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. For prescription drug related questions only, call 7 days a week 8:00 a.m. - 8:00 p.m. You, your physician or your appointed representative may file a coverage determination, including an exception, 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 15 - 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: Precertification Department
Tufts Health Plan Medicare Preferred
705 Mt. Auburn Street
Watertown, MA 02472

Or by fax to: 1-617-972-9409.

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).