Get Tufts Health Plan Universal Pharmacy Programs Request Form 2017-2026

Filling out the Tufts Health Plan Universal Pharmacy Programs Request Form online can seem daunting, but with this comprehensive guide, you will be able to navigate each section with confidence. This form is essential for requesting coverage for drug products that may be restricted under specific pharmacy management programs.

Follow the steps to complete your request form effectively.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering patient information in the designated fields. This includes the patient's name, member ID, date of birth, and contact information.
3. Next, provide prescriber information. Fill out the prescriber's name, NPI, DEA/xDEA number, phone, fax, office contact, and specialty.
4. In the 'Requested Drug' section, fill in the name and strength of the drug. Indicate whether generic substitution is authorized or if you prefer dispense as written (DAW). Specify the dosage form, route of administration, and requested quantity.
5. Answer the question about whether the drug will be supplied by and administered in the provider’s office by selecting 'Yes' or 'No'.
6. Provide clinical justification for the request if applicable. Specify any prior medications, adverse reactions, treatment failures, and the length of therapy. Offer detailed explanations as needed.
7. Answer the questions specific to eligibility for expedited review and if the member resides in long-term care or is enrolled in hospice. Provide explanations for drug-related conditions if necessary.
8. If applicable, indicate if this is a request for a formulary tier exception and ensure to attach supporting documentation from the prescribing physician.
9. Sign and date the form to certify that the information provided is accurate and that supporting documentation is available if requested.
10. Finally, save your changes, and choose to download, print, or share the completed form as necessary.

Start completing your Tufts Health Plan Universal Pharmacy Programs Request Form online today!