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Get Tufts Prior Authorization Form

Universal Pharmacy Programs Request Form Pharmacy Utilization Management Department 705 Mt. Auburn St. Watertown MA 02472 Commercial Provider Services 888 884-2404 Fax 617 673-0988 Tufts Medicare Preferred HMO and PDP Tufts Health Plan Senior Care Options HMO SNP Provider Relations 800 279-9022 Fax to 617 673-0956 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 PRESCRIBER INFORMATION Name Date Specialty Member ID DOB Tufts Health Plan Provider ID Diagnosis Phone Relevant Co-morbid Diagnoses Office Contact Additional Comments/History NPI Prescriber Signature required REQUESTED DRUG Name and Strength Select one Dispense As Written Generic Substitution Authorized Dosage Form Fax THIS SECTION APPLIES TO TUFTS MEDICARE PREFERRED HMO PDP AND TUFTS HEALTH PLAN SENIOR CARE OPTIONS HMO SNP ONLY 1. Does the member s condition require expedited review 24 Hours Quantity Yes No By checking the Yes 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* Duration of requested treatment CLINICAL JUSTIFICATION FOR REQUEST if applicable 2. Does this member reside in long-term care Yes No Adverse Reaction Treatment Failure 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 Prior Medications Complex patient with one or more chronic conditions is stable on current drug s high risk of Length of Therapy EXPLANATION Describe adverse reaction or treatment failure in detail* If not as effective length of therapy on each drug and outcome. Rationale for prior authorization or exception request. Check statement s that apply and include supporting documentation under Clinical Justification and Explanation sections on the left drug. significant adverse clinical outcome with medication change. Document anticipated 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 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* attach separate sheet if needed Revised 06/2013 Indication. 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 PRESCRIBER INFORMATION Name Date Specialty Member ID DOB Tufts Health Plan Provider ID Diagnosis Phone Relevant Co-morbid Diagnoses Office Contact Additional Comments/History NPI Prescriber Signature required REQUESTED DRUG Name and Strength Select one Dispense As Written Generic Substitution Authorized Dosage Form Fax THIS SECTION APPLIES TO TUFTS MEDICARE PREFERRED HMO PDP AND TUFTS HEALTH PLAN SENIOR CARE OPTIONS HMO SNP ONLY 1..

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