Attachment L-9 Benefit Design Document_TPharm5.xlsx

Pharmacy Cost Shares

1. Tricare Reimbursement Manual, Chapter 2, Addendum A –Pharmacy Payment Matrix.

2. Tricare Reimbursement Manual, Chapter 4, Section 3, § 5 – Tricare Deductible in Double Coverage

Military Treatment Facility (MTF) $0 $0 Not Applicable 2

Mail Order 4,7,8 $X $XX $XX 3

Retail Network Pharmacy 4,6,8 $XX $XX $XX 3

2. Non-formulary drugs are generally not available at MTFs.

3. The non-formulary copayment applies unless medical necessity is established. An established medical necessity will allow a formulary copay.

4. Selected Vaccines in retail and OTC drugs in both retail and mail may be cost shared ($0 copay for vaccines; generic copay for covered OTC’s except Plan B One Step OTC - $0) when designated by the Assistant Secretary of Defense, Health Affairs

5. Compounded medications will have a cost share equal to or not less than the prevailing Formulary brand name cost share

6. For member submitted claims for prescriptions filled at a network pharmacy, allowable charges, member cost shares and reimbursement will be based on network pharmacy rates.

7. Selected prescription and OTC smoking cessation drugs (up to 60-day supply) may be cost shared in mail order ($0 copay) when designated by the Assistant Secretary of Defense, Health Affairs

8. Copayments remain the same as the 2017 rates for dependent survivors of Active Duty Service Members and medically retired service members and their dependents.

General Benefit Design

MAIL ORDER: Up to 90 days per copay*

MTF and MHS GENESIS: Up to 365 days supply for non controlled substances; 180 days for controlled substances as allowed under federal law.

* Day supply limits apply to ADSM but copayments do not apply.

TIER 4 - Not covered Section 702(b)(10) of the NDAA 2018 was published on December 11, 2018, and is found at: https://www.federalregister.gov/documents/2018/12/11/2018-26562/tricare-pharmacy-benefitsprogram-reforms.

Tier 4 Drug List: <https://www.health.mil/Military-Health-Topics/Access-Cost-Quality-and-Safety/Access-to-Healthcare/Pharmacy-Program/TRICARE-Formulary>

MANDATORY GENERIC POLICY

66% for medicaitons dispensed at Mail for the Deployment Presciption Program

Nonformulary medications are generally restricted to the mail order program according to amended section 199.21, revised paragraphs (h)(3)(i) and (ii), effective August 26, 2015.

TRICARE Policy Manual Chapter 8 Section 9.1, 2.2.12 *The Expanded MTF/Mail Pharmacy Initiative (EMMPI) medication program drug list is defined by the P&T Committee, which recommends additions and removals.

*For additional information on these two programs, refer to the August 2015 DoD P&T Committee meeting minutes, available at http://www.heallh.mil/PandT.

*100% Copayment if obtained in retail POS after 2 courtesy fills of 30 days each.

*The requirement can be waived based on individual patient needs and other appropriate circumstances.

NON-FCP; RETAIL EXCLUSIONS (703b)

NDAA 2010 Sec 703b * Manufactures non-compliant with Sec 703b regulation

* Drug are rejected for PA (by NDC) at the Retail point of service.

* PA available for emergent need or circustances requiring access at Retail

* Drugs move to Non-Formulary (Tier 3) status at Mail (no option for medical neccessity review)

* Does not impact MTF since Tier 3 drugs are generally not avaliable at these point of service Home Infusion Therapy

TRICARE Policy Manual, Ch 8, Sec 20.1 and 9.1

* No defined drug list. Providers determine which drugs are appropriate for this program

* Pharmacy Contractor apply pre-authorization to allow injectable drugs coverage through the pharmacy benefit once approval provided by MCSC.

http://www.tricare.mil/CoveredServices/Pharmacy/Drugs/NonFormulary Drugs Coverage Rules subject to change based on recent decsions from the DoD P&T process.

Most current decisions are available at: <https://health.mil/About-MHS/OASDHA/Defense-Health-Agency/Operations/Pharmacy-Division/DoD-Pharmacy-and-Therapeutics-Committee/Meeting-Minutes>

32 CFR 199.4 (g)(24) Exclusions. Cosmetic, reconstructive, or plastic surgery. Services and supplies in connection with cosmetic, reconstructive, or plastic surgery except as specifically provided in paragraph (e)(8) of this section.

