Frequently Asked Questions

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

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 docment 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 do I receive information 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 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:

  1. Your premium for the upcoming year
  2. Any changes to the cost or coverage of your medical benefits
  3. Any new medical benefits that will be part of your coverage in the upcoming year or non-Medicare benefits removed for the upcoming year
  4. Any changes to the cost of prescriptions in your prescription drug benefit (if you are enrolled in a prescription drug plan)
  5. 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:

  1. Important phone numbers and resources
  2. A medical benefits chart that explains what is covered and what you pay
  3. How to use your prescription drug coverage and the cost of your prescription drugs (if you are in a prescription drug plan)
  4. Your rights and responsibilities
  5. 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.

I'm a caregiver. Where can I find information to help?

Our caregiver page can help you find resources, support, and information. You'll find general information for caregivers as well as more specific details about where to find help, caregiver fatigue, and other topics. You'll also find links to help you learn more about our plans.

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 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 on the attached 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 Medicare Preferred
705 Mt. Auburn Street
Watertown, MA 02472

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

Appeals and Grievances
Where can I find additional information on benefits, service area, conditions/limitations, out-of-network coverage, appeals/grievances, prescription drug quality assurance, contract termination and disenrollment rights and responsibilities?

Please refer to:

Plan service area - Evidence of Coverage

Conditions/limitations - Evidence of Coverage

Out-of-network coverage - Evidence of Coverage

Coverage Determination, Appeals and Grievances - Evidence of Coverage, Chapter 9 for HMO Plans with Rx (Chapter for HMO Plans with No Rx)

Prescription drug quality assurance - Evidence of Coverage

Potential for contract termination - Evidence of Coverage

Disenrollment rights and responsibilities - Evidence of Coverage

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/navigation/help-and-support/ombudsman.aspx

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:
1-617-972-9405 or 1-617-972-9487


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).

 

Page last updated 10-29-13
 

What is the Tufts Medicare Preferred HMO plan Grievance Policy?

Appeals and Grievances

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

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).

Organization and Coverage Determination
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 Pharmacy Utilization Management clinical pharmacist 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 clinical 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 clinical 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).

Referral Information
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. When your PCP refers you to a specialist, he/she is recommending you see a doctor whose opinion your PCP trusts and who your PCP 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.

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.

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

The value of the referral process is as follows:

  1. One doctor (your PCP) oversees your care and collaborates with a team of specialists to help you get the care you need.
  2. Your PCP knows your medical history and will be involved in coordinating all aspects of your care.
  3. Your PCP will refer you to the specialist within his/her referral circle who will best meet your needs.
  4. 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: Discuss your medical condition or concerns with your PCP. Your PCP may consult with his/her medical group on the best course of action.

Step Two: Your PCP refers you to a specialist in his/her referral circle and sends your referral information to the specialist.

Step Three: Call the specialist’s office to make an appointment.

Payment and Reimbursement Information
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.

What are the benefits of EFT?

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

How do I sign up?

As long as you are a current member and have no outstanding balance on your account, you can sign up for EFT. Just fill out the EFT Authorization Form envelope. 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.

Signing up for EFT is as simple as 1-2-3.

1. Fill out the EFT form after downloading it here.
2. Mail the application with a voided check to Tufts Health Plan Medicare Preferred in the envelope provided.

Once you sign 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 will I know when the EFT amount has been deducted from my account and when?

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

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.

  1. 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.
  2. Make a photocopy of one of the following:
  3. Dated, paid receipt with club/facility’s name preprinted on the receipt, and amount paid
  4. Front and back of cancelled check written to club/facility
  5. 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.

How do I know if a health club or fitness facility qualifies 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:

  1. Traditional health clubs & community fitness centers
  2. YMCA’s, YWCA’s & Jewish Community Centers with a fitness facility on site
  3. 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 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.

Will I need to submit a Form MA 1099- HC (Healthcare) 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.

Prescription Information
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:

  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; or
  3. 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:

  1. The prescription drug you believe you need. Include the dose and strength, if known.
  2. 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.
  3. 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

Read More About Coverage Determinations

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

Read More About Redeterminations (Appeals)

Page last updated 10-29-13

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.

Travel Information
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 for you:

Requesting a vacation override

  1. 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.
  2. 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

  1. 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).
  2. 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

  1. 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.
  2. Bring copies of your prescriptions so you can fill them in the event you lose your medications.
  3. 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.
  4. Bring the name and telephone number of your doctor and pharmacy.

Protect your medications

  1. 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.
  2. When traveling by plane, pack medications in your carry-on, not in checked luggage.
  3. 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

  1. 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.

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