Using your pharmacy benefit

Follow these three, easy steps every time you receive a prescription for a new medication.

Step 1: Confirm your medication is on our list of covered drugs

A list of covered drugs is called a formulary. Use the appropriate formulary to search for the name of your medication. If your medication is not listed, call our Member Services Department.

View pharmacy formularies

Step 2: Check whether any of the following terms apply to your medication

• Prior authorization (PA)
• Step therapy (STPA)
• Quantity limitation (QL)
• Designated specialty pharmacy (SP)
• Non-covered (NC)

To learn more about these terms, see how we manage our prescription drug benefit.

If one or more of the terms apply, take the following steps: 

• Prior authorization (PA): Contact the provider who has written your prescription. If your provider believes a drug with a PA is necessary for your treatment, he or she may submit a request for coverage by faxing the appropriate form to Tufts Health Plan. We will cover the medication if it meets our medical necessity coverage guidelines. If the request is approved, you will be covered for your prescription. If it is not approved, you can appeal the decision.
• Step therapy prior authorization (STPA): Check our step therapy drug list to confirm the step your drug is on. 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 request coverage.
• Quantity limitation (QL): You are covered for up to the quantity posted in our list of covered drugs. If your provider believes it is necessary for you to take more than the QL quantity posted on the list, he or she may submit a request for coverage.
• Non-covered (NC): Contact the provider who has written your prescription. If your provider believes a drug with an NC is necessary for your treatment, he or she she may submit a request for coverage  to Tufts Health Plan. We will cover the medication if it meets our medical necessity coverage guidelines. If the request is approved, you will be covered for your prescription. If it is not approved, you can appeal the decision.
• Designated specialty pharmacy (SP): Call the designated specialty pharmacy provider indicated in your online search in Step 1 or contact our Member Services Department to help ensure you receive your medication without interruption.

Select Network Plan Members
If your drug is not included in the list of covered drugs (NC): Contact the provider who has written your prescription. If your provider believes a drug that is not covered is necessary for your treatment, he or she may submit a request for coverage.

Step 3: Check the relative cost of your covered medication

Covered drugs are grouped in four tiers, or levels, of cost:

• Tier 1: You pay the lowest copayment or coinsurance. This tier includes many generic drugs.
• Tier 2: You pay a lower copayment or coinsurance. This tier includes some generics and brand-name drugs.
• Tier 3: You pay a higher copayment or coinsurance. This tier includes some generics and brand-name covered drugs not selected for Tier 2.
• Tier 4: You pay the highest copayment or coinsurance. This tier includes brand-name covered specialty drugs¹.

Check the specifics of your pharmacy coverage to see if a deductible applies.

How we manage our prescription drug benefit

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

What do PA, STPA, QL, SP, and NC stand for? What do they mean?

Learn how

1. For Massachusetts plans, tier 4 includes brand-name covered specialty drugs included in the Specialty Pharmacy program.