Pharmacy Prior Authorization Request Forms

The following forms can be used to request coverage for drug products that are restricted in some way under any of the following pharmacy management programs:

• Prior Authorization Program
• Step Therapy Prior Authorization Program
• Quantity (Dispensing) Limitation Program
• List of noncovered drugs
• New-to-market drug evaluation process

Note: These forms are for pharmaceuticals only.

Note: 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.

Please be sure to complete the entire form and fax or send to Tufts Health Plan 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, please fax coverage requests to USFHP at 617.562.5296.