Forms
Medicare Advantage HMO Plans
Tufts Medicare Preferred HMO member cards look like the samples below:
Reimbursement Forms
2024 Tufts Health Plan Medicare Preferred Weight Management Reimbursement Form
This form is used to request the Weight Management Reimbursement Benefit offered by Tufts Health Plan Medicare Preferred plans.
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View Form called 2024 Tufts Health Plan Medicare Preferred Weight Management Reimbursement Form2024 Tufts Health Plan Medicare Preferred Wellness Allowance Reimbursement Form
This form is used to request the Wellness Allowance Reimbursement Benefit offered by the Tufts Health Plan Medicare Preferred plans.
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View Form called 2024 Tufts Health Plan Medicare Preferred Wellness Allowance Reimbursement FormOptum Medicare Part D Prescription Reimbursement Form
This form allows you to request a reimbursement for a prescription that was not initially covered by Tufts Health Plan.
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View Form called Optum Medicare Part D Prescription Reimbursement FormTufts Health Plan Medicare Advantage (HMO) Member Dental Claim Form
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.
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View Form called Tufts Health Plan Medicare Advantage (HMO) Member Dental Claim FormTufts Health Plan Medicare Advantage and Medicare Supplement Member Reimbursement Form
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.
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View Form called Tufts Health Plan Medicare Advantage and Medicare Supplement Member Reimbursement FormTufts Health Plan Medicare Preferred Out-of-Network Vision Services Claim Form
This form allows you to file a claim for vision services obtained through a provider that is not part of the EyeMed network.
View Document called Tufts Health Plan Medicare Preferred Out-of-Network Vision Services Claim FormPrescription (Rx) Drugs and Pharmacy Forms
2025 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.
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View Form called 2025 HMO Medicare Prescription Payment Plan Participation Request FormCoverage 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).
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View Form called Coverage Determination and Prior Authorization Request for Medicare Part B versus Part DHepatitis C Medication Request Form
Use this form to request Hepatitis C medication.
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View Form called Hepatitis C Medication Request FormMedication Therapy Management (MTM) Blank Medication List
This form is used to document medications as part of the MTM programming.
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View Form called Medication Therapy Management (MTM) Blank Medication ListOptumRx 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 (HMO-SNP), and Tufts Health Plan Prescription Drug Plan (PDP) plan members.
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View Form called OptumRx Home Delivery Prescription Order FormPart 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.
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View Document called Part D Late Enrollment Penalty (LEP) Reconsideration Request FormRequest 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.
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View Form called Request For Medicare Prescription Drug Coverage DeterminationTufts Health Plan Medicare Preferred OptumRx Part D Prescription Reimbursement Form
This form allows you to request a reimbursement for a prescription that was not initially covered by Tufts Health Plan.
View Form called Tufts Health Plan Medicare Preferred OptumRx Part D Prescription Reimbursement FormTufts 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.
View Document called Tufts Health Plan Personal Medication ListEnrollment and Dis-enrollment Forms
2024 HMO Dental Option Enrollment Form
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.
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View Form called 2024 HMO Dental Option Enrollment Form2024 Tufts Health Plan Medicare Preferred HMO/PPO Disenrollment Form
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.
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View Form called 2024 Tufts Health Plan Medicare Preferred HMO/PPO Disenrollment Form2024 Tufts Health Plan Medicare Preferred Pre Enrollment Checklist
This form helps you better understand the enrollment process, plan benefits and plan rules before enrolling.
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View Form called 2024 Tufts Health Plan Medicare Preferred Pre Enrollment Checklist2024 Tufts 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.
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View Form called 2024 Tufts Medicare Preferred HMO Short Enrollment Form2024 Tufts Medicare Preferred Individual Enrollment Form
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.
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View Form called 2024 Tufts Medicare Preferred Individual Enrollment Form2025 HMO Dental Option Enrollment Form
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.
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View Form called 2025 HMO Dental Option Enrollment Form2025 Tufts Health Plan Medicare Preferred HMO Employer Group Pre Enrollment Checklist
This form helps you better understand the enrollment process, plan benefits and plan rules before enrolling.
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View Form called 2025 Tufts Health Plan Medicare Preferred HMO Employer Group Pre Enrollment Checklist2025 Tufts Health Plan Medicare Preferred Pre Enrollment Checklist
This form helps you better understand the enrollment process, plan benefits and plan rules before enrolling.
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View Form called 2025 Tufts Health Plan Medicare Preferred Pre Enrollment Checklist2025 Tufts 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.
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View Form called 2025 Tufts Medicare Preferred HMO Short Enrollment Form2025 Tufts Medicare Preferred Individual Enrollment Form
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.
