Pharmacy Benefit

How prescriptions are covered

The HMO plan includes a pharmacy benefit, meaning prescriptions that are listed in the plan’s formulary (list of covered drugs) are covered. There is a copay associated with prescriptions, and is determined by the drug prescribed.

The drugs covered under this plan (and their associated copay) are organized into up to four levels, or tiers.

  • Tier 1: Includes most generic drugs, and is the lowest copay.
  • Tier 2: Includes many generic and brand-name drugs, and is the next-highest copay.
  • Tier 3: Includes the most expensive generic and brand-name drugs, and is the secondhighest copay.
  • Tier 4: Includes specialty drugs and those with an exceptionally high cost, and is the highest copay.

You can have your prescription filled at any pharmacy that’s part of the CVS Caremark network. The vast majority of pharmacies in the U.S. are part of the CVS Caremark network, including most national retail chains and independent pharmacies. If you have a medication that needs to be refilled continually (eg. diabetes medication, asthma inhalers), you can fill your prescriptions by mail through the CVS Caremark mail service pharmacy, often at a cost savings.

Is your prescription covered?

Every plan is different. The fastest way to find out if your prescription is covered is to see your plan’s specific benefits at mytuftshealthplan.com.

Filling Your Prescriptions

Prescription drugs and their associated co-pay are broken down into tiers. You can easily check to see which tier your drug is on by visiting the members' pharmacy section. If you don’t see your drug listed, call our Member Services Department at the number printed on your ID card.

Tier Level Tier Copay Tier Description
Tier 1 Lowest Cost Includes most generic prescription drugs on our list of covered drugs.
Tier 2 Next Highest Cost Includes many generic and brand-name prescription drugs on our list of covered drugs.
Tier 3 Second Highest Cost Includes the most expensive prescription drugs on our list of covered drugs.
Tier 4 Highest Cost Includes specialty drugs and those with an exceptionally high cost.

Once you find your drug on the list, check to see if one of the following codes is listed after it. If not, you can proceed with getting your prescription filled.

  • PA: Prior Authorization
  • STPA: Step Therapy Prior Authorization
  • NTM: New-To-Market Drug Evaluation
  • QL: Quantity Limitation
  • SP: Designated Specialty Pharmacy
  • NC: Non-Covered

PA: Prior Authorization

Some drugs must meet certain criteria before they’re covered. If your provider believes a drug with a prior authorization is necessary for your treatment, the provider should submit a request for coverage by faxing a Universal Pharmacy Medical Review Request Form to Tufts Health Plan. If the drug meets our pharmacy medical necessity coverage guidelines, your request will be approved, and we will cover the drug. If for some reason it is not approved, you always have the option of appealing the decision.

STPA: Step Therapy Prior Authorization

You may be required to try a certain drug to treat a specific medical condition before Tufts Health Plan will approve the coverage of another drug to treat the same condition. If you have not previously taken the steps required by our pharmacy coverage guidelines, and your provider believes the drug prescribed for you is medically necessary, he or she may submit a request for coverage by faxing a Universal Pharmacy Medical Review Request Form. If you are a new member, please call us at the number on the back of your ID card, and let us know if you are currently taking a step therapy drug from another plan.

NTM: New-To-Market Drug Evaluation

In an effort to ensure the new-to-market prescriptions we cover are safe, effective and affordable, we delay coverage of many new drug products until our Pharmacy and Therapeutics (P&T) Committee and physician specialist review them. These drugs require prior authorization until the review is complete and a coverage decision has been made.

QL: Quantity Limitation

There may be a limit on how much of a drug you can get for a specific time period. You’re covered for up to the quantity posted in our list of covered drugs. If your provider believes it’s necessary for you to take more than the quantity limit posted on the list, he or she may submit a Universal Pharmacy Medical Review Request Form to request coverage.

SP: Designated Specialty Pharmacy

We’ve designated special pharmacies to supply a select number of medications used in the treatment of complex disease states. These pharmacies specialize in providing these medications and are staffed with nurses, coordinators and pharmacists to provide support services for members. Call the designated specialty pharmacy provider indicated in your search results of covered drugs, or contact the Tufts Health Plan Member Services Department at the number on your ID card. We want to make sure you receive your drug without interruption.

NC: Non-Covered

There are thousands of drugs listed on the Tufts Health Plan covered drug list. In fact, most drugs are covered. There is, however, a list of drugs that Tufts Health Plan currently does not cover. In many cases, these drugs are not covered by Tufts Health Plan because there are safe, comparably effective, and cost-effective alternatives available. Our goal is to keep pharmacy benefits as affordable as possible.

If your provider believes a non-covered drug is necessary for your treatment, he or she may submit a request for coverage by faxing a Universal Pharmacy Medical Review Request Form. If the drug meets our pharmacy medical necessity coverage guidelines, your request will be approved, and we will cover the drug. If it is not approved, you always have the option of appealing the decision.

Tips to save money on prescriptions.

There are ways to save a little money without compromising your treatment’s effectiveness.

  • Get a prescription for a generic drug when possible
  • Use CVS Caremark Mail Service Pharmacy for maintenance medications (those you use regularly)
  • Talk to your doctor about less expensive alternatives to your medications
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