Universal Pharmacy Programs Request Form

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Universal Pharmacy Programs Request Form
This form is only used for pharmacy requests that require prior review by Tufts Health Plan.
For Medicare Part B vs. Part D Coverage Determinations for Tufts Medicare Preferred HMO, Tufts Medicare PDP and Tufts Health Plan Senior Care Options (HMO SNP)
members,
click here
for the criteria/request form.
PATIENT’S PLAN:
Commercial
Tufts Medicare Preferred HMO or PDP
Tufts Health Plan Senior Care Options (HMO SNP)
Fax to 617-673-0988
Fax to 617-673-0956
Fax to 617-673-0956
PATIENT INFORMATION
PRESCRIBER INFORMATION
Name:_____________________________________________ Date:____________________
Name:_________________________________________ Specialty:_____________________
Member ID:________________________________________ DOB:_____________________
Tufts Health Plan Provider ID:______________________ NPI:__________________________
Diagnosis: ___________________________________________________________________
Phone: _____________________________ Fax: ____________________________________
Relevant Co-morbid Diagnoses: __________________________________________________
Office Contact: _______________________________________________________________
Additional Comments/History: __________________________________________________
Prescriber Signature (required):_________________________________________________
REQUESTED DRUG
THIS SECTION APPLIES TO TUFTS MEDICARE PREFERRED HMO and PDP AND TUFTS HEALTH
Name and strength:___________________________________________________________
PLAN SENIOR CARE OPTIONS (HMO SNP) ONLY
Select one:
Dispense as written
Generic substitution authorized
Does the member’s condition require expedited review [24 hours]?
Yes*
No
* By checking this box and signing above, I certify that the 72-hour standard review time may
Dosage form: _______________________________ Quantity:_________________________
seriously jeopardize the life or health of the member or the member’s ability to regain
___________________________________________
Duration of requested treatment:
maximum function.
CLINICAL JUSTIFICATION FOR REQUEST (if applicable)
Does this member reside in long-term care?
Yes
No
Adverse
Treatment
Prior Medications
Length of Therapy
Rationale for prior authorization or exception request. Check statement(s) that apply and
Failure
Reaction
include supporting documentation under Clinical Justification and Explanation sections on the
left:
Alternate formulary drug(s) contraindicated or previously tried, but with adverse
outcome.
EXPLANATION: Describe adverse reaction or treatment failure in detail. If not as effective,
Document drug name, adverse outcome, and, if therapeutic failure, length of therapy on
length of therapy on each drug and outcome.
drug.
___________________________________________________________________
Complex patient with one or more chronic conditions is stable on current drug(s); high
risk of significant adverse clinical outcome with medication change. Document
___________________________________________________________________
anticipated significant adverse clinical outcome.
___________________________________________________________________
Medical need for different dosage form and/or higher dosage. Document dosage form(s)
___________________________________________________________________
and/or dosage(s) tried and explain medical reason.
___________________________________________________________________
Is this a request for a tier exception*?
Yes
No
___________________________________________________________________
* All formulary/preferred drug(s) on lower tier(s) contraindicated to the member’s condition
___________________________________________________________________
or were tried and failed, or not as effective as requested drug. Specialty tier is excluded from
___________________________________________________________________
tiering exception.
___________________________________________________________________
Indication:
(attach separate sheet if needed)
____________________________________________________________________________
Provider Services
Revised 4/2013
1
Universal Pharmacy Programs Request Form
2113408

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