At Tufts Health Freedom 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:
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.
New Hampshire 4-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 4-tier copayment program. This allows us to leave prescribing decisions to physicians.
If the member’s plan includes a 4-Tier Copayment design, all covered drugs are divided into four tiers. The 4-Tier Copayment Program features a specialty tier for drugs included in and obtained through the designated specialty pharmacy (SP) program. Drugs that are part of the SP program include but are not limited to medications used in the treatment of rare diseases, infertility, hepatitis C, growth hormone deficiency, multiple sclerosis, rheumatoid arthritis, and cancers treated with oral medications.
The 4-Tier Copayment Program places all covered prescriptions into one of the following tiers:
Depending on the plan chosen, coverage for prescription drugs may be subject to an annual deductible amount or be limited to our generic-focused formulary.
For coverage dates starting 01/01/2019, please refer to the following links:
- Small Group and Individual 4-Tier Formulary: PDF | Searchable List
- Large Group 3-tier Formulary
- Large Group 4-tier 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 Freedom 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 Freedom 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.
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.
To set up mail orders, call CVS Caremark Customer Service toll free at 800.581.5300.