Does Tufts Medicare Preferred require prior authorization?

Prior Authorization: Tufts Medicare Preferred HMO requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Tufts Medicare Preferred HMO before you fill your prescriptions.

Does Tufts HMO require prior authorization?

Prior authorization is required for certain procedures, drugs, items, and/or supplies that require medical necessity or utilization review either through Tufts Health Plan or select approved vendors. Services that require prior authorization may also require a referral to the rendering specialist.

Is a referral prior authorization?

A referral is issued by a primary care physician (PCP) for the patient to see a specialist. In contrast, prior authorization is issued by the payer (an insurance provider), giving a medical practice or physician the approval to perform a medical service.

What is the payer ID for Tufts Health Plan?

Toll Free Phone Number: 1-866-642-9703. Providers are encouraged to use EDI claims submission. Tufts Health Plan payor ID number is 04298.

Does Tufts require authorization?

PHARMACY INFORMATION Tufts Health Plan requires prior authorization for coverage of certain drugs. Tufts Health Plan's pharmacy medical necessity guidelines are used in conjunction with a member's plan document and in coordination with the prescribing provider submitting the request for authorization.

How do I write a prior authorization request?

The following information is generally required for all prior authorization letters. The demographic information of the patient (name, date of birth, insurance ID number and more) Provider information (both referring and servicing provider) ... Requested service/procedure along with specific CPT/HCPCS codes.

What is the fax number for Tufts prior authorization?

Prior authorization requests should be faxed to the Precertification Operations Department at 888-415-9055 (Tufts Health Together, Tufts Health Direct), 857-304-6304 (Tufts Health Unify) or 857-304-6404 (Tufts Health RITogether).

Does Tufts require authorization?

PHARMACY INFORMATION Tufts Health Plan requires prior authorization for coverage of certain drugs. Tufts Health Plan's pharmacy medical necessity guidelines are used in conjunction with a member's plan document and in coordination with the prescribing provider submitting the request for authorization.

Get Forms

Universal Pharmacy Programs Request Form Pharmacy Utilization Management Department 705 Mt. Auburn St. Watertown MA 02472 Commercial Provider Services 888 884-2404 Fax 617 673-0988 Tufts Medicare Preferred HMO and PDP Tufts Health Plan Senior Care Options HMO SNP Provider Relations 800 279-9022 Fax to 617 673-0956 This form is only used for pharmacy requests that require prior authorization review by Tufts Health Plan. For details of Tufts Health Plan Pharmacy Programs go to tuftshealthplan.com/providers. For Tufts Medicare Preferred HMO PDP and Tufts Health Plan Senior Care Options HMO SNP members click here for criteria/request form for Medicare Part B vs Part D Coverage Determinations. PATIENT INFORMATION PRESCRIBER INFORMATION Name Date Specialty Member ID DOB Tufts Health Plan Provider ID Diagnosis Phone Relevant Co-morbid Diagnoses Office Contact Additional Comments/History NPI Prescriber Signature required REQUESTED DRUG Name and Strength Select one Dispense As Written Generic Substitution Authorized Dosage Form Fax THIS SECTION APPLIES TO TUFTS MEDICARE PREFERRED HMO PDP AND TUFTS HEALTH PLAN SENIOR CARE OPTIONS HMO SNP ONLY 1. Does the member s condition require expedited review 24 Hours Quantity Yes No By checking the Yes box and signing above I certify that the 72-hour standard review time may seriously jeopardize the life or health of the member or the member s ability to regain maximum function* Duration of requested treatment CLINICAL JUSTIFICATION FOR REQUEST if applicable 2. Does this member reside in long-term care Yes No Adverse Reaction Treatment Failure Alternate formulary drug s contraindicated or previously tried but with adverse outcome. Document drug name adverse outcome and if therapeutic failure length of therapy on Prior Medications Complex patient with one or more chronic conditions is stable on current drug s high risk of Length of Therapy EXPLANATION Describe adverse reaction or treatment failure in detail* If not as effective length of therapy on each drug and outcome. Rationale for prior authorization or exception request. Check statement s that apply and include supporting documentation under Clinical Justification and Explanation sections on the left drug. significant adverse clinical outcome with medication change. Document anticipated Medical need for different dosage form and/or higher dosage. Document dosage form s and/or dosage s tried and explain medical reason* 3. Is this a request for a tier exception All formulary or preferred drug s on lower tier s contraindicated to the member s condition or were tried and failed or not as effective as requested drug. Specialty tier is excluded from tiering exception* attach separate sheet if needed Revised 06/2013 Indication. For Tufts Medicare Preferred HMO PDP and Tufts Health Plan Senior Care Options HMO SNP members click here for criteria/request form for Medicare Part B vs Part D Coverage Determinations. PATIENT INFORMATION PRESCRIBER INFORMATION Name Date Specialty Member ID DOB Tufts Health Plan Provider ID Diagnosis Phone Relevant Co-morbid Diagnoses Office Contact Additional Comments/History NPI Prescriber Signature required REQUESTED DRUG Name and Strength Select one Dispense As Written Generic Substitution Authorized Dosage Form Fax THIS SECTION APPLIES TO TUFTS MEDICARE PREFERRED HMO PDP AND TUFTS HEALTH PLAN SENIOR CARE OPTIONS HMO SNP ONLY 1.

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