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View Form called 2025 Tufts Medicare Preferred Individual Enrollment FormFinancial and Payment Forms
Tufts Health Plan Electronic Funds Transfer (EFT) Authorization Form
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.
View Document called Tufts Health Plan Electronic Funds Transfer (EFT) Authorization FormAppeals and Grievances Forms
Tufts Health Plan Medicare Preferred 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.
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View Document called Tufts Health Plan Medicare Preferred Request for Redetermination of Medicare Prescription Drug DenialRequest for Protected Health Information
Member Request for Protected Health Information
This form is for use by members to request their own protected health information from Tufts Health Plan.
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View Form called Member Request for Protected Health InformationPPO Access Plan
Tufts Medicare PPO Access member cards look like the sample below:
Reimbursement Forms
2024 Tufts Health Plan Medicare Preferred Weight Management Reimbursement Form
This form is used to request the Weight Management Reimbursement Benefit offered by Tufts Health Plan Medicare Preferred plans.
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View Form called 2024 Tufts Health Plan Medicare Preferred Weight Management Reimbursement Form2024 Tufts Health Plan Medicare Preferred Wellness Allowance Reimbursement Form
This form is used to request the Wellness Allowance Reimbursement Benefit offered by the Tufts Health Plan Medicare Preferred plans.
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View Form called 2024 Tufts Health Plan Medicare Preferred Wellness Allowance Reimbursement FormOptum Medicare Part D Prescription Reimbursement Form
This form allows you to request a reimbursement for a prescription that was not initially covered by Tufts Health Plan.
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View Form called Optum Medicare Part D Prescription Reimbursement FormTufts Health Plan Medicare Advantage and Medicare Supplement Member Reimbursement Form
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.
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View Form called Tufts Health Plan Medicare Advantage and Medicare Supplement Member Reimbursement FormPrescription (Rx) Drugs and Pharmacy Forms
2025 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.
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View Form called 2025 PPO Medicare Prescription Payment Plan Participation Request FormHepatitis C Medication Request Form
Use this form to request Hepatitis C medication.
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View Form called Hepatitis C Medication Request FormMedication Therapy Management (MTM) Blank Medication List
This form is used to document medications as part of the MTM programming.
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View Form called Medication Therapy Management (MTM) Blank Medication ListOptumRx 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 (HMO-SNP), and Tufts Health Plan Prescription Drug Plan (PDP) plan members.
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View Form called OptumRx Home Delivery Prescription Order FormRequest 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.
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View Form called Request For Medicare Prescription Drug Coverage DeterminationEnrollment and Dis-enrollment Forms
2024 Tufts Health Plan Medicare Preferred HMO/PPO Disenrollment Form
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.
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View Form called 2024 Tufts Health Plan Medicare Preferred HMO/PPO Disenrollment Form2024 Tufts Health Plan Medicare Preferred Pre Enrollment Checklist
This form helps you better understand the enrollment process, plan benefits and plan rules before enrolling.
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View Form called 2024 Tufts Health Plan Medicare Preferred Pre Enrollment Checklist2024 Tufts Medicare Preferred Individual Enrollment Form
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.
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View Form called 2024 Tufts Medicare Preferred Individual Enrollment Form2025 Tufts Health Plan Medicare Preferred Pre Enrollment Checklist
This form helps you better understand the enrollment process, plan benefits and plan rules before enrolling.
Last Updated:
View Form called 2025 Tufts Health Plan Medicare Preferred Pre Enrollment Checklist2025 Tufts Medicare Preferred Individual Enrollment Form
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.
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View Form called 2025 Tufts Medicare Preferred Individual Enrollment FormFinancial and Payment Forms
Appeals and Grievances Forms
Request for Protected Health Information
Member Request for Protected Health Information
This form is for use by members to request their own protected health information from Tufts Health Plan.
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View Form called Member Request for Protected Health InformationMedicare Supplement Plans
Tufts Medicare Preferred Supplement member cards look like the sample below:
Reimbursement Forms
2024 Tufts Health Plan Medicare Preferred Medicare Supplement Weight Management Reimbursement Form
This form is used to to request the Weight Management Reimbursement offered by Tufts Health Plan Medicare Preferred Supplement plans. This form must be received by Tufts Health Plan by March 31 of the following plan year.
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View Form called 2024 Tufts Health Plan Medicare Preferred Medicare Supplement Weight Management Reimbursement FormFitness and Nutritional Counseling Benefit Reimbursement Form
This form is used to request the Fitness and Nutritional Counseling Reimbursement offered through Tufts Health Plan Medicare Preferred Supplement plans. Please note, this benefit does not cover membership fees you pay to non-qualified health clubs or fitness facilities, including but not limited to martial arts centers, gymnastics facilities, country clubs and social clubs, or for sports activities such as golf and tennis.
