Tufts Health Plan offers 3-tier and 4-tier pharmacy program options depending on the size of your employer group.
To help maintain flexibility in the pharmacy benefit, we encourage the use of cost-effective medications and preferred brand names through our 3-tier and 4-tier copayment programs. This allows us to leave prescribing decisions to physicians.
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.
Tiered pharmacy programs
The Premium formulary is strategically designed to cover a wide variety of categories and classes of drugs. Exclusions may include cosmetic and high-dollar/low-value drugs and products.
The plan offers a 3-Tier and a 4-Tier Premium formulary.
3-tier program
Covered medications are categorized into one of three tiers. Copayments are determined by the tier in which the drug is assigned, for up to a 30-day supply per prescription or refill. We encourage patients and physicians to discuss pharmaceutical treatment options that are therapeutically appropriate and most cost effective.
- Tier 1 is primarily made up of generic drugs and select brand-name drugs that the plan has determined to be more effective, less costly or to have fewer side effects than similar medications. Members pay the lowest copayment or coinsurance amount for Tier 1.
- Tier 2 is primarily made up of brand-name drugs. and higher cost generic drugs.
- Tier 3 is made up of drugs that the plan has not included in Tier 1 or Tier 2. Members pay the highest copayment or coinsurance amount for Tier 3 drugs.
4-tier program
Covered medications are categorized into one of four tiers. Copayments are determined by the tier in which the drug is assigned, for up to a 30-day supply per prescription or refill. We encourage patients and physicians to discuss pharmaceutical treatment options that are therapeutically appropriate and most cost effective.
- Tier 1 is made up of lower cost generic drugs. Members pay the lowest copayment or coinsurance amount for Tier 1 drugs.
- Tier 2 is primarily made up of generic drugs and select brand-name drugs.
- Tier 3 is primarily made up of brand-name drugs and higher cost generic drugs.
- Tier 4 is made up of drugs that we have not included in Tiers 1- 3. Members pay the highest copayment or coinsurance for Tier 4 drugs.
We offer a 3-tier and 4-tier Value formulary. The Value formulary covers a variety of classes of medications. Exclusions may include cosmetic and high-dollar/low-value drugs and products.
3-tier program
Covered medications are categorized into one of three tiers. Copayments are determined by the tier in which the drug is assigned, for up to a 30-day supply per prescription or refill. We encourage patients and physicians to discuss pharmaceutical treatment options that are therapeutically appropriate and most cost effective.
- Tier 1 is primarily made up of generic drugs.
- Tier 2 is primarily made up of preferred brand name drugs and some generic drugs.
- Tier 3 is primarily made up of preferred specialty drugs and non-preferred brand name and specialty drugs. Tier 3 may also include some higher cost generic drugs.
4-tier program
Covered medications are categorized into one of four tiers. Copayments are determined by the tier in which the drug is assigned, for up to a 30-day supply per prescription or refill. We encourage patients and physicians to discuss pharmaceutical treatment options that are therapeutically appropriate and most cost effective.
- Tier 1 is primarily made up of generic drugs.
- Tier 2 is primarily made up of preferred brand name drugs and some generic drugs.
- Tier 3 is primarily made up of preferred specialty drugs, non-preferred brand name drugs, and higher cost generics.
- Tier 4 is primarily made up of non-preferred specialty drugs. Tier 4 may also include selected brand and generic drugs.
How we cover prescriptions
Your plan includes a pharmacy benefit, which means that thousands of medications in our covered drug list (also known as a formulary) are available with a doctor’s prescription if you need them.
Each covered drug has a cost-share. The amount of the cost-share depends on which drug it is and what “tier” or level it’s on.
The drugs covered under your plan (and their cost-share) are organized into up to four tiers:
- Tier 1 includes most generic drugs, and is the lowest cost-share.
- Tier 2 includes many generic and brand-name drugs.
- Tier 3 includes the most expensive generic and brand-name drugs.
- Tier 4 includes specialty drugs, and is the highest cost-share.
Benefits of integrating pharmacy and medical benefits with a single carrier
Our agreements with our PBM (Optum Rx) include clinical program terms and conditions, with many clinical programs provided at no cost. Plus, we have extensive audit rights to protect our clients. We issue competitive RFPs every three years or more frequently as market conditions change.
The reality is that, with more than one million members, our size gives us the power to negotiate aggressive discounts and maintain a low pharmacy trend. We offer nominal dispensing fees and waive administrative fees—and we’re fully transparent with our pricing and rebates.
We can customize large employers' pharmacy programs to meet specific needs, utilizing:
- Flexible networks
- Multiple formularies
- Tiered copayment plans
- Mail-order refills, and
- Preferred-product strategies
Our Pharmacy & Therapeutics Committee includes local doctors familiar with practice patterns in our market. Carve outs, on the other hand, have to work within generic national guidelines.
Our targeted pharmacy program promotes close monitoring of medication compliance. The program is focused around chronic conditions, using specialty pharmacy care teams to help ensure adherence to complex—and expensive—medication schedules for better outcomes.
We also practice active management of specialty drugs. We take a proactive role to secure price protections, reassess preferred drug strategies, and negotiate rebates for all new drug launches.