CHANGE M MAY 30, Page 1 Page 1. CHAPTER 8 Section 9.1, pages 1 and 2 Section 9.1, pages 1 and 2
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2 CHANGE M MAY 30, 2018 REMOVE PAGE(S) INSERT PAGE(S) FOREWORD FOREWORD Page 1 Page 1 CHAPTER 8 Section 9.1, pages 1 and 2 Section 9.1, pages 1 and 2 2
3 HPOB April 1, 2015 Foreword Revision: C-24, May 30, 2018 The TRICARE Policy Manual (TPM) M, in conjunction with the TRICARE Reimbursement Manual (TRM), M, contains operational policy necessary to efficiently implement the Code of Federal Regulations at 32 CFR 199. This manual augments the 32 CFR 199 and must be used in conjunction for complete policy information, providing guidance, policy interpretation and decisions implementing TRICARE, including those policies and procedures applicable to the TRICARE Health Plan. The Department of Defense (DoD) has a License Agreement with the American Medical Association (AMA) regarding the use of the Physician s Current Procedural Terminology (CPT), a coding work of medical nomenclature developed by the AMA. In accordance with the terms of that Agreement, the DoD has agreed to: 1. Include a Copyright notice in every section that references CPT codes; 2. Specifically identify procedure codes as CPT procedure codes; 3. Use only short descriptions with CPT codes and delete all long descriptions; and 4. Italicize short descriptions wherever they are used. The TRICARE Manuals provide instructions, guidance and responsibilities in addition to the requirements set forth in the incorporated federal statutes and the regulations and may not be interpreted in contradiction thereto. John L. Arendale, Branch Chief Health Plan Operations Branch (HPOB) Defense Health Agency (DHA) Definitions are available in the Apr 2015 TRICARE Operations Manual (TOM), Appendix A. Acronyms and abbreviations are available at DownloadManualFile.aspx?Filename=Acronyms.pdf. 1 C-24, May 30, 2018
4 ATTENTION Links from the documents contained within this manual (and placed on the TRICARE Manuals web site) may include links providing direct access to other Internet resources, including web sites. Because of the dynamic nature of the Internet, Defense Health Agency (DHA) cannot be responsible for the accuracy of or content of information contained in the links to other web sites.
5 TRICARE Policy Manual M, April 1, 2015 Other Services Chapter 8 Section 9.1 Pharmacy Benefits Program Issue Date: August 2002 Authority: 32 CFR 199.2(b), 32 CFR 199.4(b)(2)(vi), (b)(3)(iii), (b)(5)(v), (d)(3)(vi), (e)(11)(i), 32 CFR 199.5(d)(12); 32 CFR , and 10 USC 1074g Revision: C-24, May 30, DESCRIPTION 1.1 General The TRICARE Pharmacy (TPharm) benefit includes retail and mail order prescription services, medications provided by physicians and other appropriate clinicians, and pharmaceutical agents provided in support of home health care. TRICARE uses a number of contractors to administer the benefit. 1.2 Retail Prescription Service Retail pharmacy services, network and non-network, will be provided under a TPharm contract and will be subject to the Uniform Formulary. The TRICARE formulary is found at The retail pharmacy contractor is responsible for administering claims related to pharmaceuticals dispensed by an authorized provider with a National Council of Prescription Drug Programs (NCPDP) or other nationally recognized pharmacy designation. 1.3 Mail Order Prescription Service Mail order prescription services are provided under a TPharm contract and will be subject to the Uniform Formulary. The TRICARE formulary is found at Medical Claims That Include Pharmaceutical Agents Pharmaceutical agents provided by physicians and other appropriate clinicians, and pharmaceutical agents provided in support of home health care are processed by the contractor(s). Claims for pharmaceutical agents (e.g., injectables) not appropriate for self-administration are the responsibility of the contractor. 1.5 Infusion Drug Therapy Delivered In The Home When injectable and infusion drug therapy are medically necessary, and delivery and administration in the home is appropriate the contractor shall provide prior authorization of injectable or infused drugs to a TRICARE authorized pharmacy in order for the pharmaceutical agent to be fulfilled under the pharmacy benefit pursuant to Section 20.1, Infusion Drug Therapy Delivered in the Home. 1 C-24, May 30, 2018