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View Form called Fitness and Nutritional Counseling Benefit Reimbursement FormTufts Health Plan Medicare Advantage and Medicare Supplement Member Reimbursement Form
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.
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View Form called Tufts Health Plan Medicare Advantage and Medicare Supplement Member Reimbursement FormTufts Health Plan Medicare Supplement Member Dental Claim Form
This form is used to request reimbursement for covered dental services that were not originally covered by Tufts Health Plan at point of service. Last Updated 02/09/2023
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View Form called Tufts Health Plan Medicare Supplement Member Dental Claim FormEnrollment and Dis-enrollment Forms
2024 Tufts Health Plan Medicare Preferred Supplement Enrollment Application
This form is used to enroll in a Tufts Health Plan Medicare Preferred Supplement plan.
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View Form called 2024 Tufts Health Plan Medicare Preferred Supplement Enrollment Application2025 Tuft Health Plan Medicare Supplement Dental Option Enrollment Form
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.
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View Form called 2025 Tuft Health Plan Medicare Supplement Dental Option Enrollment Form2025 Tufts Health Plan Medicare Preferred Supplement Enrollment Application
This form is used to enroll in a Tufts Health Plan Medicare Preferred Supplement plan.
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View Form called 2025 Tufts Health Plan Medicare Preferred Supplement Enrollment ApplicationFinancial and Payment Forms
Tufts Health Plan Electronic Funds Transfer (EFT) Authorization Form
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.
View Document called Tufts Health Plan Electronic Funds Transfer (EFT) Authorization FormRequest for Protected Health Information
Member Request for Protected Health Information
This form is for use by members to request their own protected health information from Tufts Health Plan.
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View Form called Member Request for Protected Health InformationTufts Health Plan Senior Care Options (HMO-SNP)
Tufts Health Plan Senior Care Options member cards look like the samples below:
Reimbursement Forms
2024 Tufts Health Plan Medicare Preferred Senior Care Options (HMO-SNP) Wellness Allowance Reimbursement Form
This form is used to to request the Wellness Allowance Reimbursement Benefit offered by the Tufts Health Plan Medicare Preferred Senior Care Options (SCO) plans.
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View Form called 2024 Tufts Health Plan Medicare Preferred Senior Care Options (HMO-SNP) Wellness Allowance Reimbursement Form2024 Tufts Health Plan Senior Care Options (HMO-SNP) Over-the-Counter (OTC) Reimbursement Form
This form allows Tufts Health Plan Senior Care Options members to request reimbursement for Medicare and Medicaid-approved over-the-counter (OTC) items that they purchase out-of-pocket instead of using their Instant Savings card.
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View Form called 2024 Tufts Health Plan Senior Care Options (HMO-SNP) Over-the-Counter (OTC) Reimbursement Form2024 Tufts Health Plan Senior Care Options (HMO-SNP) Weight Management Reimbursement Form
This form is used to to request the Weight Management Reimbursement offered by Tufts Health Plan Senior Care Options plan.
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View Form called 2024 Tufts Health Plan Senior Care Options (HMO-SNP) Weight Management Reimbursement FormOptum Medicare Part D Prescription Reimbursement Form
This form allows you to request a reimbursement for a prescription that was not initially covered by Tufts Health Plan.
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View Form called Optum Medicare Part D Prescription Reimbursement FormTufts Health Plan Medicare Preferred Out-of-Network Vision Services Claim Form
This form allows you to file a claim for vision services obtained through a provider that is not part of the EyeMed network.
View Document called Tufts Health Plan Medicare Preferred Out-of-Network Vision Services Claim FormTufts Health Plan Senior Care Options (HMO-SNP) Member Dental Claim Form
This form is used to request reimbursement for covered dental services that were not originally covered by Tufts Health Plan at point of service.
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View Form called Tufts Health Plan Senior Care Options (HMO-SNP) Member Dental Claim FormTufts Health Plan Senior Care Options (HMO-SNP) Member Reimbursement Form
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).
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View Form called Tufts Health Plan Senior Care Options (HMO-SNP) Member Reimbursement FormPrescription (Rx) Drugs and Pharmacy Forms
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).
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View Form called Coverage Determination and Prior Authorization Request for Medicare Part B versus Part DHepatitis C Medication Request Form
Use this form to request Hepatitis C medication.
