Pharmacy Coverage Decision

A coverage decision about your drugs is a decision about your benefits and covered drugs or the amount we will pay for your drugs. This applies to your Part D drugs, MassHealth prescription drugs and MassHealth over-the-counter drugs.

You may request a coverage decision if you:

Need a drug that is not on our List of Covered Drugs (2024) (PDF)
Have been using a drug that was previously included on our List of Covered Drugs, but is being removed or was removed from this list during the plan year
Need prior authorization for a drug your doctor has prescribed
Want to request an exception to the requirement that you try another drug before you get a drug your doctor prescribed
Want to request an exception to the limit on the number of pills (quantity limit) you can receive so that you can get the number of pills your doctor prescribed
Want to be reimbursed for a covered prescription drug that you paid for out of pocket

Questions about your prescription coverage:

What if my prescription drugs cannot be filled?

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.

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

How do I request a coverage decision?

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 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.

Are there any restrictions or limits on drug coverage? Or are there any required actions I need to take in order to get certain drugs?

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.

Can I ask for exceptions to coverage rules?

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.

What should I do if my request is denied?

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 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.

Tufts Health One Care is a health plan that contracts with both Medicare and MassHealth to provide benefits of both programs to enrollees under the One Care program.

Benefits, the List of Covered Drugs and pharmacy and provider networks may change from time to time throughout the year and on Jan. 1 of each year.

Limitations and restrictions may apply. For more information, call Tufts Health One Care member services toll-free at 855-393-3154 (TTY: 711).

Disclaimers

Tufts Health One Care is a health plan that contracts with both Medicare and MassHealth to provide benefits of both programs to enrollees. It is for people with both Medicare and MassHealth ages 21 through 64 at the time of enrollment.

This is not a complete list. The benefit information is a brief summary, not a complete description of benefits. For more information contact the plan or read the Member Handbook (2024).

ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-855-393-3154 (TTY: 711), seven days a week, from 8 a.m. to 8 p.m. The call is free.

Si habla español, tiene disponible los servicios de asistencia de idioma gratis. Llame al 1-855-393-3154 (TTY: 711), siete días de la semana, de 8 a.m. a 8 p.m. La llamada es gratuita.

You can get this document for free in other formats, such as large print, formats that work with screen reader technology, braille, or audio. Call 1-855-393-3154 (TTY:711), seven days a week, from 8 a.m. to 8 p.m. The call is free.

The List of Covered Drugs and/or pharmacy and provider networks may change from time to time throughout the year. We will send you a notice before we make a change that affects you.

Benefits may change on January 1 of each year.

H7419_4520_CMS Approved
Page modified on: 12/29/2017 5:06:24 PM