Pharmacy programs

All you need to know about our pharmacy programs

Tiered pharmacy programs

Check with your employer to determine which pharmacy program your plan uses.

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The Premium formulary is strategically designed to cover a wide variety of categories and classes of drugs. Exclusions may include cosmetic and high-dollar/low-value drugs and products.

The plan offers a 3-Tier and a 4-Tier Premium formulary.

3-tier program

Covered medications are categorized into one of three tiers. Copayments are determined by the tier in which the drug is assigned, for up to a 30-day supply per prescription or refill. We encourage patients and physicians to discuss pharmaceutical treatment options that are therapeutically appropriate and most cost effective.

  • Tier 1 is primarily made up of generic drugs and select brand-name drugs that the plan has determined to be more effective, less costly or to have fewer side effects than similar medications. Members pay the lowest copayment or coinsurance amount for Tier 1.
  • Tier 2 is primarily made up of brand-name drugs and higher cost generic drugs.
  • Tier 3 is made up of drugs that the plan has not included in Tier 1 or Tier 2. Members pay the highest copayment or coinsurance amount for Tier 3 drugs.

4-tier program

Covered medications are categorized into one of four tiers. Copayments are determined by the tier in which the drug is assigned, for up to a 30-day supply per prescription or refill. We encourage patients and physicians to discuss pharmaceutical treatment options that are therapeutically appropriate and most cost effective.

  • Tier 1 is made up of lower cost generic drugs. Members pay the lowest copayment or coinsurance amount for Tier 1 drugs.
  • Tier 2 is primarily made up of generic drugs and select brand-name drugs.
  • Tier 3 is primarily made up of brand-name drugs and higher cost generic drugs.
  • Tier 4 is made up of drugs that we have not included in Tiers 1- 3. Members pay the highest copayment or coinsurance for Tier 4 drugs.

We offer a 3-tier and 4-tier Value formulary. The Value formulary covers a variety of classes of medications. Exclusions may include cosmetic and high-dollar/low-value drugs and products.

3-tier program

Covered medications are categorized into one of three tiers. Copayments are determined by the tier in which the drug is assigned, for up to a 30-day supply per prescription or refill. We encourage patients and physicians to discuss pharmaceutical treatment options that are therapeutically appropriate and most cost effective.

  • Tier 1 is primarily made up of generic drugs.
  • Tier 2 is primarily made up of preferred brand name drugs and some generic drugs.
  • Tier 3 is primarily made up of preferred specialty drugs and non-preferred brand name and specialty drugs. Tier 3 may also include some higher cost generic drugs.

4-tier program

Covered medications are categorized into one of four tiers. Copayments are determined by the tier in which the drug is assigned, for up to a 30-day supply per prescription or refill. We encourage patients and physicians to discuss pharmaceutical treatment options that are therapeutically appropriate and most cost effective.

  • Tier 1 is primarily made up of generic drugs.
  • Tier 2 is primarily made up of preferred brand name drugs and some generic drugs.
  • Tier 3 is primarily made up of preferred specialty drugs, non-preferred brand name drugs, and higher cost generics.
  • Tier 4 is primarily made up of non-preferred specialty drugs. Tier 4 may also include selected brand and generic drugs.

Tufts Health Plan works with Optum Rx for pharmacy benefit management services. Choose your drug program to find an Optum Rx network pharmacy near you, see what drugs your plan covers, and if you have a deductible for prescriptions, use the Drug Pricing Tool to learn how much your drugs may cost before you reach the annual deductible.

2024 drug programs

Mail-order pharmacy program

Here’s how to get started with the Optum Rx mail-order pharmacy service:

  • Be sure you have any necessary approvals in place.
  • Call Optum Rx Customer Service toll free at 855-258-1561. If your medication does not need an approval, a representative will help you get started with the mail-order service. You will need the following when you make the call:
    • Your Tufts Health Plan ID card
    • Medication name
    • Your physician’s name and phone number
    • Shipping address
    • Credit card information and expiration date

Once you begin receiving medications by mail, you can order refills easily online or by phone.