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)

H2256_2012_137 CMS Approved (01/04/2012)