Understanding the TRICARE Pharmacy Benefit

Understanding the TRICARE Pharmacy Benefit
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MOAA-membership-card_3.jpgNote: This article first appeared in Transitioning Into Medicare and TRICARE For Life, a publication exclusive to MOAA Premium and Life members. Find more member-exclusive publications at this link, and check out member-exclusive discounts at this link.


The TRICARE Pharmacy Program provides pharmacy benefits for all uniformed services beneficiaries. Eligible beneficiaries can receive their medications through:

  • a military treatment facility (MTF) pharmacy;
  • TRICARE Pharmacy Home Delivery;
  • a TRICARE retail pharmacy; or
  • a non-network pharmacy.


TRICARE For Life (TFL) beneficiaries are required to use TRICARE Pharmacy Home Delivery for all maintenance medications. Beneficiaries who use an MTF or have other pharmacy insurance are not subject to this mandate.


Individual case-by-case waivers may be issued by Express Scripts. See the mail-order pharmacy section below for enrollment information.


Military Treatment Facilities (MTFs)

You can have your prescriptions filled through MTF pharmacies free of charge if they carry your drug on their formulary. However, not all medications are available at every MTF pharmacy.


TRICARE Mail-Order Pharmacy

TRICARE Pharmacy Home Delivery, administered by Express Scripts, provides you with up to a 90-day supply of your prescription. It provides a comprehensive, easy-to-use drug benefit with a low out-of-pocket cost. Your prescription will be checked against your medication profile to ensure the medications being dispensed will not result in an adverse reaction with your other medications.


Call the Express Scripts Member Choice Center at (877) 363-1303 for enrollment and prescription transfer assistance, or visit www.militaryrx.express-scripts.com/home-delivery.


TRICARE Retail Pharmacy

If you use a TRICARE retail pharmacy for your prescriptions, you will need to show your uniformed services ID card when the prescription is filled, and you can receive up to a 30-day supply of the drug.


Many national pharmacy chains are members of the TRICARE network. To find out which civilian retail pharmacies in your area participate in the program, call (877) 363-1303 or visit www.militaryrx.express-scripts.com/find-pharmacy.


Non-Network Pharmacy

A non-network pharmacy is the most costly option. In addition to higher copays, the TRICARE deductible of $150 per person with a $300 cap per family per calendar year applies to prescriptions filled at non-network pharmacies.


Using Other Health Insurance

If you have other health insurance that has a pharmacy benefit, as of April 4, 2006, the retail pharmacy will coordinate these benefits online.


Simply show your military ID card as proof of your TRICARE insurance along with your other insurers’ card.


Until you exhaust your other insurance’s pharmacy benefit, you are prohibited from using the TRICARE Pharmacy Home Delivery program — with the exception of a drug that is not covered by your other insurance plan but is covered by TRICARE.


Once you have used up your other insurance’s pharmacy benefit for the year, you then can use the TRICARE Pharmacy Home Delivery program for your pharmacy needs until the next benefit period on your other insurance begins.


For more information regarding other health insurance and pharmacy claims, call (877) 363-1303 or visit TRICARE.mil/ohi. Claim forms (DD Form 2642) and the required drug information can be mailed to: Express Scripts Inc., PO Box 60903, Phoenix, AZ 85082


Pharmacy Costs

The amount you pay out-of-pocket for prescription drugs will vary, depending on whether you use the mail-order pharmacy, a retail network pharmacy, a non-network pharmacy, or a military treatment facility. Visit the TRICARE website for the latest prescription costs.


All TRICARE For Life beneficiaries are required to use either military pharmacies or the mail-order system for maintenance medicine refills. The law establishes requirements to ensure no one is turned away at retail pharmacies without enough medication to last until a mail-order account is established for them. DoD also has authority to waive the requirement for select medications or beneficiaries (e.g., nursing home patients).


Frequently Asked Questions

Q. How can I determine whether the medication I need is on the TRICARE Pharmacy Home Delivery formulary?

A. There are two sources of DoD formulary information: The TRICARE website (TRICARE.mil/pharmacyformulary) and Express Scripts customer service at (877) 363-1303. Explain that you are a DoD beneficiary, provide the sponsor’s military identification number, and ask them to confirm coverage of the drug.

Q. How do I fill my prescription at a TRICARE network pharmacy?
A. Simply present a prescription written by your health care provider to the pharmacist, along with your uniformed services ID card. The pharmacist will verify your enrollment in the Defense Enrollment Eligibility Reporting System, fill the prescription, and charge you the copayment. There is no annual deductible or enrollment fee to meet when you use participating pharmacies.


Q. Does TRICARE require a generic drug be dispensed for a brand-name drug?

A. It’s DoD’s policy to substitute generic medications for brand-name medications when available. Brand-name drugs that have a generic equivalent may be dispensed only if the prescribing physician is able to justify medical necessity for use of the brand-name drug in place of the generic equivalent. If a generic equivalent drug does not exist, the brand-name drug will be dispensed at the brand-name copay.

For more information from the Food and Drug Administration (FDA) on generic drugs, visit the FDA website.

Q. If I must use a non-network pharmacy, what will I have to do and how will I file a claim with TRICARE to recover some of the cost?

A. If you use a non-network pharmacy, you might be required to pay the full cost for your medication and file for reimbursement with Express Scripts. Mail your reimbursement claim to: Express Scripts Inc., PO Box 52132, Phoenix, AZ 85072.

Q. I live in a foreign country. Will I be able to use the TRICARE Pharmacy Program?

Yes. Retirees residing in foreign countries can use military pharmacies (if available), TRICARE Pharmacy Home Delivery (under certain conditions), or local pharmacies. While an overseas military pharmacy might be able to fill your prescription, services will depend on the country, the source of the prescription, and the local policies of the military treatment facility commander.

TRICARE Pharmacy Home Delivery can be used but only under certain restrictions because of FDA requirements and state and international shipping laws. As an alternative, retirees can use local economy pharmacies (as non-network pharmacies), paying the full cost and filing a claim for reimbursement from the TRICARE Overseas Regional Contractor.

Q. How does Medicare Part D affect me?

A. We suggest you do not enroll in any other pharmacy plan. For most TFL beneficiaries, there is no added value in purchasing Medicare prescription drug coverage. It is unlikely Medicare Part D coverage would provide better coverage than the pharmacy benefits available under TRICARE, and unlike Medicare Part D, the TRICARE pharmacy benefit doesn’t cost you monthly premiums. If a TFL beneficiary chooses to enroll in Part D, their TFL pharmacy benefits will be affected, as TFL becomes the final payer behind Medicare Part D. This means manual claims must be filed for reimbursement, and you will not be able to use the TRICARE home delivery service.

Beneficiaries who lose TRICARE eligibility (e.g., survivors who remarry a spouse who is not a military beneficiary or certain beneficiaries in cases of divorce) might benefit from Medicare Part D. Those losing TRICARE eligibility must enroll in Part D within 63 days or they will face a late-enrollment penalty for Part D.

Low-income beneficiaries eligible for Medicaid (not Medicare) automatically are enrolled in Part D and have Part D premiums waived. TRICARE will be the second payer to Part D for these beneficiaries.


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