Tufts Health Plan SCO

Formularies

2020

Step Therapy and Prior Authorization Guidelines

Tufts Health Plan SCO requires prior authorization and/or step therapy guidelines 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).

Please see the below clinical criteria for coverage of drugs with prior authorization or step therapy prior authorization requirements:

2020

Forms

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

Hepatitis C Medication Request Form: Request coverage for Hepatitis C Medications.

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.