6 1.6 Overseas Claims TRICARE Policy Manual M, April 1, 2015 Chapter 8, Section 9.1 Pharmacy Benefits Program The TRICARE overseas claims processor (see the TRICARE Operations Manual (TOM), Chapter 24, Section 9) processes pharmaceutical claims from most overseas locations. As of June 1, 2004, the TPharm contractor processes network and non-network retail pharmaceutical claims in Puerto Rico, the U.S. Virgin Islands, Northern Mariana Islands, and Guam. 2.0 POLICY 2.1 Formulary Formulary management will be the responsibility of the Government as defined by 32 CFR , Pharmacy Benefits Program. This regulation establishes procedures for the inclusion of pharmaceutical agents on a Uniform Formulary based upon relative clinical effectiveness and cost effectiveness; establishes cost-sharing requirements, including a tiered copayment structure, for generic, formulary and non-formulary pharmaceutical agents; establishes procedures to assure the availability of pharmaceutical agents not included on the Uniform Formulary to eligible beneficiaries at the non-formulary cost-share tier; establishes procedures to provide, when clinically necessary, pharmaceutical agents not included on the Uniform Formulary under the same terms and conditions as an agent on the Uniform Formulary; establishes procedures to assure the availability of clinically appropriate non-formulary pharmaceutical agents to members of the uniformed services; establishes procedures for prior authorization when required; and establishes a Department of Defense Pharmacy and Therapeutics Committee (DoD P&T Committee) and a Uniform Formulary Beneficiary Advisory Panel. All formulary decisions, to include prior authorization requirements, designation of nonformulary agents, quantity limits, and other medication use policies will be communicated to all contractors who have responsibility for administering the pharmacy benefit. 2.2 General Prescription Coverage The Pharmacy Benefits Program generally requires mandatory substitution of generic drugs in accordance with 32 CFR (i)(2). If state law prohibits generic substitution on drugs, the contractor, at the direction of the Government, shall be able to process the brand product Eligible beneficiaries shall pay a copayment for drug claims that are cost-shared under the Pharmacy Benefit Program in accordance with the TRICARE Reimbursement Manual (TRM), Chapter 2, Addendum B. Section 702 of National Defense Authorization Act (NDAA) 2018 states the cost-sharing amounts for a dependent of a member of uniformed services who dies while on active duty, a member retired under Chapter 61, or a dependent of a member retired under such chapter shall be equal to the cost-sharing amount, if any, for TRICARE is the secondary payor on claims where Other Health Insurance (OHI) coverage exists. OHI claims are reimbursed in accordance with TRM, Chapter 4, Section 3. Reimbursement will be the lesser of the TRICARE allowed amount or the remaining amount after OHI payment Labeled Indications. Pharmaceutical agents may be cost-shared when: The pharmaceutical agent is approved for marketing by the U.S. Food and Drug Administration (FDA); 2
Chapter 8 Section 9.1
Other Services Chapter 8 Section 9.1 Issue Date: August 2002 Authority: 32 CFR 199.2(b), 32 CFR 199.4(b)(2)(vi), (b)(3)(iii), (b)(5)(v), (d)(3)(vi), (e)(11)(i), 32 CFR 199.5(d)(12); 32 CFR 199.17, and
Chapter 8 Section 9.1
Other Services Chapter 8 Section 9.1 Issue Date: August 2002 Authority: 32 CFR 199.2(b), 32 CFR 199.4(b)(2)(vi), (b)(3)(iii), (b)(5)(v), (d)(3)(vi), (e)(11)(i), 32 CFR 199.5(d)(12); 32 CFR 199.17, and
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