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Print Forms and Documents

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Click below to download enrollment materials for:

Enrollment Forms:

2009 HMO Enrollment Form (Health Maintenance Organization)

2009 PPO Enrollment Form (Preferred Provider Organization)

2009 PFFS Enrollment Form (Private Fee-for-Service)

Prescription Drug Forms:

Universal Pharmacy Form

Coverage Determination Request Form

HMO Caremark Mail Order Form

PPO Caremark Mail Order Form

PFFS Caremark Mail Order Form

Plan Information:

Plan Highlights

2009 HMO Summary of Benefits

2009 PPO Summary of Benefits

2009 PFFS Summary of Benefits

2009 HMO Basic Evidence Of Coverage **coming soon**

2009 HMO Value Evidence Of Coverage **coming soon**

2009 HMO Prime Evidence Of Coverage **coming soon**

2009 PPO Evidence Of Coverage **coming soon**

2009 PFFS Basic Evidence Of Coverage **coming soon**

2009 PFFS Prime Evidence Of Coverage **coming soon**

Additional Information:

Preferred Extras **coming soon**

H2256-2009-19 9/30/08 H2229-2009-15 9/30/08 H3057-2009-17 9/30/08

This document was last modified: 9/30/08

Link to Tufts Health Plan Home

The Medicare Advantage contract between Tufts Health Plan and the Centers for Medicare & Medicaid Services (CMS) is valid for one calendar year. The benefits, premiums, copayments and service area offered by Tufts Health Plan are subject to change on an annual basis. Please contact Tufts Health Plan Medicare Preferred for details. Tufts Health Plan Medicare Preferred is a medicare advantage organization that contracts with the Federal Government.

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