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Provider Handbook
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Medicare Part D Coverage
Pharmacy Data Transaction Service
Injectable Speciality Medications and TRICARE |
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Medicare Part D Coverage |
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Effective January 1, 2006, the new Medicare Part D prescription drug coverage became available to everyone with Medicare Part A and/or Medicare Part B.
You may direct eligible beneficiaries who inquire about Medicare Part D coverage to visit the TRICARE Web site. However, beneficiaries should visit the Medicare Web site for the most uptodate information on the Medicare Part D prescription drug benefit.
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Pharmacy Data Transaction Service |
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The Pharmacy Data Transaction Service (PDTS) creates a global centralized data repository that records information about prescriptions filled for DoD beneficiaries at MTFs, the TRICARE retail pharmacy network, and the mail-order pharmacy. PDTS improves the quality of prescription services and enhances patient safety by reducing the likelihood of adverse drug-drug interactions, therapeutic overlaps, and duplicate treatments across the highly transient population of active duty and retired beneficiaries. PDTS conducts an online prospective drug utilization review (a clinical screening) against a beneficiary’s complete medication history for each new or refilled prescription in real-time before it is dispensed to the patient. Regardless of where a beneficiary fills a prescription within the Military Health System, information about the prescription is stored in a robust central data repository and is available to authorized PDTS providers as a seamless enhancement to the current workflow processes. The PDTS provides the means for application of benefit design rules for consistency across all points of service available to DoD beneficiaries. |
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Injectable Specialty Medications and TRICARE |
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What is “specialty pharmacy?” |
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New drugs like Xolair® for asthma, recombinant hemophilia factors, Avonex® for multiple sclerosis (MS), and Enbrel® for rheumatoid arthritis are rapidly transforming medicine. These new high-cost biotechnology drugs and injectable antineoplastic drugs are known as “specialty pharmacy” products. These drugs are a breakthrough in treatment of many chronic diseases. It is expected that 30 or more new products will become available every year. This progress comes with a high price, as most of these medicines cost more than $1000 each month, with some costing more than $100,000 per year. |
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How does TRICARE cover injectable specialty medications? |
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TRICARE covers outpatient specialty pharmacy products in three ways:
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- Administered and billed by the provider
- Administered by the provider and billed by a specialty pharmacy
- Administered by the patient and billed by a specialty pharmacy
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Humana Military processes claims for specialty drugs administered by providers such as physicians and home health agencies. Allowable charges for these drugs are set by the government in the CMAC fee schedule. |
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Can TRICARE provide injectable drugs to my office? |
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Humana Military now has a network specialty pharmacy that can dispense prescriptions for TRICARE beneficiaries to provider offices. The preferred method for ordering specialty drugs to be administered by the provider is to submit a fax order form. You may download the fax order form from the Provider Resources section.
Beneficiaries may obtain self-administered specialty drugs through the TRRx program by calling
1-866-DoD-TRRX (1-866-363-8779).
Visit the TRICARE Web site to access the CMAC fee schedule.
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