Pharmacy Benefits
 
 

How We Cover Prescriptions

Your plan includes a pharmacy benefit, which means that thousands of medications in our covered drug list (also known as a formulary) are available with a doctor’s prescription if you need them.

Each covered drug has a cost-share. The amount of the cost-share depends on which drug it is and what “tier” or level it’s on.

The drugs covered under your plan (and their cost-share) are organized into up to four tiers:

  • Tier 1 includes most generic drugs, and is the lowest cost-share.
  • Tier 2 includes many generic and brand-name drugs.
  • Tier 3 includes the most expensive generic and brand-name drugs.
  • Tier 4 includes specialty drugs, and is the highest cost-share.

Is my prescription covered?

Every plan is different, so follow these three steps to check your specific coverage:

1. Find your drug on the list of covered drugs (formulary)

You can easily find the list of covered drugs for your specific plan in the My Coverage (1) section of mytuftshealthplan.com, just select Pharmacy (2).

2. If your medication is on our covered drug list, check whether any of the following apply to it: If any do apply, you’ll need to contact your doctor.

Prior Authorization (PA)

Contact the doctor who wrote your prescription. If the doctor believes the drug that requires PA is necessary for your treatment, he or she may submit a request for coverage by faxing a Universal Pharmacy Medical Review Request Form to Tufts Health Plan. We’ll cover the medication if it meets our medical necessity coverage guidelines. If we do not cover the medication, you can appeal the decision.

Step Therapy Prior Authorization (STPA)

Check our step therapy drug list to find out which step your drug is on. If you haven’t previously taken the steps we require, and your doctor believes the drug prescribed for you is medically necessary, he or she may request coverage.

Quantity Limitation (QL)

You’re covered for up to the quantity posted in our covered drug list. If your doctor believes you need to take more than that quantity, he or she may submit a request for coverage.

Designated Specialty Pharmacy (SP)

Log in to the member portal and click on My Coverage, then Pharmacy. Call the designated specialty pharmacy provider indicated, or contact our member services department to help you receive your medication without interruption.

Non-covered (NC)

Contact the doctor who wrote your prescription. If your doctor believes a non-covered drug is necessary for your treatment, he or she may submit a request for coverage to Tufts Health Plan. We will cover the medication if it meets our medical necessity coverage guidelines. If the request is approved, you will be covered for your prescription. If it is not approved, you can appeal the decision.

3. Check the relative cost of your covered medication.

What if my drug is not covered?

In some cases when a brand-name drug has safe, effective alternatives or generic versions that become available, we'll cover those instead. Your doctor may submit a request to us for coverage if he or she believes that you have a medical reason for treatment with a non-covered drug.

View our Low-Cost Generic Drug Program List

Where can I get my prescriptions filled?

Retail Locations

Go to any of the 68,000 participating retail pharmacies in the CVS/caremark™ network to obtain most covered medications. To be clear, this includes more than just CVS Pharmacy® locations. In fact, most pharmacies participate, including retail chain stores (ex. Walmart, Target), independent pharmacies, and designated specialty pharmacies.

Locate a nearby pharmacy

Mail Order

Use the CVS/caremark mail-order pharmacy service for most covered maintenance medications. In general, mail-order service is not recommended for medications that are dispensed in limited quantities, because prescriptions for these medications are typically dispensed in less than a 90-day supply.

Online Tools to Manage Your Prescriptions

Members that fill their prescriptions with Tufts Health Plan’s pharmacy benefits manager (PBM), CVS/caremark, have access to the following online tools to manage their pharmacy benefits:

  • Direct access through our secure member portal
  • With the CVS/caremark App

Learn more in the Digital Tools You Can Use section of this welcome kit.