TRICARE Pharmacy Program

TRICARE

The TRICARE Pharmacy Program has been updated. The following information and resources will help to make the most of this vital benefit:

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 Pharmacy Home Delivery option; at TRICARE retail network pharmacies; 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, use the TRICARE Formulary Search Tool; and for more information on how to save money and make the most of the TRICARE pharmacy benefit, go to www.tricare.mil/mybenefit/home/Prescriptions, call 1-877-363-1303, or Download the TRICARE Pharmacy Handbook (PDF).

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How to Fill Prescriptions

TRICARE offers several convenient ways for you to have prescriptions filled depending on your family's specific needs.  You can have prescriptions filled at any of these pharmacies, based on your specific situation, and you can use more than one option at a time.

While each option is available worldwide, some may be limited outside of the United States.

To have a prescription filled, you'll need a written prescription and a valid uniformed services identification card. All prescriptions filled through the MTF and Mail Order Pharmacy are checked against your TRICARE prescription history for potential drug interactions.

Pharmacy Copayment and Cost-Share Structure

The current pharmacy cost-share structure-meaning the percentage or fixed amount that the beneficiary pays toward the cost of the medication-is based on whether a prescription medication is a generic, formulary or non-formulary pharmaceutical. The copayment 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 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 TRICARE Pharmacy Home Delivery, or at one of the more than 54,000 TRICARE Retail Pharmacy Network 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 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 copayments and the associated quantity of medication dispensed, is noted in the chart below.

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TRICARE Pharmacy Copayments In the U.S.
As of 2/1/2013
(Including Puerto Rico, Guam, Virgin Islands)
Place of Service
Generic
Formulary
(brand name)
Non-formulary*
Military Treatment Facility (MTF) Pharmacy
$0
$0
Not Applicable**

TRICARE Pharmacy Home Delivery
(up to a 90-day supply)

$0
$13
$43***
Retail network pharmacy
(up to a 30-day supply)
$5
$17
$5***

Non-network Retail Pharmacy
(up to a 30-day supply)

 

For those who are Not enrolled in TRICARE Prime:
$17 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)

For those who are Not enrolled in TRICARE Prime:
$44 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 (POS) deductibles ($300 per person/$600 per family deductible)
TRICARE Prime:
50 percent cost-share after point-of-service (POS) deductibles ($300 per person/$600 per family deductible; 50 percent cost-share)
Note: Beneficiaries using non-network pharmacies may have to pay the total amount of their prescription first and file a claim (DD Form 2642) to receive partial reimbursement.

*For more information on non-formulary medications, beneficiaries can use the TRICARE Formulary Search Tool.

**MTFs are prohibited by law 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 cost share for up to a 30-day supply in the TRICARE Retail Pharmacy Network or a 90-day supply in the TRICARE Pharmacy Home Delivery program.

****After applicable deductables have been met.

Note 1: Contact the TRICARE contractor for your overseas location for reimbursement rates and assistance in filing your claim. Go to TRICARE Overseas and click on your particular region

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Medicare Part D

Medicare's prescription drug coverage, Medicare Part D, is available to anyone who's eligible for Medicare (Part A and/or Part B). Note: Beneficiaries who live in overseas areas (non-U.S. territories) or who are in prison are not eligible for Medicare Part D.

You don't need to enroll in a Medicare Part D prescription drug plan to keep your TRICARE benefits.  If you decide to enroll in a Medicare Part D prescription drug plan outside of your Initial Enrollment Period, you won't be required to pay the Medicare Part D late enrollment penalty because TRICARE prescription drug coverage is creditable coverage.  

For the most up-to-date information on Medicare prescription drug coverage, visit the Medicare Part D Web site.

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, the MTF pharmacy is the best value to the beneficiary.

TRICAREPharmacy Home Delivery

The TRICARE Pharmacy Home Delivery 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 TRICARE Pharmacy Home Delivery unless the medication is not covered under the other plan, or unless the beneficiary exceeds the dollar limit of coverage under the other plan.

