TRICARE Pharmacy Program

TIP:
You pay absolutely nothing for prescriptions filled by your Military Treatment Facility pharmacy.

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 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; and 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 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 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 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.

TRICARE Pharmacy Copayments In the U.S. (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 Mail Order Pharmacy (TMOP) (up to a 90-day supply)	$3	$9	$22***
Retail network pharmacy (up to a 30-day supply)	$3	$9	$22***
Non-network Retail Pharmacy (up to a 30-day supply)	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)		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 (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.
Beneficiary Cost Share at all other overseas locations (May Vary by Location - See Note 1)
Active Duty Servicemembers	Active Duty family members ****			Retirees and family members
	Global Remote Overseas	Prime Overseas	Standard Overseas
No copay	0%	50%	25%	25%

*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 TRRx or a 90-day supply in the TMOP 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 www.tricare.osd.mil/overseas/index.cfm and click on your particular region

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.

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 unless 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 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 TMOP, beneficiaries can visit the ESI Website at www.express-scripts.com/TRICARE or contact TMOP 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).

TRICARE Retail Pharmacy Program (TRRx)

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 (866) DoD-TRRx, (866) 363-8779.

More information on the retail pharmacy program is available on the TRICARE Website at www.tricare.osd.mil/pharmacy/ or at Frequently Asked Questions, (select "Pharmacy" as a category). Beneficiaries may also visit the TRRx 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 Doctor Call Line at (866) 684-4488, 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 TMOP, except the doctor call line for that program is (877) 283-3858.

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.

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 Website: 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 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 TRRx or through the TMOP 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.

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 our 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.

For more information about the TRICARE Pharmacy program, please visit the TRICARE pharmacy Website at http://www.tricare.mil/mybenefit/home/Prescriptions. or contact TRICARE at one of the following:

TRICARE Retail Pharmacy Program
Express Scripts, Inc.
1-866-DoD-TRRx (1-866-363-8779)
www.express-scripts.com/TRICARE

TRICARE Mail Order Pharmacy Program
Express Scripts, Inc.
Stateside: 1-866-DoD-TMOP (1-866-363-8667)
Overseas: 1-866-ASK-4PEC (1-866-275-4732)
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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