Hair growth:

TRICARE Policy Manual 6010.57-M Chapter 8 Section 12.1 Exclusions. Any diagnostic or therapeutic method or supply intended to encourage hair re-growth.

When the following products are Not Covered implement the standard defaults to allow overrides to adjudicate correctly.

Non-injectable monthly:

1 package at Retail 3 packages at Mail Order

Injectable-30 days supply Yes

Emergency – ALL (e.g Plan B One Step) Yes* *Plan B One Step and its generics are covered for all ages of females at Retail and MTF for $0 copay. No prescription is needed. The pharmacist can submit a claim to TRICARE.

All other Rx EC products covered for females aged 16 years and younger with prescription, OTC and not covered for age 17 and older.

Not available at MOP.

QLL = 1 tablet per dispensing

FERTILITY AGENTS Oral/Vaginal

(ex. Clomid, Crinone)

Others are covered without Subject to quantity limits referenced in DoD Formulary Limits and Restrictions Approved PA's only good for 1 yr

**QLL is collective across all oral products.

***QLL applies to Cialis 2.5mg and 5 mg as well

32 CFR 199.4 (d)(3)(vi)(A) Prescription Drugs and Medicines. Drugs administered by a physician or other authorized individual professional provider as an integral part of a procedure covered under paragraph (b) or (c) of this section (such as chemotherapy) are not covered under this subparagraph inasmuch as the benefit for the institutional services or the professional services in connection with the procedure itself also includes the drug used.

TRICARE Policy Manual 6010.57-M Chapter 8 Section 9.1 Other Pharmaceutical Delivery Venues. (1.4) Pharmaceutical agents provided by physicians and other appropriate clinicians, and pharmaceutical agents provided in support of home health care are processed by the Managed Care Support Contractor(s) (MCSC). Claims for pharmaceutical agents (e.g., injectables) not appropriate for self-administration are the responsibility of the MCSC. (1.5) When injectable and infusion drug therapy are medically necessary, and delivery and administration in the home is appropriate the MCSC shall provide prior authorization of injectable or infused drugs to a TRICARE authorized pharmacy in order for the pharmaceutical agent to be fulfilled under the pharmacy benefit pursuant to Section 20.1, “Infusion Drug Therapy Delivered in the home”

Allergens No* *Covered at MHS Genesis

Products for Hemophilia Yes Covered at all POS

VACCINES Special List Yes All vaccines are only covered at Retail and MHS Genesis

* Flu Vaccine(only allow coverage for current years) *CDC reference and guidelines y Retail_Vaccine Listing_Sept 2019

VACCINES: Special products Typhim VI Vivotif Berna Imovax Rabies Ixiaro

YF-VAX

Rabavert Rabies Biothrax No* *Only covered at MHS Genesis with no restrictions

TRICARE Policy Manual 6010.57-M Chapter 8 Section 7.1 Exclusions. Vitamins or mineral preparations, except as provided in POLICY above or by Chapter 8 Section 9.1.

TRICARE Policy Manual 6010.57-M Chapter 1 Section 1.2 Exclusions. Food, food substitutes, vitamins, or other nutritional supplements, including those related to prenatal care, except as specifically covered (see chapter 8, Sections 7.1 and 7.2) 32 CFR 199.4 (g)(57) Exclusions. Food, food substitutes, vitamins, or other nutritional supplements, including those related to prenatal care.

Therapeutic agents used for specific deficiencies and conditions (ex. Rocaltrol, Calcitriol, Niacin, Potaba) Yes Legend products only covered

Legend Multivitamins (usually have OTC counterparts)

(ex. Nephrocaps, Vitacon Forte, Berocca) Yes Legend products only covered

Supplemental agents (usually have OTC counterparts) Ex. Biotin Yes Legend products only covered

Hemopoetic agents used to treat anemia (ex. Folic Acid, Niferex Forte) Yes Legend products only covered

OTC VITAMINS ALL No* *Select OTC vitamins are covered at MHS Genesis and Retail/Mail y MHS Genesis OTCs

LEGEND and OTC SMOKING CESSATION PRODUCTS Varenicline (Chantix) Bupropion SR (Zyban) Nicotine nasal spray (Nicotrol NS) Nicotine inhalation system (Nicotrol) Nicotine transdermal systems (Nicoderm CQ or equivalent products) Nicotine gum (Nicorette or equivalent products) Nicotine lozenges (Nicorette or equivalent products) Yes* *Specific smoking cessation products are covered at mail order only with $0 copay for non-Medicare eligible patients over age 17.

