Understanding Your Pharmacy Benefit

First things first. Find out if your drug is covered.

The fastest and easiest way to find out if your drug is covered is to check to see if your drug is on the lists of covered drugs for your plan. These lists are called formularies.

Check your Summary of Benefits and Coverage (SBC) to determine the formulary for your plan.

For coverage dates starting 01/01/2019, please refer to the following links:

For coverage dates starting 01/01/2018, please refer to the following links:

If you see any of the terms below in connection with your prescription, be sure to take any action necessary in order to ensure your prescription is filled in a timely manner.

PA: Prior Authorization

Some drugs must meet certain criteria before they’re covered. If your provider believes a drug with a prior authorization is necessary for your treatment, the provider should submit a request for coverage by faxing a Universal Pharmacy Medical Review Request Form to Tufts Health Freedom Plan. The form is available at thfp.com in the Provider a Resource Center. If the drug meets our medical necessity coverage guidelines, your request will be approved, and we will cover the drug. If for some reason it is not approved, you always have the option of appealing the decision.

STPA: Step Therapy Prior Authorization

You may be required to try a certain drug to treat a specific medical condition before Tufts Health Freedom Plan will approve the coverage of another drug to treat the same condition. If you have not previously taken the steps required by our pharmacy coverage guidelines, and your provider believes the drug prescribed for you is medically necessary, he or she may submit a request for coverage by faxing a Universal Pharmacy Medical Review Request Form. If you are a new member, please call us and let us know if you are currently taking a step therapy drug from another plan.

NTM: New-To-Market Drug Evaluation

In an effort to ensure the new-to-market prescriptions we cover are safe, effective and affordable, we delay coverage of many new drug products until our Pharmacy and Therapeutics (P&T) Committee and physician specialist review them. These drugs require prior authorization.

QL: Quantity Limitation

There may be a limit on how much of a drug you can get for a specific time period. You’re covered for up to the quantity posted in our list of covered drugs. If your provider believes it’s necessary for you to take more than the quantity limit posted on the list, he or she may submit a Universal Pharmacy Medical Review Request Form to request coverage.

SP: Designated Specialty Pharmacy

We’ve designated special pharmacies to supply a select number of medications used in the treatment of complex disease states. These pharmacies specialize in providing these medications and are staffed with nurses, coordinators and pharmacists to provide support services for members. Call the designated specialty pharmacy provider indicated in your search results of covered drugs, or contact the Tufts Health Freedom Plan Member Services Department at the number on your ID card. We want to make sure you receive your covered drug without interruption.

NC: Non-Covered

There are thousands of drugs listed on the Tufts Health Freedom Plan covered drugs lists. In fact, most drugs are covered. There is, however, a list of drugs that Tufts Health Freedom Plan currently does not cover. In many cases, these drugs are not covered by Tufts Health Freedom 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 provider believes a non-covered drug is necessary for your treatment, he or she may submit a request for coverage by faxing a Universal Pharmacy Medical Review Request Form. If the drug meets our medical necessity coverage guidelines, your request will be approved, and we will cover the drug. If it is not approved, you always have the option of appealing the decision.

Find out what it costs.

Not every drug is priced the same. There is a cost share or copay associated with every non-preventive prescription, and the amount you will have to pay is determined by the drug prescribed. When you check your formulary, you’ll see that there are up to four tiers, or levels of drugs. Be sure to check our website each time you need a prescription for the most updated formularies and tiers.

Tier 1: Includes most generic drugs, and is the lowest copay.

Tier 2: Includes many generic and brand-name drugs, and is the next-highest copay.

Tier 3: Includes the most expensive generic and brand-name drugs, and is the highest copay.

Tier 4 (optional): When this tier is chosen by employers, this becomes the highest copay tier.

Low-cost Generic Drug Program

With our low-cost generic drug program*, members pay just $5 for a 30-day supply of medication at the pharmacy—and just $10 for a 90-day supply through mail-order.

Check the full list of low-cost generics to see if you can save.

Have your prescription filled via pharmacy or mail-order.

You can have your prescription filled either through a pharmacy or, if your drug qualifies, through the mail.

If your prescription has a supply of less than 90 days, you would typically have it filled at a pharmacy. You can go to any of the nearly 68,000 pharmacies that are part of the CVS Caremark network. Just to be clear, the CVS Caremark network includes more than just CVS pharmacies. In fact, the vast majority of pharmacies in the U.S. are part of the CVS Caremark network, including most national retail chains and independent pharmacies.

If your drug is a Tier 4 drug or has a SP designation on the formulary list, you must have it filled at a participating designated speciality pharmacy.

If your prescription is ongoing and has a supply of 90 days or more, such as for a chronic condition like asthma or diabetes, mail order is typically recommended. This option typically saves you money, and you can arrange it so that your medication arrives automatically so you don’t run out.

Be sure you have any necessary approvals in place, then call CVS Caremark Customer Service at 800.581.5300. If your medication doesn’t need approval, you’ll be transferred to CVS Caremark FastStart. Once your account is set up, you can easily order refills online or by phone. Be sure to have the following ready:

  • Your Tufts Health Freedom Plan ID Card
  • Your medication name
  • Your physician’s name and phone number
  • Your shipping address
  • Your credit card

Our goal is to make the Tufts Health Freedom Plan pharmacy benefit simple to use. If you have any questions at all, please don’t hesitate to contact us. We’re here to help.


*Tufts Health Freedom Plan’s low-cost generic drug program is not available to some Saver plan members. Please check with your employer for details.

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