A formulary is a list of prescription medications developed by a committee of practicing physicians and practicing pharmacists who represent a variety of specialty areas and who are knowledgeable in the diagnosis and treatment of disease.
Brand-name drugs are typically the first products to gain U.S. Food and Drug Administration (FDA) approval.
Generic drugs have the same active ingredients and come in the same strengths
and dosage forms as the equivalent brand-name drug. Multiple manufacturers may
produce the same generic drug and the product may differ from its brand name
counterpart in color, size or shape, but the differences do not alter the effectiveness.
Generic versions of brand-name drugs are reviewed and approved by the FDA.
The FDA works closely with all pharmaceutical companies to make sure that all
drugs sold in the U.S. meet appropriate standards for strength, quality, and purity.
3-Tier Pharmacy Copayment Program (3-Tier Program)
To help maintain affordability in the pharmacy benefit, we encourage the use of cost-effective drugs and preferred brand names through the three-tier program. This program gives you and your doctor the opportunity to work together to find a prescription medication that's affordable and appropriate for you.
All covered drugs are placed into one of three tiers. Your physician may have the option to write you a prescription for a Tier 1, Tier 2, or Tier 3 drug (as defined below); however, there may be instances when only a Tier 3 drug is appropriate, which will require a higher copayment.
- 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 tier placement is subject to change throughout the year.
A copayment is the fee a member pays for certain covered drugs. A member pays the copayment directly to the provider when he/she receives a covered drug, unless the provider arranges otherwise.
Coinsurance requires the member to pay a percentage of the total cost for certain covered drugs.
Medical Review Process
Tufts Health Plan has pharmacy programs in place to help manage the
pharmacy benefit. Requests for medically necessary review for coverage
of drugs included in the New-to-Market Drug Evaluation Process (NTM),
Prior Authorization Program (PA), Step Therapy Prior Authorization Program (STPA),
Quantity Limitations Program (QL), Non-Covered Drugs (NC) With Suggested Alternatives Program
should be completed by the physician and sent to Tufts Health Plan. Drugs excluded under your
pharmacy benefit will not be covered through this process. The request must include clinical
information that supports why the drug is medically necessary for you. Tufts Health
Plan will approve the request if it meets coverage guidelines. If Tufts Health Plan
does not approve the request, you have the right to appeal. The appeal process is described
in your benefit document.
Note: Drugs approved through the Medical Review Process will be subject to a Tier 3 copayment.
Quantity Limitation (QL) Program
Because of potential safety and utilization concerns, Tufts Health Plan has placed quantity limitations on some prescription drugs. You are covered for up to the amount posted in our list of covered drugs. These quantities are based on recognized standards of care as well as from FDA-approved dosing guidelines. If your provider believes it is necessary for you to take more than the QL amount posted on the list, he or she may submit a request for coverage under the Medical Review Process.
New-to-Market Drug Evaluation Process (NTM)
In an effort to make sure the new-to-market prescription drugs we cover are safe, effective and affordable, we delay coverage of many new drug products until the Plan's Pharmacy and Therapeutics Committee and physician specialists have reviewed them. This review process is usually completed within six months after a drug becomes available.
The review process enables us to learn a great deal about these new drugs, including how a physician can safely prescribe these new drugs and how physicians can choose the most appropriate patients for the new therapy. During the review process, if your physician believes you have a medical need for the New-to-Market drug, your doctor can submit a request for coverage to Tufts Health Plan under the Medical Review Process.
If your plan includes the 3-Tier Copayment Program, then you will pay the Tier-3 (highest) copayment if the medication is approved for coverage.
Non-Covered Drugs (NC) - Prior Authorization required
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.
Prior Authorization (PA) Program
In order to ensure safety and affordability for everyone, some medications require prior authorization. This helps us work with your doctor to ensure that medications are prescribed appropriately.
If your doctor feels it is medically necessary for you to take one of the drugs listed below, he/she can submit a request for coverage to Tufts Health Plan under the Medical Review Process.
Step Therapy Prior Authorization (STPA)
Step Therapy 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. Some types of Step Therapy include requiring the use of generics before brand name drugs, preferred before non-preferred brand name drugs, and first-line before second-line therapies.
Medications included on step 1- the lowest step-are usually covered without authorization. We have noted the few exceptions, which may require your physician to submit a request to Tufts Health Plan for coverage. 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 physician 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, the prescription will deny at the point-of-sale with a message indicating that a Prior Authorization (PA) is required. Physicians may submit requests for coverage to Tufts Health Plan for members who do not meet the Step Therapy criteria at the point of sale under the Medical Review process.
Designated Specialty Pharmacy Program (SP)
Our goal is to offer you the most clinically appropriate and cost-effective services. To do this, we partner with specialty pharmacies that have expertise on particular illnesses.
- Specialty Pharmacies supply up to a 30-day supply of specific medications for treatment of complex diseases and are staffed with nurses to provide support services you may need.
- Depending on your plan, you may need to obtain specific medications from our Specialty Pharmacy network for benefit coverage.
- For a listing of our specialty pharmacies, or to find out if your plan requires this program, contact us.
Designated Specialty Infusion Program for Drugs Covered Under the Medical Benefit (SI)
Tufts Health Plan has designated home infusion providers for a select number of specialized pharmacy products and drug administration services.
The designated specialty infusion provider offers clinical management of drug therapies, nursing support, and care coordination to members with acute and chronic conditions. 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 the treatment of hemophilia, pulmonary arterial hypertension, and immune deficiency. Other specialty infusion providers and medications may be identified and added to this program from time to time.
Managed Mail (MM) Program
Our Managed Mail (MM) Program applies to certain plans. It requires that in order to be covered, prescriptions for most maintenance medications must be filled by our mail order pharmacy. Maintenance medications are those you refill monthly for chronic conditions like asthma, high blood pressure, or diabetes. Under this program, you are allowed an initial fill at a retail pharmacy and a limited number of refills. After that, in order to be covered, you must fill your maintenance prescription through the mail order program offered by CVS Caremark, our pharmacy benefits manager. You may obtain up to a 90-day supply for these maintenance medications at mail order. Please note that some medications may not be appropriate for mail order. These include medications with quantity limitations (QL) of less than 84 or 90 days.
If you have questions about this program, please contact us at the number listed on the back of your member identification card.
Over-The-Counter Drugs (OTC)
When a medication with the same active ingredient or a modified version of an active ingredient that is therapeutically equivalent, becomes available over-the-counter, Tufts Health Plan may exclude coverage of the specific medication or all of the prescription drugs in the class. For more information, please call our Member Services Department at the number listed on the back of your member identification card.