Some drugs require prior authorization. Refer to the Tufts Health Direct formulary and the Tufts Health Plan's pharmacy medical necessity guidelines before submitting a request for prior authorization.
For Tufts Health Direct members, requests are reviewed and initial determinations regarding prior authorizations are made within two business days of receiving complete medical information. Once a decision is made, Tufts Health Plan will notify providers by telephone or fax within one business day.
For medication coverage under the pharmacy benefit, refer to the standard Medication Prior Authorization Request Form.
Pharmacy benefit applies to drugs that are self-administered (i.e., subcutaneous or taken orally) and are filled at retail pharmacies.
Providers can submit the completed form for pharmacy benefit via:
- Fax: 617.673.0988
- Mail: Tufts Health Plan 1 Wellness Way Canton, MA 02021-1166 Attn: Pharmacy Utilization Management Department
For medication coverage under the medical benefit, refer to the standard Medication Prior Authorization Request Form.
Medical benefit applies to drugs that require skilled administration (i.e., intravenous, infusion) by a medical provider.
Providers can submit the completed form for medical benefit via:
- Fax: 888.415.9055
- Mail: Tufts Health Plan 1 Wellness Way Canton, MA 02021-1166 Attn: Precertification