Senior Care Options (D-SNP) Frequently Asked Questions
Four helpful things for Tufts Health Plan Senior Care Options members with a prescription drug plan to know:
1. How To Find Your Drug On Our Formulary (Drug List)
A “Formulary” is a list of drugs that our plan covers. To find out if a drug that is prescribed to you is covered:
- Look up the name of the drug in the Formulary by using the index.
- A tier number will be listed next to each drug.
- The tier number determines the relative cost of the drug.
You can view the most current version of our formulary on the plan documents page of our website. A printed copy is mailed to you each year. You can also call Member Services for assistance.
2. What To Know About Generic Drugs
- Generic drugs generally cost less than brand name drugs. One reason why is because unlike makers of brand name drugs, generic drug manufacturers don’t need to spend as much money on research, development or advertising.
- Generic drugs are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand name drugs.
- A generic drug has the same active-ingredient formula as a brand name drug.
- Make sure to talk to your doctor to see if generic drugs are right for you.
3. OptumRx Home Delivery Offers Convenience
If your plan has prescription coverage, you can have prescriptions you take regularly delivered to your door with Optum Home Delivery! You may be able to save up to $53 for a 90-day supply of prescription medications (depending on the plan you are in and the tier your drug is on). That’s a potential savings of up to $212 a year!
Signing up for home delivery is easy. You can sign up online, by phone, or by mail:
- Online: Visit OptumRx.com
- By phone: HMO: 1-800-299-7648, PPO: 1-800-460-0322. Have your Tufts Health Plan member ID number, prescription number(s), and credit card information ready whenever you call.
- By mail: Complete the order form on our website. You should receive your order in approximately two weeks.
4. Where To Find More Information About Your Prescription Drug Coverage
Each of our plans has an Evidence of Coverage (EOC) booklet that describes the benefits. Each EOC booklet contains a chapter that explains the prescription drug benefit for that plan including how to use your prescription drug coverage (if you are in a prescription drug plan). Each year an EOC booklet is mailed to you. The EOCs are also available on the plan documents page of our website. If you have any questions about your prescription drug coverage you can always call Member Services.
Customer Relations Can Answer Your Questions
If you have any questions, just call Customer Relations at 1-855-670-5934 (TTY: 711). Representatives are available 8 a.m. – 8 p.m., 7 days a week (Mon. – Fri. from Apr. 1 – Sept. 30).
Some covered drugs may have additional requirements or limits on coverage known as Utilization Management. These requirements and limits may include:
Prior Authorization: Tufts Health Plan Senior Care Options requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Tufts Health Plan Senior Care Options before you fill your prescriptions. If you don't get approval, Tufts Health Plan Senior Care Options may not cover the drug.
Quantity Limits: For certain drugs, Tufts Health Plan Senior Care Options limits the amount of the drug that Tufts Health Plan Senior Care Options will cover. For example, Tufts Health Plan Senior Care Options provides 30 tablets per prescription for zolpidem. This may be in addition to a standard one month or three month supply.
Step Therapy: In some cases, Tufts Health Plan Senior Care Options requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Tufts Health Plan Senior Care Options may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Tufts Health Plan Senior Care Options will then cover Drug B.
You can ask Tufts Health Plan Senior Care Options to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make:
- You can ask us to cover your drug even if it is not on our formulary.
- You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Tufts Health Plan Senior Care Options may limit the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more.
When you are requesting a formulary or utilization restriction exception, you should submit a statement from your physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescribing physician's supporting statement. You can request an expedited (faster) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get your prescribing physician's supporting statement.
Tufts Health Plan Senior Care Options uses a Formulary to list the prescription drugs that we cover. Use the Drug Coverage Page to view formularies and online drug search tools.
We have contracts with over 850 pharmacies within our pharmacy network. The link below provides a list of our participating pharmacies. This directory is updated annually, however this does not guarantee that the pharmacy is still in the network. Contact Member Services at 1-855-670-5934 (TTY: 711) with additional questions.
Tufts Health Plan Senior Care Options may add or remove drugs from our formulary during the year. The cover page of the posted formulary PDFs include the last date the document was updated. For questions call Member Services at 1-855-670-5934 (TTY: 711). Representatives are available 8 a.m. – 8 p.m., 7 days a week (Mon. – Fri. from Apr. 1 – Sept. 30).
