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.