We have recently received a few emails from some readers affected by a new mandate under the 2013 National Defense Authorization Act, the TRICARE for Life Pharmacy Pilot, which went into effect on Feb. 14, 2014. The TFL Pharmacy Pilot requires TRICARE for Life members to refill their prescription medications at Military Treatment Facilities (MFTs) or via the mail order system. Prescription medication refills done at a retail pharmacy may be ineligible for reimbursement. This only applies to maintenance medications, and not for medications to treat acute illnesses. (There are some exceptions; read on).
Here is some more information to see if this applies to you, and how it would affect you.
Who is affected: This only affects TRICARE for Life members who are using affected medications. This does not apply to TFL members who have other prescription coverage. It also does not affect active duty members or retirees under TRICARE Prime.
Which medications are affected? This only applies to maintenance medications, and not for medications to treat acute illnesses. Maintenance medications are those usually used to treat chronic illnesses such as high blood pressure, high cholesterol, diabetes, and similar chronic conditions. Medications prescribed for acute conditions, such as antibiotics, pain killers, etc. are unaffected by this pilot program. Here is a list of affected medications.
How the Pilot Works
You will receive a notification from Express Scripts informing you if you will need to participate in the Pilot program. When you fill a prescription for a medication covered by the Pilot at a network pharmacy, you’ll get a letter from Express Scripts. When you receive the letter, you will need to review your prescription refill options and decide how you want to refill your prescriptions in the future.
If you fill your prescription a second time at a network pharmacy, you’ll get another letter from Express Scripts about switching to Home Delivery. If you fill your prescription a third time at a network pharmacy, you’re responsible to pay 100% of the cost.
Options for Refilling Your Prescriptions
You can refill your prescription medications through these means:
- Home delivery: You can set this up by calling the Member Choice Center at 1-877-882-3335, or by requesting your provider to fax your prescription to Express Scripts at 1-877-895-1900. You can also set it up online at Express Scripts.
- Fill your prescriptions at a Military Pharmacy: Prescriptions filled at military pharmacies are free, however, military pharmacies have different regulations for transferring prescriptions, and may not stock all medications covered under this Pilot Program. Call ahead to determine if this is the best option for you.
- Use generic medications: Most generic drugs aren’t covered on the Pilot program and can continue to be filled at retail pharmacies for $5. This is still relatively low cost and may be more convenient in some circumstances.
- Continue filling your prescriptions at a Network Pharmacy: This is the most costly option, as you will be required to pay 100% of the drug refill cost after your third prescription refill at a retail pharmacy.
Waivers may be available in limited circumstances. Some TFL members may be eligible for waivers from the Pilot program, depending on circumstances. Examples include emergencies, hardship, or special circumstances such as living in a nursing home. As you might expect, waivers are granted on a case-by-case basis. Here is more information on qualifying for a waiver from the Pilot program.
How to ensure your prescription medication is reimbursed: The best way to ensure your prescriptions will be reimbursed is to fill your prescriptions at a Military Treatment Facility or get it refilled through the mail. Refills can be ordered by calling 1-877-363-1303 or by going online at Express Scripts.
Everyone Saves Money Under This Pilot Program
The primary driver for this program is to reduce costs for everyone involved. The government spends approximately 17% less on mail order prescription refills compared to retail orders. TRICARE recipients also spend less money when refilling prescriptions at an MTF or through the mail. A generic 90-day refill is free via the mail, but incurs a $5 copay for a 30-day prescription when filled at a retail location. Name brand prescription refills are $13 by mail for a 90-day prescription, or $17 for a 30-day prescription. (More about TRICARE Pharmacy co-pay costs).
The savings adds up for both parties. Individuals could save $15 on a generic refill for a 90-day prescription, or $38 on a name-brand refill for a 90-day prescription. The government determined they could save approximately $120 million per year if all medications were filled via mail or MTFs vs. being filled at retail pharmacy locations.
But the change does require some additional planning on your end if you are affected by this change. You will now need to plan your prescription refills a little more closely if you do not live near a military base. Otherwise, a last minute trip to the neighborhood pharmacy could prove costly.
Opting Out of the Pilot Program
The TRICARE for Life Pharmacy Pilot is currently slated to last 5 years. TFL beneficiaries are able to opt out of the mail-order program after one year, starting from the date they made their first prescription refill under the program.