The Prescription Drug Transition Process (PDF) document can answer the following questions:
- What if your drug is no longer covered?
- What if your drug is excluded from coverage?
- What if you just joined Tufts Health Plan Senior Care Options and did not know that your drug was not covered?
- What if your drug requires Prior Authorization?
- What if your drug is part of a Step Therapy program?
We have programs that can help our members with special situations. For example, some members have several complex medical conditions or they may need to take many drugs at the same time, or they could have very high drug costs.
These programs are voluntary and free to members. A team of pharmacists and doctors developed the programs for us. The programs can help make sure that our members are using the drugs that work best to treat their medical conditions and help us identify possible medication errors.
One program is called a Medication Therapy Management (MTM) program. Some members who take several medications for different medical conditions may qualify. A pharmacist or other health professional will give you a comprehensive review of all your medications.
Learn more on the Medication Therapy Management page.
This form is used to request coverage for medications that require prior authorization or exceptions for non-covered drugs. Your physician must be involved in filling out this form since he or she will need to provide information regarding the medical necessity of your request.
Your Rights
If your pharmacist cannot fill your prescription drugs you have the right to request a coverage determination from Tufts Health Plan Senior Care Options. This request includes the right to request a special type of coverage determination called an “exception” if you believe:
- 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;
- 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.
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:
- The prescription drug you believe you need. Include the dose and strength, if known.
- If you ask for an exception, your doctor or other prescriber will need to provide Tufts Health Plan Senior Care Options 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.
- The date your prescription was rejected at the pharmacy.
Tufts Health Plan Senior Care Options 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
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 the Redetermination Form (PDF)
Interested in learning more about the aggregate number of appeals, grievances and exceptions filed with Tufts Health Plan Senior Care Options?
Call Member Services at 1-855-670-5934 (TTY: 711) for a copy of our Tufts Health Plan Senior Care Options Appeals and Grievances Report.
An organization determination is our initial decision about whether we will cover the medical care or service you request, or pay for a service you have received. If our initial decision is to deny your request, you may appeal the decision. When we make an "organization determination," we are giving our interpretation of how the benefits and services that are covered for members of the Plan apply to your specific situation. Please refer to your EOC for additional details.
Learn more about organization determination in Chapter 8, section 1-9 of your EOC.
When we make a coverage determination, we are making a decision whether or not to cover or pay for a Part D 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). 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 clinicians 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 nurse during off hours for requests for Part D pharmacy coverage.
By phone:
Call Member Services at 1-855-670-5934 (TTY: 711). For prescription drug related questions only, call 8 a.m. – 8 p.m., 7 days a week (Mon. – Fri. from Apr. 1 – Sept. 30). After hours and on holidays, please leave a message. The voice mail boxes are checked routinely on weekends and holidays by the on-call nurse to address requests for Part D pharmacy coverage.
Online:
Go to Online Coverage Determination for details on submitting a Coverage Determination online
Coverage Determination Form (PDF)
By mail:
Write to us at:
Attn: Pharmacy Utilization Management Department
Tufts Health Plan
1 Wellness Way
Canton, MA 02021
For more information:
Learn more about filing a coverage determination in Chapter 8, section 1-9 of your EOC.
You, your physician or your appointed representative may file a coverage determination by calling Member Services at 1-855-670-5934 (TTY: 711). Representatives are available 8 a.m. – 8 p.m., 7 days a week (Mon. – Fri. from Apr. 1 – Sept. 30), or by writing to:
Attn: Pharmacy Utilization Management Department
Tufts Health Plan
1 Wellness Way
Canton, MA 02021
Or by fax to:
1-617-673-0956.
If you are requesting a formulary exception, your physician must provide a statement to support your request. Your physician can submit the request using our Universal Pharmacy Form (PDF) or the Medicare Part D Coverage Determination Request Form (PDF). The form asks your physician for information regarding your diagnosis, what other drug(s), if any, has been prescribed for the diagnosis and why it has not worked, and other questions. Your physician should send the completed form to:
Attn: Pharmacy Utilization Management Department
Tufts Health Plan
1 Wellness Way
Canton, MA 02021
Or by fax to:
1-617-673-0956.
