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.
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.
You may request prior authorization or exception for a medical or pharmacy drug in one of the following ways:
- PromptPA — With this online tool you can quickly and easily submit requests for medical and pharmacy benefit drugs. View drug-specific criteria, attach clinical information, check the status of your PromptPA request, and receive a response more quickly. Submit your request or view the PromptPA User Guide for more information.
- Electronic PA (ePA) — CoverMyMeds (pharmacy and medical benefit drugs), or Surescripts (pharmacy drugs only)
- FAX — Submit your request using the corresponding form (found on the pharmacy medical necessity guideline page) and fax to the number indicated on the form.
- Mail prior authorization form to:
- Tufts Health Plan
- Attn: Pharmacy Utilization Management Department
- 1 Wellness Way
- Canton, MA 02021-1166
Pharmacy benefit Submit pharmacy drug prior authorization request to Optum Rx using one of the following ways:
Submit medical drug prior authorization request to Cigna using one of the following ways:
- Web: Cigna’s prior authorization/precertification portal
- Fax: 855-840-1678