Fort Bliss Monitor

TRICARE provides world-class pharmacy benefit

TRICARE management activity

TRICARE provides a world-class pharmacy benefit to all Uniformed Servicemembers eligible for TRICARE, including TRICARE for Life beneficiaries entitled to Medicare Part A and B based on their age, disability or end-stage renal disease.

Eligible beneficiaries may fill prescription medications at military treatment facility pharmacies, the TRICARE Mail Order Pharmacy, retail network pharmacies, and non-network pharmacies. All beneficiaries must have their address and other information updated in the Defense Enrollment Eligibility Reporting System.

To have a prescription filled beneficiaries need a written prescription and a valid Uniformed Services identification card. TFL beneficiaries who turned age 65 April 1, 2001, or later, must be enrolled in Medicare Part B. TFL beneficiaries who turned age 65 before April 1, 2001, are not required to be enrolled in Medicare Part B for the pharmacy program, but are required to be enrolled in Medicare Part B for all other benefits available under TRICARE for Life.

As with most prescription drug plans, beneficiaries can enjoy a significant cost savings by asking their doctors to prescribe the generic equivalent of a brand-name drug. In the U.S., all generic drugs must undergo Food and Drug Administration testing and approval, and are considered safe alternatives to brand-name drugs. To learn more about any medication, check for generic equivalents, and about common food and drug interactions, beneficiaries may use the many Pharmacy resources, including the “Rx Checker,” available under the TRICARE Online General Health Information link on www.tricareonline.com. For more information on how to save costs and make the most of your benefit go to www.tricare.osd. mil/pharmacy or use the pharmacy link found on www.tricareonline.com.

MTF Pharmacy
Prescriptions may be filled (up to a 90-day supply for most medications) at a MTF pharmacy free of charge. Beneficiaries should contact their local MTF for specific details about filling and refilling prescriptions at its’ pharmacy.

Mail order pharmacy
TMOP is available for prescriptions that beneficiaries take on a regular basis. Beneficiaries may receive up to a 90-day supply for most medications. TMOP is administered by Express Scripts, Inc. Through this program, beneficiaries register with TMOP then mail their health care provider’s written prescription, along with the appropriate cost share, to TMOP and the medications are sent directly to the beneficiary. Prescriptions may be refilled by mail, phone or online.
For more information about how to use TMOP, beneficiaries may visit the Express Scripts Web site at www.express-scripts.com or contact TMOP member services at (866) 363-8667, within the United States, or toll-free (866) 275-4732, outside the U.S. They may also visit the TRICARE pharmacy Web site at www.tricare. osd.mil/pharmacy/tmop.cfm.

Retail pharmacy program
As of June 1, beneficiaries in the United States and its territories may now use an expanded, nationwide network of more than 53,000 retail pharmacies to fill prescriptions without having to file claims for reimbursement if the pharmacy is outside the beneficiary’s primary region.

Beneficiaries may use the TRICARE pharmacy locator service available on the Express Scripts Web site at http://member.express-scripts. com/pharmacyLocator/openPharmacyLocator.do?portal=dodCustom&net=1991 or call (866) 363-8779 to find a network pharmacy anywhere in the U.S., Puerto Rico, U.S. Virgin Islands and Guam. For information on the retail pharmacy program, visit the TRICARE Web site at www.tricare. osd.mil/pharmacy/.

The new contract with ESI provides beneficiaries with one central point of contact for pharmacy customer services and claims processing. A beneficiary should mail claims for other health insurance, or pharmacy claims for a non-network pharmacy to: Express Scripts, P.O. Box 66518, St. Louis, Mo., 63166-6518. A downloadable TRICARE claim form is available on the Express Scripts Web site at http://member. express-scripts.com/dodCustom/welcome.do. Beneficiaries may call Express Scripts at the numbers stated above for assistance.

