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DoD Pharmacy Benefits

DoD Pharmacy Benefits. LTC Stacia Spridgen Director, DoD Pharmacoeconomic Center Hector Morales Deputy Director, Pharmacy Operations Center. TRICARE Pharmacy Program. FY08 – over 9.3 million TRICARE eligible beneficiaries FY08 - ~ 7 million use the pharmacy benefit

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DoD Pharmacy Benefits

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  1. DoD Pharmacy Benefits LTC Stacia Spridgen Director, DoD Pharmacoeconomic Center Hector MoralesDeputy Director, Pharmacy Operations Center

  2. TRICARE Pharmacy Program • FY08 – over 9.3 million TRICARE eligible beneficiaries • FY08 - ~ 7 million use the pharmacy benefit • 3- cost tier Uniform Formulary implemented in 2005 • DoD Pharmacy & Therapeutics Committee charged with review and recommendations on an evidence-based cost and clinical evaluation • Different than civilian pharmacy benefit plans • Coverage rules/copayments set by law • Congress approved changes • Forum for public comment on formulary changes

  3. TRICARE Pharmacy Program • MTF Pharmacy • TRICARE retail and mail-order programs administered by Express Scripts, Inc. • TRICARE Mail Order Pharmacy (TMOP) • TRICARE Retail Network Pharmacy (TRRx) • Non-network Retail Pharmacy

  4. TRICARE Mail Order Pharmacy (TMOP) • Convenient home delivery (FPO or APO for overseas locations) • Low Cost • Generic medication – $3 for up to a 90-day supply • Brand name medication – $9 for up to a 90-day supply • Non-formulary medication – $22 for up to a 90-day supply • Note: Up to a 30-day supply for controlled substances • Free Shipping & Handling • Visit www.express-scripts.com/TRICARE • 1-866-DoD-TMOP (1-888-363-8667)

  5. Beneficiary Cost Savings (TMOP versus Retail) Co-pay costs over 1 year of non-formulary medication: Retail $264 vs. TMOP $88 Savings per TMOP Rx over one year equals: $176 (non-formulary) $81 (Branded) $24 (Generic)

  6. TRICARE Retail Pharmacy Network • May have prescriptions filled at a local retail pharmacy in the TRICARE network • Over 60,000 retail pharmacies in the network • Portable across all regions—no claims to file • Generic medication—$3 per 30-day for up to a 90-day supply • Brand name medication—$9 per 30-day for up to 90-day supply • Non-formulary medication—$22 per 30 day for up to a 90-day supply (Except with Medical Necessity) • Visit www.tricare.osd.mil/pharmacy to locate a retail network pharmacy near you • 1-866-DoD-TRRx (1-866-363-8779)

  7. Non-Network Pharmacies • Most costly option for beneficiaries and government • TRICARE Standard deductibles and cost-shares apply • TRICARE Prime point of service option applies for TRICARE Prime beneficiaries • May have to pay for prescription and file paper claim with Express Scripts for reimbursement

  8. Generic Drug Use Policy • Generic drugs will be substituted for brand name when available • Must justify medical necessity for brand name to be dispensed • http://www.tricare.mil/mybenefit/home/Prescriptions/Medications/Non-FormularyMedications? If generic equivalent drug does not exist the brand name drug will be dispensed

  9. Drugs Requiring Prior Authorization • Certain medications require prior authorization, and quantity limits • Per DoD contracts, some drugs must be dispensed from retail, MTF, or mail order pharmacy • TRICARE covers all FDA approved prescription drugs approved for outpatient use with some exclusions established by law • http://www.tricare.mil/mybenefit/home/Prescriptions/Medications/PriorAuthorization?

  10. Other Health Insurance (OHI) • OHI is primary to TRICARE • Medicare Part D wrap around with COB • Not eligible for TMOP • Coordination of Benefits (COB) • Drugs not covered by OHI and exhausted benefits

  11. Claims (Out of network and OHI) Prescription claims must be filed within one year of the date of service.  To file a pharmacy claim, obtain and fill out a Patient's Request for Medical Payment (DD Form 2642). Prescription claims require the following information for each drug: • Name of the patient • Name, strength, date filled, days supply, quantity dispensed and price of each drug • National Drug Code, if available • Prescription number of each drug • Name and address of the pharmacy • Name and address of the prescribing physician

  12. http://www.tricareformularysearch.org/dod/medicationcenter/default.aspxhttp://www.tricareformularysearch.org/dod/medicationcenter/default.aspx

  13. PEC Website - Homepage https://rxnet.army.mil/pec/

  14. Contact Information To register for TMOP https://member.express-scripts.com/web/member/loginreg/dodRegistrationStart.do • 1-866-DoD-TMOP (1-888-363-8667) • Pharmacoeconomic Center 210-295-1271 • Pharmacy Operations Center 1-866-275-4732 option 8

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