Forms

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.

This form helps you better understand the enrollment process, plan benefits and plan rules before enrolling.

This form helps you better understand the enrollment process, plan benefits and plan rules before enrolling.

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.

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.

The Medicare Prescription Payment Plan is a voluntary payment option that works with your current drug coverage to help you manage your out-of-pocket Medicare Part D drug costs by spreading them across the calendar year (January-December). This payment option might help you manage your expenses, but it doesn’t save you money or lower your drug costs.

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).

Use this form to request Hepatitis C medication.

This form is used to document medications as part of the MTM programming.

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.

This form is used to submit a request for reconsideration to eliminate your Part D late enrollment penalty.

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.  

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. 

This form is used to request the Wellness Allowance Reimbursement Benefit offered by the Tufts Health Plan Medicare Preferred plans.

This form allows you to request a reimbursement for a prescription that was not initially covered by Tufts Health Plan.

This form is used to request reimbursement for covered dental services that were not originally covered by Tufts Health Plan at the point of service.

This form allows Tufts Health Plan Medicare Preferred and Medicare Supplement 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.

This form allows you to request a reimbursement for a prescription that was not initially covered by Tufts Health Plan.

This form allows you to file a claim for vision services obtained through a provider that is not part of the EyeMed network.

This form is used to request the Weight Management Reimbursement Benefit offered by Tufts Health Plan Medicare Preferred plans.

This form allows you to authorize Tufts Health Plan to disclose your protected health information to a person or entity.

This form is used by Medicare/Medicaid members to appoint a representative to act on their behalf in filing a grievance, requesting an initial determination, or in dealing with any of the levels of the appeal. To view this form in Spanish, please click here!

This form may is used to designate a representative to act on a member’s behalf and authorize Tufts Health Plan to disclose the member’s protected health information to the representative.

This form is used as a cover sheet to submit with your legal personal representative documents.

This form allows a member to terminate an existing authorization or restriction.

This form is for use by members to request their own protected health information from Tufts Health Plan.

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.

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.