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TRICARE Reimbursement Manual 6010.64-M, April 2021
Beneficiary Liability
Chapter 2
Addendum B
Pharmacy Benefits Program - Cost-Shares
Revision:  C-11, October 11, 2024
Figure 2.B-1  Pharmacy Payment Matrix - Calendar year 2024/2025 Cost-Shares
TRICARE Pharmacy (TPharm) Copayments/Cost-Shares in the United States (US) (including Puerto Rico, Guam, the US Virgin Islands, American Samoa, and the Northern Marianna Islands)
Place Of Service
FORMULARY
Non-FORMULARY
Not Covered
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 (US) (including Puerto Rico, Guam, the US Virgin Islands, American Samoa, and the Northern Marianna Islands)
Place Of Service
FORMULARY
Non-FORMULARY
Not Covered
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 (US) (including Puerto Rico, Guam, the US Virgin Islands, American Samoa, and the Northern Marianna Islands)
Place Of Service
FORMULARY
Non-FORMULARY
NOT COVERED
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.
Approved medicationsMedications for smoking cessation will be are available at the TMOP for up to a 60-day supply per fill, at $0 copayment 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)
$10
$29
$60
Not Available
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-2  Pharmacy Payment Matrix - Calendar Year 2018/2019 Cost-Shares
TRICARE Pharmacy (TPharm) Copayments/Cost-Shares in the United States (US) (including Puerto Rico, Guam, the US Virgin Islands, American Samoa, and the Northern Marianna Islands)
Place Of Service
FORMULARY
Non-FORMULARY
Generic
(Tier 1)
Brand Name
(Tier 2)
(Tier 3)
Note:   If medical necessity is established for a non-formulary drug, patients may qualify for the $28 copayment for up to a 30-day supply at the retail POS or a $24 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.
Approved medications for smoking cessation will be available at the TMOP for up to a 60-day supply per fill, at $0 copayment.
Market/Military Medical Treatment Facility (MTF) Pharmacy
(up to a 90-day supply)
$0
$0
Not Applicable
TRICARE Mail Order Pharmacy (TMOP)
(up to a 90-day supply)
$7
$24
$53
TRICARE Retail Pharmacy Network
(up to a 30-day supply)
$11
$28
$53
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: $28 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: $53 or 20% of total cost, whichever is greater, after annual deductible is met. See Section 2 for deductibles.
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 (US) (including Puerto Rico, Guam, the US Virgin Islands, American Samoa, and the Northern Marianna Islands)
place OF SERVICE
FORMULARY
Non-FORMULARY
NOT COVERED
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.
Approved medicationsMedications for smoking cessation will be are available at the TMOP for up to a 60-day supply per fill, at $0 copayment 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)
$0
$20
$49
Not Available
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.
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