Utilization Management

Prior Authorization Requirements

In order to ensure safety and manage cost, Tufts Health Plan requires prior authorization for certain drugs. For detailed information, refer to the Pharmacy Medical Necessity Guidelines and Medical Drug Medical Necessity Guidelines in the Resource Center for the Tufts Health Plan commercial, Tufts Health Direct, Tufts Health RITogether, and Tufts Health Together products

For other products, please reference the prior authorization guidelines below:

• Tufts Medicare Preferred
• Tufts Health Plan Senior Care Options
• Tufts Health Unify

Step Therapy

Step Therapy requires the use of certain preferred drugs to treat a medical condition before Tufts Health Plan will cover non-preferred drugs for that condition. 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 the member has taken the required pre­requisite drugs. However, if you prescribe a medication on a higher step, and the member has not yet taken the required medication(s) on a lower step, or if the member is a new Tufts Health Plan member and does not have any prescription drug claims history, a request for coverage must be submitted to Tufts Health Plan.

View our Formularies to see which drugs are included in our step therapy program.

You can also reference the step therapy guidelines for the below products:

• Tufts Medicare Preferred
• Tufts Health Plan Senior Care Options
• Tufts Health Unify

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.

Drug Prior Authorization and Exception Requests

You may request prior authorization or exceptions for a pharmacy and medical drug in one of the following ways:

1. PromptPA — With this online tool you can quickly and easily submit requests for pharmacy benefit drugs. View drug-specific criteria, attach clinical information, check the status of your PromptPA request, and receive a response more quickly. Submit your request or view the PromptPA User Guide for more information.
2. Electronic PA (ePA) — Utilize ePA through EMR, CoverMyMeds (for both pharmacy and medical benefit drugs), or Surescripts (for pharmacy drugs only).
3. FAX — Submit your request using the corresponding form below and fax to the number indicated on the form. You can access a full list of available forms in the Resource Center.
4. Mail prior authorization form to:
   • Tufts Health Plan
   • Pharmacy Utilization Management Department
   • 1 Wellness Way
   • Canton, MA 02021-1166

Commercial (including Tufts Health Direct)

• Massachusetts Standard Form for Medication Prior Authorization Requests
• Massachusetts Standard Form for Hepatitis C Prior Authorization Requests
• Massachusetts Standard Form for Synagis^® Prior Authorization Requests
• Massachusetts Standard Form for Chemotherapy and Supportive Care Prior Authorization Requests
• Tufts Health Plan Medication Prior Authorization Request Form (Non-Massachusetts Providers)

Tufts Medicare Preferred, Tufts Health Plan Senior Care Options, Tufts Health Unify

• Hepatitis C Medication Request Form
• Request for Medicare Prescription Drug Coverage Determination (Tufts Medicare Preferred)
• Request for Medicare Prescription Drug Coverage Determination (Senior Care Options)
• Request for Medicare Prescription Drug Coverage Determination (Tufts Health Unify)
• Coverage Determination and Prior Authorization Request for Medicare Part B vs Part D

Tufts Health RITogether

• Tufts Health Plan Medication Prior Authorization Request Form
• Massachusetts Standard Form for Synagis^® Prior Authorization Requests

Tufts Health Together

Tufts Health Together utilizes MassHealth’s Unified Formulary for pharmacy medications and select medical benefit drugs; for drug coverage and criteria refer to the MassHealth Drug List.

• Massachusetts Standard Form for Synagis^® Prior Authorization Requests