04 Sep Getting Your Medication
This page contains all the information you need to know to determine your eligibility, Getting Your Medication, the kind of prescription drugs that are covered by TRICARE and how these prescriptions can be filled out.
Who is Eligible?
The TRICARE health care plan offers coverage for certain prescription drugs. The people who can qualify for this coverage are people who are actively serving in the military forces as well as their families, as well as members of the National Guard and Reserve and their families. Men and women who have retired from their post in the military, together with their families, are also eligible, as are retired members of the National Guard and Reserve and their families.
In addition, the survivors of members of the military forces (including their spouses and specific ex-spouses) may also be eligible. Furthermore, individuals who have been awarded the Medal of Honor and their families can also receive coverage from TRICARE for prescription drugs. Any individual who has qualified for the TRICARE Reserve Select plan, the TRICARE Retired Reserve plan, the TRICARE Young Adult plan or the Continued Health Care Benefit Program will also be covered for prescription drugs. There may also be other beneficiaries, such as members of the foreign forces and their families.
If an individual has the US Family Health Plan (or its TRICARE Young Adult Prime plan), then TRICARE will not provide coverage for prescription drugs. Instead, such individuals will have to make use of the pharmacies operating under the US Family Health Plan.
How Do You Fill Prescriptions?
If you are considered eligible for the coverage of prescription drugs under your TRICARE health care plan, then there are a number of ways in which you can fill the prescription. Although most of these options can be availed across the world, you may find certain limitations cropping up outside the United States.
The first option is to visit a military pharmacy. This is the most cost effective way of getting your prescription filled and you will not have to occur any out-of-pocket additional costs. Most military pharmacies function out of a military clinic or hospital (which are located on the military bases). However, some military pharmacies also function independently. If you choose to go to a military pharmacy, all you need to do is present your prescription. The pharmacy may provide you with your prescription drugs there and then. If not, you can also just drop the prescription and pick up the drugs once they are available.
The second option is to avail the service of home delivery. This is a very safe, convenient and easy to use system. If you do not have access to a military pharmacy, then this is the next best cost effective option to choose. Once you have used up your supply of prescription drugs, you can simply request for refills by calling, emailing or via the website. This would be a good option if you are using a certain prescription drug on a regular basis. An additional advantage of using the home delivery service is that you can use it whenever you are travelling as well.
The third option is to visit a network pharmacy. These are pharmacies that are a part of the TRICARE network of providers. At present, there are upwards of 57,000 pharmacies in the TRICARE network across the United States, as well as in other U.S. Territories. The advantage of opting for this method of filling your prescriptions is that you will, most likely, have easy access to a network pharmacy. Thus, you can be assured to get fast service.
The fourth option that is available to get a prescription filled is to go to a non-network pharmacy. This is a pharmacy that is not a part of the TRICARE network of providers. This is the most costly option out of the available options. It is generally advised to keep this as your last option if you are currently residing in the United States or the United States Territories. However, if you are residing overseas, then it is possible that this may be the only option you have.
If you want to get a certain prescription filled, you will be required to show the written prescription. In addition to this, you will also be asked to present a valid identification card from your uniformed services department.
The TRICARE network is designed in such a manner that any and every prescription that a beneficiary gets filled using a military pharmacy, home delivery or a TRICARE network pharmacy is checked against the beneficiary’s prescription history with Tricare. An automated system is used to carry out this check. This has two main advantages. Firstly, it prevents duplicate treatments. Secondly, it also lowers the risk of having a bad drug interaction.
The TRICARE health care plans cover almost all of the drugs that have received approval from the Food and Drug Administration of the United States. These are covered either under the medical benefit or pharmacy benefit.
The TRICARE website has a Formulary, which contains a list of most of the branded names of prescription drugs that are covered by TRICARE. There are three main tiers of this formulary: formulary-generic, formulary-brand name and non-formulary.
This comprehensive list is evaluated and revised at least four times in each year. It is possible that this review may change the way in which different prescription drugs have been classified, which means it is possible that a drug that was initially given formulary status may then be switched to non-formulary status. In case there is such a change, all individuals who are using that particular drug will receive a letter sent by Express Scripts, which will notify them of the change.
