Tufts Prior Authorization Form – Fill Out and Use This PDF

The Tufts Prior Authorization form is a crucial document used exclusively for pharmacy requests needing prior review by Tufts Health Plan. It facilitates coverage determinations for medications under Tufts Medicare Preferred HMO, Tufts Medicare Preferred PDP, and Tufts Health Plan Senior Care Options (HMO SNP) members, ensuring the necessary medication is accessible and aligned with the patient's health plan. For assistance with filling out the form accurately and efficiently, click the button below.

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Tufts Prior Authorization Form PDF Details

Navigating healthcare processes often involves navigating through detailed forms and requests, especially when it comes to obtaining necessary medications. The Tufts Prior Authorization form plays a crucial role for patients within the Tufts Health Plan, serving as a necessary step for those requiring pharmacy requests that mandate a review before approval. This form is a universal pathway for various patient plans under Tufts, including Commercial, Tufts Medicare Preferred HMO, Tufts Medicare Preferred PDP, and Tufts Health Plan Senior Care Options (HMO SNP), with specific fax numbers dedicated to each. Details it gathers range from patient information such as name, member ID, and diagnosis to prescriber information like specialty and contact numbers. The form delves deeper into the requested drug's specifications, including its name, strength, and dosage, and it accommodates space for clinical justification for the request, highlighting prior medications, treatment failures, and adverse reactions in detail. Additionally, for select Tufts plans, it explores patient conditions that might necessitate expedited review or special considerations, such as residence in long-term care or hospice enrollment. Prescribers are also prompted to provide detailed explanations if the drug is prescribed for conditions not associated with a terminal illness and to furnish rationale for prior authorization or exception requests, indicating if a tier exception is sought for the prescribed medication. The comprehensive nature of this form ensures that both patient and prescriber viewpoints are thoroughly considered, facilitating a detailed review process by Tufts Health Plan.

Question	Answer
Form Name	Tufts Prior Authorization Form
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	tufts together prior authorization form, tufts interqual forms 2018, tufts health plan prior authorization form, tufts prior authorization

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Universal Pharmacy Programs Request Form

This form is only used for pharmacy requests that require prior review by Tufts Health Plan.

For Medicare Part B vs. Part D Coverage Determinations for Tufts Medicare Preferred HMO, Tufts Medicare Preferred PDP and Tufts Health Plan Senior Care Options (HMO SNP) members, click here for the criteria/request form.

PATIENT’S PLAN

Commercial: Fax to 617-673-0988

Tufts Medicare Preferred HMO or Tufts Medicare Preferred PDP: Fax to 617-673-0956

Tufts Health Plan Senior Care Options (HMO SNP): Fax to 617-673-0956

PATIENT INFORMATION

Name:______________________________________

Member ID:_________________________________

Date of Birth: _______________________________

Diagnosis: __________________________________

PRESCRIBER INFORMATION

Name:_________________________ Specialty: _____________

NPI:___________________ DEA/xDEA:_____________________

Phone: ___________________ Fax: _______________________

Office Contact: ________________________________________

REQUESTED DRUG

Name and strength:___________________________________________ Dosage form:____________________________

Select one:

Generic substitution authorized

Dispense as written

Route of Administration: _________________ Requested Quantity:_____________ Requested Duration:_____________

Will the drug be supplied by and administered in the Provider’s office (i.e. Buy & Bill)?

Yes

CLINICAL JUSTIFICATION FOR REQUEST (if applicable)

Prior Medications	Adverse	Treatment	Length of Therapy
Prior Medications	Reaction	Failure	Length of Therapy
	Reaction	Failure

EXPLANATION: Describe adverse reaction, treatment failure or significant adverse clinical outcomes in detail. If not as effective, length of therapy on each drug and outcome.

__________________________________________________________________________________________________

(attach separate sheet if needed)

THIS SECTION APPLIES TO TUFTS MEDICARE PREFERRED HMO, TUFTS MEDICARE PREFERRED PDP AND TUFTS HEALTH PLAN SENIOR CARE OPTIONS (HMO SNP) ONLY

Does the member’s condition require expedited review [24 hours]?

Yes*

*By checking this 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.

Does this member reside in long-term care?

Is the member enrolled in Hospice?

Yes

If no, disenrollment date: _________________________

Is the requested drug treating the terminal illness or related conditions?

Yes

Revised 08/2014	1	Universal Pharmacy Programs Request Form
2113408

Provide an explanation of why the drug is being prescribed if not to treat the terminal illness/related conditions:

__________________________________________________________________________________________________

Rationale for prior authorization or exception request. Check statement(s) that apply, and include supporting documentation under the Clinical Justification and Explanation sections above:

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 drug.

Complex patient with one or more chronic conditions is stable on current drug(s); high risk of significant adverse clinical outcome with medication change. Document anticipated significant adverse clinical outcome.

Medical need for different dosage form and/or higher dosage. Document dosage form(s) and/or dosage(s) tried and explain medical reason.

Is this a request for a tier exception*?

Yes

*All formulary/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.

Indication: _________________________________________________________________________________________

__________________________________________________________________________________________________

Prescriber Signature (required):______________________________________________ Date:_____________________

Provider Services

Provider Relations

Revised 08/2014

Universal Pharmacy Programs Request Form

How to Edit Tufts Prior Authorization Form Online for Free

This PDF editor was built with the objective of allowing it to be as effortless and intuitive as possible. The following steps are going to make filling out the tufts medication prior authorization form simple.

Step 1: The following web page contains an orange button saying "Get Form Now". Please click it.

Step 2: The document editing page is currently open. Include information or manage existing details.

Create the following parts to create the document:

filling in tufts health plan prior authorization form step 1

The software will require you to submit the Prior Medications, Adverse Reaction, Treatment Failure, Length of Therapy, EXPLANATION Describe adverse, Does the members condition require, Yes, By checking this box and signing, Does this member reside in, Yes, Is the member enrolled in Hospice, Yes, If no disenrollment date, Is the requested drug treating the, and Yes box.

Completing tufts health plan prior authorization form part 2

Write down the crucial information in Provide an explanation of why the, Rationale for prior authorization, Alternate formulary drugs, Document drug name adverse outcome, Complex patient with one or more, clinical outcome with medication, Medical need for different dosage, explain medical reason, Is this a request for a tier, Yes, All formularypreferred drugs on, Indication, and Prescriber Signature required Date area.

part 3 to finishing tufts health plan prior authorization form

It is important to identify the rights and obligations of every party in box Revised, and Provider Services Provider.

part 4 to filling out tufts health plan prior authorization form

Step 3: Hit the button "Done". The PDF document may be exported. It is possible to upload it to your computer or send it by email.

Step 4: To avoid any kind of complications in the long run, you should have a minimum of several duplicates of your document.

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