To use TRICARE Pharmacy Home Delivery, beneficiaries simply register with TRICARE Pharmacy Home Delivery by completing the registration form available online at www.express-scripts.com/TRICARE. They should follow the instructions on the ESI Website to submit the form. Beneficiaries should then mail their health care provider's written prescription and the appropriate 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 TRICARE Pharmacy Home Delivery, beneficiaries can visit the ESI Website at www.express-scripts.com/TRICARE or contact TRICARE Pharmacy Home Delivery member services at (866) DOD-TMOP, (866) 363-8667, within the U.S.; or toll-free, (866) ASK-4PEC, (866) 275-4732, outside the U.S. Beneficiaries may also visit the TRICARE pharmacy Website at www.tricare.osd.mil/pharmacy/TMOP.cfm or search Frequently Asked Questions (FAQs) (select "Pharmacy" as a category).

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TRICARE Retail Pharmacy Network

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. By using a pharmacy in the ESI network, beneficiaries no longer have to file claims for reimbursement if the pharmacy is outside the beneficiary's primary region. 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 Website, or they may call 1-877-363-1303.

More information on the retail pharmacy program is available on the TRICARE website at www.tricare.mil/pharmacy.aspx or at Frequently Asked Questions, (select "Pharmacy" as a category). Beneficiaries may also visit the TRICARE Retail Pharmacy Network Webpage on ESI's website, www.express-scripts.com/TRICARE.

Medical Necessity

TRICARE understands that patient-treatment decisions are between the patient and the doctor. Within a therapeutic class, if the physician feels that it is medically necessary for the patient to receive the non-formulary medication instead of the formulary medication, then the physician should call the Express Scripts at 1-877-363-1303, prior to the patient obtaining the initial prescription or refill, in order to first obtain medical necessity approval by ESI. The procedures are the same for the Home Delivery Option, except the doctor call line for that program is 1-877-363-1303.

In order for medical necessity to be established, one or more of the following must occur:

  • 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.
  • There is no alternative pharmaceutical agent on the formulary.

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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 1-877-363-1303. 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 you have your prescription filled at a non-network pharmacy or if you have other health insurance with a prescription drug plan, you will need to submit a claim to the pharmacy contractor for reimbursement.

Prescription claims must be filed within one year of the date of service.  To file a pharmacy claim, obtain and fill out a Patient's Request for Medical Payment (DD Form 2642). Prescription claims require the following information for each drug:

  • Name of the patient
  • Name, strength, date filled, days supply, quantity dispensed and price of each drug
  • National Drug Code, if available
  • Prescription number of each drug
  • Name and address of the pharmacy
  • Name and address of the prescribing physician

Where you send your claim depends on where you live.  If living in the United States, you'll file your claim with the pharmacy contractor.  But, if you live outside of the United States, you'll file your claims with your overseas claims processor, the same place as your health care claims.

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 website:www.tricare4u.com/apps-portal/tricareapps-app/static/pdf/dd2642.pdf. Beneficiaries may call ESI at 1-877-363-1303 for questions on how to file a pharmacy claim.

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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 formulary cost-share, or recommends non-formulary status and 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 TRICARE Retail Pharmacy Network or through the TRICARE Pharmacy Home Delivery program but at a higher 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.

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Using Other Health Insurance

Any non-TRICARE health insurance that is not considered a supplement. This insurance is acquired through an employer, entitlement program, or other source. TRICARE pays second after all other health plans except for Medicaid, TRICARE supplements, the Indian Health Service, or other programs or plans as identified by the TRICARE Management Activity.

For more information about the TRICARE Pharmacy program, please visit the TRICARE pharmacy website at www.tricare.mil/pharmacy.aspx or contact TRICARE at one of the following: 

TRICARE Retail Pharmacy Program
Express Scripts, Inc.
1-877-363-1303
www.express-scripts.com/TRICARE

TRICARE Mail Order Pharmacy Program
Express Scripts, Inc.
Stateside: 1-877-363-1303
Dial the in-country access code listed below:
- Germany: 00+800-3631-3030
- Italy: 00+800-3631-3030
- Japan-IDC: 0061+800-3631-3030
- Japan - Japan Telecom: 0041+800-3631-3030
- Japan - KDD: 010+800-3631-3030
- Japan - Other: 0033+800-3631-3030
- South Korea: 002+800-3631-3030
- Turkey: 0811-288-0001
(once prompted, input 877-363-1303)
- United Kingdom: 00+800-3631-3030
www.express-scripts.com/TRICARE

For general information about TRICARE, call one of the many toll-free TRICARE information lines found at the TRICARE Contact Us web page.

TRICARE has many other programs including TRICARE for Life, TRICARE Retiree Dental, etc... For more information see our TRICARE section, or click on the links below to learn more about:

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