Forms
Medicare Advantage HMO Plans
Tufts Medicare Preferred HMO member cards look like the samples below:
Reimbursement Forms
2023 Optum Medicare Part D Prescription Reimbursement Form
This form allows you to request a reimbursement for a prescription that was not initially covered by Tufts Health Plan.
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View Form called 2023 Optum Medicare Part D Prescription Reimbursement Form2023 Tufts Health Plan Medicare Advantage 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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View Form called 2023 Tufts Health Plan Medicare Advantage Member Reimbursement Form2023 Tufts Health Plan Medicare Preferred Weight Management Reimbursement Form
This form is used to to request the Wellness Allowance Reimbursement Benefit offered by Tufts Health Plan Medicare Preferred plans.
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View Form called 2023 Tufts Health Plan Medicare Preferred Weight Management Reimbursement Form2023 Tufts Health Plan Medicare Preferred Wellness Allowance Reimbursement Form
This form is used to to request the Wellness Allowance Reimbursement Benefit offered by the Tufts Health Plan Medicare Preferred plans.
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View Form called 2023 Tufts Health Plan Medicare Preferred Wellness Allowance Reimbursement Form2023 Tufts Health Plan New Hampshire Group Retiree Plan Member Reimbursement Form
This form allows Tufts Health Plan Group Retiree Plan members to request reimbursement for any health care services you have received that were not initially covered by Tufts Health Plan (including out-of-country health care services).
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View Form called 2023 Tufts Health Plan New Hampshire Group Retiree Plan Member Reimbursement FormTufts Health Plan Medicare Advantage HMO & Access (PPO) Member Dental Claim Form
This form is used to request reimbursement for covered dental services that were not originally covered by Tufts Health Plan at point of service. Note for Tufts Health Plan Medicare Advantage HMO plan members: Covered services are limited to services received from a dentist in the Dominion PPO Network.
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View Form called Tufts Health Plan Medicare Advantage HMO & Access (PPO) Member Dental Claim FormTufts 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.
View Document called Tufts Health Plan Medicare Preferred Out-of-Network Vision Services Claim FormPrescription (Rx) Drugs and Pharmacy Forms
2023 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).
View Form called 2023 Coverage Determination and Prior Authorization Request for Medicare Part B versus Part D2023 Hepatitis C Medication Request Form
Use this form to request Hepatitis C medication.
View Form called 2023 Hepatitis C Medication Request Form2023 OptumRx Home Delivery Prescription Order Form
This form allows Tufts Health Plan Medicare Advantage plan members to request home delivery of prescription drugs through the OptumRx mail order service. This exclusive to Tufts Health Plan Medicare Advantage HMO, Tufts Medicare Preferred Access PPO, Tufts Health Plan Senior Care Options (HMO-SNP), and Tufts Health Plan Prescription Drug Plan (PDP) plan members.
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View Form called 2023 OptumRx Home Delivery Prescription Order Form2023 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 and PPO plans. 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.
View Form called 2023 Request For Medicare Prescription Drug Coverage DeterminationMedication Therapy Management (MTM) Blank Medication List
This form is used to document medications as part of the MTM programming.
View Form called Medication Therapy Management (MTM) Blank Medication ListPart 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.
View Document called Part D Late Enrollment Penalty (LEP) Reconsideration Request FormTufts 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 Document called Tufts Health Plan Personal Medication ListEnrollment and Dis-enrollment Forms
2023 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.
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View Form called 2023 Dental Option Enrollment Form2023 Tufts Health Plan Medicare Preferred HMO/PPO 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.
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View Form called 2023 Tufts Health Plan Medicare Preferred HMO/PPO Disenrollment Form2023 Tufts Health Plan Medicare Preferred Pre Enrollment Checklist
This form helps you better understand the enrollment process, plan benefits and plan rules before enrolling.
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View Form called 2023 Tufts Health Plan Medicare Preferred Pre Enrollment Checklist2023 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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View Form called 2023 Tufts Medicare Preferred HMO Short Enrollment Form2023 Tufts Medicare Preferred Individual Enrollment Form
This form is used to apply for enrollment in a Tufts Health Plan Medicare Preferred plans. 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 plans Short Enrollment Form.
