Forms
Medicare Advantage HMO Plans
Tufts Medicare Preferred HMO member cards look like the samples below:
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Prescription (Rx) Drugs & Pharmacy
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).
Hepatitis C Medication Request Form
Use this form to request Hepatitis C medication.
HMO Medicare Prescription Payment Plan Participation Request 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.
Medication Therapy Management (MTM) Blank Medication List
This form is used to document medications as part of the MTM programming.
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 (D-SNP), and Tufts Health One Care (D-SNP) plan members.
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 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.
Tufts Health Plan Medicare Preferred HMO 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.
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.
PPO Access Plan
Tufts Medicare PPO Access member cards look like the sample below:
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Prescription (Rx) Drugs & Pharmacy
Hepatitis C Medication Request Form
Use this form to request Hepatitis C medication.
Medication Therapy Management (MTM) Blank Medication List
This form is used to document medications as part of the MTM programming.
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 (D-SNP), and Tufts Health One Care (D-SNP) plan members.
PPO Medicare Prescription Payment Plan Participation Request 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.
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.
Tufts Health Plan Medicare Preferred PPO 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 PPO 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
Tufts Medicare Preferred Supplement member cards look like the sample below:
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Tufts Health Plan Senior Care Options (D-SNP)
Tufts Health Plan Senior Care Options member cards look like the samples below:
Find a Document
Active Filters
Prescription (Rx) Drugs & Pharmacy
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).
Hepatitis C Medication Request Form
Use this form to request Hepatitis C medication.
Medication Therapy Management (MTM) Blank Medication List
This form is used to document medications as part of the MTM programming.
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 (D-SNP), and Tufts Health One Care (D-SNP) plan members.
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.
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 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.
Tufts Health One Care (D-SNP)
Tufts Health One Care member cards look like the samples below:
Find a Document
Active Filters
Prescription (Rx) Drugs & Pharmacy
Medication Therapy Management (MTM) Blank Medication List
This form is used to document medications as part of the MTM programming.
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 (D-SNP), and Tufts Health One Care (D-SNP) plan members.
Request For Medicare Prescription Drug Coverage Determination One Care (D-SNP)
This form is used to submit a request for coverage, or payment, of a prescription drug through a Tufts Health One Care 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 One Care (D-SNP) 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 One Care 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.