Since 06-07-05
Updated June 6, 2005 TRICARE Pharmacy Program
Since 06-07-05
From: Waspscpo@aol.com [mailto:Waspscpo@aol.com]
Sent: Tuesday, June 07, 2005 2:52 AM
To: undisclosed-recipients
Subject: Updated June 6, 2005 TRICARE Pharmacy Program
Updated June 6, 2005TRICARE Pharmacy Program
TRICARE provides a world-class pharmacy benefit to all eligible Uniformed
Services members, including TRICARE for Life (TFL) beneficiaries entitled to
Medicare Part A and B based on their age, disability and/or end-stage renal
disease. Eligible beneficiaries may fill prescription medications at military
treatment facility (MTF) pharmacies; through the TRICARE Mail Order Pharmacy (TMOP);
at TRICARE retail network pharmacies (TRRx); and at non network pharmacies. To
have a prescription filled, beneficiaries need a written prescription and a
valid Uniformed Services identification card. To update information and obtain a
valid identification card, beneficiaries should contact the
Defense Enrollment Eligibility Reporting System (DEERS).
TFL beneficiaries who turned age 65 on April 1, 2001, or later, must be enrolled
in Medicare Part B to use the pharmacy program. TFL beneficiaries who turned age
65 before April 1, 2001, are not required to be enrolled in Medicare Part B for
the pharmacy program, but are required to be enrolled in Medicare Part B for all
other benefits available under TRICARE for Life.
TRICARE's mandatory
generic drug policy, which has been in place for more than 10 years,
requires that prescriptions be filled with a generic product, if one is
available. As with most prescription drug plans, beneficiaries enjoy a
significant cost savings by asking their doctors to prescribe the generic
equivalent of a brand-name drug. In the United States, all generic drugs must
undergo Food and Drug Administration (FDA) testing and approval, and are
considered safe alternatives to brand-name drugs.
To learn more about any medication, check for generic
equivalents, and even learn about common drug interactions, beneficiaries may
use the TRICARE
Formulary Search Tool. For more information on how to save money and make
the most of the TRICARE pharmacy benefit, they can go to www.tricare.osd.mil/pharmacy,
or call (877) DoD-MEDS, (877) 363-6337.
Pharmacy Benefit Program Copayment/Cost-Share Structure
The current pharmacy copayment (fixed amount) or cost share (percentage) that
the beneficiary pays toward the cost of the medication is based on whether a
prescription medication is a generic, brand-name or non-formulary
pharmaceutical. The copayment or cost share is the same for all TRICARE
beneficiaries (except active duty service members, who receive medications
free-of-charge) depending on where the beneficiary chooses to fill their
prescription.
Active duty service members do not pay copayments or cost shares for
prescriptions. However, if they are overseas and receive medications through an
out-of-network pharmacy, they may need to pay out-of-pocket for the total cost
of the medication and then file a claim for reimbursement for the full amount.
Beneficiaries may have prescriptions filled in one of four places: at the MTF,
through the TMOP or at one of the more than 54,000 TRRx in the nationwide
network. Beneficiaries may also have prescriptions filled at non-network
pharmacies, but will pay significantly more and must meet a deductible.
This copayment/cost-share structure applies to all beneficiaries, regardless of
their TRICARE Prime enrollment status. More information on TRICARE Prime,
TRICARE Extra and TRICARE Standard is available in the
TRICARE handbook or in the
TRICARE Basics Fact Sheet. A comparison of the point-of-service copayment/cost
share and the associated quantity of medication dispensed is noted in the chart
below.
TRICARE Pharmacy Copayments/Cost Shares In the United States (Including Puerto
Rico, Guam, Virgin Islands)
Place of Service Formulary Non-formulary*
Generic Brand Name
Military Treatment Facility (MTF) pharmacy
(up to a 90-day supply) $0 $0 Not Applicable**
TRICARE Mail Order Pharmacy (TMOP)
(up to a 90-day supply) $3 $9 $22***
TRICARE Retail Pharmacy Network pharmacy (TRRx)
(up to a 30-day supply) $3 $9 $22***
Non-network retail pharmacy
(up to a 30-day supply)
Note: Beneficiaries using non-network pharmacies may have to pay the total
amount of their prescription first and then file a claim to receive partial
reimbursement. For those who are not enrolled in TRICARE Prime: $9 or 20
percent of total cost, whichever is greater, after deductible is met (E1-E4:
$50/ person; $100/family; all others, including retirees, $150/person,
$300/family)
TRICARE Prime: 50 percent cost share after point-of-service deductibles ($300
per person/$600 per family deductible) For those who are not enrolled in
TRICARE Prime: $22 or 20 percent of total cost, whichever is greater, after
deductible is met (E1-E4: $50/ person; $100/family; all others, including
retirees, $150/person, $300/family)
TRICARE Prime: 50 percent cost share after point-of-service deductibles ($300
per person/$600 per family deductible)
Beneficiary Copayment/Cost Share At All Other Overseas Locations
Active duty service members Active Duty family members (ADFMs) enrolled in
Prime ADFMs not enrolled in Prime Retirees and family members
Copayment/
Cost Share No copayment/
cost share No copayment/
cost share* * * * 20% cost share after deductible of $50/100 for E1-E4 ADFMs;
$150/300 for E5 and above ADFMs is met 25% cost share after deductible of
$150/300 is met
*For more information on non-formulary medications, beneficiaries can use the TRICARE Formulary Search Tool.
