Medicare Advantage HMO Plans
Reimbursement Forms
2020 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.
2020 Tufts Health Plan Medicare Preferred HMO Plans Wellness Allowance Reimbursement Form
This form is used to to request the Wellness Allowance Reimbursement Benefit offered by the Tufts Health Plan Medicare Preferred HMO plans. Updated 03/02/2021
2021 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.
2021 Tufts Health Plan Medicare Preferred HMO Plans Weight Management Reimbursement Form
This form is used to to request the $150 Wellness Allowance Reimbursement Benefit offered by Tufts Health Plan Mediare Preferred HMO plans.
2021 Tufts Health Plan Medicare Preferred HMO Plans Wellness Allowance Reimbursement Form
This form is used to to request the Wellness Allowance Reimbursement Benefit offered by the Tufts Health Plan Medicare Preferred HMO plans.
Tufts Health Plan Medicare Preferred CVS/Caremark Prescription Reimbursement Form
This form allows you to request a reimbursement for a prescription that was not initially covered by Tufts Health Plan.
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.
Tufts Health Plan Medicare Preferred HMO Plans Weight Management Reimbursement Form
This form is used to to request the $150 Wellness Allowance Reimbursement Benefit offered by Tufts Health Plan Mediare Preferred HMO plans.
Tufts Health Plan Medicare Preferred Out-of-Network Vision Services Claim Form
This form allows you to file a claim for vision services obtained through a provider that is not part of the EyeMed network.
Prescription (Rx) Drugs and Pharmacy Forms
Coverage Determination and Prior Authorization Request for Medicare Part B versus Part D
This form allows physicians to submit information to Tufts Health Plan to help determine drug coverage for Tufts Health Plan Medicare Preferred, Tufts Health Plan Senior Care Options, Tufts Health Unify and proper payment under Medicare Part B versus Part D per the Centers for Medicare and Medicaid Services(CMS).
CVS/Caremark HMO Mail Service Order Form
This form allows Tufts Health Plan Medicare Preferred HMO plan members to request delivery of prescription drugs through the CVS/Caremark mail order service.
Hepatitis C Medication Request Form
Use this form to request Hepatitis C medication.
Part D Late Enrollment Penalty (LEP) Reconsideration Request Form
This form is used to submit a request for reconsideration to eliminate your Part D late enrollment penalty.
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.
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.
Enrollment and Dis-enrollment Forms
2021 Dental Option Enrollment Form
This form is used to apply for enrollment in the Dominion Dental Option. The Dominion Dental Option is a rider benefit that must be added to, or purchased with, a Tufts Health Plan Medicare Preferred HMO plan. Please note, there may be enrollment restrictions depending on when you originally enrolled in your Tufts Health Plan Medicare Preferred HMO coverage.
2021 Tufts Health Plan Medicare Preferred Pre-Enrollment Checklist
This form helps you better understand the enrollment process, plan benefits and plan rules before enrolling.
2021 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.
2021 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.
Tufts Health Plan Medicare Preferred HMO Disenrollment Form
This form is used to disenroll from Tufts Health Plan Medicare Preferred plans. Please note that you must continue to get all medical care from Tufts Health Plan Medicare Preferred until the effective date of disenrollment.
Authorization and Appointment of Representative Forms
Authorization to Disclose Protected Health Information - HMO Plans
This form allows you to authorize Tufts Health Plan to disclose your protected health information to a person or entity. This form should be used for member enrolled in a Tufts Health Plan Medicare Preferred HMO plan.
Centers for Medicare & Medicaid Services Appointment of Representative Form
This form allows you to appoint an individual to act as your personal representative with regard to any matter related to your insurance coverage and benefits provided by Tufts Health Plan Medicare Preferred.
Tufts Health Plan Medicare Preferred Appointment of Personal Representative (AOR) Form
This form allows you to appoint an individual to act as your personal representative with regard to any matter related to your insurance coverage and benefits provided by Tufts Health Plan Medicare Preferred.
Financial and Payment Forms
Tufts Health Plan Electronic Funds Transfer (EFT) Authorization Form
This form allows you to sign up for EFT (Electronic Funds Transfer) payments. When you sign up for EFT payments, your Tufts Health Plan premium payment is automatically deducted from your checking or savings account each month.
Appeals and Grievances Forms
Tufts Health Plan Medicare Preferred Request for Redetermination of Medicare Prescription Drug Denial
This form is used to submit a redetermination (appeal) of a previously declined request for coverage or payment of a prescription drug through a Tufts Health Plan Medicare Preferred HMO plan. Please note that you have 60 days from the date of the initial Notice of Denial of Medicare Prescription Drug Coverage to request a redetermination.
Medicare Supplement Plans
Reimbursement Forms
2020 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.
2021 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.
