employers

Pharmacy

At Tufts Health Plan, our goal is to help keep our members healthy, while doing all that we can to keep health care affordable for employer groups.

A number of factors contribute to increasing pharmacy costs, including:

  • New-to-market drugs, which cost more than those that have been available longer
  • State-of-the-art technology used to develop drugs
  • Pharmaceutical companies employing direct-to-consumer marketing/advertising
  • Aging population means more people are taking more prescriptions
  • Rising cost of generics

Containing Costs While Maintaining Quality—Our Pharmacy Management Programs
We continue to develop pharmacy management programs to help manage the rising cost of drugs, while working for the needs of the member. Our Pharmacy and Therapeutics (P&T) Committee includes doctors and pharmacists from the community, along with members of Tufts Health Plan's clinical staff, who meet regularly to review drug data and studies in order to make clinical recommendations.

Three-Tier Pharmacy Copayment Program
To help maintain flexibility in the pharmacy benefit, we encourage the use of cost-effective medications and preferred brand names through the three-tier copayment program. This allows us to leave prescribing decisions to physicians.

Tier-1: lowest copayment; includes most generic drugs - typically $5 to $10
Tier-2: middle level copayment; primarily includes selected cost-effective brand name drugs - typically $10 to $30
Tier-3: highest copayment; includes non-preferred formulary drugs, formulary drugs not selected for Tier-2, and all covered non-formulary drugs - typically $25 to $45

There may be instances when only a Tier-3 drug is appropriate, however, a vast majority of the higher-priced Tier-3 drugs have lower cost alternatives on Tier-1 or Tier-2.

If a physician prescribes a Tier-3 or Tier-2 drug, the member can work with him or her to determine if there is an appropriate drug available that will be less costly. Please note that tier placement is subject to change throughout the year.

Depending on the plan chosen, coverage for prescription drugs may be subject to an annual deductible amount or be limited to our generic formulary.

Pharmacy Management Programs Include:
New-to-Market Drug Evaluation Process
New drugs are constantly being introduced to the market, and according to a study by the FDA, many of these medications are modified versions of existing drugs that offer little to no clinical advantages over older counterparts already available. Our P&T Committee reviews all new drugs and evaluates them for inclusion under our pharmacy benefit.

List of Non-Covered Drugs
A small number of drugs (less than 1%) are not covered by Tufts Health Plan because we have determined that there are safe, effective, and more affordable alternatives available. If a prescribing physician feels a particular non-covered drug is needed for one of our members, the physician may submit a request for coverage under our medical review process.

Drugs Requiring Prior Authorization
To support safety and affordability for everyone, Tufts Health Plan requires prior authorization for certain drugs. This helps us work with physicians to see that medications are prescribed appropriately. Our P&T Committee reviews all prior authorization criteria annually and as new information becomes available.

Prior Authorization Step Therapy
Step Therapy is an automated form of Prior Authorization, which uses claims history for approval of a drug at the point of sale. Step Therapy programs help encourage the clinically proven use of first-line therapies and are designed to promote the utilization of the most therapeutically appropriate and cost-effective agents first, before other treatments may be covered.

Drugs with Quantity Limitations
Because of potential safety and utilization concerns, and because some drugs should only be taken for a limited period of time, a small number of drugs have quantity limitations.

Special Designated Pharmacy Program
Our goal is to offer members the most clinically appropriate and cost-effective services through our arrangements with special pharmacies. These special designated pharmacies supply a select number of medications - used in the treatment of complex diseases - and are staffed with nurses to provide support services for members.

Helping Members Navigate Pharmacy Benefits
We understand that dealing with pharmacy coverage can be confusing for your employees. That's why we've made it easy for them to gather information, check benefits, review claims, and even order prescriptions online.

Caremark, Tufts Health Plan's pharmacy benefit manager, provides information about prescription coverage and allows members to view drugs by tier level, therapeutic class, or alphabetical order. Search our drug lists:


Frequently Asked Pharmacy Questions for Members - We have compiled a list of answers to members' most frequently asked questions about the prescription drug benefit to help clarify costs, copayments, and other issues.

Prescription-by-Mail service - FastStart is a discount program in which members can get a 3-month supply of their ongoing maintenance medications for the cost of two months, delivered to their door.