2.2.1 The Pharmacy Benefits Program
generally requires mandatory substitution of generic drugs in accordance
with
32 CFR 199.21(j)(2). Where the law of a specific
state prohibits generic substitution of a specific drug, the contractor,
at the direction of the Government, shall be able to process the
brand product.
2.2.2 Eligible
beneficiaries shall pay a copayment for drug claims that are cost-shared
under the Pharmacy Benefit Program in accordance with the TRICARE
Reimbursement Manual (TRM),
Chapter 2, Addendum B. Section 702 of National
Defense Authorization Act (NDAA) 2018 states the cost-sharing amounts
for a dependent of a member of uniformed services who dies while
on active duty, a member retired under Chapter 61, or a dependent of
a member retired under such chapter shall remain at the January
1, 2018 cost-share rates.
2.2.3 TRICARE
is the secondary payer on claims where Other Health Insurance (OHI)
coverage exists. OHI claims are reimbursed in accordance with TRM,
Chapter 4, Section 3. Reimbursement shall
be the lesser of the TRICARE allowed amount or the remaining amount
after OHI payment.
2.2.4 Cost-sharing
of pharmaceuticals is determined by formulary status as described
in
32 CFR 199.21.
Types of pharmaceuticals include, but are not limited to:
• Legend drugs;
• Pharmaceutical agents grandfathered
by the Federal Food, Drug and Cosmetic Act of 1938 if US Food and
Drug Administration (FDA) approved;
• Insulin and related supplies
for known diabetics, even if a prescription is not required by state
law;
• Immunizations/vaccines;
• Legend vitamins, including
prenatal vitamins;
• Smoking cessation products;
and
• Over-the-counter (OTC) medications.
2.2.6 NDAA Fiscal Year (FY) 2015,
Section 702 mandates beneficiaries to obtain select brand name maintenance
medications from the TRICARE Mail Order Pharmacy (TMOP) or the Market/MTF
pharmacy beginning October 1, 2015. Active Duty Service Members
(ADSMs) are exempt.
2.2.6.1 Maintenance medications are
defined as medications prescribed for a chronic, long-term condition that
is taken on a regular, recurring basis. Those maintenance medications
which are clinically appropriate and cost-effective to dispense
at TMOP will be included in the program as select maintenance medications.
2.2.6.2 Defense Health Agency (DHA)
will establish, maintain, and periodically revise and update a list
of select maintenance medications accessible at
http://www.health.mil/SelectDrugList and
by telephone through the pharmacy contractor’s call center.
2.2.6.3 The NDAA authorizes a waiver
of the mail order requirement based upon patient needs and other appropriate
circumstances. This waiver is obtained through an administrative
override request to the TRICARE Pharmacy contractor under procedures
established by the Director, DHA or designee. There is a blanket
waiver for prescription medications that are for acute care needs.
There is also a blanket waiver for prescriptions covered by OHI.
There is a case-by-case waiver to permit prescription maintenance
medication refills at a retail pharmacy when necessary due to personal
need or hardship, emergency, or other special circumstances (i.e.,
nursing home residents).
2.2.6.4 Beneficiaries shall be advised
that they may receive up to two, 30-day fills at a retail pharmacy
while they transition their prescription. The beneficiary shall
be contacted after each of these two fills and advised that the
prescription must be filled at a Market/MTF pharmacy or through
home delivery. Requests for a third fill at a retail pharmacy shall
be blocked and the beneficiary advised to call the TRICARE Pharmacy
contractor for assistance.
2.2.6.5 A fill is considered the dispensing
of a prescription for:
2.2.6.5.1 A medication, strength and
form that has not previously appeared on the patient’s pharmacy profile;
or
2.2.6.5.2 The same medication, strength
and form that is already on the patient’s pharmacy profile.