TRICARE does not cover those drugs that are not considered to be absolutely essential in the diagnoses or the treatment of an illness that is otherwise covered by the TRICARE health plan that an individual may have. In general, the medical benefit covers the drugs that a person receives in case he or she is hospitalized, or those that are administered to a patient during his or her outpatient visit. It is possible that a person will be prescribed a certain drug that has only recently received approval from the Food and Drug Administration (FDA) of the United States. In this case, users of TRICARE health plans can rest assured that such type of prescription drugs can be readily available within a couple of days at network pharmacies (that is, those pharmacies that are a part of the TRICARE network). In addition to this, people can also make use of the home delivery service to acquire newly approved prescription drugs. However, if a drug is not covered by the TRICARE system or the pharmacy benefit, then it will not be available, even if it is covered by the medical benefit. In addition to this, certain prescription drugs may not be considered suitable for distribution through network pharmacies or the home delivery service. Thus, certain prescription drugs may not be available.
Costs of Filling Prescriptions
How much it is going to cost you to fill your prescriptions depends on what your status is as a beneficiary, where you choose to get your prescription filled out, as well as the type of drug that you wish to use.
For members who are currently on active duty service, the prescriptions can be filled out from any pharmacy. This service will not cost them anything at all. It is possible that as an actively serving member, you could be asked for an up front payment for the prescription that you are getting filled out, whether you are at a pharmacy that is part of the TRICARE network or at a non-network pharmacy. However, once you have filed your claim with the Express Scripts service and it has been processed, you will receive a full reimbursement for the amount that you have paid at the pharmacy. If you have been asked to use a drug that is classified as a non-formulary drug, then your medical health care provider needs to establish that there is a medical necessity that requires you to use that particular drug. In this case, you can receive the drug without any cost.
For beneficiaries who are not actively serving members of the military forces, the same rules and procedures hold. If you get your prescription filled from a medical pharmacy, you can get a supply of most of your prescription drugs that can last you up to almost 90 days. There is zero co-payment for this.
If you opt for the home delivery service, you can, again, get most of your prescription drugs that can last you for almost 90 days. If you are getting a drug that is classified as generic formulary, then there is no co-payment. If you want to get a prescription drug that is classified as a brand name formulary, then the co-payment will be approximately $16. For a prescription drug that has been classified as a non-formulary drug by the TRICARE system, you will have to pay $46 (the exception to this case would be where your medical health care provider has shown that there is a medical necessity for this particular prescription drug).
If you wish to get your prescription filled from a pharmacy that is a part of the TRICARE network, then you can get a supply of almost all of your prescription drugs that can last you for a time period of approximately 30 days. There is co-payment involved in this method though. If Tricare has classified the drug that you are using as a generic formulary drug, then you will have to pay $8. There is a co-payment of $20 for a drug that has been classified as a brand name formulary drug by the Tricare health care system, while a $47 co-payment will have to be made for a prescription drug that falls in the category of a non-formulary drug. Once again, this co-payment may be waived off if the medical health care provider shows that there is a very valid medical reason for why you need to be using a particular prescription drug.
If you choose to go to a non-network pharmacy in order to get your prescription filled, bear in mind that you will have to pay more. How much it is going to cost you is going to depend on where the pharmacy is located, what your status is as a beneficiary, as well as which TRICARE health care plan you are using. In some cases, the pharmacy may ask you for an up front payment. However, you can obtain a reimbursement by filing for a claim. For non-network pharmacies that are located either in the United States or the United States Territories, all actively servicing members of the military forces can get a complete reimbursement. However, the same will not hold for other beneficiaries. If you are using a TRICARE Prime health care plan, you will have to pay half of the total cost. If you are using any other plan, then you will have to pay 20% of the total cost or $20 in the case of a formulary drug (whichever amount is greater) and 20% of the total amount or $47 in the case of a non-formulary drug (again, whichever amount is greater). This will apply once you have met the annual deductible.
If the non-network pharmacy is such that it is located overseas, then a full reimbursement will get given once a claim has been filed to all those individuals who have a TRICARE Prime Overseas health care plan. For the family members of active duty members of the military forces (who are enrolled in a TRICARE Standard Overseas health care plan) or the beneficiaries who are covered by a TRICARE Reserve Select health care plan, 20% of the total cost will have to be paid after they have met their annual deductible. Any other beneficiary will have to pay 25% of the total cost after meeting the annual deductible in case he or she goes to a non-network pharmacy that is located overseas.