**MTFs are prohibited under the Code of Federal Regulations from carrying non
formulary medications.
***If medical necessity is established for a non-formulary drug, patients may
qualify for the $9 copayment for up to a 30-day supply in the TRRx or a 90-day
supply in the TMOP program.
* * * *ADFMs enrolled in TRICARE Overseas Program Prime (at an MTF) who use host
nation pharmacies are subject to Prime point of service deductibles of $300/600
and 50% cost-shares.
MTF Pharmacy
Prescriptions may be filled (up to a 90-day supply for most medications) at an
MTF pharmacy at no cost to the beneficiary, if the medication is on the MTF
formulary. Beneficiaries should contact their local MTF to find out what is on
the formulary and for specific details about filling and refilling prescriptions
at the MTF pharmacy. They can use the TRICARE
Formulary Search Tool to find out what medications must be made available at
all full service military pharmacies (called the Basic Core Formulary), and they
may visit the
MTF locator to find the closest MTF. With no copayment or cost share, the
MTF pharmacy is the best value to the beneficiary.
TRICARE Mail Order Pharmacy (TMOP)
TMOP
is administered by Express Scripts Inc. (ESI), and is available for
prescriptions that beneficiaries take on a regular basis. For the beneficiary,
it is the more cost-effective way to receive prescriptions compared with using
retail pharmacies. Beneficiaries may receive up to a 90-day supply for most
medications. Prescription refills may be requested by mail, phone or online.
Beneficiaries who have prescription drug coverage from another health insurance
plan may not use TMOP, unless the medication is not covered under the other
plan, or the beneficiary exceeds the dollar limit of coverage under the other
plan.
To use TMOP, beneficiaries simply register with TMOP by completing the
registration form available online at
www.express-scripts.com/TRICARE. They should follow the instructions on the
ESI Web site to submit the form. Beneficiaries should then mail their health
care provider's written prescription and the appropriate copayment or cost share
to ESI. New prescriptions may also be faxed or phoned in by the provider. Within
10-14 days, the medications are sent directly to the beneficiary. Beneficiaries
may also contact the TRICARE Service Center for assistance.
For more information about how to use TMOP, beneficiaries can visit the ESI Web
site at
www.express-scripts.com/TRICARE or contact TMOP member services at (866)
DOD-TMOP, (866) 363-8667, within the United States; or toll-free, (866)
ASK-4PEC, (866) 275-4732, outside the United States. Beneficiaries may also
visit the TRICARE pharmacy Web site at
www.tricare.osd.mil/pharmacy/tmop.cfm or search
Frequently Asked Questions (FAQs) (select "Pharmacy" as a category in the
box entitled "Search").
TRICARE Retail Pharmacy Program (TRRx)
TRRx is also administered by Express Scripts Inc. (ESI). Beneficiaries in the
United States and its territories (Guam, Puerto Rico, U.S. Virgin Islands) may
use an expanded, nationwide network of more than 54,000 retail pharmacies to
fill prescriptions. To find a network pharmacy anywhere in the 50 United States,
Puerto Rico, the U.S. Virgin Islands and Guam, beneficiaries may use the
TRICARE pharmacy locator service available on the ESI Web site or they may
call (866) DoD-TRRx, (866) 363-8779.
More information on the retail pharmacy program is available on the TRICARE Web
site at
www.tricare.osd.mil/pharmacy/ or at
Frequently Asked Questions, (select "Pharmacy" as a category in the box
entitled "Search"). Beneficiaries may also visit the TRRx Web page on ESI's Web
site,
www.express-scripts.com/TRICARE.
Medical Necessity
TRICARE understands that patient-treatment decisions are between the patient and the doctor. If a doctor believes that it is medically necessary for a patient to receive a non-formulary medication instead of any of the formulary alternatives that are on the Uniform Formulary, the medication can be provided at the formulary copayment or cost share if medical necessity can be substantiated.
