How to Use Your Pharmacy Benefit - Tufts Health Plan

YOUR PHARMACY BENEFIT
Your Tufts Health Plan benefits include coverage for prescription drugs.
Here is a guide to help you make the most of your prescription drug benefit.
As you may be aware, prescription drug prices vary–including drugs used to treat the same condition. We place
prescription drugs into three tiers (or levels) to help you and your doctor choose the most cost-effective option for the
medication you need. Each tier has a specific copay amount that you pay when you fill or order your prescription.

YOUR PHARMACY B
Things that may affect the
cost of your drugs:
n If your doctor prescribes a Tier-3 drug, you can
work with him or her to determine if there is an
appropriate drug available that will cost less.
n If your plan has a deductible or a coinsurance
requirement, you may have to pay all or part of
the cost of your drug until your deductible or
coinsurance amount is met.
DEDUCTIBLE
The amount of money you need to pay out-of-pocket
before the health plan begins to pay eligible claims.
COINSURANCE
The percentage of cost members must pay for some
covered services. The percentage you are required to
pay depends on your particular plan.
TIER LEVEL TIER COPAY TIER DESCRIPTION
Tier 1 Lowest
cost
Tier 2 Middle
cost
Tier 3 Highest
cost
Includes most generic
prescription drugs
on our list of
covered drugs
Includes generics
and brand-name
prescription drugs
on our list of
covered drugs
Includes the most costly
covered generic and
brand-name drugs not on
Tier 1 or Tier 2
What tier is my drug on?
Finding out which tier your drug is on is easy.
Go to tuftshealthplan.com and click on the
I’m a member tab and click Pharmacy.
On the Pharmacy screen, click on one of the following
links depending on what plan you have:
n Massachusetts employer-based plans
n Massachusetts individuals and families
n Rhode Island employer-based plans
n Select Network and Connector Commonwealth
Saver Plans
Search for the name of your drug. If it’s listed,
you’ll see either the name of the drug or its generic
equivalent, the tier that it is listed on, and any
pharmacy programs, if applicable. Please note that
a drug’s tier placement can change at any time
throughout the year.
Log in to mytuftshealthplan.com and click on
View Benefits and Coverage and then click
on Pharmacy to check your drug coverage
and cost.

ENEFIT
Does my drug need special approval?
Once you find your drug, you will know if it needs special approval if you see one of the following codes listed next
to the drug name. If special approval is not required, you can go ahead and get your prescription filled.
PA: Prior authorization
NC: Non-covered
If one of the above codes is listed next to your drug,
please follow the instructions below in order to get
approval before getting your prescription filled.
PA (prior authorization):
Some drugs must meet certain criteria before they
are covered. Contact the provider who has written
your prescription. If your provider believes a drug with
a PA is necessary for your treatment, he or she may
submit a request for coverage by faxing a Universal
Pharmacy Medical Review Request Form–available
at tuftshealthplan.com–to Tufts Health Plan. We will
cover the drug if it meets our medical necessity
coverage guidelines. If the request is approved,
you will be covered for your prescription. If it is
not approved, you can appeal the decision.
NC (non-covered):
Certain drugs like those that are available over-the
counter, are experimental, or have generic equivalents,
may not be covered by Tufts Health Plan. Contact the
provider who has written your prescription. 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–available at tuftshealthplan.
com–to Tufts Health Plan. We will cover the drug if
it meets our medical necessity coverage guidelines.
If the request is approved, you will be covered for
your prescription. If it is not approved, you can
appeal the decision.
QL: Quantity limitation
ST PA : Step therapy
SP: Designated specialty
pharmacy
QL (quantity limitation):
There may be a limit on how much of a drug you can
get for a specific time period. You are covered for up
to the quantity posted in our list of covered drugs. If
your provider believes it is 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.
ST PA (step therapy):
You may be required to try a certain drug to treat a
specific medical condition before Tufts Health Plan
will approve the coverage of another drug to treat the
same condition. Check the step therapy document in
the Pharmacy section at tuftshealthplan.com/members
to confirm the step your drug is on. 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 Universal Pharmacy Medical
Review Request Form to request coverage. New
members–call us if you are currently taking
a step therapy drug from another plan.
SP (designated specialty pharmacy):
Prescriptions for certain specialty drugs can be filled
only at designated specialty pharmacies. Call the
designated specialty pharmacy provider indicated in
your search results of covered drugs or contact the
Tufts Health Plan Member Services Department at the
number on your ID card to help ensure that you receive
your drug without interruption.

