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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.
This form allows you to request a reimbursement for a prescription that was not initially covered by Tufts Health Plan.
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.
This form is used to to request the $150 Wellness Allowance Reimbursement Benefit offered by Tufts Health Plan Mediare Preferred HMO plans.
This form is used to to request the Wellness Allowance Reimbursement Benefit offered by the Tufts Health Plan Medicare Preferred HMO plans.
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 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).
This form allows Tufts Health Plan Medicare Preferred HMO plan members to request delivery of prescription drugs through the CVS/Caremark mail order service.
Use this form to request Hepatitis C medication.
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.
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 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 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.
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 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.
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.
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.
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.
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.
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.
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.
This form is used to to request the $150 Fitness and Nutritional Counseling Reimbursement offered through Tufts Medicare Preferred Supplement plans.
This form is used to to request the $150 Weight Management Reimbursement offered by Tufts Health Plan Medicare Preferred Supplement plans.
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.
This form is used to enroll in a Tufts Health Plan Medicare Preferred Supplement plan.
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.
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.
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 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.
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.
This form is used to to request the $200 Wellness Allowance Reimbursement Benefit offered by the Tufts Health Plan Senior Care Options plans.
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 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.
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.
This form is used to to request the $200 Weight Management Reimbursement offered by Tufts Health Plan Senior Care Options plan.
This form is used to to request the $200 Wellness Allowance Reimbursement Benefit offered by the Tufts Health Plan Senior Care Options plans.
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).
This form allows Tufts Health Plan Senior Care Options plan members to request delivery of prescription drugs through the CVS/Caremark mail order service.
Use this form to request Hepatitis C medication.
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 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.
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.
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.
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.
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.
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 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.
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 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.
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.
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 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).
This form allows Tufts Health Plan Prescription Drug Plan (PDP) members to request delivery of prescription drugs through the CVS/Caremark mail order service.
Use this form to request Hepatitis C medication.
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.