spanning pharmacy benefits across the mhs mtf, tmop, trrx and medicare part d

1. Spanning Pharmacy Benefits Across the MHS � MTF, TMOP, TRRx and Medicare Part D TRICARE Retail Pharmacy

3. What Part D Enrollment Means to TRICARE Beneficiaries Enrollee must pay Part D monthly premium Approximately $37/month (varies by plan, adjusted yearly) Part D annual deductible - $250 TRICARE pays the deductible (first $250) Next $250 - $2250 drug costs Part D pays 75% ($1500), enrollee pays 25% ($500) Copayments may vary from plan to plan TRICARE covers copayments ($500)

4. Part D and TRICARE (con�t) $2250 - $5100 drug costs (Donut Hole) Enrollee responsible for 100% of drug cost Up to Part D cap of $3600 TRICARE becomes primary payer Bene pays TRICARE copayments $3 generic, $9 formulary, $22 non-formulary $5100 and up Bene continues to pay greater of 5% or $2/$5 copays after out-of pocket expenses = $3600

5. Part D and TRICARE (con�t) TRICARE copayments do not count toward Part D out-of-pocket spending cap of $3600 Cap calculated on calendar year Beneficiary copayments do apply to TRICARE cap of $3000 Cap calculated on a fiscal year

6. Doing the Math $37/mo premium (adjusted annually) Paid by the beneficiary $37 � $9 (formulary copay) 4 Rx�s per month through TRRx 12 Rx�s per month through TMOP $37 � $3 (generic copay) 12 Rx�s per month through TRRx 36 Rx�s per month through TMOP Part D formulary possibly more restrictive than TRICARE formulary Fewer pharmacies to choose from

7. Uniform Formulary Guidance found in CFR199.21 Pharmacy Benefits Program Three tier co-pay structure (TMOP/TRRx) $3.00 generic, $9.00 brand, $22.00 non-formulary $22.00 copay can be rolled back to $9.00 if medical necessity (MN) is established Active duty cannot pay $22.00 copay � can only receive non-formulary drug when MN established Non-formulary products are not available at MTF�s unless medical necessity is established

8. Uniform Formulary (con�t) Medical necessity approval is portable from MTF to TRRx/TMOP If MN approved in MTF, beneficiary can get drug for $9 at TRRx/TMOP Benefit coverage rules unchanged � mandatory generic policy still in effect Beneficiary cannot pay $22.00 copay for brand name product with equivalent generic

9. Uniform Formulary (con�t) DoD P&T committee makes recommendations for uniform formulary based on relative clinical & cost effectiveness DoD P&T committee develops medical necessity criteria to be used across MHS Medical necessity criteria available at www.tricare.osd.mil/pharmacy Beneficiary advisory panel reviews and comments on development of uniform formulary Comments on non-formulary recommendations and implementation period

10. Uniform Formulary Rx Co-Pays A simple chart. You have seen it before. It is a simple message. Our beneficiaries have a choice and may actively participate in managing the most comprehensive and robust pharmacy benefit in the nation. It isn�t free, but then, how many things do you truly value, that cost you nothing?A simple chart. You have seen it before. It is a simple message. Our beneficiaries have a choice and may actively participate in managing the most comprehensive and robust pharmacy benefit in the nation. It isn�t free, but then, how many things do you truly value, that cost you nothing?

