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WEEKEND MAINTENANCE: The maintenance outage is scheduled for June 22nd at 6:00am EST ending NLT Sunday, June 23rd at 11:59pm Eastern EST. The TRICARE Manuals web site may be available intermittently during this period but it's usage is not recommended.

TRICARE Operations Manual 6010.59-M, April 1, 2015
TRICARE Pharmacy (TPharm)
Chapter 23
Section 1
General
Revision:  C-36, September 14, 2018
1.0  General
1.1  The TRICARE Pharmacy (TPharm) Benefits Program offers worldwide services through:
•  Direct Care (DC) pharmacies located at Military Treatment Facilities (MTFs)/Enhanced Multi-Service Markets (eMSMs);
•  Retail network pharmacies;
•  A Mail Order Pharmacy (MOP) program including specialty pharmacy services; and
•  Retail non-network pharmacies.
1.2  The requirements/guidelines in this chapter apply only to the TPharm contractor.
2.0  Eligibility
2.1  The TPharm Benefits Program is available to all TRICARE eligible beneficiaries, including Uniformed Service members, TRICARE Prime Remote (TPR) enrollees, TRICARE Dual Eligibles, and TRICARE Reserve Select (TRS) members. Eligible beneficiaries need not enroll in order to use the pharmacy program. The contractor shall use the Defense Enrollment Eligibility Reporting System (DEERS) to verify TRICARE eligibility prior to dispensing pharmaceuticals (or paying any claim) for all beneficiaries, except for certain beneficiaries during calendar year 2018. See Chapter 8, Section 1.
2.2  Foreign Force Members (FFMs) and their dependents from countries that are party to a North Atlantic Treaty Organization (NATO), Status of Forces Agreement (SOFA), or Partnership for Peace (PfP) SOFA (see Chapter 17, Section 3) may be eligible to receive pharmaceuticals dispensed through retail pharmacies. If eligible, coverage will be subject to the same rules regarding adjudication and payment as applicable to U.S. active duty members (no copay or cost-share) and Active Duty Family Members (ADFMs) with TRICARE Standard (through December 31,2017) and with TRICARE Select Group B cost-shares (effective January 1, 2018). See the TRICARE Reimbursement Manual (TRM), Chapter 4, Sections 2 and 4, for coordination of benefits rules. Refer to http://tricare.mil/CoveredServices/Pharmacy/Eligibility.aspx for information on potential coverage.
2.3  Guard or Service members who are injured or become ill while serving on active duty or performing official drills with their unit may be eligible for continued care/treatment associated with the specific episode of care once their active duty or drill status has terminated. Documentation from Specified Authorization Staff (SAS) will serve as proof of eligibility and pharmaceutical claims will be processed for reimbursement. SAS, per Chapter 17, Section 2, paragraph 1.2, has authority to approve claims for drugs not covered under standard benefit guidelines.
3.0  Applicability Of TRICARE Requirements
Unless waived or superseded by the provisions of this chapter or the contract, all normal TRICARE requirements set forth in the TRICARE Operations Manual (TOM), TRICARE Policy Manual (TPM), TRM, and TRICARE Systems Manual (TSM) apply. Sections or language in these Manuals that obviously have no direct application to the pharmacy contractor do not apply (e.g., requirements related to enrolling beneficiaries in TRICARE Prime, requirements related to medical benefit determinations, etc.).
4.0  Performance/Processing Standards
Performance standards for the TPharm Benefits Program are located in Section C of the TPharm contract. Additionally, the contractor shall comply with the TRICARE Encounter Data (TED) timeliness and TED accuracy standards included in Chapter 1, Section 3.
5.0  Specialty Pharmaceuticals
Specialty pharmaceuticals may be obtained at retail or mail order. Some specialty pharmaceuticals are eligible for specialty care services at mail order. Pharmaceuticals eligible for specialty care services under the pharmacy contract are listed https://www.health.mil/Military-Health-Topics/Access-Cost-Quality-and-Safety/Access-to-Healthcare/Pharmacy-Program/TRICARE-Formulary/Specialty-Care-Drug-List.
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