This page contains additional information about your health coverage. Please select from the topics below.

• Extra Help
• Universal Pharmacy Form
• Fraud, Waste, & Abuse
• Appeals and Grievances
• Quality Assurance Policies and Procedures
• Coverage Determination
• Organization Determination
• Privacy Notice
• For More Information

Extra Help
If you qualify for extra help with your Medicare Prescription Drug Plan costs, your premium and drug costs will be lower. When you join Tufts Health Plan Medicare Preferred, Medicare will tell us how much extra help you are getting. Then, we will let you know the amount you will pay. The premiums listed do not include any Part B premium the member may have to pay. The premiums listed are for both medical services and prescription drug benefits.

• HMO Premium Changes Low Income Subsidy **coming soon **
  
• PPO Premium Changes Low Income Subsidy **coming soon **
  
• PFFS Premium Changes Low Income Subsidy **coming soon **
  

Beneficiaries interested in qualifying for extra help with Medicare Prescription Drug Plan costs should call:

• The Social Security Administration at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY/TDD users should call 1-800-325-0778
  
• 1-800-MEDICARE (1-800-633-4227). TTY/TDD users should call 1-877-486-2048 (24 hours a day/7 days a week) or
  
• Your State Medicaid Office
  

Universal Pharmacy Form
This form is used to request coverage for medications that require prior authorization, for exceptions for non-covered drugs, or for tier exceptions. Your physician must be involved in filling out this form since he or she will need to provide information regarding the medical necessity of your request. Your physician can also directly access this form on the Tufts Health Plan provider website.

Fraud, Waste, & Abuse
Click here for information about Tufts Health Plan's Fraud, Waste and Abuse Hotline.


Appeals and Grievance Processes

What to do if you have complaints
Tufts Medicare Preferred is dedicated to providing its members with comprehensive health care coverage. However, there may be times when you have concerns or problems related to your coverage or care. In these instances, you have the right to make formal complaints to Tufts Medicare Preferred. If you make a complaint, we must be fair in how we handle it, and you cannot be disenrolled or penalized in any way.

There are two types of formal complaints you can make. They are appeals and grievances. In this document, we will explain the differences between the two types of complaints and provide a high-level description of the processes for each.

Appeals
We encourage you to let us know right away if you have questions, concerns, or problems related to your Medicare Adavantage Plan which covers Medical and Hospital Services and/or Medicare Part D Prescription Drug Benefits. A complaint will be handled as a grievance, coverage determination, or an appeal, depending on the subject of the complaint. Federal law guarantees your right to make complaints if you have concerns or problems with any part of your care as a plan member. The Medicare program has helped set the rules about what you need to do to make a complaint and what we are required to do when we receive a complaint. If you make a complaint, we must be fair in how we handle it. You cannot be disenrolled or penalized in any way if you make a complaint.

Please not that Section 9 of your Evidence of Coverage (EOC) addresses how to file an appeal about your Medicare Advantage Plan which covers Medical and Hospital Services and Section 10 addresses how to file an appeal about your Medicare Part D Prescription Drug Benefits. These sections give the rules for making complaints in different types of situations.

An "appeal" is a complaint you make when you want us to reconsider and change a decision we've made about a request for authorization of services or payment of a denied claim. For example, you can file an appeal if: we refuse to cover or pay for services or Part D drugs you think we should cover; we or one of our plan providers refuses to give you a service you think should be covered; we or one of our plan providers reduces or cuts back on services or benefits you have been receiving, or stops your coverage of a service or benefit too soon.

Grievances
A "grievance" is a complaint you make if you have any other type of problem with Tufts Health Plan or one of our plan providers. For example, you would file a grievance if you have a problem with the quality of your care, waiting times for appointments or in the waiting room, the way your doctors or others behave, being able to reach someone by phone or get the information you need, or the cleanliness or condition of the doctor's office or pharmacy.

If you have a complaint, we encourage you to call Customer Relations and we will try to resolve the complaint over the phone. If you request a written response to your phone complaint, we will respond in writing to you. If we cannot resolve your complaint over the phone, we have a Formal Standard Grievance Process. You must file a grievance either orally or in writing no later than 60 days after the event. We must notify you of our decision no later than 30 calendar days after receiving the complaint. We may extend this timeframe by 14 days at your request, or if we feel it is justified and in your best interest. You can also request an expedited grievance that we must respond to within 24 hours of your complaint.

For more detailed information about appeals and grievances information for both Medicare Advantage and Part D prescription drug benefits, please see your Evidence of Coverage booklet that you receive as a Tufts Medicare Preferred member, or call Customer Relations at 1-800-701-9000 (TDD 1-800-208-9562), Monday - Friday, 8:30 a.m. - 5:00 p.m. For prescription drug coverage questions only, call 7days a week 8:00 a.m. - 8:00 p.m.

How to file a grievance or appeal:
You, your physician or your appointed representative (authorization of representative form) may file a grievance or appeal by calling Customer Relations at 1-800-701-9000 (TDD 1-800-208-9562) Monday - Friday, 8:30 a.m. - 5:00 p.m. (For Prescription drug related questions only, call 7 days a week 8:00 a.m. to 8:00 p.m.) or by writing to:

Tufts Medicare Preferred
705 Mt. Auburn Street
Watertown, MA 02472
Attn: Appeals & Grievance Department

Or by fax to: 1-617-972-9405 or 1-617-972-9487.

How to find additional information about grievances and appeals:
Please see Section 8: Grievances, Section 9: Complaints about Medical Services and Benefits and Section 10: Complaints about Prescription Drug Benefits of your Evidence of Coverage (EOC) for more information on our grievance and appeals process.

