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Medicare Advantage HMO Plans

Tufts Medicare Preferred HMO member cards look like the samples below:

Reimbursement Forms

Tufts Health Plan Medicare Preferred HMO & Supplement Plans Member Reimbursement Form

This form allows Tufts Health Plan Medicare Preferred members to request reimbursement for any healthcare services you have received that were not initially covered by Tufts Health Plan (including out-of-country healthcare services). Please note that this form is not intended to be used for Wellness Allowance reimbursements, Weight Management reimbursements, Fitness and Nutritional Counseling reimbursements, or for non-plan vision provider reimbursements through Eyemed.

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Prescription (Rx) Drugs and Pharmacy Forms

Request For Medicare Prescription Drug Coverage Determination

This form is used to submit a request for coverage, or payment, of a prescription drug through a Tufts Health Plan Medicare Preferred HMO plan. This form can be used as the Exception Request Forms for physicians, Prior Authorization Form for Physicians and Enrollees and the Utilization Management Form for Physicians and Enrollees.  

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Tufts Health Plan Personal Medication List

Complete this form to help organize and track your medications. Keeping it up to date will ensure you have a list of your current medications which can be shared with doctors, caregivers and loved ones as needed. 

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Enrollment and Dis-enrollment Forms

2020 Tufts Medicare Preferred HMO Individual Enrollment Form

This form is used to apply for enrollment in a Tufts Health Plan Medicare Preferred HMO plan. Please note, this form is intended for new enrollments. If you are a current member and need to switch your plan, please use the Tufts Health Plan Medicare Preferred HMO Short Enrollment Form.

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2020 Tufts Medicare Preferred HMO Short Enrollment Form

This form allows current Tufts Health Plan Medicare Preferred members to request enrollment in a different Tufts Health Plan Medicare Preferred plan, in order to switch from one Tufts Health Plan Medicare Preferred plan to another, or add the Dental Option to a current Tufts Health Plan Medicare Preferred plan.  Please note, there may be enrollment restrictions depending on when you originally enrolled in your Tufts Health Plan coverage.

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Authorization and Appointment of Representative Forms

Financial and Payment Forms

Appeals and Grievances Forms

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Medicare Supplement Plans

Tufts Medicare Preferred Supplement member cards look like the sample below:

Reimbursement Forms

Tufts Health Plan Medicare Preferred HMO & Supplement Plans Member Reimbursement Form

This form allows Tufts Health Plan Medicare Preferred members to request reimbursement for any healthcare services you have received that were not initially covered by Tufts Health Plan (including out-of-country healthcare services). Please note that this form is not intended to be used for Wellness Allowance reimbursements, Weight Management reimbursements, Fitness and Nutritional Counseling reimbursements, or for non-plan vision provider reimbursements through Eyemed.

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Enrollment and Dis-enrollment Forms

2020 Tuft Health Plan Medicare Supplement Dental Option Enrollment Form

This form is used to apply for enrollment in the Tufts Health Plan Medicare Supplement Dental Option. The Dental Option is a rider benefit that must be added to, or purchased with, a Tufts Health Plan Medicare Preferred Supplement plan. Please note, there may be enrollment restrictions depending on when you originally enrolled in your Tufts Health Plan Medicare Preferred Supplement coverage. 

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Authorization and Appointment of Representative Forms

Financial and Payment Forms

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Senior Care Options Plan (HMO-SNP)

Tufts Medicare Preferred Senior Care Options member cards look like the samples below:

Reimbursement Forms

Tufts Health Plan Senior Care Options Member Reimbursement Form

This form allows Tufts Health Plan Senior Care Options plan members to request reimbursement for any healthcare services you have received that were not initially covered by Tufts Health Plan (including out-of-country healthcare services). Please note that this form is not intended to be used for Wellness Allowance reimbursements, Weight Management reimbursements, Fitness and Nutritional Counseling reimbursements, or for non-plan vision provider reimbursements through Eyemed.

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Prescription (Rx) Drugs and Pharmacy Forms

Tufts Health Plan Personal Medication List

Complete this form to help organize and track your medications. Keeping it up to date will ensure you have a list of your current medications which can be shared with doctors, caregivers and loved ones as needed. 

View Form

Enrollment and Dis-enrollment Forms

Authorization and Appointment of Representative Forms

Financial and Payment Forms

Appeals and Grievances Forms

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PDP

Prescription Drug Plan (PDP)

Tufts Medicare Preferred Prescription Drug Plan (PDP) member cards look like the sample below:

Reimbursement Forms

Authorization and Appointment of Representative Forms

Financial and Payment Forms

Prescription (Rx) Drugs and Pharmacy Forms

Request For Medicare Prescription Drug Coverage Determination

This form is used to submit a request for coverage, or payment, of a prescription drug through a Tufts Health Plan Medicare Preferred PDP plan. This form can be used as the Exception Request Forms for physicians, Prior Authorization Form for Physicians and Enrollees and the Utilization Management Form for Physicians and Enrollees.  

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