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. You, your physician or your appointed representative may file a coverage determination, including an exception, by calling Customer Relations 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 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) Monday - Friday, 8:30 a.m. - 5:00 p.m. (For Prescription drug related questions only, call 7 days a week 8:00 a.m. to 8:00 p.m.).
How to find additional information about coverage determinations:
Please see your Evidence of Coverage (EOC) for more information on our coverage determination process.
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 Customer Relations.
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.
