Tufts Health Direct

Formulary

The formulary is a tool to promote appropriate and cost-effective prescription drugs for Tufts Health Direct members. Providers should refer to the formulary to confirm the drugs being prescribed are covered by Tufts Health Plan. The Pharmacy and Therapeutics Committee reviews and revises the formulary on a monthly basis to reflect the committee’s prevailing clinical opinion. Each quarter, formulary updates are included in Provider Update. To register to receive Provider Update by email, complete the online registration form.

Pharmacy Updates
Visit the Pharmacy Updates page to find monthly pharmacy updates for Tufts Health Public Plans members.
Medication Request Forms
Some drugs require prior authorization. Refer to the Tufts Health Direct formulary and the Tufts Health Plan's pharmacy medical necessity guidelines before submitting a request for prior authorization.

For Tufts Health Direct members, requests are reviewed and initial determinations regarding prior authorizations are made within two business days of receiving complete medical information. Once a decision is made, Tufts Health Plan will notify providers by telephone or fax within one business day.

For medication coverage under the pharmacy benefit, refer to the standard Medication Prior Authorization Request Form.

Pharmacy benefit applies to drugs that are self-administered (i.e., subcutaneous or taken orally) and are filled at retail pharmacies.

Providers can submit the completed form for pharmacy benefit via:

  • Fax: 617.673.0988
  • Mail: Tufts Health Plan 705 Mount Auburn Street Watertown, MA 02472 Attn: Pharmacy Utilization Management Department

For medication coverage under the medical benefit, refer to the standard Medication Prior Authorization Request Form.

Medical benefit applies to drugs that require skilled administration (i.e., intravenous, infusion) by a medical provider.

Providers can submit the completed form for medical benefit via:

  • Fax: 888.415.9055
  • Mail: Tufts Health Plan 705 Mount Auburn Street Watertown, MA 02472 Attn: Precertification
Formulary Tier Structure

Tufts Health Direct: 3-Tier Pharmacy Copayment Program

All covered drugs are divided into three tiers. Providers have the option to write a prescription for a Tier-1, Tier-2 or Tier-3 drug (as defined below). Tufts Health Plan realizes 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 cost sharing amount
  • Tier 2: Medications on this tier have a higher cost sharing amount
  • Tier 3: Medications on this tier have the highest cost sharing amount

Note: Tiers are subject to change throughout the year.