Plan Documents

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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).

• 2012 Tufts Medicare Preferred HMO Basic No Rx Plan Evidence of Coverage » H2256_2012_26 File & Use 8/22/2011
• 2012 Tufts Medicare Preferred HMO Basic Rx Plan Evidence of Coverage » H2256_2012_25 File & Use 8/22/2011
• 2012 Tufts Medicare Preferred HMO Value No Rx Plan Evidence of Coverage » H2256_2012_24 File & Use 8/22/2011
• 2012 Tufts Medicare Preferred HMO Value Rx Plan Evidence of Coverage » H2256_2012_23 File & Use 8/22/2011
• 2012 Tufts Medicare Preferred HMO Prime No Rx Plan Evidence of Coverage » H2256_2012_22 File & Use 8/22/2011
• 2012 Tufts Medicare Preferred HMO Prime Rx/Rx Plus Plan Evidence of Coverage » H2256_2012_20 File & Use 8/22/2011
• Errata Sheet to the Tufts Medicare Preferred HMO Basic Rx Evidence of Coverage 2012 » H2255_2012_83 Approved 9/26/2011
• Errata Sheet to the Tufts Medicare Preferred HMO Value Rx Evidence of Coverage 2012 » H2256_2012_83 Approved 9/26/2011
• Errata Sheet to the Tufts Medicare Preferred HMO Prime Rx/Rx Plus Plan Evidence of Coverage 2012 » H2256_2012_83 Approved 9/26/2011
• 2012 Tufts Medicare Preferred Supplement Core Policy (coming soon) » xx-MSCorePolicy-12
• 2012 Tufts Medicare Preferred Supplement One Policy » 16-MS1Pol-12
• 2012 Fitness/Nutrition Benefit Form - HMO members » H2256_2012_65 CMS Approved 09/21/2011
• Fitness Benefit Form - Medicare Supplement members
• 2012 Weight Watchers Form
• Member Reimbursement Form » H2256_2009_164 CMS Approved 3/17/2009
• Electronic Funds Transfer (EFT) Authorization Form » H2256_2012_77 File & Use 10/03/2011
• 2012 Tufts Health Plan Medicare Preferred Claims Profile Request Form (coming soon) » H2256_2012_XX File & Use mm/dd/yyyy
• Tufts Medicare Preferred HMO Doctor Visit Information Sheet
• Tufts Medicare Preferred HMO Medicines Worksheet

Prescription Drug Forms

• Universal Pharmacy Form
• Medicare Part D Coverage Determination Request Form
• HMO Caremark Mail Order Form
• Prescription Drug Transition Process » H2256_2010_69 CMS Approved 9/24/2009
• 2012 HMO Prime Rx Plus Premium Changes for Low Income Subsidy (coming soon)
• 2012 HMO Prime Rx Premium Changes for Low Income Subsidy (coming soon)
• 2012 HMO Value Rx Premium Changes for Low Income Subsidy (coming soon)
• 2012 HMO Basic Rx Premium Changes for Low Income Subsidy (coming soon)

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.

• 2012 Tufts Medicare Preferred HMO Formulary » H2256_2012_3 File & Use 7/16/2011
• 2012 Tufts Medicare Preferred HMO Employer Group Formulary » 6-EGHMOForm-12
• 2012 Tufts Medicare Preferred Group Retiree PDP Formulary » 2-EGPDPForm-12
• 2012 Tufts Medicare Preferred HMO Pharmacy Directory » H2256_2012_39 File & Use 7/16/2011
• 2012 Tufts Medicare Preferred Group Retiree Pharmacy Directory » 31-EGPDPPharm-12
• 2012 Tufts Medicare Preferred HMO Provider Directory » H2256_2012_2 File & Use 8/31/2011
• Prior Authorization criteria for HMO and PDP plans
• Step Therapy criteria for HMO and PDP plans

Plan Highlights Brochures

• 2012 Tufts Medicare Preferred HMO Plan Highlights Brochure » H2256_2012_5 CMS Approved 8/31/2011
• 2012 Tufts Medicare Preferred Supplement Plan Highlights Brochure » 22-MSPH-12

Summary of Benefits/Outline of Coverage

• 2012 Tufts Medicare Preferred HMO Summary of Benefits Brochure » H2256_2012_1 CMS Approved 9/6/2011
• 2012 Tufts Medicare Preferred Supplement Outline of Coverage » 23-MSOC-12

Preferred Extras

• 2012 Tufts Medicare Preferred HMO Preferred Extras » 12-PrefExtras-12
• 2012 Tufts Medicare Preferred Supplement Preferred Extras » 17-MSPrefExtras-12

Additional Documents

• Appoint Representative Form
• Authorization to Disclose Protected Health Information Request Form (coming soon)
• Privacy Notice
• Fraud, Waste & Abuse

Enrollment Forms

• 2012 Tufts Medicare Preferred HMO Plan Enrollment Form (Health Maintenance Organization) » H2256_2012_5 CMS Approved 09/21/2011
• 2012 Tufts Medicare Preferred Supplement Enrollment Form » 13-MSEroll-12