(774) 228-7135 View Bellingham, MA 02019 Janet Sherman Psychologist, PhD Verified I am a licensed psychologist who has had extensive experience working with adults, adolescents and children in. Universal Pharmacy Form Coverage Determination Form (PDF). Tufts Health Planproducts are also available through the Massachusetts Health Connector. Interested in learning more about the aggregate number of appeals, grievances and exceptions filed with Tufts Health Plan Senior Care Options? Qualified health clubs and fitness facilities provide cardiovascular and strength-training exercise equipment on site. Medication Therapy Management (MTM) If you do go to an out-of-network pharmacy for the reasons listed above, you will have to pay the full cost (rather than just paying your copayment) when you fill your prescription. There are also limited situations where you do not choose to leave, but we are required to end your membership. View your Evidence of Coverage (EOC) to see your HMO Summary of Benefits. Tufts Health Plan Medicare Preferred Asked by: Carlee Hegmann | Last update: February 11, 2022 Score: 4.1/5 ( 36 votes ) We are uniquely positioned to tailor what we do to those who receive their health coverage through the GIC. You can also contact Member Services at the number below and ask to have a Wellness Allowance Form sent to you. Your Evidence of Coverage (EOC) document tells you when you can end your membership in the plan. Office of Medicaid Remember, you do not need to pay anything extra to participate. Read here.. Learn More Your physician must be involved in filling out this form since he or she will need to provide information regarding the medical necessity of your request. What If I'm out-of-network and run out of my prescription? By issuing all the referrals, your PCP is able to oversee the care you receive and help you see the specialist that is right for you. Physical Therapy often helps in recovering from surgery or injury and can help manage long-term health issues like arthritis. Covers up to 12 visits in 90 days for members with chronic lower back pain. 8 additional visits covered for those demonstrating an improvement. Navigator by Tufts Health Plan is a point of service (POS) plan that covers preventive and medically necessary health care services and supplies. For more information: Learn more about filing an appeal or coverage determination in your plan's Evidence of Coverage document found on the Plan Documents page. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get your prescribing physician's supporting statement. We offer medication therapy management programs at no additional cost for HMO SNP (Medicare and Medicaid) members who have multiple medical conditions, who are taking many prescription drugs, or who have high drug costs. If you are unable to get a covered drug in a timely manner within our service area because there are no network pharmacies within a reasonable driving distance that provide 24-hour service. Print and Mail-in a Coverage Determination form Complete Request for Coverage Determination Online, Print and Mail-in the Redetermination Form (PDF). Representatives are available 8 a.m. 8 p.m., 7 days a week (Mon. How can I make a complaint about my Medicare plan directly to Medicare online? You have the right to ask us for an "exception" if you believe you need a drug that is not on our list of covered drugs (formulary) or believe you should get a drug at a lower co-payment. Ultrasounds: $100 per day; Others: $200 per day for other services. Coverage rules include: requiring prior authorization by the plan before the drug is covered, quantity limits for dosage and or length of time on a drug, and/or or step therapy requirements asking you to try another drug to treat your medical condition before the Plan covers the drug prescribed by your physician. Include the exact name of the prescription, dosage, frequency that it is taken, and the name of the physician who prescribed it. Each row represents a specific benefit covered by our products including medical, hospital, prescription and wellness benefits. 