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Submission Instructions for Medication Prior Authorization Requests

Massachusetts commercial products and CareLink

The pharmacy benefit is defined as self administration (i.e., subcutaneous or taken orally) and is filled at retail pharmacies. The medical benefit is defined as skilled administration (i.e., intravenous, infusion) by medical provider.

Commercial products (excluding Tufts Health Freedom Plan)

Note: The Commercial Pharmacy Medication Prior Authorization Submission Guide provides information on which form to use based on state and product. Prior to submitting the standard form to Tufts Health Plan, providers should refer to Tufts Health Plan’s pharmacy medical necessity guidelines, coverage policies and member benefits. Providers should also refer to the Commercial formularies to determine medication coverage and whether a drug should be reviewed under medical or pharmacy benefit.

Pharmacy benefit

For medication coverage under the pharmacy benefit, submit the completed standard form to the following:

Fax:  617.673.0988
Mail:  Tufts Health Plan
          705 Mount Auburn Street
          Watertown, MA 02472
          Attn: Pharmacy Utilization Management Department

Medical benefit

For medication coverage under the medical benefit, submit the completed standard form to the following:

Fax:  617.972.9409
Mail:  Tufts Health Plan
          705 Mount Auburn Street
          Watertown, MA 02472
          Attn: Precertification Operations – MS #66

CareLink

Pharmacy benefit

For medication coverage under the pharmacy benefit, submit the completed standard form here:

Fax:   866.443.1172
Mail:  CVS Caremark
          Appeals Department
          MC109
          PO Box 52084
          Phoenix, AZ 85072-2084

Medical benefit

For medication coverage under the medical benefit, submit the completed standard form here:

Fax:  855.840.1678
Web:  Log in to Cigna’s prior authorization/precertification portal and select the “New Prior Authorization”