In
order for medical necessity to be established, sufficient information must be
submitted to show that one or more of the following conditions exist:
Use of all formulary medications is contraindicated, and the use of the
non-formulary medication is not contraindicated; The patient must experience, or
would be likely to experience, significant adverse effects from the formulary
medication, and the patient is reasonably expected to tolerate the non-formulary
medication;
The formulary medication has resulted in, or is likely to result in, therapeutic
failure, and the patient is reasonably expected to respond to the non-formulary
medication;
The patient has previously responded to the non-formulary medication, and changing to a formulary medication would incur an unacceptable clinical risk; or There is no alternative pharmaceutical agent on the formulary.
Medical necessity forms are available on the TRICARE Pharmacy Web site
http://www.tricare.osd.mil/pharmacy/medical-nonformulary.cfm. Procedures for
how to complete and submit medical necessity information can be found on the
form.
Non-Network Pharmacies
A
"non-network pharmacy" is a retail pharmacy that is not part of the TRICARE
network. To verify that a pharmacy is or is not a part of the TRICARE network,
beneficiaries should check the
TRICARE pharmacy locator service, or call (866) DoD-TRRX, (866) 363-8779.
Filling prescriptions at non-network pharmacies is the most expensive option and
is not recommended. Beneficiaries may have to pay for the total amount first,
and file a claim to receive a partial reimbursement.
Filing Claims
If a beneficiary has
other health insurance, and is filing a pharmacy claim with TRICARE, the
claim should be mailed to: Express Scripts Inc., P.O. Box 66518, St. Louis, MO,
63166-6518. Claims must be filed within one year of the date of service. A
downloadable TRICARE claim form (DD 2642) is available on the TRICARE Pharmacy
Web site:
http://www.tricare.osd.mil/pharmacy/claims.cfm. Beneficiaries may call ESI
at (866) DoD-TRRX, (866) 363-8779 for questions on how to file a pharmacy claim.
How to Fill Prescriptions
Valid prescriptions must be submitted electronically, faxed or phoned-in to a
retail network or non-network pharmacy by the provider, depending on state
pharmacy laws. The provider may give the beneficiary a written prescription to
take to a retail pharmacy or mail to the TMOP. Beneficiaries should talk with
their provider if they have a preference on where they would like their
prescriptions filled.
The Uniform Formulary Process
In the Fiscal Year 2000 National Defense Authorization Act, Congress directed
the Department of Defense (DoD) to establish a Uniform Formulary process. As
part of this process, the
DoD Pharmacy & Therapeutics (P&T) Committee, comprised of physicians,
pharmacists and representatives from the Services and the Veterans
Administration, systematically reviews and evaluates FDA-approved prescription
medications to determine their relative clinical and cost effectiveness. The
committee makes recommendations as to whether a drug should be on the uniform
formulary at the generic or brand-name copayment/cost share, or recommends
non-formulary status and copayment/cost shares, and forwards those
recommendations to the Director of TRICARE. Prior to the Director of TRICARE's
decision, the
Beneficiary Advisory Panel, which represents the interests of TRICARE
beneficiaries, provides comments on the committee's recommendations.
Any drug in a therapeutic class determined to be either not as relatively
clinically effective or as relatively cost effective as other drugs in the class
may be recommended for placement in the non-formulary category as a part of the
Uniform Formulary process. Any drug placed into the non-formulary category will
still be available to beneficiaries through TRRx or the TMOP program, but at a
higher copayment or cost share. Non-formulary drugs will not be available in
MTFs, unless the prescription was written by an MTF provider and medical
necessity for the drug has been established.
Using Other Health Insurance
When using insurance other than TRICARE, the other health insurance must be the
first payer. Beneficiaries may then be eligible for full or partial
reimbursement from TRICARE for out-of-pocket costs, including copayments and/or
cost shares. Beneficiaries who have other health insurance should use a retail
pharmacy under their private insurer that is also in the TRICARE retail network,
to avoid paying the TRICARE non-network deductible. Beneficiaries who have
prescription drug coverage from another health insurance plan may not use TMOP,
unless the medication is not covered under the other plan, or unless the
beneficiary exceeds the dollar limit of coverage under the other plan. When a
beneficiary has other health insurance, the rules of that insurer apply.
Beneficiaries should call ESI at (866) DoD-TRRx, (866) 363-8779, for specific
instructions about filing pharmacy claims if they have other health insurance.
Other Helpful Information:
TRICARE Basics Fact Sheet
"Formulary Search Tool" at
http://www.tricareformularysearch.org
TRICARE Eligibility Fact Sheet
TRICARE for Life and Medicare Part B Fact Sheet
TRICARE Prime Point-of-Service Option Fact Sheet
Defense Eligibility Enrollment Reporting System (DEERS) Fact Sheet
DEERS Verification Changes for Unremarried Former Spouses Fact Sheet