The list of drugs covered by our pharmacy benefit
is called our formulary. Most drugs are included
in our formulary.
We use a variety of approaches to manage your
pharmacy benefit. Some of these approaches
include the three-tier pharmacy copayment, prior
authorization, step therapy, quantity limitation,
and designated specialty pharmacy programs.
QUICK TIPS TO SAVE MONEY
* Get a prescription for a generic drug
when possible
* Use CVS Caremark Mail Service Pharmacy
for maintenance medications
* Talk to your doctor about less expensive
alternatives for your medications
What if my drug is not listed?
If your drug is not listed, call our Member Services
Department at the number printed on your ID card.

Where do I get my
prescription filled?
Use a Participating Retail Pharmacy
Go to any of the 63,000 participating retail pharmacies in the CVS Caremark network to obtain most covered
drugs. The list of participating retail pharmacies includes most independent pharmacies as well as the major chain
pharmacies, such as Walgreens and Rite Aid, in addition to CVS locations. Medications with quantity limitations
should not be filled through CVS Caremark Mail Service Pharmacy.
Use CVS Caremark Mail Service Pharmacy
Based on your benefits, you may be able to save money by using the CVS Caremark Mail Service Pharmacy for most
covered maintenance medications. Maintenance medications are those that you refill every month for conditions like
diabetes, high blood pressure, and asthma.
Once you have all the necessary approvals (if required) for your drugs, you can start getting your prescriptions
through CVS Caremark Mail Service Pharmacy–you may save time and money. You will need the following:
n Your Tufts Health Plan ID card
n Drug name
n Your doctor’s name and phone number
n Shipping address
n Credit card information
Instructions:
1. Call CVS Caremark at 888-424-6618, Monday through Friday, 8 a.m. to 8 p.m.
2. Let the representative know that you want to start using the mail-order service.
3. Once the representative has your information, he or she will contact your doctor for a 90-day prescription of your
current medicine.
Once you begin receiving medications by mail, you can order refills easily online or by phone.
For Massachusetts members, and in rare instances when the prescription is for a designated specialty drug, the
prescription can be filled only through participating designated specialty pharmacies.
Tufts Health Plan and CVS Caremark
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 Pharmacy is required for HMO Select Network members who take
maintenance medications.
FOR MORE INFORMATION
Tufts Health Plan Member Services: 800-462-0224
tuftshealthplan.com

