How We Manage Our Prescription Drug Benefit

What drugs require prior authorization or have dispensing limitations?

Learn how we balance quality, safety, and affordability, so you and your doctor can make the best decisions for your care.

Prior Authorization (PA)

In order to ensure safety and affordability for everyone, some medications need prior authorization. This helps us work with your doctor to ensure medications are prescribed appropriately.

  • If it is medically necessary for you to take a drug requiring prior authorization, your doctor will submit a request. View our pharmacy medical necessity guidelines.
  • If the request is approved, we will cover the medication.
  • If the request is not approved, you can opt to pay the full cost of the medication, and you and your doctor can appeal that decision.

Quantity Limitations (QL)

Our quantity limitation program helps monitor safety and keep prescription drugs affordable for you.

  • If it is medically necessary for you to take higher than approved quantities of a specific drug within a given time period, your doctor can request a medical review.
  • If the request is approved, we will cover the medication.
  • If the request is not approved, you can choose to pay the full cost of the additional medication and you and your physician can appeal the decision.

New-to-Market Medications (NTM)

We work with physicians and pharmacists to evaluate new-to-market drugs for safety, cost-effectiveness, and appropriateness. This comprehensive review process, designed for your protection, can delay coverage determinations.

  • If it is medically necessary for you to take a new-to-market drug your doctor can request a medical review.
  • If the request is approved, we will cover the medication.
  • If the request is not approved, you can choose to pay the full cost of the medication and you and your physician can appeal the decision.

Designated Specialty Pharmacies (SP)

Our goal is to offer you the most clinically appropriate and cost-effective services. To do this, we partner with specialty pharmacies that have expertise on particular illnesses.

  • Specialty pharmacies supply specific medications for treatment of complex diseases and are staffed with nurses to provide support services you may need.
  • Up to a 30-day supply of medication for conditions such as infertility, multiple sclerosis, hemophilia, hepatitis C and growth hormone deficiency can be obtained from specialty pharmacies.
  • Depending on your plan, you may need to obtain specific medications from our Specialty Pharmacy network for benefit coverage.
  • For a listing of our specialty pharmacies, or to find out if your plan requires this program, contact us.

Non-Covered (NC)

We cover most FDA approved prescription medications. However, there are a few that we don't cover, typically because more cost-effective alternatives are available.

  • If it is medically necessary for you to be treated with a non-covered drug, your doctor can request a medical review.
  • If the request is approved, you will pay the tier 3 (highest) copayment.
  • If the request is not approved, you and your doctor can appeal that decision.

Step Therapy Prior Authorization (STPA)

Step Therapy Prior Authorization (STPA) is an automated form of prior authorization. It encourages the use of therapies that should be tried first, before other treatments are covered, based on clinical practice guidelines and cost-effectiveness. Medications on Step 1—the lowest step—are usually covered without authorization. Medications on Step 2 or higher are automatically authorized at the point-of-sale if you have taken the required pre­requisite drugs. However, if your provider prescribes a medication on a higher step, and you have not yet taken the required medication(s) on a lower step, or if you are a new Tufts Health Plan member and do not have any prescription drug claims history, we will consider coverage of the medication only if your provider submits a request for coverage to Tufts Health Plan.

Designated Specialty Infusion Program (SI)

The designated Specialty Infusion Program (SI) offers clinical management of drug therapies, nursing support and care coordination to members with acute and chronic conditions. Tufts Health Plan has designated specialty infusion providers for a select number of specialized pharmacy products and drug administration services. Place of service may be in the home or alternate infusion site based on availability of infusion centers and determination of the most clinically appropriate site for treatment. These medications are covered under the medical benefit (not the pharmacy benefit) and generally require support services, medication dose management and special handling in addition to the drug administration services. Medications include, but are not limited to, medications used in treatment in hemophillia pulmonary hypertension, and immune deficiency. Drugs in the Specialty Infusion Program are listed throughout the formulary with (SI), indicating the Specialty Infusion Program. Other specialty infusion providers and medications may be identified and added to this program from time to time.