TRICARE Plans
Pharmacy
Servicemembers enrolled in a TRICARE program receive pharmacy benefits. Depending on circumstances, prescriptions can be filled at military treatment facility (MTF) pharmacies, through the TRICARE Mail Order Pharmacy (TMOP), TRICARE network retail pharmacies and non-network pharmacies. Servicemember receive tier one and tier two generic and name brand prescription drugs at no cost from military treatment facilities.
How It Works
TRICARE Pharmacy pays for generic and brand name medication listed in its formulary, which is a manual that contains a list of medicines and formulas to create them. Most often, nonformulary medication is covered on a partial basis. In some instances, getting nonformulary medication requires a deductible to be satisfied before cost-sharing can begin. TRICARE Pharmacy will only pay for nonformulary medication when it is deemed medically necessary, and it defines a medical necessity as falling under one of these five categories.
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Category 1
The use of all formulary medications is not recommended by the residing physician. -
Category 2
The patient may be likely to experience significant ill effects from the formulary medication, but will tolerate the nonformulary medication. -
Category 3
The formulary medication has or is likely to fail, and the nonformulary medication is expected to work. - Category 4
The nonformulary medication is working and changing to a formulary medication would be a medical risk.
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Category 5
There is no alternative medication to the nonformulary medication listed in the formulary.
TRICARE Mail Order Pharmacy
For beneficiaries who do not live near a military treatment facility pharmacy, it is cheaper to get prescriptions through the TRICARE Mail Order Pharmacy (TMOP) than retail pharmacies. Beneficiaries can be dispensed up to a 90-day supply of medication. Requests for refills can be made online, by phone or fax, or through the mail.
To use the TRICARE Mail Order Pharmacy, you must activate your accounts through Express Scripts, and then and then mail your written prescription and the appropriate cost-share to Express Scripts, Inc. Medication orders are usually filled within 10-14 days and sent directly to the you.
Drawbacks
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Only prescriptions filled at military treatment facility pharmacies are free to the beneficiary. Using other pharmacies will cost the beneficiary a deductible of $3-$22 for each prescription.
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If available, prescriptions must be filled with a generic medication. Name brand prescriptions require a physician explanation.
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TRICARE Pharmacy will only pay for one 30-day supply of medication at a time. Dispensing more medication will result in additional charges. Beneficiaries will be charged one copayment for each additional 30-day supply. The maximum allowable amount of medication that can be dispensed at one time is a 90-day supply.
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Using another insurance provider can be a hassle. If a beneficiary has coverage with another provider, that provider must be the primary payer. It is also important that a beneficiary uses a pharmacy that is in both the TRICARE and their private insurer's networks to avoid paying out-of-network copayments and deductibles. You can find more information on filing claims with multiple insurers by calling (877) 363-6337.