Limited to two 120 day quit attempts per 365 calendar days; 3rd attempt allowed with Prior Authorization. QLL applies.

*MOP replenishment provided with TAA compliant products.

No drug restrictions for MHS Genesis

*See Smoking Cessation drug list for applicable NDC’s.

32 CFR 199.4 (e) (30). The TRICARE smoking cessation program is a behavioral modification program to assist eligible beneficiaries who desire to quit smoking. The program consists of a pharmaceutical benefit; smoking cessation counseling; access to a toll-free quit line for non-medical assistance; and, access to print and internet web-based tobacco cessation materials.

32 CFR 199.21 (a) (2) (ii). The pharmaceutical benefit under the TRICARE smoking cessation program under § 199.4(e)(30) is available to TRICARE beneficiaries who are not entitled to Medicare benefits authorized under Title XVIII of the Social Security Act.

TRICARE Policy Manual 6010.57-M Chapter 8 Section 9.1. Exclusions. Drugs, including compounded preparations, that are available over the counter.

TRICARE Policy Manual 6010.57-M chapter 8 Section 9.1 (II)(A) Paragraph 2. The prescription drug benefit under TRICARE provides cost sharing for drugs and medicines that (1) are approved for marketing by the U.S. Food and Drug Administration (FDA), and (2) by United States law require a physician’s or other authorized individual professional provider prescription (acting within the scope of their license), and (3) are actually ordered or prescribed by an authorized provider in accordance with state and federal law. The benefit does not include prescription drugs for medical conditions that are expressly excluded form the TRICARE benefit by statute or regulation. The Pharmacy Benefits Program will include a Uniform Formulary of pharmaceutical agents that will assure the availability of pharmaceutical agents in the complete range of therapeutic classes authorized under the TRICARE prescription drug benefit.

32 CFR 199.4 (d)(3)(vi)(A). Other covered services and supplies: Prescription Drugs and Medicines. Prescription drugs and medicines that by United States Law require a physician’s or other authorized individual professional provider’s prescription (acting within the scope of their license) and that are ordered or prescribed by a physician or other authorized individual professional provider (except that insulin is covered for a known diabetic, even though a prescription may not be required for its purchase) in connection with an otherwise covered condition or treatment, including Rh immune globulin. MHS Genesis Yes** **P&T will make updates to the list Y MHS Genesis OTCs

TRICARE Policy Manual 6010.57-M chapter 1 Section 2.1. Any drug, device, medical treatment, or procedure whose safety and efficacy has not been established is unproven and excluded from coverage.

32 CFR 199.4 (d)(3)(vi)(B). CHAMPUS benefits may not be extended for drugs not approved by the U.S. Food and Drug Administration for commercial marketing. Drugs grandfathered by the Federal Food, Drug and Cosmetic Act of 1938 may be covered under CHAMPUS as if FDA approved.

32 CFR 199.4 (e)(15). Unproven drugs, devices and medical treatments or procedures. By law, CHAMPUS can only cost share medically necessary supplies and services. Any drug, device, or medical treatment or procedure, the safety and efficacy of which have not been established, as described in this paragraph (g)(15), is unproved and cannot be cost shared by CHAMPUS.

32 CFR 199.4 (e)(15)(i)(A). A drug, device, or medical treatment or procedure is unproven: if the drug or device cannot be lawfully marketed without the approval or clearance of the United States Food and Drug Administration (FDA) and approval or clearance for marketing has not been given at the time the drug or device is furnished to the patient

LEGEND MEDICAL FOOD Example: Neophe Tablet , Deplin Tablet Zycose Tablet No* *Medical foods are only covered if they are dual classified as a legend vitamin as well (2009 implementation).

*Not covered at MHS Genesis: override ability in place Y MHS Genesis OTCs

DOES NOT APPLY to MHS Genesis

NON-FCP, RETAIL EXCLUSION, NDAA 2010; Section 703b Special List Yes - Retail Only Government Directed List - NDC level Drugs are NF at MOP (MN does not apply) Drugs reject at Retail without an approved PA.

*Drug list is managed by the DoD P&T (currently only one drug identified) DOES NOT APPLY to MHS Genesis

*Maintenance meds only *Govt maintained list *2 courtesy fills at retail; waivers available *DOES NOT APPLY to MHS Genesis

Vimovo Lexette No No PA *Appeals accepted for coverage determination Drug List <https://www.health.mil/Military-Health-Topics/Access-Cost-Quality-and-Safety/Access-to-Healthcare/Pharmacy-Program/TRICARE-Formulary>