Tufts Prior Authorization Form – Fill Out and Use This PDF

The Tufts Prior Authorization Form is a helpful tool for finding out the medical services that are covered through your plan.

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Tufts Prior Authorization Form PDF Details

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
Form Name	Tufts Prior Authorization Form
Form Length	2 pages
Fillable?	Yes
Fillable fields	60
Avg. time to fill out	12 min 34 sec
Other names	tufts prior authorization form, tufts health plan prior authorization form, tufts prior authorization, tufts authorization form

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Form Preview Example

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

No

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*

No

*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

Yes

No

No

If no, disenrollment date: _________________________

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

Yes

No

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

No

*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

2

Universal Pharmacy Programs Request Form

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Create the following parts to create the document:

filling in 888 415 9055 step 1

The software will require you to submit the Adverse, Reaction Failure, attach, separate, sheet, if, needed Yes, Does, this, member, reside, in, long, term, care Yes, Is, the, member, enrolled, in, Hospice Yes, and If, nod, is, enrollment, date box.

Completing 888 415 9055 part 2

Write down the crucial information in Yes, and Revised area.

part 3 to finishing 888 415 9055

It is important to identify the rights and obligations of every party in box explain, medical, reason Is, this, a, request, for, a, tier, exception Yes, and Indication.

part 4 to filling out 888 415 9055

End by reading the following areas and completing them correspondingly: Prescribe, r, Signature, required, Date

part 5 to completing 888 415 9055

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