Transition to ESI
In the transition to a new retail contract, which began June 1, some patients and providers may have been inconvenienced by the enforcement of TRICARE’s long-standing mandatory generic drug policy. TRICARE recognizes that enforcing this policy under the new TRICARE Retail pharmacy program may have caused a hardship for beneficiaries previously taking brand-name medications. In the interim, while the Department of Defense seeks documentation that may have been previously submitted to validate medical necessity, any beneficiary who has received a brand-name product when a generic alternative exists within 180 days from the date of the extension – from Dec. 21, 2003 through June 18, 2004 – will be allowed to continue receiving the brand-name product for a grace period of 180 days from June 18. This timeframe was extended Oct. 13 for an additional 60 days, a total of 180 days, and now expires Dec. 12. On the next visit to the doctor, beneficiaries should ask if a generic medication is appropriate for them.

Uniform formulary process
In the Fiscal Year 2000 National Defense Authorization Act, Congress directed DoD to establish a Uniform Formulary process. As part of this process, a DoD Pharmacy & Thera-peutics committee composed of pharmacists and physicians will systematically review and evaluate FDA-approved prescription medications to determine their relative clinical and cost effectiveness. The committee will make a recommendation as to which formulary tier a drug should be placed – generic, formulary or non-formulary – and will forward that recommendation to the Director of TRICARE Management Activity. Prior to the TMA decision, the recommendations will be reviewed by a new Beneficiary Advisory Panel who can provide comments to the TMA Director.

Currently, medications are available under one of two tiers: generic and brand name. Any drug in a therapeutic class determined to be either not as clinically effective or as cost effective as other drugs in the class may be recommended for placement in the third, non-formulary tier.

Any drug placed into the third tier will still be available to beneficiaries in retail pharmacies or through the TRICARE mail order pharmacy program, but at a higher cost. Non-formulary tier drugs will not be available in MTFs unless the prescription was written by a MTF provider and medical necessity for the drug has been established.

The new cost-share structure will affect all beneficiaries with the exception of active duty members who never pay cost shares for prescriptions.

The evaluations of therapeutic drug classes are underway; however, there are currently no drugs in the third (non-formulary) tier. As the process continues, some drugs will be placed in the third tier based on their relative clinical and cost effectiveness. Any change will be widely publicized prior to implementation.

Special cases
Beneficiaries may be able to request special review of medications in the third tier to make them available at second-tier costs. If a drug is classified in third tier, but is deemed “medically necessary” by the beneficiary’s provider for treatment of a TRICARE-covered service, meaning that there is a valid clinical reason the beneficiary must use the “non-formulary” medication, it may be considered as a special case. These special cases may include allergies to alternate medications, or interactions with other prescriptions a beneficiary is taking. Specific guidelines for requesting the review of a prescription medication as “medically necessary” will be available to both beneficiaries and providers.

Pharmacy co-pay structure
The current pharmacy cost share structure is based on whether a prescription medication is a brand-name pharmaceutical or a “generic” equivalent. The cost share chart outlines the costs and includes the new third tier, which is not yet in place. This co-pay structure applies to all beneficiaries, regardless of their TRICARE Prime enrollment status. Active duty do not pay co-payments for medications; however, if they fill prescriptions at non-network pharmacies, they will be required to pay 100 percent of the cost out-of-pocket and file a claim through which they will be reimbursed 100 percent for covered products.

• There are no medications yet listed in the third tier. Third-tier medications are generally unavailable in the MTF.

• Third-tier medications are not available to active-duty service members unless they obtain a medical necessity waiver.

Non-network pharmacies
Filling prescriptions at non-network pharmacies is the most expensive option and is not recommended. Beneficiaries may have to pay for the total amount first and file a claim to receive a partial reimbursement.

Using other health insurance
Beneficiaries who have prescription drug coverage from another health insurance plan may not use TMOP unless the medication is not covered under the other plan, or unless the beneficiary exceeds the dollar limit of coverage under the other plan. Beneficiaries may be eligible for full or partial reimbursement from TRICARE for out-of-pocket costs. Beneficiaries should call Express Scripts for specific instructions about filing pharmacy claims if they have other health insurance.

