Pharmacy Prior Authorization Request Forms

The following forms can be used to request drug coverage that are restricted under any of the following pharmacy utilization management programs:

• Prior Authorization Program
• Step Therapy Prior Authorization Program
• Quantity Limitation Program
• Non-Covered Drugs Program
• New-To-Market Drug Evaluation Process

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
1 Wellness Way
Canton, MA 02021-1166
Fax: 617.673.0988

Note: For Uniformed Services Family Health Plan (USFHP) members, fax coverage requests to USFHP at 617.562.5296.