TRICARE Pharmacy

Army Reserve: Retired

Benefit Fact Sheet

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Summary:

TRICARE provides a pharmacy benefit to all eligible Soldiers, including beneficiaries entitled to Medicare Parts A and Parts B based on their age. Eligible beneficiaries may fill prescription medications at military treatment facility (MTF) pharmacies; through the TRICARE Express Scripts, Inc. (Express Scripts); at TRICARE retail network pharmacies; and at non-network retail pharmacies. Prescriptions filled through the MTF, TRICARE Pharmacy Home Delivery, and retail network pharmacies are checked for accuracy and are checked against your TRICARE prescription history for potential drug interactions. To have a prescription filled; beneficiaries need a written prescription and a valid Uniformed Services identification card.

Benefit Highlights:

Benefit Highlights:

TRICARE's mandatory generic drug policy requires that prescriptions be filled with a generic product, if one is available. In the United States, all generic drugs must undergo Food and Drug Administration testing and approval, and are considered safe alternative to brand-name drugs.

Beneficiaries pay the pharmacy copayment based on whether the prescription medication is classified as a formulary generic (Tier 1), formulary brand name (Tier 2), or non-formulary (Tier 3) drug. The copayment depends on where the beneficiary chooses to fill their prescription.

All TRICARE-eligible beneficiaries who are registered in Defense Enrollment Eligibility Reporting System (DEERS) are automatically eligible for the retail network pharmacy option. This option allows you to fill your prescriptions at TRICARE retail network pharmacies throughout the country without having to submit a claim. You have access to a network of approximately 60,000 retail pharmacies in the United States and its territories (American Samoa,* Guam, the Northern Mariana Islands, Puerto Rico, and the U.S. Virgin Islands). Registration is not required. To find the nearest TRICARE retail network pharmacy, visit http://www.express-scripts.com/TRICARE/ or call 1-877-363-1303.

Active duty Soldiers do not pay copayments for prescriptions. However, if they receive medications through an overseas pharmacy or an out-of-network pharmacy, they may need to pay out-of-pocket for the total cost of the medication and then file a claim for reimbursement for the full amount.

Pharmacy Copayments

TRICARE Pharmacy Copayments In the United States (Including Puerto Rico, Guam, Virgin Islands, America Samoa, and the Northern Marianna Islands)

Type of Pharmacy

Uniform Formulary

Formulary Drugs

Non-Formulary Drugs
(Tier 3)*

Generic (Tier 1)

Brand Name (Tier 2)

Military Treatment Facility (MTF) (up to a 90-day supply)

$0

$0

Not Applicable**

TRICARE Pharmacy Home Delivery
(up to a 90-day supply)

$0

$13

$43*

Retail Network Pharmacy
(up to a 30-day supply)

$5

$17

$44*

Non-network Pharmacy (up to a 30-day supply)

TRICARE Prime options: 50% copayment applies after point-of-service (POS) deductible met***

All other beneficiaries: $17 or 20% of total cost, whichever is greater, after deductible is met ***

TRICARE Prime options: 50% copayment applies after POS deductible is met***

All other beneficiaries: $44 or 20% of total cost, whichever is greater, after deductible is met***

* Not available to active duty service members (ADSMs) without medical-necessity approval, in which case the copayment is $0.

** Not available without medical-necessity approval.

*** See Figure 5.3 for annual deductible amounts.

Using Other Health Insurance (OHI):

You are not eligible to use TRICARE Pharmacy Home Delivery if you have other health insurance (OHI) with a prescription plan, including a Medicare Part D prescription program, unless you meet one of the following requirements:

  • Your OHI does not include pharmacy benefits
  • The medication you need is not covered by your OHI
  • You have met your OHI's benefit cap (i.e., you have met your benefit's maximum coverage limit)

Once you have met one of these requirements, you may submit your prescription to TRICARE Pharmacy Home Delivery. You'll need to send proof from your other plan that it isn't covered or you've met the benefit cap.

There are three ways to send new prescriptions to Express Scripts for Home Delivery. Ask your provider to write the prescription for the maximum supply allowed, which is 90 days for most drugs.

Electronically

e-Prescribing is the easiest, safest, and most effective way.

  • Sent by your provider to Express Scripts.
  • Your provider:
    • selects the TRICARE formulary in their e-prescribing system.
    • chooses the default location of "Express Scripts Mail Pharmacy."
  • Express Scripts uses the information submitted with your prescription to complete your registration.
  • By law, e-prescribing currently doesn't allow prescriptions for controlled substances.

By Fax

  • Sent by your provider (with a fax cover sheet) directly to Express Scripts:
    • 1-877-895-1900 in the United States
    • 1-602-586-3911 if Overseas
  • Express Scripts will only accept prescriptions faxed directly from your provider's office.
  • By law, faxing currently doesn't allow prescriptions for Schedule II controlled substances.

By Mail

  • Sent by you to Express Scripts
  • Complete the New Patient Mail Order Form-follow all the instructions on the form
  • Write the following information on the back of each written prescription:
    • Patient's full name
    • Date of birth
    • Address
    • Sponsor's ID number
  • Include your prescription copayment. Payment can be by credit card, check, or money order.
  • Mail the completed form, written prescription and copayment to:

Express Scripts, Inc.
P.O. Box 52150
Phoenix, AZ 85072-9954

If your OHI provides only medical coverage (not pharmacy coverage), you still may be eligible to use TRICARE Pharmacy Home Delivery as your prescription benefit. For more information, call Express Scripts, Inc. at 1-877-363-1303.

Having OHI does not prevent you from using TRICARE retail network pharmacies. If you have pharmacy benefits through your OHI, TRICARE becomes the second payer by law.

Note: Supplemental and discount prescription drug programs, such as Senior Friends and American Association of Retired Persons, do not count as OHI pharmacy coverage.

Additional Information:

For more information, please visit the TRICARE Pharmacy Program webpage maintained by the TRICARE Management Activity:
http://www.tricare.mil/pharmacy.aspx

TRICARE Pharmacy Program Handbook:
http://www.tricare.mil/~/media/Files/TRICARE/Publications/Handbooks/Pharmacy_HBK.ashx

TRICARE DEERS Information:
http://www.tricare.mil/DEERS

Document Review Date: 6 March 2014