Pharmacy Overview

Commercial

Tufts Health Plan requires prior authorization for coverage of certain services including drugs, devices and equipment. Our Pharmacy Medical Necessity Guidelines for these services are used in conjunction with a member's plan document and in coordination with the member's physician(s). Visit the Resource Center to find a complete list of pharmacy medical necessity guidelines.

Note: Refer to the Commercial Pharmacy Medication Prior Authorization Submission Guide for information on which prior authorization form to use based on state and product.

Members can check drug coverage, refill prescriptions and more at CVS Caremark. You can acccess the 'drug interaction checker' in the Pharmacy section to check interactions. In addition to our website, you can interact with a pharmacy electronically through e-prescribing.

Formularies

For coverage dates starting 01/01/2019, please refer to the following links:

Pharmacy Programs

Select one of the programs below to learn what we're doing to provide our members with a pharmacy benefit that emphasizes quality, safety and affordability:

3-Tier Pharmacy Copayment Program

Tufts Health Plan has adopted a three-tiered approach to the cost of prescription drugs in order to provide members with choice and affordable options when it comes to prescription drugs.

All covered drugs are divided into three tiers. You have the option to write a prescription for a Tier-1, Tier-2 or Tier-3 drug (as defined below). We realize there may be instances when only a Tier-3 drug is appropriate, which will require a higher copayment from the member.

  • Tier-1: Medications on this tier have the lowest copayment. This tier includes many generic drugs.
  • Tier-2: Medications on this tier are subject to the middle copayment. This tier includes some generics and brand-name drugs.
  • Tier-3: This is the highest copayment tier and includes some generics and brand-name covered drugs not selected for Tier 2. (Please note that tiers are subject to change throughout the year.)

Complete covered drug lists of medications included in the 3-Tier Pharmacy Copayment Program are available on the Tufts Health Plan website.

4-Tier Pharmacy Copayment Program – Massachusetts

If the member’s plan includes a 4-Tier Copayment design, all covered drugs are divided into four tiers. You have the option to write a prescription for a Tier-1, Tier-2, Tier-3, or Tier-4 drug (as defined below). We realize there may be instances when only a Tier-4 drug is appropriate, which will require a higher copayment from the member.

The 4-Tier Copayment Program features a specialty tier for drugs included in and obtained through the designated specialty pharmacy (SP) program. Drugs that are part of the SP program include but are not limited to medications used in the treatment of rare diseases, infertility, hepatitis C, growth hormone deficiency, multiple sclerosis, rheumatoid arthritis, and cancers treated with oral medications.

The 4-Tier Copayment Program places all covered prescriptions into one of the following tiers:

  • Tier-1: Most covered generic drugs (lowest copayment)
  • Tier 2: Brand and high-cost generic drugs that are more cost-effective than comparable drugs listed in tier-3 (lower copayment or coinsurance amount)
  • Tier-3: Higher cost brand and generic drugs (higher copayment or coinsurance amount)
  • Tier-4: Specialty drugs included in the SP program (highest copayment or coinsurance amount)

Complete lists of covered drugs, including specialty drugs included in the SP program and subject to the specialty tier, are available on the Tufts Health Plan website.

4-Tier Pharmacy Copayment Program – Rhode Island

If the member’s plan includes a 4-Tier Copayment design, all covered drugs are divided into four tiers. You have the option to write a prescription for a Tier-1, Tier-2, Tier-3, or Tier-4 drug (as defined below). We realize there may be instances when only a Tier-4 drug is appropriate, which will require a higher copayment from the member.

The 4-Tier Copayment Program features a specialty tier for high-cost specialty, self-injectable and biotech drugs. Drugs subject to the specialty tier include but are not limited to medications used in the treatment of rare diseases, hepatitis C, growth hormone deficiency, multiple sclerosis, rheumatoid arthritis, and cancers treated with oral medications.

The 4-Tier Copayment Program places all covered prescriptions into one of the following tiers:

  • Tier-1: Most covered generic drugs (lowest copayment)
  • Tier-2: Brand and high-cost generic drugs that are more cost-effective than comparable drugs listed in tier-3 (lower copayment or coinsurance amount)
  • Tier-3: Higher-cost brand and generic drugs (higher copayment or coinsurance amount)
  • Tier-4: Specialty drugs (highest copayment or coinsurance amount)

Complete lists of covered drugs, including specialty drugs included in the SP program and subject to the specialty tier, are available on the Tufts Health Plan website.

Note: Infertility drugs are not included in our 4-Tier copayment program for Rhode Island members. Members who receive prior authorization for coverage of infertility drugs will pay a 20% coinsurance for each drug they utilize.

Noncovered Drugs (NC)

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 doctor feels that one of the non-covered drugs is needed, your doctor can submit a request for coverage to Tufts Health Plan under the Medical Review Process.

Note: Drugs approved through the Medical Review Process may be subject to the highest copayment.

New-to-Market Evaluation, Prior Authrorization and Quantity Limitations

New-to-Market Evaluation

Tufts Health Plan requires that all drugs meet a series of high standards before we include them in our formulary. We understand it may be frustrating to discover a new drug isn't yet covered by Tufts Health Plan, but we want you to know that it may be for a good reason.

Prior Authorization

In order to ensure safety and cost controls on pharmacy benefits, Tufts Health Plan requires prior authorization for certain drugs, particularly those that are new to market.

Even after going through the Tufts Health Plan new-to-market evaluation process, we evaluate the medications in order to measure over time, the uses and effects.

You must submit a request to Tufts Health Plan for prescriptions for drugs on the prior authorization requirement list before we will approve that drug for a member.

Quantity Limitations

As with all our Pharmacy programs, Tufts Health Plan developed the Quantity Limitation program (formerly the Dispensing Limitation program) in an effort to monitor safety and help control the cost of prescription drugs for our members. Our Quantity Limitations Program limits the quantity of a drug a member can receive in a given time period.

Designated Specialty Pharmacy Program

Tufts Health Plan continuously works to offer its members the most clinically appropriate and cost-effective services.

As a result, the Plan has designated specialty pharmacies to supply a select number of medications used in the treatment of complex diseases. These pharmacies are specialized in providing these medications and are staffed with nurses, coordinators and pharmacists to provide support services for members. Medications include, but are not limited to, those used in the treatment of infertility, multiple sclerosis, hemophilia, hepatitis C and growth hormone deficiency. Other designated specialty pharmacies and medications may be identified and added to this program from time to time.

If you have questions about Designated Providers, please contact us.

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.