Pharmacy coverage decision

You can always check our up-to-date List of Covered Drugs. If your pharmacist cannot fill your prescription drugs, you have the right to request a coverage decision (or coverage determination). This includes the right to ask for a special type of coverage decision, called an exception, if you believe:

• Your primary care provider (PCP) or other doctor has prescribed a drug that is not in the List of Covered Drugs. The List of Covered Drugs is called a formulary, and a drug not on our formulary is called a nonformulary drug.

OR

• One of the coverage rules should not apply to you for medical reasons. Coverage rules include: 
  • Prior authorization we require before the drug is covered
  • Quantity limits for dosage and/or length of time on a drug
  • Step-therapy requirements asking you to try another drug to treat your medical condition before we cover the drug prescribed by your doctor or prescriber 

To request a coverage decision, your doctor or prescriber can fill out our Request for Medicare Prescription Drug Coverage Determination form (PDF), or you can call us toll-free at 1-855-393-3154 (TTY: 711), seven days a week, from 8 a.m. to 8 p.m. 

If you prefer to mail your form, print, complete and mail your Request for Medicare Prescription Drug Coverage Determination form to: 

Tufts Health Plan
Attn: Pharmacy Utilization Management Department
P.O. Box 524
Canton, MA 02021-1166

You will need the following information in order to complete the form or make your request over the phone:

• The name of the prescription drug you believe you need, including the dose and/or strength, if known
• The date the pharmacy rejected your prescription
• If you're asking for an exception, your doctor or prescriber will need to provide us with a statement explaining:
  • Why you need the nonformulary drug
  • Why the coverage rules should not apply to you
  • Why an exception should be made

Once we receive and process your request, we will send you a written decision. If we do not approve your requested coverage, we will explain why this coverage was denied.

Yes, some drugs have coverage rules or limits on the amount you can get. In some cases, you must do something before you can get the drug. For example:

• Prior approval (or prior authorization) — for some drugs, you or your doctor must get approval from us before you fill your prescription. If you don't get approval, we may not cover the drug. If you or your doctor asks for a coverage decision, we will give you an answer on a prior authorization within 72 hours. You can request an expedited (fast) prior authorization if you or your doctor believes that your health could be seriously harmed by waiting up to 72 hours for a decision. If you request an expedited prior authorization, we must give you a decision within 24 hours.
• Quantity limits — sometimes we limit the amount of a drug you can get.
• Step therapy — sometimes we require you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor thinks the first drug doesn't work for you, then we will cover the second.

You can ask us to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make, such as asking us to cover your drug even if it is not in our formulary. You can also ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, we may limit the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more.

When you are requesting a formulary or utilization restriction exception, your doctor or prescriber should submit a statement supporting your request. Generally, we must make our decision within 72 hours of getting your doctor’s or prescriber's supporting statement. You can request an expedited (fast) exception if you or your doctor believes that your health could be seriously harmed by waiting up to 72 hours for a decision. If you request an expedited exception, we must give you a decision no later than 24 hours after we get your doctor's or prescriber's supporting statement.

If you disagree with our decision, you, your doctor or prescriber, or your appointed representative (PDF), can file a redetermination request, also called an appeal. You can call, write or fax us to file an appeal.

• Call us toll-free at 1-855-393-3154 (TTY: 711), seven days a week, from 8 a.m. to 8 p.m. 
• Fax us at 857-304-6342
• Write us at:

Tufts Health Plan
Attn: Appeal and Grievance Team
P.O. Box 524
Canton, MA 02021-1166

For more information about appeals and grievances, please see Chapter 9 of the Tufts Health One Care Member Handbook.