Prior Authorization and Step Therapy Guidelines

Tufts Health Plan Medicare Preferred requires prior authorization and/or step therapy prior authorization for selected drug products that have a specific indication for use, are expensive, or pose significant safety concerns. Our pharmacy prior authorization and step therapy guidelines are used in conjunction with a member's plan document and in coordination with the member's provider(s).

For requests regarding prescription medications that have coverage limitations, the provider may submit clinical documentation using one of the forms listed below:

Universal Pharmacy Programs Request Form: request coverage for drug products that are restricted in some way under any of the pharmacy management programs.

Request For Medicare Prescription Drug Coverage Determination:  request drug coverage under our pharmacy management programs.

Coverage Determination and Prior Authorization Request for Medicare Part B vs Part D: Use this form to determine Medicare coverage under Part B or D. Coverage decisions are made on a case-by-case basis and consider the individual member's health care needs.

Pharmacy Medical Necessity Guidelines

Clinical criteria for coverage of drugs with prior authorization or step therapy prior authorization requirements

2018

2017

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