Your physician can also provide an oral supporting statement by calling Member Services at 1-855-670-5934 (TTY: 711). 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 1 - Feb 14).
Learn more about filing a coverage determination in Chapter 8, section 1-9 of your EOC.
Learn more about filing a coverage determination in Chapter 8, section 1-9 of your EOC.
Senior Care Options (HMO SNP) Plan Evidence of Coverage
If you have questions about any of this processes, or if you want to inquire about the status of a coverage determination request, you, your physician or your appointed representative may contact us at 1-855-670-5934 (TTY: 711).
Representatives are available 8 a.m. – 8 p.m., 7 days a week (Mon. – Fri. from Apr. 1 – Sept. 30).
You, your physician or your appointed representative (find the Authorization of Representative form here) may file a grievance or appeal by calling Customer Relations at 1-855-670-5934 (TTY: 711) Representatives are available 8 a.m. – 8 p.m., 7 days a week (Mon. – Fri. from Apr. 1 – Sept. 30).
You may also file a grievance or appeal by writing to:
Tufts Health Plan Medicare Preferred
Attn: Appeals and Grievances
1 Wellness Way
Canton, MA 02021
Or by fax to:
1-617-972-9516.
You may pursue a MassHealth Board of Hearings (BOH) review, in addition to, or instead of, filing a standard or expedited appeal with Tufts Health Plan Senior Care Options. If you choose to pursue an external appeal, you must submit your written hearing request to BOH within 120 calendar days from the date of mailing of the Tufts Health Plan Senior Care Options notice to deny coverage for your services.
The Tufts Health Plan Senior Care Options Appeals and Grievances Department may assist you with this process. Hearing requests should be sent to:
Executive Office of Health and Human Services
Board of Hearings
Office of Medicaid
100 Hancock Street, 6th floor
Quincy, MA 02171
Or by fax to:
1-617-847-1204
Learn more about filing an appeal or coverage determination in your plan's Evidence of Coverage document found on the Plan Documents page.
Please see your Evidence of Coverage: Complaints about Medical Services and Benefits: Complaints about Prescription Drug Benefits of your Evidence of Coverage (EOC) for more information on our grievance and appeals process.
Tufts Health Plan Senior Care Options (HMO SNP) Plan Evidence of Coverage
If you have questions about this process, or if you want to inquire about the status of a grievance or appeal request, you, your physician or your appointed representative may contact us at 1-855-670-5934 (TTY: 711). Representatives are available 8 a.m. – 8 p.m., 7 days a week (Mon. – Fri. from Apr. 1 – Sept. 30).
Learn more about filing an appeal in Chapter 8, section 1-9 and a grievance in Chapter 9, section 11 of your EOC. Also, to learn more about filing an appeal with MassHealth please review Chapter 9, section 12 of your EOC.
Every individual enrolled in a Tufts Health Plan Senior Care Options plan has the right to appoint an individual to act as their representative in connection with a claim or asserted right under title XViii (18) of the Social Security act (the “act”) and related provisions of title Xi (11) of the act.
You can authorize this individual to make any request; to present or to elicit evidence; to obtain appeals information; and to receive any notice in connection with an appeal, wholly in your stead. It is important to understand that personal medical information related to your appeal may be disclosed to the representative that you indicate on the Appointment of Personal Representative (PDF) form.
Where do I send this form?
Send this form to the same location where you are sending (or have already sent) an appeal if you are filing an appeal, grievance if you are filing a grievance, initial determination or decision if you are requesting an initial determination or decision.
Attn: Appeals & Grievances
P.O. Box 474
Canton, MA 02021-0474
Or by fax to: 1-617-972-9405 or 1-617-972-9487.
To find out how many grievances, appeals, and exceptions have been filed with the Tufts Health Plan Senior Care Options you may contact us at 1-855-670-5934 (TTY: 711). Representatives are available 8 a.m. – 8 p.m., 7 days a week (Mon. – Fri. from Apr. 1 – Sept. 30).
