Pharmacy FAQs

Frequently Asked Questions About Our Pharmacy Program

General Information
Cost

General Information
Where do you go if you have questions about your pharmacy coverage? Right here. We've taken some of the most frequently asked questions and answered them here so you can better understand your coverage.

What is the difference between a generic drug and a brand-name drug?
Brand-name drugs are typically the first product to gain FDA approval. Generic versions of these drugs have the same active ingredients, come in the same strength and dosage, and are also reviewed and approved by the FDA.

You can expect a generic drug to produce the same effects as the brand-name drug. The FDA works closely with all pharmaceutical companies to make sure that all brands and generics sold in the U.S. meet appropriate standards for strength, quality, and purity.

Are there any drugs that are not covered by my pharmacy benefit?
Yes. Tufts Health Plan covers thousands of drugs, but in some cases when safe, comparatively effective alternatives or generic versions of the brand-name product become available, we'll cover that instead. The Tufts Health Plan Pharmacy and Therapeutics Committee and Physicians Special Advisory Committees review new drugs for safety, cost-effectiveness, and appropriateness to determine which drugs will be added to the list of non-covered drugs. Of course, if your doctor believes that you have a medical reason for treatment with a non-covered drug, your doctor may submit a request for coverage.

How does Tufts Health Plan determine which new drugs are covered?
At Tufts Health Plan, we work with community physicians and pharmacists to review new drugs for safety, cost-effectiveness, and appropriateness. Because of the faster approval process for new drugs, we delay coverage determinations on those new drugs until we evaluate the new drugs for safety of effectiveness.

I have a prescription for a drug that requires prior-authorization. Why do I need prior authorization?
Some medications need prior authorization to help us work with your doctor to ensure that medications are prescribed appropriately. It also helps us manage the rising cost of prescriptions to keep the benefit more affordable for you.

If your doctor feels it is medically necessary for you to take the drug, he/she just submits the request to Tufts Health Plan. If it's approved, Tufts Health Plan will cover the medication. If the request is denied, you can still opt to pay the full cost of the medication, and you and your physician will have the right to appeal the decision.

I have a prescription for a drug with a quantity limitation. What are quantity limitations?
To help ensure safe and cost-effective use of a small number of prescription drugs, we limit the amount of medication you can receive in a given time period. But, your doctor may request a review for coverage for additional quantities. If the request is approved, the additional amounts will be covered. If it's denied, you can choose to pay the full cost of the additional medication and you and your physician will have the right to appeal the decision.

Where can I go to fill my prescriptions?
If you have the Tufts Health Plan prescription drug benefit, just present your prescription and Tufts Health Plan ID card at any of our designated pharmacies. Most of the pharmacies in Massachusetts are included and additional pharmacies nationwide. In emergencies, you'll be reimbursed for prescriptions filled at non-participating pharmacies. Your prescription drug benefit is honored only at Tufts Health Plan designated pharmacies. For reimbursement details, please contact a Tufts Health Plan member services coordinator.

In addition, Tufts Health Plan has designated certain pharmacies to supply a select number of medications used in the treatment of complex diseases. These pharmacies specialize in providing these medications and are staffed with nurses, coordinators and pharmacists to provide support for members.

If you take a maintenance medication, you can save money and enjoy the convenience of having your prescription sent through the mail. (A maintenance medication is a drug used to treat chronic conditions, such as diabetes, high blood pressure and asthma.)

Cost
No matter what plan they're on, people always have questions concerning the cost of their prescription. Below you'll find several questions and answers concerning the cost of your pharmacy coverage.

I'm on a brand-name drug with the highest copayment. How can I find out if there's an appropriate alternative at a lower copayment?
Talk with your physician. It may be that staying on the brand-name drug is most appropriate for your condition, or that no generic alternative is available. If there is a generic drug or a preferred brand-name drug with a lower copayment that's appropriate for your treatment, your physician can prescribe it for you.

For some prescriptions, I actually pay less than the standard copayment. Why?
If the cost of your prescription is less than your standard copayment because of the tier placement of the drug, you'll always pay the lesser amount.

Is there a way for me to save money on my copayment(s) for the drug(s) I use consistently every month?
Yes. Members with the Tufts Health Plan pharmacy benefit can use the mail service, Caremark, to save money on maintenance medications, which are used to treat chronic conditions such as diabetes and high blood pressure. Members can get three-month supply of maintenance medications delivered confidentially and conveniently through the mail, for the cost of a two-month copayment.

Refills are easy. Order them 24 hours a day online, by phone, or by mail. Learn more about FastStart, or call a member services coordinator. Mail order is not recommended for medications used to treat short-term medical conditions, medications with quantity limitations or mediations that are part of our Special Designated Pharmacy Program.

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