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The following forms can be used to request drug coverage that are restricted under any of the following pharmacy utilization management programs:
The Commercial Pharmacy Medication Prior Authorization Submission Guide provides information on which form to use based on state and product for both the prescription drug benefit and the medical benefit.
Be sure to complete the entire form and fax or send to Tufts Health Plan's Pharmacy Utilization Management Department at:
Tufts Health Plan Pharmacy Utilization Management Department 705 Mount Auburn St. Watertown, MA 02472 Fax: 617.673.0988
Note: For Uniformed Services Family Health Plan (USFHP) members, fax coverage requests to USFHP at 617.562.5296.