2021 Tufts Health Plan Medicare Preferred Medicare Supplement Fitness and Nutritional Counseling Reimbursement Form
This form is used to to request the $150 Fitness and Nutritional Counseling Reimbursement offered through Tufts Medicare Preferred Supplement plans.
2021 Tufts Health Plan Medicare Preferred Medicare Supplement Weight Management Reimbursement Form
This form is used to to request the $150 Weight Management Reimbursement offered by Tufts Health Plan Medicare Preferred Supplement plans.
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.
Tufts Health Plan Medicare Preferred Medicare Supplement Fitness and Nutritional Counseling Reimbursement Form
This form is used to to request the $150 Fitness and Nutritional Counseling Reimbursement offered through Tufts Medicare Preferred Supplement plans.
Tufts Health Plan Medicare Preferred Medicare Supplement Weight Management Reimbursement Form
This form is used to to request the $150 Weight Management Reimbursement offered by Tufts Health Plan Medicare Preferred Supplement plans.
Enrollment and Dis-enrollment Forms
2021 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.
2021 Tufts Health Plan Medicare Preferred Supplement Enrollment Application
This form is used to enroll in a Tufts Health Plan Medicare Preferred Supplement plan.
Authorization and Appointment of Representative Forms
Centers for Medicare & Medicaid Services Appointment of Representative Form
This form allows you to appoint an individual to act as your personal representative with regard to any matter related to your insurance coverage and benefits provided by Tufts Health Plan Medicare Preferred.
Tufts Health Plan Medicare Preferred Appointment of Personal Representative (AOR) Form
This form allows you to appoint an individual to act as your personal representative with regard to any matter related to your insurance coverage and benefits provided by Tufts Health Plan Medicare Preferred.
Financial and Payment Forms
Tufts Health Plan Electronic Funds Transfer (EFT) Authorization Form
This form allows you to sign up for EFT (Electronic Funds Transfer) payments. When you sign up for EFT payments, your Tufts Health Plan premium payment is automatically deducted from your checking or savings account each month.
Senior Care Options Plan (HMO-SNP)
Reimbursement Forms
2020 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.
2020 Tufts Health Plan Senior Care Options Over-the-Counter (OTC) Reimbursement Form
This form allows Tufts Health Plan Senior Care Options plan members to request the quarterly $130 over-the-counter allowance that is available to them. Please note, this allowance can be used once per calendar quarter, up to four times per year, for Medicare approved over-the-counter (OTC) items.
2020 Tufts Health Plan Senior Care Options Wellness Allowance Reimbursement Form
This form is used to to request the $200 Wellness Allowance Reimbursement Benefit offered by the Tufts Health Plan Senior Care Options plans.
2021 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.
2021 Tufts Health Plan Senior Care Options Over-the-Counter (OTC) Reimbursement Form
This form allows Tufts Health Plan Senior Care Options plan members to request reimbursement for the quarterly $112 Instant Savings card allowance and/or the quarterly $25 DailyCare+ card allowance. These allowances are replenished once per calendar quarter. The $112 Instant Savings card quarterly allowance may be used to purchase Medicare-approved over-the-counter (OTC) items.1 The $25 DailyCare+ card quarterly allowance may be used to purchase Medicaid-approved over-the-counter items. Approved reimbursement amounts will be deducted from the balance of the DailyCare+ card and/or Instant Savings card for the calendar quarter in which items were purchased.
2021 Tufts Health Plan Senior Care Options Weight Management Reimbursement Form
This form is used to to request the $200 Weight Management Reimbursement offered by Tufts Health Plan Senior Care Options plan.
2021 Tufts Health Plan Senior Care Options Wellness Allowance Reimbursement Form
This form is used to to request the $200 Wellness Allowance Reimbursement Benefit offered by the Tufts Health Plan Senior Care Options plans.
Tufts Health Plan Medicare Preferred CVS/Caremark Prescription Reimbursement Form
This form allows you to request a reimbursement for a prescription that was not initially covered by Tufts Health Plan.
Tufts Health Plan Medicare Preferred Out-of-Network Vision Services Claim Form
This form allows you to file a claim for vision services obtained through a provider that is not part of the EyeMed network.
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.
Tufts Health Plan Senior Care Options Over-the-Counter (OTC) Reimbursement Form
This form allows Tufts Health Plan Senior Care Options plan members to request the quarterly $105 over-the-counter allowance that is available to them. Please note, this allowance can be used once per calendar quarter, up to four times per year, for Medicare approved over-the-counter (OTC) items.
Tufts Health Plan Senior Care Options Weight Management Reimbursement Form
This form is used to to request the $200 Weight Management Reimbursement offered by Tufts Health Plan Senior Care Options plan.
