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 Chapter 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 U.S. 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 TMOP or the
MTF/
eMSM
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 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 TPharm 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 an MTF/eMSM Pharmacy
or through home delivery. Requests for a third fill
at a retail pharmacy
shall be blocked and the beneficiary advised to call the TPharm 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.