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This year, TRICARE is establishing a single Department of Defense (DoD) Uniform Formulary under the TRICARE Pharmacy Benefits Program, implemented through
Title 32 Code of Federal Regulations, Part 199.21. Major provisions of the rule include
the establishment of:
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When the final rule for the new formulary was published in April 2004, 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.”
Charged with establishing and maintaining the DoD Uniform Formulary, the DoD P&T Committee is a representative
group of uniformed services clinicians, primarily physicians and pharmacists. The physicians and pharmacists on the committee will evaluate prescription drugs based on their relative clinical and cost effectiveness when compared with
other drugs in the same therapeutic class to recommend in which tier a drug should be categorized.
The committee will meet on a quarterly basis. Any committee recommendations regarding the DoD Uniform
Formulary will be reviewed and commented on by the BAP. Committee minutes and BAP comments will then be forwarded to the Director of the TRICARE Management Activity for approval.
How Does the DoD Uniform Formulary Affect the TRICARE Pharmacy Benefit?
Drug coverage under the TRICARE Pharmacy benefit has not changed; however, cost-shares for certain drugs may change should they be moved to the third-tier (non-formulary tier) under the DoD Uniform Formulary.
Changes to the formulary tier for specific medications will be communicated to providers via this newsletter or on the TRICARE Pharmacy Web site (www.tricare.osd.mil/pharmacy), in addition to other electronic and print media.
The Cost of Filling Prescriptions
Cost-shares for the TRICARE pharmacy benefit are detailed in the chart below. Note that the cost-shares for generic
and formulary medications remain unchanged.
Drugs moved to the third tier (non-formulary status), however, may be prescribed and dispensed to the beneficiary
at the third tier cost-share.
Non-formulary (third tier) drugs may also be cost-shared at the formulary (second tier) amount, if documentation is submitted to TRICARE to validate that the non-formulary drug is medically necessary compared to the formulary
products. For example, the patient cannot use comparable formulary medications because of allergic reactions, etc.
Additionally, TRICARE has a long-standing mandatory generic drug policy and will not pay for brand name products
when generic alternatives exist. TRICARE will cover brand name drugs when generic alternatives exist, only if you
justify medical necessity for use of the brand name drug.
More information on the pharmacy benefit and formulary coverage may be found at www.tricare.osd.mil/pharmacy.
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