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View Form called 2023 Tufts Medicare Preferred Individual Enrollment FormTufts 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.
View Document called Tufts Health Plan Medicare Preferred HMO Disenrollment FormFinancial 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.
View Document called Tufts Health Plan Electronic Funds Transfer (EFT) Authorization FormAppeals 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.
View Document called Tufts Health Plan Medicare Preferred Request for Redetermination of Medicare Prescription Drug DenialRequest for Protected Health Information
Member Request for Protected Health Information
This form is for use by members to request their own protected health information from Tufts Health Plan.
View Form called Member Request for Protected Health InformationPPO Access Plan
Tufts Medicare PPO Access member cards look like the sample below:
Reimbursement Forms
2023 Optum Medicare Part D Prescription Reimbursement Form
This form allows you to request a reimbursement for a prescription that was not initially covered by Tufts Health Plan.
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View Form called 2023 Optum Medicare Part D Prescription Reimbursement Form2023 Tufts Health Plan Medicare Advantage 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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View Form called 2023 Tufts Health Plan Medicare Advantage Member Reimbursement Form2023 Tufts Health Plan Medicare Preferred Weight Management Reimbursement Form
This form is used to to request the Wellness Allowance Reimbursement Benefit offered by Tufts Health Plan Medicare Preferred plans.
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View Form called 2023 Tufts Health Plan Medicare Preferred Weight Management Reimbursement Form2023 Tufts Health Plan Medicare Preferred Wellness Allowance Reimbursement Form
This form is used to to request the Wellness Allowance Reimbursement Benefit offered by the Tufts Health Plan Medicare Preferred plans.
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View Form called 2023 Tufts Health Plan Medicare Preferred Wellness Allowance Reimbursement FormTufts Health Plan Medicare Advantage HMO & Access (PPO) Member Dental Claim Form
This form is used to request reimbursement for covered dental services that were not originally covered by Tufts Health Plan at point of service. Note for Tufts Health Plan Medicare Advantage HMO plan members: Covered services are limited to services received from a dentist in the Dominion PPO Network.
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View Form called Tufts Health Plan Medicare Advantage HMO & Access (PPO) Member Dental Claim FormPrescription (Rx) Drugs and Pharmacy Forms
2023 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).
View Form called 2023 Coverage Determination and Prior Authorization Request for Medicare Part B versus Part D2023 Hepatitis C Medication Request Form
Use this form to request Hepatitis C medication.
View Form called 2023 Hepatitis C Medication Request Form2023 OptumRx Home Delivery Prescription Order Form
This form allows Tufts Health Plan Medicare Advantage plan members to request home delivery of prescription drugs through the OptumRx mail order service. This exclusive to Tufts Health Plan Medicare Advantage HMO, Tufts Medicare Preferred Access PPO, Tufts Health Plan Senior Care Options (HMO-SNP), and Tufts Health Plan Prescription Drug Plan (PDP) plan members.
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View Form called 2023 OptumRx Home Delivery Prescription Order Form2023 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 and PPO plans. 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.
View Form called 2023 Request For Medicare Prescription Drug Coverage DeterminationMedication Therapy Management (MTM) Blank Medication List
This form is used to document medications as part of the MTM programming.
View Form called Medication Therapy Management (MTM) Blank Medication ListEnrollment and Dis-enrollment Forms
2023 Tufts Health Plan Medicare Preferred HMO/PPO 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.
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View Form called 2023 Tufts Health Plan Medicare Preferred HMO/PPO Disenrollment Form2023 Tufts Health Plan Medicare Preferred Pre Enrollment Checklist
This form helps you better understand the enrollment process, plan benefits and plan rules before enrolling.
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View Form called 2023 Tufts Health Plan Medicare Preferred Pre Enrollment Checklist2023 Tufts Medicare Preferred Individual Enrollment Form
This form is used to apply for enrollment in a Tufts Health Plan Medicare Preferred plans. 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 plans Short Enrollment Form.