1 Sept. 30). You can ask Tufts Health Plan Senior Care Options to make an exception to our coverage rules. During this time period, anyone wishing to join a Medicare Advantage plan or a Prescription Drug Plan, or switch to a different plan, may do so. Your physician can also provide an oral supporting statement by calling Member Services at 1-855-670-5934 (TTY: 711). Our representatives are available 8 a.m. 8 p.m., 7 days a week (Mon. Referrals are an important part of an HMO plan because they help your doctor keep track of the care you receive and ensure that the care is right for you. Our representatives are available 8 a.m. 8 p.m., 7 days a week (Mon. If you lose or run out of prescriptions when traveling, we will cover prescriptions that are filled at an out-of-network pharmacy if a network pharmacy is not available. If you are selected to join a medication therapy management program, we will send you information about the specific program, including information about how to access the program. It is important to understand that personal medical information related to your appeal may be disclosed to the representative that you indicate in the appointment of representative forms. You can request an expedited (faster) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. Fri. from Apr. After hours and on holidays, please leave a message and a representative will return your call the next business day. Representatives are available 8 a.m. 8 p.m., 7 days a week (Mon. You may also email your request for the directory to: TMPCustomerRelations@tufts-health.com. Utilization management may be conducted in several ways, including preauthorization review, concurrent review (while you are receiving care), and retrospective review (after care has been provided). Included with Plan: 50% of total cost. Please note: If you receive your benefits from a current or former employer, please contact your benefits administrator regarding plan options and enrollment information. When you sign up for EFT, your monthly premium payment is automatically deducted from your checking or savings account each month and transferred to Tufts Health Plan Medicare Preferred. The Notice of Privacy Practices provides detailed information about our privacy practices and your rights regarding your personal health information. Coverage rules include: requiring prior authorization by the plan before the drug is covered, quantity limits for dosage and or length of time on a drug, and/or or step therapy requirements asking you to try another drug to treat your medical condition before the Plan covers the drug prescribed by your physician. 1 Sept. 30). If your drug has a quantity limit, you can ask us to waive the limit and cover more. Your monthly plan premium will be withdrawn from your account on the 9th of every month for the current month's plan premium. $40 per visit in-network; 40% of cost out-of-network. Tufts Health Plan Medicare Preferred may add or remove drugs from our formulary during the year. You, your physician or your appointed representative may file a coverage determination by calling Member Services at 1-855-670-5934 (TTY: 711). You also search for your specific prescription drugs and their costs on our plans using our Drug Search tool. If you ask for an exception, your doctor or other prescriber will need to provide Tufts Health Plan Senior Care Options with a statement explaining: why you need the non-formulary drug, why a coverage rule should not apply to you, or why an exception should be made. If you are a Tufts Health Together (MassHealth), Tufts Health RITogether (Rhode Island Medicaid), Tufts Health Unify (Medicare-Medicaid plan), or Tufts Health Plan Senior Care Options (65+ Medicare-Medicaid plan) member: You may need to renew your coverage this year. Tufts Health Plan Medicare Preferred You have 60 days from the date of our Notice of Denial of Medicare Prescription Drug Coverage to ask for a redetermination. 1 Sept. 30). We will contact you by mail when your application has been approved. What is urgently needed care? Customer Relations Can Answer Your Questions. Attn: Pharmacy Utilization Management Department To help monitor quality of care and manage health care costs, Tufts Health Plan Senior Care Options conducts utilization management activities for all its members. How do you find additional information about coverage determinations? Beneficiaries interested in qualifying for extra help with Medicare Prescription Drug Plan costs should call: The Social Security Administration at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. After hours and on holidays, please leave a message and a representative will return your call the next business day. To fax completed enrollment forms: 1-617-673-0785, Hours of Operation: 8 a.m. 8 p.m., 7 days a week (Mon. Prior authorization may be required for non-emergency transportation. Hours of Operation: 8 a.m. 8 p.m., 7 days a week (Mon. This Member Handbook describes the Navigator Health Care Plan. Faxed requests can be sent 24-hours a day, 7 days a week. Bring copies of your prescriptions so you can fill them in the event you lose your medications. Tufts Health Plan Senior Care Options also includes case management services for medically complex situations in which the . Fri. from Apr. An organization determination is our initial decision about whether we will cover the medical care or service you request, or pay for a service you have received. Fri. from Apr. For example, for certain drugs, Tufts Medicare Preferred HMO