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View Form called Hepatitis C Medication Request FormMedication Therapy Management (MTM) Blank Medication List
This form is used to document medications as part of the MTM programming.
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View Form called Medication Therapy Management (MTM) Blank Medication ListOptumRx 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 (HMO-SNP), and Tufts Health Plan Prescription Drug Plan (PDP) plan members.
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View Form called OptumRx Home Delivery Prescription Order FormRequest 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.
View Form called Request For Medicare Prescription Drug Coverage Determination Senior Care Options (HMO-SNP)Tufts Health Plan Medicare Preferred OptumRx Part D Prescription Reimbursement Form
This form allows you to request a reimbursement for a prescription that was not initially covered by Tufts Health Plan.
View Form called Tufts Health Plan Medicare Preferred OptumRx Part D Prescription Reimbursement FormTufts 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.
View Document called Tufts Health Plan Personal Medication ListEnrollment and Dis-enrollment Forms
2024 Tufts Health Plan Senior Care Options (HMO-SNP) Enrollment Form
This form is used to apply for enrollment in the Tufts Health Plan Senior Care Options (HMO-SNP) plan.
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View Form called 2024 Tufts Health Plan Senior Care Options (HMO-SNP) Enrollment Form2024 Tufts Health Plan Senior Care Options (HMO-SNP) Pre Enrollment Checklist
This form helps you better understand the enrollment process, plan benefits and plan rules before enrolling.
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View Form called 2024 Tufts Health Plan Senior Care Options (HMO-SNP) Pre Enrollment Checklist2025 Tufts Health Plan Senior Care Options (HMO-SNP) Enrollment Form
This form is used to apply for enrollment in the Tufts Health Plan Senior Care Options (HMO-SNP) plan.
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View Form called 2025 Tufts Health Plan Senior Care Options (HMO-SNP) Enrollment Form2025 Tufts Health Plan Senior Care Options (HMO-SNP) Pre Enrollment Checklist
This form helps you better understand the enrollment process, plan benefits and plan rules before enrolling.
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View Form called 2025 Tufts Health Plan Senior Care Options (HMO-SNP) Pre Enrollment ChecklistTufts Health Plan Senior Care Options (HMO SNP) Disenrollment Form
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.
View Document called Tufts Health Plan Senior Care Options (HMO SNP) Disenrollment FormFinancial and Payment Forms
Tufts Health Plan Electronic Funds Transfer (EFT) Authorization Form
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.
View Document called Tufts Health Plan Electronic Funds Transfer (EFT) Authorization FormAppeals and Grievances Forms
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.
View Document called Tufts Health Plan Senior Care Options Request for Redetermination of Medicare Prescription Drug DenialRequest for Protected Health Information
Member Request for Protected Health Information
This form is for use by members to request their own protected health information from Tufts Health Plan.
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View Form called Member Request for Protected Health InformationPrescription Drug Plan (PDP)
Tufts Medicare Preferred Prescription Drug Plan (PDP) member cards look like the sample below:
Reimbursement Forms
Optum Medicare Part D Prescription Reimbursement Form
This form allows you to request a reimbursement for a prescription that was not initially covered by Tufts Health Plan.
Last Updated:
View Form called Optum Medicare Part D Prescription Reimbursement FormFinancial and Payment Forms
Tufts Health Plan Electronic Funds Transfer (EFT) Authorization Form
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.
View Document called Tufts Health Plan Electronic Funds Transfer (EFT) Authorization FormPrescription (Rx) Drugs and Pharmacy Forms
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).
Last Updated:
View Form called Coverage Determination and Prior Authorization Request for Medicare Part B versus Part DHepatitis C Medication Request Form
Use this form to request Hepatitis C medication.
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View Form called Hepatitis C Medication Request FormMedication Therapy Management (MTM) Blank Medication List
This form is used to document medications as part of the MTM programming.
Last Updated:
View Form called Medication Therapy Management (MTM) Blank Medication ListOptumRx 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 (HMO-SNP), and Tufts Health Plan Prescription Drug Plan (PDP) plan members.
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View Form called OptumRx Home Delivery Prescription Order FormPart 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.
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View Document called Part D Late Enrollment Penalty (LEP) Reconsideration Request FormTufts Health Plan Medicare Preferred OptumRx Part D Prescription Reimbursement Form
This form allows you to request a reimbursement for a prescription that was not initially covered by Tufts Health Plan.
View Form called Tufts Health Plan Medicare Preferred OptumRx Part D Prescription Reimbursement FormOther Forms
Member Request for Protected Health Information
This form is for use by members to request their own protected health information from Tufts Health Plan.
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View Form called Member Request for Protected Health Information