My Employer Has Switched to Tufts Health Freedom Plan

Our online provider directory allows you to customize your search based on the information most important to you. You can perform this search to determine if your current PCP or specialist participates in the network.

You may also see if a primary care provider (PCP) is accepting new patients. If you are an existing patient, you may still select your PCP even if there is an indicator that says “not accepting new patients.” If your current PCP is listed as not accepting new patients, please call Member Services. 

If your plan requires referrals, please contact your PCP to submit them for any upcoming or on-going services such as Physical Therapy as you switch to Tufts Health Freedom Plan.

It’s important to notify all of your providers that your health insurance has changed. You may need to move your care from one facility or provider to another if your current provider does not participate in the Tufts Health Freedom Plan network.

If you or a dependent on your plan is undergoing active treatment for a condition that will need to continue after you become a Tufts Health Freedom Plan member, contact us as soon as possible so we can provide you with guidance.

Some procedures require prior authorization for coverage in addition to approval for the scheduled date of your service. When prior authorization is required, your provider submits a request to Tufts Health Freedom Plan, or an authorized reviewer, to assess whether your procedure meets our medical necessity guidelines for coverage.

To assist with your switch to Tufts Health Freedom Plan, please complete this form within one month prior to effective date if you or your family member(s):

• Have a scheduled surgery or hospitalization
• Have a serious condition such as heart disease, cancer, or multiple sclerosis
• Are currently being supported by a case manager or disease management program
• Are currently receiving home health care services
• Are pregnant and considered “high risk”

Complete the New Member Care Form Now

If you have a complex medical condition such as cancer, end-stage renal disease, or another serious illness, and you are receiving ongoing treatment, the Priority Care team will pair you with one of our nurse case managers to make your switch smoother. A nurse case manager will work with you and your doctors to support your health care treatment and goals. To learn more about this program, call 888-880-8699, ext. 53532.

As our pharmacy benefits manager, CVS Caremark reviews and processes your claims when you purchase prescription medications. Members covered by our pharmacy benefit may fill prescriptions at any of the more than 63,000 CVS Caremark–participating pharmacies, which include retail chain stores, independent pharmacies, and designated specialty pharmacies, in addition to CVS/pharmacy locations. The CVS Caremark mail service is available for members who take maintenance medications. Maintenance medications are those you refill each month for conditions such as diabetes, high blood pressure, and asthma.

If you are currently on a medication, be sure you have enough on hand to last until your new coverage takes effect.

When you’re ready to fill a new prescription, follow these 3 easy steps:

1. Confirm that your medication is on our list of covered drugs. If your medication is not listed, speak to your provider about alternatives that are covered.

View Pharmacy Formularies

2. Check whether any of the following pharmacy management programs apply to your medication:

• PA: Prior authorization 
• NC: Non-covered
• STPA: Step therapy
• QL: Quantity limitation 
• SP: Designated specialty pharmacy

If any of these programs apply, follow the applicable recommendations outlined in step 3, below.

3. Follow these appropriate steps for any applicable pharmacy management programs:

• Prior Authorization (PA): 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.
• Step Therapy Prior Authorization (STPA): 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.
• New-To-Market Drug Evaluation (NTM): 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.
• Quantity Limitation (QL): 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.
• Designated Specialty Pharmacy (SP): 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.
• Non-Covered (NC): 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.

Mail order is a quick, convenient, and economical way to fill your prescriptions for most maintenance medications. You will need to have any necessary approvals in place (see steps 2 and 3 above). Then call CVS Caremark Customer Service at 800- 581-5300. If your medication does not need an approval, you will be transferred to CVS Caremark’s FastStart^SM service, which will get you started with the mail-order service.

You will need the following information when you make the call:

• Your Tufts Health Freedom Plan ID card
• Medication name
• Your provider’s name and phone number
• Shipping address
• Credit card information and expiration date

Once you begin receiving medications by mail, you can order refills easily online or by phone.