Pharmacy

Tufts Health Plan requires prior authorization for coverage of certain services including drugs, devices and equipment. Pharmacy medical necessity guidelines for these services are used in conjunction with a member's plan document and in coordination with the member's physician(s). Visit the Resource Center to find a complete list of pharmacy medical necessity guidelines.

Note: Refer to the Commercial Pharmacy Medication Prior Authorization Submission Guide for information on which prior authorization form to use based on state and product.

Formularies

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

For coverage dates starting 1/1/2018, please refer to the following links:

List of Noncovered Drugs With Suggested Alternatives
We cover thousands of drugs, giving you flexibility in prescribing for your patients. There are, however, a small number of drugs Tufts Health Plan currently does not cover. They are on a list called the Prescription Alternative Program (PAP).

These drugs are not covered by Tufts Health Plan because in most cases there are safe, comparably effective alternatives available.

If you feel a drug listed on the non-covered list is necessary, you may submit a request for coverage. The request should be submitted to Tufts Health Plan's Clinical Review Department and should include the clinical documentation that support the need for the particular medication. Tufts Health Plan will cover the medication if it meets coverage guidelines.

New-to-Market Evaluation
Tufts Health Plan requires that all drugs meet a series of high standards before we include them 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.

Prior Authorization
In order to ensure safety and cost controls on pharmacy benefits, Tufts Health Plan requires prior authorization for certain drugs, particularly those that are new to market.

Even after going through the Tufts Health Plan new-to-market evaluation process, we evaluate the medications in order to measure over time, the uses and effects.

You must submit a request to Tufts Health Plan for prescription drugs on the prior authorization requirement list before that request can be approved for that member.

Quantity Limitations
As with all our pharmacy programs, Tufts Health Plan developed the Quantity Limitation Program (formerly the Dispensing Limitation Program) in an effort to monitor safety and help control the cost of prescription drugs for our members. Our Quantity Limitations Program limits the quantity of a drug a member can receive in a given time period.

Designated Specialty Pharmacy Program
Tufts Health Plan continuously works to offer its members the most clinically appropriate and cost-effective services.

As a result, the Plan has designated specialty pharmacies to supply a select number of medications used in the treatment of complex diseases. These pharmacies are specialized in providing these medications and are staffed with nurses, coordinators and pharmacists to provide support services for members. Medications include, but are not limited to, those used in the treatment of infertility, multiple sclerosis, hemophilia, hepatitis C and growth hormone deficiency. Other designated specialty pharmacies and medications may be identified and added to this program from time to time.

If you have questions about Designated Providers, please contact us.

Step Therapy Prior Authorization (STPA)
Step Therapy Prior Authorization (STPA) 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. 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 you have taken the required pre­requisite drugs. However, if your provider 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, we will consider coverage of the medication only if your provider submits a request for coverage to Tufts Health Plan.

Designated Specialty Infusion (SI) Program
The Designated Specialty Infusion (SI) Program  offers clinical management of drug therapies, nursing support and care coordination to members with acute and chronic conditions. Tufts Health Plan has designated specialty infusion providers for a select number of specialized pharmacy products and drug administration services. 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 treatment in hemophillia pulmonary hypertension, and immune deficiency. Drugs in the Specialty Infusion Program are listed throughout the formulary with (SI), indicating the Specialty Infusion Program. Other specialty infusion providers and medications may be identified and added to this program from time to time.

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