The Tufts Prior Authorization Form, also known as the PAF, is a document that medical professionals use to request authorization from insurance companies for specific treatments or procedures. The PAF must be completed and submitted to the insurance company before any treatment or procedure can be performed. This form is typically used in cases where the patient's insurance coverage has not been determined in advance or when there is a question about whether the procedure will be covered by the patient's insurance plan. The Tufts Prior Authorization Form can be downloaded from the Tufts University website. It is important to note that not all treatments and procedures require prior authorization, so it is important to check with your insurer before completing this form.
This knowledge will help you understand better the details of the tufts prior authorization form before you start filling it out.
Question | Answer |
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Form Name | Tufts Prior Authorization Form |
Form Length | 1 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 15 sec |
Other names | tufts authorization form, tufts interqual forms 2018, tufts medication prior authorization form, tufts health plan prior authorization form |
Universal Pharmacy Programs Request Form
Pharmacy Utilization Management Department: 705 Mt. Auburn St. Watertown, MA 02472
Commercial: Provider Services: (888)
Tufts Medicare Preferred HMO and PDP & Tufts Health Plan Senior Care Options (HMO SNP)
•Provider Relations: (800)
•Fax to (617)
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 |
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PRESCRIBER INFORMATION |
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Name: |
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Date: |
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Name: |
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Specialty: |
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Member ID: |
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DOB: |
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Tufts Health Plan Provider ID: |
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__ NPI: |
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Diagnosis: |
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Phone: |
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Fax: |
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Relevant |
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Office Contact: |
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Additional Comments/History: |
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Prescriber Signature (required): |
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REQUESTED DRUG: Name and Strength:_________________________________________ |
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THIS SECTION APPLIES TO TUFTS MEDICARE PREFERRED HMO, PDP AND TUFTS |
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Select one: |
☐ Dispense As Written |
☐ Generic Substitution Authorized |
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HEALTH PLAN SENIOR CARE OPTIONS (HMO SNP) ONLY |
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Dosage Form:______________________________________ Quantity: |
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1. Does the member’s condition require expedited review (24 Hours)? ☐ Yes* |
☐ No |
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* By checking the “Yes” box and signing above, I certify that the |
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Duration of requested treatment: |
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may seriously jeopardize the life or health of the member or the member’s ability to regain |
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maximum function. |
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CLINICAL JUSTIFICATION FOR REQUEST (if applicable) |
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☐ Yes |
☐ No |
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2. Does this member reside in |
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Prior Medications |
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Adverse |
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Treatment |
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Length of Therapy |
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Rationale for prior authorization or exception request. Check statement(s) that apply and |
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Reaction |
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Failure |
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include supporting documentation under Clinical Justification and Explanation sections on the left: |
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☐ |
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☐ |
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Alternate formulary drug(s) contraindicated or previously tried, but with adverse outcome. |
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☐ |
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☐ |
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Document drug name, adverse outcome, and, if therapeutic failure, length of therapy on |
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☐ |
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☐ |
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drug. |
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Complex patient with one or more chronic conditions is stable on current drug(s); high risk of |
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EXPLANATION: Describe adverse reaction or treatment failure in detail. If not as |
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significant adverse clinical outcome with medication change. Document anticipated |
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significant adverse clinical outcome. |
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effective, length of therapy on each drug and outcome. |
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Medical need for different dosage form and/or higher dosage. Document dosage form(s) |
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and/or dosage(s) tried and explain medical reason. |
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3. Is this a request for a tier exception*? |
☐ Yes |
☐ No |
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* All formulary or preferred drug(s) on lower tier(s) contraindicated to the member’s condition or were |
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tried and failed, or not as effective as requested drug. Specialty tier is excluded from tiering |
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exception. |
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Indication: |
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___ |
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(attach separate sheet if needed) |
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Revised 06/2013