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.

You, your physician, or your appointed representative may file a coverage determination, including an exception, by either faxing, calling, filling out a form online, or writing to us. For requests received outside normal business hours, we have Pharmacy Utilization Management clinical pharmacist on-call for processing  requests for Part D pharmacy coverage.

By fax:

1–617-673-0956.

Faxed requests can be sent 24-hours a day, 7 days a week. Faxes are checked routinely during business hours and by the on-call clinical pharmacist during off hours, weekends and on holidays for requests for Part D pharmacy coverage.

By phone:

Call Customer Relations at 1-800-701-9000 (TTY 1-800-208-9562). For prescription drug related questions, please call Monday to Friday from 8:00 a.m.- 8:00p.m (Representatives are available 7 days a week, 8:00 a.m - 8:00 p.m from Oct.1 - Feb.14). After hours, weekends and on holidays, please leave us a message. The confidential voice mail box is checked routinely by our on-call clinical pharmacist to address requests for Part D pharmacy coverage.

Online:

Go to tuftsmedicarepreferred.org/coverage for details on submitting a Coverage Determination online, or go right to the form by clicking here.

By mail:

Write to us at:

Attn: Pharmacy Utilization Management Department
Tufts Health Plan Medicare Preferred
705 Mt. Auburn Street
Watertown, MA 02472

For more information:

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).

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