For information about the TRICARE pharmacy program, visit www.tricare.osd.mil/pharmacy/ or call (877) 363-6337.



www.bliss.army.mil	Published for the Fort Bliss/El Paso, Texas Community	October 21, 2004

<map name="boxmap-b4"> <area shape="rect" coords="0, 589, 120, 600" href="http://rcm.amazon.com/e/cm/privacy-policy.html?o=1" > <area coords="0,0,10000,10000" href="http://www.amazon.com/exec/obidos/redirect?tag=&creative=92501&camp=8117&link_code=dl1&path=subst/misc/amazon-cobrand-cc/v3/marketing-from-associates-step1.html/ref%3Db1_assoc_29" > </map>	TRICARE provides world-class pharmacy benefit TRICARE management activity TRICARE provides a world-class pharmacy benefit to all Uniformed Servicemembers eligible for TRICARE, including TRICARE for Life beneficiaries entitled to Medicare Part A and B based on their age, disability or end-stage renal disease. Eligible beneficiaries may fill prescription medications at military treatment facility pharmacies, the TRICARE Mail Order Pharmacy, retail network pharmacies, and non-network pharmacies. All beneficiaries must have their address and other information updated in the Defense Enrollment Eligibility Reporting System. To have a prescription filled beneficiaries need a written prescription and a valid Uniformed Services identification card. TFL beneficiaries who turned age 65 April 1, 2001, or later, must be enrolled in Medicare Part B. TFL beneficiaries who turned age 65 before April 1, 2001, are not required to be enrolled in Medicare Part B for the pharmacy program, but are required to be enrolled in Medicare Part B for all other benefits available under TRICARE for Life. As with most prescription drug plans, beneficiaries can enjoy a significant cost savings by asking their doctors to prescribe the generic equivalent of a brand-name drug. In the U.S., all generic drugs must undergo Food and Drug Administration testing and approval, and are considered safe alternatives to brand-name drugs. To learn more about any medication, check for generic equivalents, and about common food and drug interactions, beneficiaries may use the many Pharmacy resources, including the “Rx Checker,” available under the TRICARE Online General Health Information link on www.tricareonline.com. For more information on how to save costs and make the most of your benefit go to www.tricare.osd. mil/pharmacy or use the pharmacy link found on www.tricareonline.com. MTF Pharmacy Prescriptions may be filled (up to a 90-day supply for most medications) at a MTF pharmacy free of charge. Beneficiaries should contact their local MTF for specific details about filling and refilling prescriptions at its’ pharmacy. Mail order pharmacy TMOP is available for prescriptions that beneficiaries take on a regular basis. Beneficiaries may receive up to a 90-day supply for most medications. TMOP is administered by Express Scripts, Inc. Through this program, beneficiaries register with TMOP then mail their health care provider’s written prescription, along with the appropriate cost share, to TMOP and the medications are sent directly to the beneficiary. Prescriptions may be refilled by mail, phone or online. For more information about how to use TMOP, beneficiaries may visit the Express Scripts Web site at www.express-scripts.com or contact TMOP member services at (866) 363-8667, within the United States, or toll-free (866) 275-4732, outside the U.S. They may also visit the TRICARE pharmacy Web site at www.tricare. osd.mil/pharmacy/tmop.cfm. Retail pharmacy program As of June 1, beneficiaries in the United States and its territories may now use an expanded, nationwide network of more than 53,000 retail pharmacies to fill prescriptions without having to file claims for reimbursement if the pharmacy is outside the beneficiary’s primary region. Beneficiaries may use the TRICARE pharmacy locator service available on the Express Scripts Web site at http://member.express-scripts. com/pharmacyLocator/openPharmacyLocator.do?portal=dodCustom&net=1991 or call (866) 363-8779 to find a network pharmacy anywhere in the U.S., Puerto Rico, U.S. Virgin Islands and Guam. For information on the retail pharmacy program, visit the TRICARE Web site at www.tricare. osd.mil/pharmacy/. The new contract with ESI provides beneficiaries with one central point of contact for pharmacy customer services and claims processing. A beneficiary should mail claims for other health insurance, or pharmacy claims for a non-network pharmacy to: Express Scripts, P.O. Box 66518, St. Louis, Mo., 63166-6518. A downloadable TRICARE claim form is available on the Express Scripts Web site at http://member. express-scripts.com/dodCustom/welcome.do. Beneficiaries may call Express Scripts at the numbers stated above for assistance. Transition to ESI In the transition to a new retail contract, which began June 1, some patients and providers may have been inconvenienced by the enforcement of TRICARE’s long-standing mandatory generic drug policy. TRICARE recognizes that enforcing this policy under the new TRICARE Retail