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DoD Uniform Formulary Creates Three-Tiered Pharmacy Cost Structure (Article 7) |
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This year, TRICARE is in the process of establishing a single Department of Defense (DoD) Uniform Formulary. Prescription drugs available to TRICARE beneficiaries will be categorized in three tiers: generic, formulary (brand name) and non-formulary.
When the final rule for the new formulary was published in April, Dr. William Winkenwerder, Jr., assistant secretary of defense for health affairs, explained, “The formulary will bring consistency and standardized management to our $4 billion pharmacy benefit. The new tiered cost structure encourages a more cost-effective use of the benefit, while also providing beneficiaries with continued access to the medications they need.” |
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The DoD Pharmacy and Therapeutics Committee is establishing the DoD Uniform Formulary process. Physicians and pharmacists on the committee are evaluating prescription drugs based on their clinical and cost effectiveness when compared with other drugs in the same therapeutic class. This will help determine in which tier a drug should be categorized.
There will be no drugs in the non-formulary tier until the committee has finished its evaluation in accordance with the DoD Uniform Formulary process. Once the final approval has been made, more specific information will be made available to beneficiaries and providers.
The Cost of Filling Your Prescriptions
Costs for generic and brand name (formulary) medications will be the same as they were prior to the formulary ruling. A third-tier pricing structure will be added for non-formulary medications (see chart).
You may still be able to get a non-formulary medication at the formulary cost-share (see chart) if your doctor submits documentation that shows that the non-formulary drug is medically necessary because you cannot use the comparable formulary drugs, have had allergic reactions to them, etc.
Information on how to request a review of a prescription medication as “medically necessary” will be made available to both beneficiaries and providers once the final DoD Uniform Formulary process has been approved. For the most current information, visit the TRICARE Pharmacy Web site.
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TRICARE Pharmacy Cost-Shares
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| Place of Service |
Generic |
Formulary (brand name) |
Non-formulary |
| Military Treatment Facility (MTF) Pharmacy |
$0 |
$0 |
$0 |
TRICARE Mail Order Pharmacy (TMOP)
(up to a 90-day supply) |
$3 |
$9 |
$22 |
Retail Network Pharmacy
(up to a 30-day supply) |
$3 |
$9 |
$22 |
Non-network Retail Pharmacy
(up to a 30-day supply) |
$9 or 20% of total cost (whichever is greater) after deductible has been met (E1-E4 $50 per person/$100 per family; All others $150 per person/$300 per family)
TRICARE Prime—50% cost-share after point-of service (POS) deductible has been met ($300 per person/$600 per family) |
$22 or 20% of total cost (whichever is greater) after deductible has been met (E1-E4 $50 per person/$100 per family; All others $150 per person/$300 per family)
TRICARE Prime— 50% cost-share after POS deductible has been met ($300 per person/$600 per family) |
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“The military treatment facility remains the best value for all users of the TRICARE pharmacy program,” said Army Colonel William Davies, director of DoD pharmacy programs. “By having prescriptions filled at the MTF, TRICARE beneficiaries eliminate their out-of-pocket costs.” |
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Last Reviewed: December 4, 2007
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