Commercial Pharmacy

At Tufts Health Plan, our goal is to help keep our members healthy, while doing all that we can to keep health care affordable for employer groups.

A number of factors contribute to increasing pharmacy costs, including:

Containing Costs While Maintaining Quality—Our Pharmacy Management Programs

We continue to develop pharmacy management programs to help manage the rising cost of drugs, while working for the needs of the member. Our Pharmacy and Therapeutics (P&T) Committee includes doctors and pharmacists from the community, along with members of Tufts Health Plan's clinical staff, who meet regularly to review drug data and studies in order to make clinical recommendations.

Low Cost Generic Drug (LCGD) Program Offered to MA Small Groups

We are introducing a new Low Cost Generic Drug program for all of our plans in 2017, except for Connector Premier plans. A subset of generic drugs will now switch to a new lower copay of $5. Other generic drugs not on this list will continue to require the higher Tier 1 copay. The 2017 formulary will be displayed on our public site as of November 1, 2016, with indicators if they fall under this Low Cost Generic program.

3-Tier Pharmacy Copayment Program

To help maintain flexibility in the pharmacy benefit, we encourage the use of cost-effective medications and preferred brand names through the 3-tier copayment program. This allows us to leave prescribing decisions to physicians.

There may be instances when only a Tier-3 drug is appropriate, however, a vast majority of the higher-priced Tier-3 drugs have lower cost alternatives on Tier-1 or Tier-2.

If a physician prescribes a Tier-3 or Tier-2 drug, the member can work with him or her to determine if there is an appropriate drug available that will be less costly. Please note that tier placement is subject to change throughout the year.

Depending on the plan chosen, coverage for prescription drugs may be subject to an annual deductible amount or be limited to our generic-focused formulary.

Massachusetts 4-Tier Pharmacy Copayment Program

To help maintain flexibility in the pharmacy benefit, we encourage the use of cost-effective medications and preferred brand names through the 4-tier copayment program. This allows us to leave prescribing decisions to physicians.

If the member’s plan includes a 4-Tier Copayment design, all covered drugs are divided into four tiers. The 4-Tier Copayment Program features a specialty tier for drugs included in and obtained through the designated specialty pharmacy (SP) program. Drugs that are part of the SP program include but are not limited to medications used in the treatment of rare diseases, infertility, hepatitis C, growth hormone deficiency, multiple sclerosis, rheumatoid arthritis, and cancers treated with oral medications.

The 4-Tier Copayment Program places all covered prescriptions into one of the following tiers:

Depending on the plan chosen, coverage for prescription drugs may be subject to an annual deductible amount or be limited to our generic-focused formulary.

Rhode Island 4-Tier Pharmacy Copayment Program

To help maintain flexibility in the pharmacy benefit, we encourage the use of cost-effective medications and preferred brand names through the 4-tier copayment program. This allows us to leave prescribing decisions to physicians.

If the member’s plan includes a 4-Tier Copayment design, all covered drugs are divided into four tiers. The 4-Tier Copayment Program features a specialty tier for high-cost specialty, self-injectable and biotech drugs. Drugs subject to the specialty tier include but are not limited to medications used in the treatment of rare diseases, hepatitis C, growth hormone deficiency, multiple sclerosis, rheumatoid arthritis, and cancers treated with oral medications.

The 4-Tier Copayment Program places all covered prescriptions into one of the following tiers:

Depending on the plan chosen, coverage for prescription drugs may be subject to an annual deductible amount or be limited to our generic-focused formulary.

Please Note: Infertility drugs are not included in our 4-Tier copayment program for Rhode Island members. Members who receive prior authorization for coverage of infertility drugs will pay a 20% coinsurance for each drug they utilize

Pharmacy Management Programs Include:

New-to-Market Drug Evaluation Process

New drugs are constantly being introduced to the market, and according to a study by the FDA, many of these medications are modified versions of existing drugs that offer little to no clinical advantages over older counterparts already available. Our P&T Committee reviews all new drugs and evaluates them for inclusion under our pharmacy benefit.

List of Non-Covered Drugs

A small number of drugs (less than 1%) are not covered by Tufts Health Plan because we have determined that there are safe, effective, and more affordable alternatives available. If a prescribing physician feels a particular non-covered drug is needed for one of our members, the physician may submit a request for coverage under our medical review process.

Drugs Requiring Prior Authorization

To support safety and affordability for everyone, Tufts Health Plan requires prior authorization for certain drugs. This helps us work with physicians to see that medications are prescribed appropriately. Our P&T Committee reviews all prior authorization criteria annually and as new information becomes available.

Prior Authorization Step Therapy

Step Therapy is an automated form of Prior Authorization, which uses claims history for approval of a drug at the point of sale. Step Therapy programs help encourage the clinically proven use of first-line therapies and are designed to promote the utilization of the most therapeutically appropriate and cost-effective agents first, before other treatments may be covered.

Drugs with Quantity Limitations

Because of potential safety and utilization concerns, and because some drugs should only be taken for a limited period of time, a small number of drugs have quantity limitations.

Special Designated Pharmacy Program

Our goal is to offer members the most clinically appropriate and cost-effective services through our arrangements with special pharmacies. These special designated pharmacies supply a select number of medications - used in the treatment of complex diseases - and are staffed with nurses to provide support services for members.

Helping Members Navigate Pharmacy Benefits

We understand that dealing with pharmacy coverage can be confusing for your employees. That's why we've made it easy for them to gather information, check benefits, review claims, and even order prescriptions online.

Caremark, Tufts Health Plan's pharmacy benefit manager, provides information about prescription coverage and allows members to view drugs by tier level, therapeutic class, or alphabetical order. Search our drug lists:

For coverage dates starting 01/01/2018, please refer to the following links:

For coverage dates starting 01/01/2019, please refer to the following links:

  • Massachusetts Individual and Small Group 3-tier Drug List: PDF | searchable list
  • Massachusetts Individual and Small Group 4-tier Drug List: PDF | searchable list
  • Rhode Island Individual and Small Group 4-tier Drug List: PDF | searchable list
  • Massachusetts Large Group 3-tier Formulary: PDF
  • Massachusetts Large Group 4-tier Formulary: PDF
  • Rhode Island Large Group 3-tier Formulary: PDF
  • Rhode Island Large Group 4-tier Formulary: PDF

Frequently Asked Pharmacy Questions for Members - We have compiled a list of answers to members' most frequently asked questions about the prescription drug benefit to help clarify costs, copayments, and other issues.

Prescription-by-Mail service - FastStart is a discount program in which members can get a 3-month supply of their ongoing maintenance medications for the cost of two months, delivered to their door.

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