Pharmacy Programs

Tufts Health Plan offers 3-tier and 4-tier pharmacy program options depending on the size of your employer group.

To help maintain flexibility in the pharmacy benefit, we encourage the use of cost-effective medications and preferred brand names through our 3-tier and 4-tier copayment programs. This allows us to leave prescribing decisions to physicians.

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.

3-Tier Pharmacy Copayment Program

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.

Massachusetts 4-Tier Pharmacy Copayment Program

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:

Rhode Island 4-Tier Pharmacy Copayment Program

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:

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

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.

Benefits of integrating pharmacy and medical benefits with a single carrier

Our agreements with our PBM (CVS Health) include clinical program terms and conditions, with many clinical programs provided at no cost. Plus, we have extensive audit rights to protect our clients. We issue competitive RFPs every three years or more frequently as market conditions change.

The reality is that, with more than one million members, our size gives us the power to negotiate aggressive discounts and maintain a low pharmacy trend. We offer nominal dispensing fees and waive administrative fees—and we’re fully transparent with our pricing and rebates.

We can customize large employers' pharmacy programs to meet specific needs, utilizing: 

  • Flexible networks
  • Multiple formularies
  • Tiered copayment plans
  • Mail-order refills, and
  • Preferred-product strategies

Our Pharmacy & Therapeutics Committee includes local doctors familiar with practice patterns in our market. Carve outs, on the other hand, have to work within generic national guidelines.

Our targeted pharmacy program promotes close monitoring of medication compliance. The program is focused around chronic conditions, using specialty pharmacy care teams to help ensure adherence to complex—and expensive—medication schedules for better outcomes.

We also practice active management of specialty drugs. We take a proactive role to secure price protections, reassess preferred drug strategies, and negotiate rebates for all new drug launches.

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