How we manage our prescription drug benefit

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 in particular diseases.

• Specialty pharmacies supply specific medications for the treatment of complex diseases and are staffed with nurses to provide support services you may need.
• You may receive 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.
• Refer to your plan’s prescription drug formulary for information regarding whether or not your specific specialty medication must be obtained from a specialty pharmacy.
• For questions related to coverage or our pharmacy network, contact Member Services.

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.