Pharmacy Utilization Management

Prior Authorization

In order to ensure safety and manage cost, Tufts Health Plan requires prior authorization for certain drugs. The 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).

Refer to the Resource Center to find a complete list of pharmacy medical necessity guidelines.

Step Therapy Prior Authorization

Step Therapy Prior Authorization 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.

Noncovered Drugs

There are thousands of drugs listed on Tufts Health Plan's formularies. 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. Tufts Health Plan's goal is to keep pharmacy benefits as affordable as possible.

Providers can submit a request for coverage to Tufts Health Plan under the Medical Review Process if a non-covered drugs is needed.

Note: Drugs approved through this Medical Review Process may be subject to the Tier-3 copayment.

New-to-Market Evaluation

Tufts Health Plan requires that all drugs meet a series of high standards before they are included 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.

Providers have the option to submit a coverage request for the new-to-market drugs while the drugs are under Tufts Health Plan new-to-market evaluation process. Drugs approved through this Medical Review Process may be subject to the Tier-3 copayment.

Quantity Limitations

As with all the pharmacy programs, Tufts Health Plan developed the Quantity Limitations Program in an effort to monitor safety and help control the cost of prescription drugs for members. The Quantity Limitations Program limits the quantity of select drugs that a member can receive in a given time period.