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View Form called 2023 Tufts Medicare Preferred Individual Enrollment FormFinancial and Payment Forms
Appeals and Grievances Forms
Request for Protected Health Information
Member Request for Protected Health Information
This form is for use by members to request their own protected health information from Tufts Health Plan.
View Form called Member Request for Protected Health InformationMedicare Supplement Plans
Tufts Medicare Preferred Supplement member cards look like the sample below:
Reimbursement Forms
2023 Fitness and Nutritional Counseling Benefit Reimbursement Form
This form is used to request the Fitness and Nutritional Counseling Reimbursement offered through Tufts Health Plan Medicare Preferred Supplement plans. Please note, this benefit does not cover membership fees you pay to non-qualified health clubs or fitness facilities, including but not limited to martial arts centers, gymnastics facilities, country clubs and social clubs, or for sports activities such as golf and tennis.
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View Form called 2023 Fitness and Nutritional Counseling Benefit Reimbursement FormTufts Health Plan Medicare Supplement Member Dental Claim Form
This form is used to request reimbursement for covered dental services that were not originally covered by Tufts Health Plan at point of service. Last Updated 02/09/2023
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View Form called Tufts Health Plan Medicare Supplement Member Dental Claim FormEnrollment and Dis-enrollment Forms
2023 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.
View Form called 2023 Tuft Health Plan Medicare Supplement Dental Option Enrollment Form2023 Tufts Health Plan Medicare Preferred Supplement Enrollment Application
This form is used to enroll in a Tufts Health Plan Medicare Preferred Supplement plan.
View Form called 2023 Tufts Health Plan Medicare Preferred Supplement Enrollment ApplicationFinancial 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.
View Document called Tufts Health Plan Electronic Funds Transfer (EFT) Authorization FormRequest for Protected Health Information
Member Request for Protected Health Information
This form is for use by members to request their own protected health information from Tufts Health Plan.
View Form called Member Request for Protected Health InformationTufts Health Plan Senior Care Options (HMO-SNP)
Tufts Health Plan Senior Care Options member cards look like the samples below:
Reimbursement Forms
2023 Optum Medicare Part D Prescription Reimbursement Form
This form allows you to request a reimbursement for a prescription that was not initially covered by Tufts Health Plan.
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View Form called 2023 Optum Medicare Part D Prescription Reimbursement Form2023 Tufts Health Plan Medicare Preferred Senior Care Options (HMO-SNP) Wellness Allowance Reimbursement Form
This form is used to to request the Wellness Allowance Reimbursement Benefit offered by the Tufts Health Plan Medicare Preferred Senior Care Options (SCO) plans.
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View Form called 2023 Tufts Health Plan Medicare Preferred Senior Care Options (HMO-SNP) Wellness Allowance Reimbursement Form2023 Tufts Health Plan Senior Care Options (HMO-SNP) 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).
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View Form called 2023 Tufts Health Plan Senior Care Options (HMO-SNP) Member Reimbursement Form2023 Tufts Health Plan Senior Care Options (HMO-SNP) Over-the-Counter (OTC) Reimbursement Form
This form allows Tufts Health Plan Senior Care Options plan members to request reimbursement for the quarterly Instant Savings card allowance and/or the quarterly DailyCare+ card allowance.
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View Form called 2023 Tufts Health Plan Senior Care Options (HMO-SNP) Over-the-Counter (OTC) Reimbursement Form2023 Tufts Health Plan Senior Care Options (HMO-SNP) Weight Management Reimbursement Form
This form is used to to request the Weight Management Reimbursement offered by Tufts Health Plan Senior Care Options plan.
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View Form called 2023 Tufts Health Plan Senior Care Options (HMO-SNP) Weight Management Reimbursement FormTufts 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.
View Document called Tufts Health Plan Medicare Preferred Out-of-Network Vision Services Claim FormTufts Health Plan Senior Care Options (HMO-SNP) Member Dental Claim Form
This form is used to request reimbursement for covered dental services that were not originally covered by Tufts Health Plan at point of service.
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View Form called Tufts Health Plan Senior Care Options (HMO-SNP) Member Dental Claim FormPrescription (Rx) Drugs and Pharmacy Forms
2023 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).
