m. - 8:00 p.m. You, your physician or your appointed representative may file a coverage determination, including an exception, 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 Nov 15 - Mar 1). After hours and on holidays, please leave a message and a representative will return your call the next business day, or by writing to: Tufts Medicare Preferred 705 Mt. Auburn Street Watertown, MA 02472 Attn: Clinical Review Department Or by fax to: 1-617-972-9409. How to 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 Nov 15 - Mar 1). After hours and on holidays, please leave a message and a representative will return your call the next business day, or by writing to: Tufts Medicare Preferred 705 Mt. Auburn Street Watertown, MA 02472 Attn: Clinical Review Department Or by fax to: 1-617-972-9409. 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 the Tufts Health Plan Universal Pharmacy Form or the Medicare Part D Coverage Determination Request Form. 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: Tufts Medicare Preferred 705 Mt. Auburn Street Watertown, MA 02472 Attn: Clinical Review Department Or by fax to: 1-617-972-9409. 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 Nov 15 - Mar 1). How to find additional information about coverage determinations: Please see your Evidence of Coverage (EOC) for more information on our coverage determination process. 2010 HMO Basic No Rx Evidence of Coverage 2010 HMO Basic Rx/Rx Plus Evidence of Coverage 2010 HMO Value No Rx Evidence of Coverage 2010 HMO Value Rx/Rx Plus Evidence of Coverage 2010 HMO Prime No Rx Evidence of Coverage 2010 HMO Prime Rx/Rx Plus Evidence of Coverage 2010 PDP Evidence of Coverage 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 1-800-701-9000 (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 Nov 15 - Mar 1). After hours and on holidays, please leave a message and a representative will return your call the next business day. HMO 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. Privacy Notice: Rights and Responsibilities on Disenrollment Ending your membership in Tufts Medicare Preferred HMO or PDP may be voluntary (your own choice) or involuntary (not your own choice):
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 Chapter 7, Section 9 for information about how to make a complaint. For more information Please refer to:
For additional information on:
Summary of Benefits
Plan service area
Evidence of Coverage
Conditions/limitations
Evidence of Coverage
Out-of-network coverage
Evidence of Coverage
Appeals and grievances
Evidence of Coverage
Prescription drug quality assurance
Evidence of Coverage
Potential for contract termination
Evidence of Coverage
Disenrollment rights and responsibilities
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