Welcome! We are very glad to have you as a new member. Our goal is to do everything we can to make your switch to our health plan as easy as possible.
Your coverage under Tufts Health Plan may be different than your previous health care coverage. Please see the important information below. If you still have questions, please call Member Services at 800-462-0224.
Our online provider directory allows you to customize your search based on the information most important to you. You can perform this search to determine if your current PCP or specialist participates in the network.
You may also see if a primary care provider (PCP) is accepting new patients. If you are an existing patient, you may still select your PCP even if there is an indicator that says “not accepting new patients.” If your current PCP is listed as not accepting new patients, please call Member Services.
If your plan requires referrals, please contact your PCP to submit them for any upcoming or on-going services such as Physical Therapy as you switch to Tufts Health Plan.
It’s important to notify all of your providers that your health insurance has changed. You may need to move your care from one facility or provider to another if your current provider does not participate in the Tufts Health Plan network.
If you or a dependent on your plan is undergoing active treatment for a condition that will need to continue after you become a Tufts Health Plan member, contact us as soon as possible so we can provide you with guidance.
Some procedures require prior authorization for coverage. When prior authorization is required, your provider submits a request to Tufts Health Plan, or an authorized reviewer, to assess whether your procedure meets our medical necessity guidelines for coverage.
To assist with your switch to Tufts Health Plan, please complete this form within one month prior to effective date if you or your family member(s):
- Have a scheduled surgery or hospitalization
- Have a serious condition such as heart disease, cancer, or multiple sclerosis
- Are currently being supported by a case manager or disease management program
- Are currently receiving home health care services
- Are pregnant and considered “high risk”
If you have a complex medical condition such as cancer, end-stage renal disease, or another serious illness, and you are receiving ongoing treatment, the Priority Care team will pair you with one of our nurse case managers to make your switch smoother. A nurse case manager will work with you and your doctors to support your health care treatment and goals. To learn more about this program, call 888-880-8699, extension 53532.
As our pharmacy benefits manager, Optum Rx reviews and processes your claims when you purchase prescription medications.
If you are currently on a medication, be sure you have enough on hand to last until your new coverage takes effect.
When you’re ready to fill a new prescription, follow these 3 easy steps:
1. Confirm that your medication is on our formulary, a list of covered drugs. If your medication is not listed, speak to your provider about alternatives that are covered.
2. Check whether any of the following pharmacy management programs apply to your medication:
- PA: Prior authorization
- NC: Non-covered
- STPA: Step therapy
- QL: Quantity limitation
- SP: Designated specialty pharmacy
If any of these programs apply, follow the applicable recommendations outlined in step 3, below.
3. Follow these appropriate steps for any applicable pharmacy management programs:
- Prior authorization (PA): Contact the provider who has written your prescription. If your provider believes a drug with a PA is necessary for your treatment, he or she may submit a request for coverage by faxing the appropriate form to Tufts Health Plan. We will cover the medication if it meets our medical necessity coverage guidelines. If the request is approved, you will be covered for your prescription. If it is not approved, you can appeal the decision.
- Step therapy prior authorization (STPA): Check our step therapy drug list to confirm the step your drug is on. If you have not previously taken the steps required by our pharmacy coverage guidelines, and your provider believes the drug prescribed for you is medically necessary, he or she may request coverage.
- Quantity limitation (QL): You are covered for up to the quantity posted in our list of covered drugs. If your provider believes it is necessary for you to take more than the QL quantity posted on the list, he or she may submit a request for coverage.
- Non-covered (NC): Contact the provider who has written your prescription. If your provider believes a drug with an NC is necessary for your treatment, he or she she may submit a request for coverage to Tufts Health Plan. We will cover the medication if it meets our medical necessity coverage guidelines. If the request is approved, you will be covered for your prescription. If it is not approved, you can appeal the decision.
- Designated specialty pharmacy (SP): Call the designated specialty pharmacy provider indicated in your online search in Step 1 or contact our Member Services Department to help ensure you receive your medication without interruption.