11. TMOP Issues Prescriptions for non-formulary medications Beneficiary will receive charge for $22 copay Drugs moved to non-formulary tier will not be �grandfathered� until all refills are gone If medical necessity is established, drug will be dispensed for $9 copay Beneficiaries must make sure the following are on all prescriptions Name, sponsor�s SSN, DOB, address

12. Deployment Prescriptions Troop Deployment Medication Management Roster (TDMMR) Soldier Readiness Processing (SRP) site writes Rx � MTF at SRP site provides initial 180 day supply SRP faxes or mails the CONUS Registration & Prescription form to Pharmacy Operations Center (POC) � formerly PDTS Customer Service Support Center Prescription then forwarded to TMOP Medication automatically pushed to member (using address on record) Soldier must provide accurate/up-to-date information on form provided at SRP site Once in theater, must provide ESI with APO address where mail can be sent

13. Run-Off Claims Claims with a date of service prior to 01 June 04 ESI has processed 1.5 million run-off claims Currently processing claims received the first week of May 05 Timely filing waivers required for claims with date of service prior to 01 Mar 04 Waivers will not be given for claims > 6 years old

14. Timely Filing Waiver Process Claims with DOS prior to 01 Mar 04 returned to beneficiary with letter explaining timely filing requirements and instructions for requesting a waiver Beneficiary requests waiver from TMA-Aurora B&PS Request is reviewed in accordance with guidance found in TOM Chapter 8, Section 3 If approved, claims and waiver forwarded to ESI for payment May take up to 12 weeks before claim is processed

15. OHI Issues ESI can accept a verbal declaration that a beneficiary does not have OHI Beneficiary should call ESI customer service at 1-866-DoD-TRRx (866-363-8779) The call will be documented OHI claims should include EOB or receipt with amount OHI and beneficiary paid If receipt does not give adequate detail, claim will be processed as a primary claim If beneficiary has a supplemental policy, should not check OHI block on DD2642

16. Paper Claim Customer Support ESI patient care advocates cannot view a paper claim submitted, but not processed Only processed claims are imaged Patient care advocates do not have ready access to processed, imaged, paper claims Patient care advocates can view how a particular claim is processed in ESI�s Compass system Beneficiaries are told they will receive a call back from the patient care advocate (within 48 hours) ESI is drafting a plan to answer beneficiary inquiries in a more timely manner

17. TRRx Network Access Over 55,000 network pharmacies in U.S., Guam, Puerto Rico, U.S. Virgin Islands 43,000 under the MCSCs Network access performance standards Urban � 2 miles of 90% of beneficiaries Suburban � 5 miles of 95% of beneficiaries Rural � 15 miles of 95% of beneficiaries Performance standards met each month since contract start Pharmacy locator www.express-scripts.com

18. Alaska TRRx Network Under MCSCs � 35 network pharmacies Under TRRx � 66 network pharmacies Problem areas � Sitka, Petersburg, Cordova, Craig, Nome Sitka refuses to sign the network agreement; POS charges waived Petersburg very close to signing agreement Cordova and Craig have signed the agreement Nome (Norton Clinic) has not yet responded

19. TRRx and Indian Health Service IHS headquarters to sign one network agreement for all IHS facilities ESI awaiting signature Each Tribal Health Facility mailed a network agreement 52 signed; 1 refused; 119 outstanding Norton Clinic in Nome a tribal health facility

20. Other Network Issues Compounding pharmacies Many refuse to join the network Patient care advocates can assist in finding a compounding pharmacy Injectable pharmaceuticals Self injected products available through TRRx Product availability found on TRICARE formulary search tool

21. CatCap/Deductible Issues TRRx programming glitch caused deductible miscalculation Non-network paper claims Affected beneficiaries being identified CatCap miscalculation TMA working with DMDC and contractors to determine scope of problem Once scope determined TMA to address the issue

22. Points of Contact TMOP Donald.degroff@amedd.army.mil TRRx Jill.pettit@amedd.army.mil MTFs Hector.morales2@amedd.army.mil Medicare Part D Travis.watson@tma.osd.mil

23. MHS Pharmacy Links To find a network pharmacy www.tricare.osd.mil/pharmacy (at the top of the page, click �Find a retail pharmacy�) To see if your prescription is covered, the copay, and where you can have it filled www.tricareformularysearch.org For prior authorization, medical necessity, quantity limit info, and to download forms www.tricare.osd.mil/pharmacy

24. Questions?