TIER 1 COPAYMENT
ACETAMINOPHEN-CODEINE
ACYCLOVIR
ALBUTEROL SULFATE QL
ALENDRONATE SODIUM
ALLOPURINOL
ALPRAZOLAM
AMITRIPTYLINE HCL
AMLODIPINE BESYLATE
AMLODIPINE BESYLATE-BENAZEP
AMOX TR-POTASSIUM CLAVULANA
AMOXICILLIN
AMPHETAMINE SALT COMBO
APRI*
ATENOLOL
AVIANE*
AZITHROMYCIN
BENZONATATE
BETAMETHASONE DIPROPIONATE
BUPROPION HCL
BUPROPION HCL SR
BUPROPION XL
BUSPIRONE HCL
BUTALBITAL-ACETAMINOPHEN-CA
CAMILA*
CARVEDILOL
CEPHALEXIN
CHERATUSSIN AC
CHLORHEXIDINE GLUCONATE
CHLORTHALIDONE
CIPROFLOXACIN HCL
CITALOPRAM HBR
CLINDAMYCIN HCL
CLINDAMYCIN PHOSPHATE
CLOBETASOL PROPIONATE
CLONAZEPAM
CLONIDINE HCL
CLOTRIMAZOLE-BETAMETHASONE
CRYSELLE*
CYCLOBENZAPRINE HCL
TIER 2 COPAYMENT
ADVAIR DISKUS QL
ANDROGEL
ATORVASTATIN CALCIUM
BENICAR
CLOPIDOGREL
COLCRYS QL
DIOVAN
ENBREL SP;PA;QL
QL;STPA
ABILIFY
CELEBREXPA CIALIS QL
CYMBALTAQL;STPA Top 200 Covered Drugs
This is a list of the 200 medications most used by Tufts Health Plan
members. This is not a complete list of drugs covered by the Tufts Health Plan
pharmacy benefit. For a complete list, visit tuftshealthplan.com. For more detailed
benefit information, please review your benefit
TIER 3 COPAYMENT
DESONIDE
DEXTROAMPHETAMINE-AMPHETAMI
DIAZEPAM
DICLOFENAC SODIUM
DILTIAZEM 24HR ER
DIVALPROEX SODIUM
DOXAZOSIN MESYLATE
DOXYCYCLINE HYCLATE
ENALAPRIL MALEATE
ENPRESSE*
ERYTHROMYCIN
ESTRADIOL
FENOFIBRATE
FINASTERIDE
FLUCONAZOLE
FLUOCINONIDE
FLUORIDE
FLUOXETINE HCL
FLUTICASONE PROPIONATE
FOLIC ACID
FUROSEMIDE
GABAPENTIN
GEMFIBROZIL
GIANVI*
GLIMEPIRIDE
GLIPIZIDE
GLIPIZIDE ER
GLYBURIDE
HYDROCHLOROTHIAZIDE
HYDROCODONE-ACETAMINOPHEN
HYDROCORTISONE
HYDROMORPHONE HCL
HYDROXYCHLOROQUINE SULFATE
HYDROXYZINE HCL
IBUPROFEN
INDOMETHACIN
IOPHEN-C NR
JUNEL*
JUNEL FE*
EPIPEN 2-PAK QL
ESCITALOPRAM OXALATE
FLOVENT HFA QL
HUMALOG
HUMIRA SP;PA;QL
JANUVIA
LANTUS
LANTUS SOLOSTAR
DIOVAN HCT
LEXAPRO STPA
PANTOPRAZOLE SODIUM STPA
PREMARIN
Please note: A drug’s tier placement may change at any time during the year.
The list of Top 200 Covered Drugs is current as of January 2013.
*Generic product covered without copayment under Women’s Health Preventive
Services Initiative.
KARIVA*
KETOCONAZOLE
LABETALOL HCL
LAMOTRIGINE
LATANOPROST
LEVETIRACETAM
LEVOFLOXACIN
LEVOTHYROXINE SODIUM
LEVOXYL
LISINOPRIL
LISINOPRIL-HYDROCHLOROTHIAZ
LITHIUM CARBONATE
LORAZEPAM
LOSARTAN POTASSIUM
LOSARTAN-HYDROCHLOROTHIAZID
LOVASTATIN
LUTERA*
MELOXICAM
METFORMIN HCL
METFORMIN HCL ER
METHOTREXATE
METHYLPHENIDATE HCL
METHYLPREDNISOLONE
METOPROLOL SUCCINATE
METOPROLOL TARTRATE
METRONIDAZOLE
MICROGESTIN FE*
MINOCYCLINE HCL
MIRTAZAPINE
MUPIROCIN
NAPROXEN
NECON*
NIFEDIPINE ER
NITROFURANTOIN MONO-MACRO
NORTREL*
NORTRIPTYLINE HCL
NYSTATIN
OCELLA*
OMEPRAZOLE QL
METHYLPHENIDATE ER
MONTELUKAST SODIUM
NASONEX QL
NOVOLOG
NUVARING
ONE TOUCH ULTRA TEST STRIPS
OXYCONTIN QL
PROAIR HFA QL
PA; QL
SUBOXONE
SYNTHROID
VENTOLIN HFAQL VIAGRAQL ONDANSETRON HCL QL
ONDANSETRON ODT QL
OXCARBAZEPINE
OXYCODONE HCL
OXYCODONE-ACETAMINOPHEN
PAROXETINE HCL
PENICILLIN V POTASSIUM
PRAVASTATIN SODIUM
PREDNISOLONE ACETATE
PREDNISOLONE SODIUM PHOSPHA
PREDNISONE
PROPRANOLOL HCL
QUINAPRIL HCL
RANITIDINE HCL
RECLIPSEN*
RISPERIDONE
SERTRALINE HCL
SIMVASTATIN
SPIRONOLACTONE
SPRINTEC*
SULFAMETHOXAZOLE-TRIMETHOPR
SUMATRIPTAN SUCCINATE QL
TAMOXIFEN CITRATE
TAMSULOSIN HCL
TOPIRAMATE
TRAMADOL HCL
TRAZODONE HCL
TRETINOIN PA
TRI-SPRINTEC*
TRIAMCINOLONE ACETONIDE
TRIAMTERENE-HCTZ
VALACYCLOVIR
VENLAFAXINE HCL
VENLAFAXINE HCL ER
VERAPAMIL ER
VITAMIN D2
WARFARIN SODIUM
ZOLPIDEM TARTRATE QL
ZOVIA 1-35E*
QUETIAPINE FUMARATE STPA
SPIRIVA QL
STRATTERA QL
SYMBICORT QL
VAGIFEM
VYVANSE STPA
ZETIA
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