pharmacy program may have caused a hardship for beneficiaries previously taking brand-name medications. In the interim, while the Department of Defense seeks documentation that may have been previously submitted to validate medical necessity, any beneficiary who has received a brand-name product when a generic alternative exists within 180 days from the date of the extension – from Dec. 21, 2003 through June 18, 2004 – will be allowed to continue receiving the brand-name product for a grace period of 180 days from June 18. This timeframe was extended Oct. 13 for an additional 60 days, a total of 180 days, and now expires Dec. 12. On the next visit to the doctor, beneficiaries should ask if a generic medication is appropriate for them. Uniform formulary process In the Fiscal Year 2000 National Defense Authorization Act, Congress directed DoD to establish a Uniform Formulary process. As part of this process, a DoD Pharmacy & Thera-peutics committee composed of pharmacists and physicians will systematically review and evaluate FDA-approved prescription medications to determine their relative clinical and cost effectiveness. The committee will make a recommendation as to which formulary tier a drug should be placed – generic, formulary or non-formulary – and will forward that recommendation to the Director of TRICARE Management Activity. Prior to the TMA decision, the recommendations will be reviewed by a new Beneficiary Advisory Panel who can provide comments to the TMA Director. Currently, medications are available under one of two tiers: generic and brand name. Any drug in a therapeutic class determined to be either not as clinically effective or as cost effective as other drugs in the class may be recommended for placement in the third, non-formulary tier. Any drug placed into the third tier will still be available to beneficiaries in retail pharmacies or through the TRICARE mail order pharmacy program, but at a higher cost. Non-formulary tier drugs will not be available in MTFs unless the prescription was written by a MTF provider and medical necessity for the drug has been established. The new cost-share structure will affect all beneficiaries with the exception of active duty members who never pay cost shares for prescriptions. The evaluations of therapeutic drug classes are underway; however, there are currently no drugs in the third (non-formulary) tier. As the process continues, some drugs will be placed in the third tier based on their relative clinical and cost effectiveness. Any change will be widely publicized prior to implementation. Special cases Beneficiaries may be able to request special review of medications in the third tier to make them available at second-tier costs. If a drug is classified in third tier, but is deemed “medically necessary” by the beneficiary’s provider for treatment of a TRICARE-covered service, meaning that there is a valid clinical reason the beneficiary must use the “non-formulary” medication, it may be considered as a special case. These special cases may include allergies to alternate medications, or interactions with other prescriptions a beneficiary is taking. Specific guidelines for requesting the review of a prescription medication as “medically necessary” will be available to both beneficiaries and providers. Pharmacy co-pay structure The current pharmacy cost share structure is based on whether a prescription medication is a brand-name pharmaceutical or a “generic” equivalent. The cost share chart outlines the costs and includes the new third tier, which is not yet in place. This co-pay structure applies to all beneficiaries, regardless of their TRICARE Prime enrollment status. Active duty do not pay co-payments for medications; however, if they fill prescriptions at non-network pharmacies, they will be required to pay 100 percent of the cost out-of-pocket and file a claim through which they will be reimbursed 100 percent for covered products. • There are no medications yet listed in the third tier. Third-tier medications are generally unavailable in the MTF. • Third-tier medications are not available to active-duty service members unless they obtain a medical necessity waiver. Non-network pharmacies Filling prescriptions at non-network pharmacies is the most expensive option and is not recommended. Beneficiaries may have to pay for the total amount first and file a claim to receive a partial reimbursement. Using other health insurance Beneficiaries who have prescription drug coverage from another health insurance plan may not use TMOP unless the medication is not covered under the other plan, or unless the beneficiary exceeds the dollar limit of coverage under the other plan. Beneficiaries may be eligible for full or partial reimbursement from TRICARE for out-of-pocket costs. Beneficiaries should call Express Scripts for specific instructions about filing pharmacy claims if they have other health insurance. For information about the TRICARE pharmacy program, visit www.tricare.osd.mil/pharmacy/ or call (877) 363-6337.