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Print Forms and Documents

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Click below to download enrollment materials for:

Enrollment Forms:

2009 HMO Enrollment Form (Health Maintenance Organization)

2009 PPO Enrollment Form (Preferred Provider Organization)

2009 PFFS Enrollment Form (Private Fee-for-Service)

Prescription Drug Forms:

Universal Pharmacy Form

Coverage Determination Request Form

HMO Caremark Mail Order Form

PPO Caremark Mail Order Form

PFFS Caremark Mail Order Form

Plan Information:

Plan Highlights

2009 HMO Summary of Benefits

2009 PPO Summary of Benefits

2009 PFFS Summary of Benefits

2009 HMO Basic No Rx Evidence of Coverage

2009 HMO Basic Rx/Rx Plus Evidence of Coverage

2009 HMO Value No Rx Evidence of Coverage

2009 HMO Value Rx/Rx Plus Evidence of Coverage

2009 HMO Prime No Rx Evidence of Coverage

2009 HMO Prime Rx/Rx Plus Evidence of Coverage

2009 PPO No Rx Evidence Of Coverage

2009 PPO Rx/Rx Plus Evidence of Coverage

2009 PFFS Basic No Rx Evidence of Coverage

2009 PFFS Basic Rx/Rx Plus Evidence of Coverage

2009 PFFS Prime No Rx Evidence of Coverage

2009 PFFS Prime Rx/Rx Plus Evidence of Coverage

Additional Information:

Preferred Extras

H2256-2009-19 9/30/08 H2229-2009-15 9/30/08 H3057-2009-17 9/30/08

This document was last modified: 9/30/08

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The Medicare Advantage contract between Tufts Health Plan and the Centers for Medicare & Medicaid Services (CMS) is valid for one calendar year. The benefits, premiums, copayments and service area offered by Tufts Health Plan are subject to change on an annual basis. Please contact Tufts Health Plan Medicare Preferred for details. Tufts Health Plan Medicare Preferred is a medicare advantage organization that contracts with the Federal Government.

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