• Tufts Medicare Preferred HMO Basic EOC **coming soon **
• Tufts Medicare Preferred HMO Value EOC **coming soon **
• Tufts Medicare Preferred HMO Prime EOC **coming soon **
• Tufts Medicare Preferred PPO EOC **coming soon **
• Tufts Medicare Preferred PFFS Basic EOC **coming soon **
• Tufts Medicare Preferred PFFS Prime EOC **coming soon **

If you have questions about this process, or if you want to inquire about the status of a grievance or appeal request, you, your physician or your appointed representative may contact us at 1-800-701-9000 (TDD 1-800-208-9562) Monday - Friday, 8:30 a.m. - 5:00 p.m.


Quality Assurance Policies and Procedures

Utilization Management
To help monitor quality of care and manage health care costs, Tufts Health Plan conducts utilization management activities for all its members. The goal of utilization management is to be sure the care for which members receive coverage is medically necessary, covered by Tufts Medicare Preferred and provided by a qualified provider. Utilization management may be conducted in several ways, including preauthorization review, concurrent review (while you are receiving care), and retrospective review (after care has been provided). Tufts Health Plan also provides case management services for medically complex situations in which the member is likely to require extensive coordination of services.

Medication Therapy Management
We offer medication therapy management programs at no additional cost for members who have multiple medical conditions, who are taking many prescription drugs, or who have high drug costs. These programs were developed for us by a team of pharmacists and doctors. We use these medication therapy management programs to help us provide better coverage for our members. For example, these programs help us make sure that our members are using appropriate drugs to treat their medical conditions and help us identify possible medication errors. We offer medication therapy management programs for members that meet specific criteria. We may contact members who qualify for these programs. You may decide not to participate but it is recommended that you take full advantage of this covered service if you are selected. Remember, you do not need to pay anything extra to participate.

If you are selected to join a medication therapy management program, we will send you information about the specific program, including information about how to access the program.


Coverage Determination

What is a coverage determination?
Whenever you ask for a Part D prescription drug benefit, the first step is called requesting a coverage determination. When we make a coverage determination, we are making a decision whether or not to provide or pay for a Part D drug and what your share of the cost is for the drug. Coverage determinations include exceptions requests. You have the right to ask us for an "exception" if you believe you need a drug that is not on our list of covered drugs (formulary) or believe you should get a drug at a lower co-payment. If you request an exception, your physician must provide a statement to support your request. You must contact us if you would like to request a coverage determination (including an exception). You cannot request an appeal if we have not issued a coverage determination. For Prescription drug related questions only, call 7 days a week 8:00 a.m. - 8:00 p.m. You, your physician or your appointed representative may file a coverage determination, including an exception, by calling Customer Service at 1-800-701-9000 (TDD 1-800-208-9562) Monday - Friday, 8:30 a.m. - 5:00 p.m. (For Prescription drug related questions only, call 7 days a week 8:00 a.m. to 8:00 p.m.) or by writing to:

Tufts Medicare Preferred
705 Mt. Auburn Street
Watertown, MA 02472
Attn: Clinical Review Department

Or by fax to: 1-617-972-9409.

How to file a coverage determination, including an exception:
You, your physician or your appointed representative may file a coverage determination by calling Customer Relations at 1-800-701-9000 (TDD 1-800-208-9562) Monday - Friday, 8:30 a.m. - 5:00 p.m. (For Prescription drug related questions only, call 7 days a week 8:00 a.m. to 8:00 p.m.) or by writing to:

Tufts Medicare Preferred
705 Mt. Auburn Street
Watertown, MA 02472
Attn: Clinical Review Department

Or by fax to: 1-617-972-9409.

If you are requesting a formulary or tiering exception, your physician must provide a statement to support your request. Your physician can submit the request using the Tufts Health Plan Universal Pharmacy Form or the Medicare Part D Coverage Determination Request Form. The form asks your physician for information regarding your diagnosis, what other drug(s), if any, has been prescribed for the diagnosis and why it has not worked, and other questions. Your physician should send the completed form to:

Tufts Medicare Preferred
705 Mt. Auburn Street
Watertown, MA 02472
Attn: Clinical Review Department

Or by fax to: 1-617-972-9409.

Your physician can also provide an oral supporting statement by calling Customer Relations at 1-800-701-9000 (TDD 1-800-208-9562) Monday - Friday, 8:30 a.m. - 5:00 p.m. (For Prescription drug related questions only, call 7 days a week 8:00 a.m. to 8:00 p.m.).

How to find additional information about coverage determinations:
Please see Sections 9 and 10 of your Evidence of Coverage (EOC) for more information on our coverage determination process.

• Tufts Medicare Preferred HMO Basic EOC **coming soon **
• Tufts Medicare Preferred HMO Value EOC **coming soon **
• Tufts Medicare Preferred HMO Prime EOC **coming soon **
• Tufts Medicare Preferred PPO EOC **coming soon **
• Tufts Medicare Preferred PFFS Basic EOC **coming soon **
• Tufts Medicare Preferred PFFS Prime EOC **coming soon **

If you have questions about any of this processes, or if you want to inquire about the status of a coverage determination request, you, your physician or your appointed representative may contact us at 1-800-701-9000 (TDD 1-800-208-9562) Monday - Friday, 8:30 a.m. - 5:00 p.m.


Organization Determination

An organization determination is our initial decision about whether we will provide the medical care or service you request, or pay for a service you have received. If our initial decision is to deny your request, you may appeal the decision. When we make an “organization determination,” we are giving our interpretation of how the benefits and services that are covered for members of the Plan apply to your specific situation. Please refer to Section 9 of your EOC for additional details.


Privacy Notice:

For more information