Plan Documents

Download Adobe reader » Below is a list of documentation useful to members. PDFs can be downloaded and then viewed with Adobe Reader.

NOTE: Worcester County residents: please refer to county specific Plan Highlights and Summary of Benefits.

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Popular Member Forms
Worcester County Documents
Prescription Drug Forms
Plan Information
Enrollment Forms
Senior Care Options (HMO SNP)

Popular Member Forms

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

2013 Tufts Medicare Preferred HMO Basic No Rx Plan Evidence of Coverage » H2256_2013_6 CMS Accepted
2013 Tufts Medicare Preferred HMO Basic Rx Plan Evidence of Coverage » H2256_2013_3 CMS Accepted
2013 Tufts Medicare Preferred HMO Value No Rx Plan Evidence of Coverage » H2256_2013_7 CMS Accepted
2013 Tufts Medicare Preferred HMO Value Rx Plan Evidence of Coverage » H2256_2013_4 CMS Accepted
2013 Tufts Medicare Preferred HMO Prime No Rx Plan Evidence of Coverage » H2256_2013_5 CMS Accepted
2013 Tufts Medicare Preferred HMO Prime Rx/Rx Plus Plan Evidence of Coverage » H2256_2013_1 CMS Accepted
2013 Tufts Medicare Preferred HMO Saver Rx Plan Evidence of Coverage » H2256_2013_139 CMS Accepted
2013 Tufts Medicare Preferred Supplement Core Policy » 100-MSCOREPOL-13
2013 Tufts Medicare Preferred Supplement One Policy » 99-MS1POL-13
2013 Fitness/Nutrition Benefit Form - HMO members » H2256_2013_238 CMS Accepted
2013 Network of Fitness Centers Directory
2013 Wellness Benefit Form - Medicare Supplement members
2013 Weight Watchers Form
Member Reimbursement Form » 111-MEMREIMFORM-13
Electronic Funds Transfer (EFT) Authorization Form » H2256_2012_77 File & Use 10/03/2011
2013 Tufts Health Plan Medicare Preferred Claims Profile Request Form (coming soon) »
Tufts Medicare Preferred HMO Doctor Visit Information Sheet

Worcester County Documents

2013 Tufts Medicare Preferred Worcester Saver Rx Plan Highlights » H2256_2013_116 CMS Accepted
2013 Tufts Medicare Preferred Worcester Basic and Basic Rx Plan Highlights » H2256_2013_117 CMS Accepted
2013 Tufts Medicare Preferred Worcester Value and Value Rx Plan Highlights » H2256_2013_118 CMS Accepted
2013 Tufts Medicare Preferred Worcester Prime and Prime Rx Plan Highlights » H2256_2013_119 CMS Accepted
2013 Tufts Medicare Preferred Worcester HMO Saver Plan Summary of Benefits » H2256_2013_137 CMS Accepted
2013 Tufts Medicare Preferred Worcester County HMO Summary of Benefits Brochure » H2256_2013_136 CMS Accepted
2013 HMO Plan Ratings » H2256_2013_163 CMS Accepted
2013 Multi-Lanugage Insert » H2256_2013_123 CMS Accepted

Prescription Drug Forms

Plan Information

Plan Directories

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