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TRICARE Reimbursement Manual 6010.61-M, April 1, 2015
Beneficiary Liability
Chapter 2
Addendum B
Pharmacy Benefits Program - Cost-Shares
Revision:  C-43, November 27, 2019
Figure 2.B-1  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
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 $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 medications for smoking cessation will be available at the TMOP for up to a 60-day supply per fill, at $0 copayment.
Military Treatment Facility (MTF)/Enhanced Multi-Service Market (eMSM) Pharmacy
(up to a 90-day supply)
$0
$0
Not Applicable
TRICARE Mail Order Pharmacy (TMOP)
(up to a 90-day supply)
$10
$29
$60
TRICARE Retail Pharmacy Network
(up to a 30-day supply)
$13
$33
$60
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.
Figure 2.B-2  Pharmacy Payment Matrix - Calendar Year 2018/2019 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
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.
Military Treatment Facility (MTF)/Enhanced Multi-Service Market (eMSM) 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-3  Pharmacy Payment Matrix - Fiscal Year 2017 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
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 $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 medications for smoking cessation will be available at the TMOP for up to a 60-day supply per fill, at $0 copayment.
Military Treatment Facility (MTF)/Enhanced Multi-Service Market (eMSM) Pharmacy
(up to a 90-day supply)
$0
$0
Not Applicable
TRICARE Mail Order Pharmacy (TMOP)
(up to a 90-day supply)
$0
$20
$49
TRICARE Retail Pharmacy Network
(up to a 30-day supply)
$10
$24
$50
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.
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