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Module 10: Pharmacy. 2 Module Objectives After this module, you should be able to: Describe the TRICARE pharmacy benefit List who is eligible for TRICARE.

Published byJulianna Loraine Little Modified over 9 years ago

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Presentation on theme: "Module 10: Pharmacy. 2 Module Objectives After this module, you should be able to: Describe the TRICARE pharmacy benefit List who is eligible for TRICARE."— Presentation transcript:

1 Module 10: Pharmacy

2 2 Module Objectives After this module, you should be able to: Describe the TRICARE pharmacy benefit List who is eligible for TRICARE Pharmacy Benefits Compare the TRICARE Pharmacy options List TRICARE pharmacy costs

3 3 TRICARE Pharmacy Benefit Overview The TRICARE pharmacy benefit provides cost sharing for drugs and medicines that are approved for marketing by the U.S. Food and Drug Administration, (2) by U.S. law require a physician’s or other authorized professional provider prescription (acting within the scope of their license), and (3) are actually ordered and prescribed by an authorized provider in accordance with state and federal law. It includes retail and mail order prescription services, medications provided by physicians and other appropriate clinicians, and medications provided in support of home health care.

4 4 TRICARE Pharmacy Benefit s TRICARE offers several convenient ways for beneficiaries to have prescriptions filled Prescriptions can be filled at any of the pharmacies listed below Beneficiaries can use more than one option at a time Military Treatment Facility Pharmacy The least expensive option with no out-of-pocket costs. Mail Order Pharmacy (including specialty services) A cost-effective and convenient way for beneficiaries to get prescription medications. Network Retail Pharmacy Allows beneficiaries to fill prescriptions at network pharmacies across the country, including U.S. territories. Non-Network Retail Pharmacy (includes overseas host nation pharmacies) A pharmacy that is not in the TRICARE pharmacy network. It is the most expensive of the four available TRICARE pharmacy options.

5 5 Military Treatment Facility Pharmacy The Military Treatment Facility (MTF) pharmacy option is the most convenient to those who live close to a military medical facility with a pharmacy All TRICARE-eligible beneficiary may use the pharmacy at an MTF Beneficiaries must show a valid uniformed services ID card Beneficiaries may have prescriptions filled (up to a 90-day supply for most medications) at an MTF pharmacy free of charge Includes prescriptions written by licensed civilian providers

6 6 Mail Order Pharmacy Option (Home Delivery) The Mail Order Pharmacy (MOP) option is a cost-effective and convenient way for beneficiaries to get prescription medications, while also helping the Department of Defense contain health care costs and sustain first class health care benefits To use the MOP, beneficiaries must establish and activate their account via mail, phone, or online. Accounts must be established for each family member desiring to use this service There are two ways to activate an account: Online: www.express-scripts.com/custom/dod/ben_message Phone: Toll free inside the U.S. 1-866-363-8667 Outside of the U.S. 1-866-275-4732 Beneficiaries can request prescriptions or refills by mail, phone, or online (up to a 90-day supply for most medications) o Prescribers must have a U.S. Drug Enforcement Agency number

7 7 Network Retail Pharmacy Option The Network Retail Pharmacy option is best for people who desire not to use the mail order option or do not live near an MTF The network retail pharmacy option allows beneficiaries to fill prescriptions at civilian pharmacies throughout the United States, including U.S. territories To get prescriptions filled, beneficiaries simply present their written prescriptions along with their uniformed services ID card TRICARE for Life beneficiaries who have Medicare Part D must show their Medicare card Prescriptions from a licensed provider may be submitted electronically, faxed, or phoned in to the network retail pharmacy of choice, depending on pharmacy laws for that state Beneficiaries can find network retail pharmacies near their home or while traveling by accessing the Pharmacy Locator at: o http://member.express-scripts.com/dodCustom/home.do o Phone: 1-866-363-1303

8 8 Non-Network Retail Pharmacy Option A non-network retail pharmacy is a pharmacy that is not in the TRICARE pharmacy network Beneficiaries may get prescriptions filled at a non-network pharmacy; however, it is the most expensive of the four available TRICARE pharmacy options When using a non-network pharmacy, beneficiaries may have to pay the total amount up front oBeneficiaries then file a claim with ESI to receive partial reimbursement after the appropriate deductible is met TRICARE Prime enrollees who get prescriptions filled at non-network pharmacies incur point of service charges

9 9 Overseas When traveling overseas, beneficiaries should be aware that TRICARE retail pharmacies are only available outside the United States in Guam, the Northern Mariana Islands, Puerto Rico, and the U.S. Virgin Islands Beneficiaries can have prescriptions filled at host nation pharmacies (Non-U.S. territory), if necessary When beneficiaries have prescriptions filled at a host nation pharmacy, they should expect to pay the total amount up front and file a claim Host nation pharmacies are regarded as non-network pharmacies, therefore beneficiaries should be prepared to pay the total amount up front oBeneficiaries will file a claim with the overseas claims processor to receive partial reimbursement after the deductible is met

10 10 TRICARE Pharmacy Option Costs TRICARE Pharmacy Co-payments/Cost Shares (Also Guam, Puerto Rico, the U.S. Virgin Islands, American Samoa, and the Northern Mariana Islands) Formulary Non-formulary (Tier 3) Type of PharmacyGeneric (Tier 1)Brand Name (Tier 2) Military Treatment Facility (up to a 90-day supply) $0 Not Applicable MTFs are prohibited under the Code of Federal Regulations from carrying non-formulary medications Mail Order Pharmacy (up to a 90-day supply) $3$9 $22 unless medical necessity is established Retail Network Pharmacy (up to a 30-day supply) $3$9 $22 unless medical necessity is established Retail Non-Network Pharmacy (up to a 30-day supply) 50 percent cost share after the point of service deductible has been met (TRICARE Prime) 50 percent cost share after the point of service deductible has been met (TRICARE Prime) 50 percent cost share after the point of service deductible has been met (TRICARE Prime) $9 or 20 percent of the total cost, whichever is greater, after the annual outpatient deductible is met (TRICARE Standard) $22 or 20 percent, whichever is greater, after your annual outpatient deductible is met (TRICARE Standard) Non-U.S. Territory Host Nation Pharmacy (up to a 30-day supply) 50 percent cost share after the point of service deductible has been met (TRICARE Prime) 50 percent cost share after the point of service deductible has been met (TRICARE Prime) 50 percent cost share after the point of service deductible has been met (TRICARE Prime) 25 percent cost share after outpatient annual deductible is met (TRICARE Standard)

11 11 TRICARE Pharmacy Benefit Additional information can be obtained from the following sources: TRICARE.mil: www.tricare.mil/pharmacy Express Scripts, Inc. http://member.express-scripts.com/dodCustom/welcome.do

12 12 Congratulations! You’ve Completed Module 10: Pharmacy! You should now be able to: Describe the TRICARE pharmacy benefit List who is eligible for TRICARE Pharmacy Benefits Compare the TRICARE pharmacy options List TRICARE pharmacy costs

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