Tufts Health Plan Senior Care Options Wellness Allowance Reimbursement Form
This form is used to to request the $200 Wellness Allowance Reimbursement Benefit offered by the Tufts Health Plan Senior Care Options plans.
Prescription (Rx) Drugs and Pharmacy Forms
Coverage Determination and Prior Authorization Request for Medicare Part B versus Part D
This form allows physicians to submit information to Tufts Health Plan to help determine drug coverage for Tufts Health Plan Medicare Preferred, Tufts Health Plan Senior Care Options, Tufts Health Unify and proper payment under Medicare Part B versus Part D per the Centers for Medicare and Medicaid Services(CMS).
CVS/Caremark Senior Care Options (SCO) Mail Service Order Form
This form allows Tufts Health Plan Senior Care Options plan members to request delivery of prescription drugs through the CVS/Caremark mail order service.
Hepatitis C Medication Request Form
Use this form to request Hepatitis C medication.
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.
Tufts Health Plan Senior Care Options Request For Medicare Prescription Drug Coverage Determination
This form is used to submit a request for coverage, or payment, of a prescription drug through the Tufts Health Plan Senior Care Options 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.
Enrollment and Dis-enrollment Forms
Tufts Health Plan Senior Care Options (HMO SNP) Disenrollment Form
This form is used to disenroll from Tufts Health Plan Senior Care Options plan. Please note that you must continue to get all medical care from Tufts Health Plan Medicare Preferred until the effective date of disenrollment.
Authorization and Appointment of Representative Forms
Authorization to Disclose Protected Health Information - Senior Care Options
This form allows Tufts Health Plan Senior Care Options plan members to authorize Tufts Health Plan to disclose their protected health information to a person or entity.
Centers for Medicare & Medicaid Services Appointment of Representative Form
This form allows you to appoint an individual to act as your personal representative with regard to any matter related to your insurance coverage and benefits provided by Tufts Health Plan Medicare Preferred.
Tufts Health Plan Senior Care Options Appointment of Personal Representative (AOR) Form
This form allows Tufts Health Plan Senior Care Options plan members to appoint an individual to act as their personal representative with regard to any matter related to their insurance coverage and benefits provided by the Tufts Health Plan Senior Care Options plan.
Financial and Payment Forms
Tufts Health Plan Electronic Funds Transfer (EFT) Authorization Form
This form allows you to sign up for EFT (Electronic Funds Transfer) payments. When you sign up for EFT payments, your Tufts Health Plan premium payment is automatically deducted from your checking or savings account each month.
Appeals and Grievances Forms
Tufts Health Plan Senior Care Options Request for Redetermination of Medicare Prescription Drug Denial
This form is used to submit a redetermination (appeal) of a previously declined request for coverage or payment of a prescription drug through the Tufts Health Plan Senior Care Options plan. Please note that you have 60 days from the date of the initial Notice of Denial of Medicare Prescription Drug Coverage to request a redetermination.
Prescription Drug Plan (PDP)
Reimbursement Forms
Tufts Health Plan Medicare Preferred CVS/Caremark Prescription Reimbursement Form
This form allows you to request a reimbursement for a prescription that was not initially covered by Tufts Health Plan.
Authorization and Appointment of Representative Forms
Centers for Medicare & Medicaid Services Appointment of Representative Form
This form allows you to appoint an individual to act as your personal representative with regard to any matter related to your insurance coverage and benefits provided by Tufts Health Plan Medicare Preferred.
Tufts Health Plan Medicare Preferred Appointment of Personal Representative (AOR) Form
This form allows you to appoint an individual to act as your personal representative with regard to any matter related to your insurance coverage and benefits provided by Tufts Health Plan Medicare Preferred.
Financial and Payment Forms
Tufts Health Plan Electronic Funds Transfer (EFT) Authorization Form
This form allows you to sign up for EFT (Electronic Funds Transfer) payments. When you sign up for EFT payments, your Tufts Health Plan premium payment is automatically deducted from your checking or savings account each month.
Prescription (Rx) Drugs and Pharmacy Forms
Coverage Determination and Prior Authorization Request for Medicare Part B versus Part D
This form allows physicians to submit information to Tufts Health Plan to help determine drug coverage for Tufts Health Plan Medicare Preferred, Tufts Health Plan Senior Care Options, Tufts Health Unify and proper payment under Medicare Part B versus Part D per the Centers for Medicare and Medicaid Services(CMS).
CVS/Caremark Prescription Drug Plan (PDP) Mail Service Order Form
This form allows Tufts Health Plan Prescription Drug Plan (PDP) members to request delivery of prescription drugs through the CVS/Caremark mail order service.
Hepatitis C Medication Request Form
Use this form to request Hepatitis C medication.
Part D Late Enrollment Penalty (LEP) Reconsideration Request Form
This form is used to submit a request for reconsideration to eliminate your Part D late enrollment penalty.
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.