Ending your membership in Tufts Health Plan Senior Care Options may be voluntary (your own choice) or involuntary (not your own choice):
- Your Evidence of Coverage (EOC) document tells you when you can end your membership in the plan.
- There are also limited situations where you do not choose to leave, but we are required to end your membership. The process for Involuntary Disenrollment requests must be preapproved; the plan must present a detailed explanation and all applicable documentation to the MassHealth SCO Operations Unit. Your Evidence of Coverage document tells you about situations when we must end your membership.
If you are leaving our plan, you must continue to get your medical care through our plan until your membership ends. If you leave the Tufts Health Plan Senior Care Options plan, it may take time before your membership ends and your new coverage goes into effect. (See your Evidence of Coverage document for information on when your new coverage begins.) During this time, you must continue to get your medical care through our plan.
If we end your membership in our plan, we must tell you our reasons in writing for ending your membership. We must also explain how you can make a complaint about our decision to end your membership. You can also look in your Evidence of Coverage document for information about how to make a complaint.
Utilization Management
To help monitor quality of care and manage health care costs, Tufts Health Plan Senior Care Options conducts utilization management activities for all its members. The goal of utilization management is to be sure the care for which members receive coverage is medically necessary, covered by Tufts Health Plan Senior Care Options and provided by a qualified provider. Utilization management may be conducted in several ways, including preauthorization review, concurrent review (while you are receiving care), and retrospective review (after care has been provided). Tufts Health Plan Senior Care Options also includes case management services for medically complex situations in which the member is likely to require extensive coordination of services.
Medication Therapy Management (MTM)
We offer medication therapy management programs at no additional cost for HMO SNP (Medicare and Medicaid) members who have multiple medical conditions, who are taking many prescription drugs, or who have high drug costs. These programs were developed for us by a team of pharmacists and doctors. We use these medication therapy management programs to help us provide better coverage for our members. For example, these programs help us make sure that our members are using appropriate drugs to treat their medical conditions and help us identify possible medication errors. We offer medication therapy management programs for members that meet specific criteria. We may contact members who qualify for these programs. You may decide not to participate but it is recommended that you take full advantage of this covered service if you are selected. Remember, you do not need to pay anything extra to participate.
If you are selected to join a medication therapy management program, we will send you information about the specific program, including information about how to access the program. For additional information, please contact Tufts Health Plan Senior Care Options Member Services at 1-855-670-5934
(TTY:711). Representatives are available 8 a.m. – 8 p.m., 7 days a week (Mon. – Fri. from Apr. 1 – Sept. 30).
Please refer to the Evidence of Coverage (EOC) for more information about:
- Benefits
- Plan service area
- Conditions/limitations
- Out-of-network coverage
Please refer to your Evidence of Coverage (EOC) document for more information on:
- Coverage Determination
- Appeals and Grievances and Coverage Determination
- Prescription drug quality assurance
- Potential for contract termination
- Disenrollment rights and responsibilities
Phone Numbers
If you are interested in becoming a member of a plan offered by Tufts Health Plan Senior Care Options call:
1- 855-670-5927 (TTY: 711)
Our representatives are available 8 a.m. – 8 p.m., 7 days a week (Mon. – Fri. from Apr. 1 – Sept. 30). After hours and on holidays, please leave a message and a representative will return your call the next business day.
If you are already a member call, our Member Services department:
1- 855-670-5934 (TTY: 711)
Our representatives are available 8 a.m. – 8 p.m., 7 days a week (Mon. – Fri. from Apr. 1 – Sept. 30).
Mailing Address:
Tufts Health Plan Senior Care Options
1 Wellness Way
Canton, MA 02021
Fax:
To fax completed enrollment forms: 1-617-673-0785
If the governor of Massachusetts, the U.S. Secretary of Health and Human Services, or the president of the United States declares a state of disaster or emergency in your geographic area, you’re still entitled to care from our plan.
Please visit the following website for information on how to obtain needed care during a disaster: https://www.medicare.gov/providers-services/disaster-emergency.
During a declared disaster, if you can’t use a network provider, you can get care from out-of-network providers at no cost to you. If you can’t use a network pharmacy during a declared disaster, you can fill your drugs at an out-of-network pharmacy. Refer to Chapter 5 of your Member Handbook for more information.