Tufts Prior Authorization Form – Fill Out and Use

PATIENT INFORMATION

PRESCRIBER INFORMATION

Name:

Date:

Name:

Specialty:

Member ID:

DOB:

Tufts Health Plan Provider ID:

__ NPI:

Diagnosis:

Phone:

Fax:

Relevant Co-morbid Diagnoses:

Office Contact:

Additional Comments/History:

Prescriber Signature (required):

REQUESTED DRUG: Name and Strength:_________________________________________

THIS SECTION APPLIES TO TUFTS MEDICARE PREFERRED HMO, PDP AND TUFTS

Select one:

☐ Dispense As Written

☐ Generic Substitution Authorized

HEALTH PLAN SENIOR CARE OPTIONS (HMO SNP) ONLY

Dosage Form:______________________________________ Quantity:

1. Does the member’s condition require expedited review (24 Hours)? ☐ Yes*

☐ No

* By checking the “Yes” box and signing above, I certify that the 72-hour standard review time

Duration of requested treatment:

may seriously jeopardize the life or health of the member or the member’s ability to regain

maximum function.

CLINICAL JUSTIFICATION FOR REQUEST (if applicable)

☐ Yes

☐ No

2. Does this member reside in long-term care?

Prior Medications

Adverse

Treatment

Length of Therapy

Rationale for prior authorization or exception request. Check statement(s) that apply and

Reaction

Failure

include supporting documentation under Clinical Justification and Explanation sections on the left:

☐

☐

 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

EXPLANATION: Describe adverse reaction or treatment failure in detail. If not as

significant adverse clinical outcome with medication change. Document anticipated

significant adverse clinical outcome.

effective, length of therapy on each drug and outcome.

 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*?

☐ Yes

☐ No

* 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.

Indication:

___

(attach separate sheet if needed)