View Form called 2023 Coverage Determination and Prior Authorization Request for Medicare Part B versus Part D2023 Hepatitis C Medication Request Form
Use this form to request Hepatitis C medication.
View Form called 2023 Hepatitis C Medication Request Form2023 OptumRx Home Delivery Prescription Order Form
This form allows Tufts Health Plan Medicare Advantage plan members to request home delivery of prescription drugs through the OptumRx mail order service. This exclusive to Tufts Health Plan Medicare Advantage HMO, Tufts Medicare Preferred Access PPO, Tufts Health Plan Senior Care Options (HMO-SNP), and Tufts Health Plan Prescription Drug Plan (PDP) plan members.
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View Form called 2023 OptumRx Home Delivery Prescription Order Form2023 Request For Medicare Prescription Drug Coverage Determination Senior Care Options (HMO-SNP)
This form is used to submit a request for coverage, or payment, of a prescription drug through a Tufts Health Plan Medicare Preferred Senior Care Options (HMO-SNP) plans. 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.
View Form called 2023 Request For Medicare Prescription Drug Coverage Determination Senior Care Options (HMO-SNP)Medication Therapy Management (MTM) Blank Medication List
This form is used to document medications as part of the MTM programming.
View Form called Medication Therapy Management (MTM) Blank Medication ListTufts 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 Document called Tufts Health Plan Personal Medication ListEnrollment and Dis-enrollment Forms
2023 Tufts Health Plan Senior Care Options (HMO-SNP) Enrollment Form
This form is used to apply for enrollment in the Tufts Health Plan Senior Care Options (HMO-SNP) plan.
View Form called 2023 Tufts Health Plan Senior Care Options (HMO-SNP) Enrollment Form2023 Tufts Health Plan Senior Care Options (HMO-SNP) Pre Enrollment Checklist
This form helps you better understand the enrollment process, plan benefits and plan rules before enrolling.
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View Form called 2023 Tufts Health Plan Senior Care Options (HMO-SNP) Pre Enrollment ChecklistTufts 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.
View Document called Tufts Health Plan Senior Care Options (HMO SNP) Disenrollment FormFinancial 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.
View Document called Tufts Health Plan Electronic Funds Transfer (EFT) Authorization FormAppeals 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.
View Document called Tufts Health Plan Senior Care Options Request for Redetermination of Medicare Prescription Drug DenialRequest for Protected Health Information
Member Request for Protected Health Information
This form is for use by members to request their own protected health information from Tufts Health Plan.
View Form called Member Request for Protected Health InformationPrescription Drug Plan (PDP)
Tufts Medicare Preferred Prescription Drug Plan (PDP) member cards look like the sample below:
Reimbursement Forms
2023 Optum Medicare Part D Prescription Reimbursement Form
This form allows you to request a reimbursement for a prescription that was not initially covered by Tufts Health Plan.
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View Form called 2023 Optum Medicare Part D Prescription Reimbursement FormFinancial 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.
View Document called Tufts Health Plan Electronic Funds Transfer (EFT) Authorization FormPrescription (Rx) Drugs and Pharmacy Forms
2023 Hepatitis C Medication Request Form
Use this form to request Hepatitis C medication.
View Form called 2023 Hepatitis C Medication Request Form2023 OptumRx Home Delivery Prescription Order Form
This form allows Tufts Health Plan Medicare Advantage plan members to request home delivery of prescription drugs through the OptumRx mail order service. This exclusive to Tufts Health Plan Medicare Advantage HMO, Tufts Medicare Preferred Access PPO, Tufts Health Plan Senior Care Options (HMO-SNP), and Tufts Health Plan Prescription Drug Plan (PDP) plan members.
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View Form called 2023 OptumRx Home Delivery Prescription Order FormMedication Therapy Management (MTM) Blank Medication List
This form is used to document medications as part of the MTM programming.
View Form called Medication Therapy Management (MTM) Blank Medication ListPart 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.
View Document called Part D Late Enrollment Penalty (LEP) Reconsideration Request FormOther Forms
Member Request for Protected Health Information
This form is for use by members to request their own protected health information from Tufts Health Plan.
View Form called Member Request for Protected Health Information