may limit the amount of the drug that we will cover. We offer Employer and Medicaid plans in Massachusetts and Rhode Island. Medicare Part D Coverage Determination Request Form (PDF). in 2023 Tufts Medicare Preferred Access (PPO) Plan, Request a Medicare Part D Coverage Determination, Request a Medicare Part D Coverage Redetermination, Multi-language Interpreter Services (HMO & PPO), Multi-language Interpreter Services (SCO), 2023 Tufts Medicare Preferred Access (PPO) Plan. Credit card statement or receipt identifying club/facility Photocopies must be on 8.5" x 11" paper. If for any reason, you arrive at your specialist appointment after receiving a referral confirmation from your PCP and are told your referral is not there, ask the specialists office to contact your PCPs office to send the referral while you wait. Every individual enrolled in a Tufts Health Plan Medicare Preferred plan has the right to appoint an individual to act as their representative in connection with a claim or asserted right under title XViii (18) of the Social Security act (the act) and related provisions of title Xi (11) of the act. Representatives are available 8 a.m. 8 p.m., 7 days a week (Mon. Tufts Health Plan Medicare Preferred takes the confidentiality of your personal health information very seriously. How can I find out more about other members experiences with Tufts Health Plan Senior Care Options Prescription Coverage? Please refer to the Evidence of Coverage (EOC) for more information about: Please refer to your Evidence of Coverage (EOC) document for more information on: Phone Numbers You can ask us to waive coverage restrictions or limits on your drug. For example, Tufts Medicare Preferred HMO provides 30 tablets per prescription for zolpidem. 1 Wellness Way What if you just joined Tufts Health Plan Senior Care Options and did not know that your drug was not covered? Learn More Fri. from Apr. Appeals and Grievances and Coverage Determination, Disenrollment rights and responsibilities. Read here. This request includes the right to request a special type of coverage determination called an exception if you believe: Tufts Health Plan Senior Care Options will provide you with a written decision. 2023 Tufts Associated Health Plans, Inc. All rights reserved. How do you file a coverage determination, including an exception? As soon as possible, you or someone else should call to tell us about your emergency (usually within 48 hours), because we need to follow up on your emergency care. You can authorize this individual to make any request; to present or to elicit evidence; to obtain appeals information; and to receive any notice in connection with an appeal, wholly in your stead. Keep this list in your purse or wallet and show it to your health care provider during an office visit, emergency room visit, or upon admission to a hospital or skilled nursing facility. A notice to our members regarding a security incident. Bring the name and telephone number of your doctor and pharmacy. Once you're signed up and receive your EFT invoice, your monthly plan premium payments will be automatically deducted from your checking or savings account. When you are requesting a formulary, tiering, or utilization restriction exception, you should submit a statement from your physician supporting your request. What is the Tufts Medicare Preferred HMO plan Grievance Policy? Occupational Therapy helps develop, recover, and improve the skills needed for daily living and working after an injury or disability. Hearing or speech-impaired members with TTY machines can call the Massachusetts Relay Association at 711for assistance contacting your PCP after hours. Covered as needed. It also explains your rights as a member and how to use your coverage for medical care or prescription drug. For requests received outside normal business hours, we have clinicians on-call for processing requests for Part D pharmacy coverage. In most cases, your prescriptions are covered only if they are filled at the plan's network pharmacies (retail or OptumRx Home Delivery). Navigator by Tufts Health Plan is a point of service (POS) plan that covers preventive and medically necessary health care services and supplies. You are allowed one Annual Physical and one Wellness Visit each plan year. Additional telehealth services not covered. Where To Find More Information About Your Prescription Drug Coverage. In addition to complying with all applicable laws, we carefully handle your personal health information in accordance with our confidentiality policies and procedures. How do I receive a reimbursement for joining a fitness club? These programs were developed for us by a team of pharmacists and doctors. Be sure that your healthcare provider reviews your medications. If you have questions about any of these processes, or