TRICARE Manuals - Display Chap 2 Addendum B (Change 75, Nov 17, 2023)

Figure 2.B-1 Pharmacy Payment Matrix - Calendar year 2024/2025 Cost-Shares
TRICARE Pharmacy (TPharm) Copayments/Cost-Shares in the United States (U.S.) (including Puerto Rico, Guam, the U.S. Virgin Islands, American Samoa, and the Northern Marianna Islands)
Place Of Service	FORMULARY		Non-FORMULARY	Not covered
Place Of Service	Generic (Tier 1)	Brand Name (Tier 2)	(Tier 3)	Excluded (Tier 4)
Note: If medical necessity is established for a non-formulary drug, patients may qualify for the $43 copayment for up to a 30-day supply at the retail POS or a $38 copayment for a 90-day supply at the mail POS. Generic copayments apply to approved Over-the-Counter (OTC) medications at retail network pharmacies and TMOP. Approved vaccines will be available at participating network retail pharmacies at $0 copayment for beneficiaries eligible to use the TPharm benefit. Medications for smoking cessation are available in accordance with 32 CFR 199.21. Some medications may be excluded from the TRICARE Pharmacy benefit in accordance with 32 CFR 199.21(e)(3)(ii). These excluded medications may also be referred to as Tier 4 drugs.
Market/Military Medical Treatment Facility (MTF) Pharmacy (up to a 90-day supply)	$0	$0	Not Applicable	Not Available
TRICARE Mail Order Pharmacy (TMOP) (up to a 90-day supply)	$13	$38	$76	Not Available
TRICARE Retail Pharmacy Network (up to a 30-day supply)	$16	$43	$76	Full Cost
Retail Non-Network Pharmacy (up to a 30-day supply) Note: Beneficiaries using non-network pharmacies may have to pay the total amount of their prescription first and then file a claim to receive partial reimbursement.	TRICARE Prime: 50% cost-share after Point of Service (POS) deductibles. See Section 2 for deductibles. For those who are not enrolled in TRICARE Prime: $43 or 20% of total cost, whichever is greater, after annual deductible is met. See Section 2 for deductibles.		TRICARE Prime: 50% cost-share after POS deductibles. See Section 2 for deductibles. For those who are not enrolled in TRICARE Prime: $76 or 20% of total cost, whichever is greater, after annual deductible is met. See Section 2 for deductibles.	All beneficiaries: No reimbursement is authorized.

Figure 2.B-2 Pharmacy Payment Matrix - Calendar year 2022/2023 Cost-Shares
TRICARE Pharmacy (TPharm) Copayments/Cost-Shares in the United States (U.S.) (including Puerto Rico, Guam, the U.S. Virgin Islands, American Samoa, and the Northern Marianna Islands)
Place Of Service	FORMULARY		Non-FORMULARY	Not Covered
Place Of Service	Generic (Tier 1)	Brand Name (Tier 2)	(Tier 3)	Excluded (Tier 4)
Note: If medical necessity is established for a non-formulary drug, patients may qualify for the $38 copayment for up to a 30-day supply at the retail POS or a $34 copayment for a 90-day supply at the mail POS. Generic copayments apply to approved Over-the-Counter (OTC) medications at retail network pharmacies and TMOP. Approved vaccines will be available at participating network retail pharmacies at $0 copayment for beneficiaries eligible to use the TPharm benefit. Medications for smoking cessation are available in accordance with 32 CFR 199.21. Some medications may be excluded from the TRICARE Pharmacy benefit in accordance with 32 CFR 199.21(e)(3)(ii). These excluded medications may also be referred to as Tier 4 drugs.
Market/Military Medical Treatment Facility (MTF) Pharmacy (up to a 90-day supply)	$0	$0	Not Applicable	Not Available
TRICARE Mail Order Pharmacy (TMOP) (up to a 90-day supply)	$12	$34	$68	Not Available
TRICARE Retail Pharmacy Network (up to a 30-day supply)	$14	$38	$68	Full Cost
Retail Non-Network Pharmacy (up to a 30-day supply) Note: Beneficiaries using non-network pharmacies may have to pay the total amount of their prescription first and then file a claim to receive partial reimbursement.	TRICARE Prime: 50% cost-share after Point of Service (POS) deductibles. See Section 2 for deductibles. For those who are not enrolled in TRICARE Prime: $38 or 20% of total cost, whichever is greater, after annual deductible is met. See Section 2 for deductibles.		TRICARE Prime: 50% cost-share after POS deductibles. See Section 2 for deductibles. For those who are not enrolled in TRICARE Prime: $68 or 20% of total cost, whichever is greater, after annual deductible is met. See Section 2 for deductibles.	All beneficiaries: No reimbursement is authorized.