if you want to inquire about the status of a coverage determination request, you, your physician or your appointed representative may contact us at at 1-800-701-9000 (HMO) or 1-866-623-0172 (PPO) (TTY: 711). Health Insurance Plan Options For Benefits Prior to June 30, 2023: Table of Contents Mass General Brigham Health Plan (Previously AllWays Health Partners) Harvard Pilgrim Health Care Health New England Tufts Health Plan UniCare Prescription Drug Benefits - Express Scripts RELATED Request for Redetermination of Medicare Prescription Drug Denial (PDF). You can be outside of our service area for up to 6 consecutive months and still be covered for emergency and urgently needed care. If you leave the Tufts Health Plan Senior Care Options plan, it may take time before your membership ends and your new coverage goes into effect. Your PCP will provide your routine care, preventive care, and treatment for common illnesses. Make a photocopy of your health club or fitness facility agreement that includes the name and address of the club/facility, your name, and the dates of your membership or exercise classes. If you have any questions, call Tufts Health Plan Medicare Preferred Member Services at 1-800-701-9000 (HMO) or 1-866-623-0172 (PPO) (TTY: 711). Some covered drugs may have additional requirements or limits on coverage known as Utilization Management. 1 Sept. 30). For example, the last ANOC/EOC was mailed in September for delivery to you no later than September 30th, and contained information for the following plan year. The change in coverage requested during this period will begin on January 1 of the next year. member ID card, please call us at: 800-462-0224, Point32Health is the parent organization of Tufts Health Plan and Harvard Pilgrim Health Care. During this time, you must continue to get your medical care through our plan. See above for enrollment period information. Always check with your PCP before seeing a specialist because your PCP needs to issue the referral. If your pharmacist cannot fill your prescription drugs you have the right to request a coverage determination from Tufts Health Plan Senior Care Options. This is the most you will pay in a plan year for covered medical expenses. This may be in addition to a standard one month or three month supply. Your PCP will communicate with your specialist to ensure you receive the care that is right for you. The Annual Notice of Change (ANOC) is a personalized letter sent to all members that highlights any changes to their benefits and costs for the upcoming year. Representatives are available 8 a.m. 8 p.m., 7 days a week (Mon. For requests received outside normal business hours, we have pharmacists on-call for processing requests for Part D pharmacy coverage. For example, the premium for the month of July will be withdrawn on July 9th. When traveling by car, remember not to leave your medications in the car, especially in warm weather, and never leave them in the trunk. An organization determination is our initial decision about whether we will provide the medical care or service you request, or pay for a service you have received. How do I know when the EFT amount has been deducted from my account? The withdrawal takes place on the 9th in order to allow for payment to be received by the invoice due date of the 15th. Learn more about organization determination in Chapter 8, section 1-9 of your EOC. If you are a Tufts Health Together (MassHealth), Tufts Health RITogether (Rhode Island Medicaid), Tufts Health Unify (Medicare-Medicaid plan), or Tufts Health Plan Senior Care Options (65+ Medicare-Medicaid plan) member: You may need to renew your coverage this year. This is especially true during times of transition or change, such as if you see a physician who does not know your medical history, if you are transported to an emergency room, or if you are released from a hospital or skilled nursing facility. Sometimes you may need to talk with your Primary Care Physician (PCP) or get medical care when your PCPs office is closed. What if your drug is part of a Step Therapy program? An important part of coordinating your care is when your PCP refers you to a specialist for services he/she isnt able to provide. This is a Medicare Advantage plan, also known as Medicare Part C. It provides you with all of your Medicare Part A and B benefits, as well as additional coverage not included in Parts A and B. However, there may be times when you have concerns or problems related to your coverage or care. To request a vacation override, contact Member Services 14 business days before leaving for your trip with your prescription and pharmacy information. Included with Plan: 50% of total cost. After hours and on holidays, please leave a message and a representative will return your call the next business day.