Figure 2.B-3 Pharmacy Payment Matrix - Calendar year 2020/2021 Cost-Shares
TRICARE Pharmacy (TPharm) Copayments/Cost-Shares in the United States (U.S.) (including Puerto Rico, Guam, the U.S. Virgin Islands, American Samoa, and the Northern Marianna Islands)
Place Of Service	Formulary		Non-Formulary	Not Covered
Place Of Service	Generic (Tier 1)	Brand Name (Tier 2)	(Tier 3)	Excluded (Tier 4)
Note: If medical necessity is established for a non-formulary drug, patients may qualify for the $33 copayment for up to a 30-day supply at the retail POS or a $29 copayment for a 90-day supply at the mail POS. Generic copayments apply to approved Over-the-Counter (OTC) medications at retail network pharmacies and TMOP. Approved vaccines will be available at participating network retail pharmacies at $0 copayment for beneficiaries eligible to use the TPharm benefit. Medications for smoking cessation are available in accordance with 32 CFR 199.21. Some medications may be excluded from the TRICARE Pharmacy benefit in accordance with 32 CFR 199.21(e)(3)(ii). These excluded medications may also be referred to as Tier 4 drugs.
Market/Military Medical Treatment Facility (MTF) Pharmacy (up to a 90-day supply)	$0	$0	Not Applicable	Not Applicable
TRICARE Mail Order Pharmacy (TMOP) (up to a 90-day supply)	$10	$29	$60	Not Applicable
TRICARE Retail Pharmacy Network (up to a 30-day supply)	$13	$33	$60	Full Cost
Retail Non-Network Pharmacy (up to a 30-day supply) Note: Beneficiaries using non-network pharmacies may have to pay the total amount of their prescription first and then file a claim to receive partial reimbursement.	TRICARE Prime: 50% cost-share after Point of Service (POS) deductibles. See Section 2 for deductibles. For those who are not enrolled in TRICARE Prime: $33 or 20% of total cost, whichever is greater, after annual deductible is met. See Section 2 for deductibles.		TRICARE Prime: 50% cost-share after POS deductibles. See Section 2 for deductibles. For those who are not enrolled in TRICARE Prime: $60 or 20% of total cost, whichever is greater, after annual deductible is met. See Section 2 for deductibles.	All beneficiaries: No reimbursement is authorized.

Figure 2.B-4 Pharmacy Payment Matrix - Fiscal Year 2017 Cost-Shares
This table reference is for those individuals falling under National Defense Authorization Act (NDAA) copay freeze at 2017 rates.
TRICARE Pharmacy (TPharm) Copayments/Cost-Shares in the United States (U.S.) (including Puerto Rico, Guam, the U.S. Virgin Islands, American Samoa, and the Northern Marianna Islands)
place OF SERVICE	Formulary		Non-Formulary	Not Covered
place OF SERVICE	GENERIC (tier 1)	BRAND NAME (TIER 2)	(tier 3)	Excluded (Tier 4)
Note: If medical necessity is established for a non-formulary drug, patients may qualify for the $24 copayment for up to a 30-day supply at the retail POS or a $20 copayment for a 90-day supply at the mail POS. Generic copayments apply to approved Over-the-Counter (OTC) medications at retail network pharmacies and TMOP. Approved vaccines will be available at participating network retail pharmacies at $0 copayment for beneficiaries eligible to use the TPharm benefit. Medications for smoking cessation are available in accordance with 32 CFR 199.21. Some medications may be excluded from the TRICARE Pharmacy benefit in accordance with 32 CFR 199.21(e)(3)(ii). These excluded medications may also be referred to as Tier 4 drugs.
Market/Military Medical Treatment Facility (MTF) Pharmacy (up to a 90-day supply)	$0	$0	Not Applicable	Not Applicable
TRICARE Mail Order Pharmacy (TMOP) (up to a 90-day supply)	$0	$20	$49	Not Applicable
TRICARE Retail Pharmacy Network (up to a 30-day supply)	$10	$24	$50	Full Cost
Retail Non-Network Pharmacy (up to a 30-day supply) Note: Beneficiaries using non-network pharmacies may have to pay the total amount of their prescription first and then file a claim to receive partial reimbursement.	TRICARE Prime: 50% cost-share after Point of Service (POS) deductibles. See Section 2, for deductibles. For those who are not enrolled in TRICARE Prime: $24 or 20% of total cost, whichever is greater, after annual deductible is met. See Section 2, for deductibles.		TRICARE Prime: 50% cost-share after POS deductibles. See Section 2, for deductibles. For those who are not enrolled in TRICARE Prime: $50 or 20% of total cost, whichever is greater, after annual deductible is met. See Section 2, for deductibles.	All beneficiaries: No reimbursement is authorized.