Congress directed the Department of Defense (DoD) to establish a Uniform Formulary (UF) process that creates a new third-tier co-pay of $22 per prescription, in both mail order and retail pharmacy services, for medications that are designated "non-formulary." The UF also creates a new DoD Pharmacy & Therapeutics (P&T) committee, to recommend which medications will be available at the third-tier co-pay, and a new Beneficiary Advisory Panel (BAP) to review the P&T committee's recommendations.

The current co-payments of $3 for generic medications and $9 for brand name medications will continue. The law designated that the third tier will have a co-pay of $22. Currently, there are no drugs in this third tier until the afore-mentioned committees meet to evaluate drugs in accordance with the UF rule, and a final approval has been made by Dr. William Winkenwerder Jr., assistant secretary of defense for health affairs (ASD/HA).

The UF final rule does not change the TRICARE prescription drug benefit. The benefit includes the U.S. Food and Drug Administration approved drugs and medicines that by U.S. law require a physician's or other authorized provider's prescription.

When the new structure is fully implemented, prescription drugs on the current Military Health System (MHS) formulary will be categorized as generic, formulary (brand-name), or non-formulary. Prescription drugs will be evaluated based on their relative clinical effectiveness as well as cost value when compared with other drugs in the same therapeutic class.

The primary recommendations as to which drugs will be moved to the $22 "non-preferred" formulary tier will be made by a DoD Pharmacy & Therapeutics committee, which will meet quarterly. In making its determinations, the P&T committee will assess whether drugs within a therapeutic class have a "significant, clinically meaningful therapeutic advantage," or are not cost effective relative to other drugs in a class--considering safety, effectiveness or outcome. Because of the volume of analysis required, it is expected that the P&T committee will only evaluate a few categories of drugs at each meeting.

The P&T committee consists of 12 voting members who are military medical physicians and pharmacists. Three will represent the Army; three the Air Force; two, the Navy one from the Coast Guard; and one representative from the Department of Veterans Affairs. As the Navy provides medical support to the Marine Corps, the USN represents both of these sea services.

The other two military members are the committee chairmen assigned from DoD's Pharmacoecononric Center, which is tasked to review "the clinical, economic, and humanistic outcomes of drug therapy in support of the readiness and managed health care missions of the Military Health System."

The thirteenth member is from the Uniformed Services Family Health Plan, a TRICARE Prime contracted provider. Minutes of the P&T committee meetings can be found at: http://www.pec.ha.osd. mil/PT_Committee.htm.

Once the P&T committee announces recommendations, the Beneficiary Advisory Panel (BAP) will meet within the following few weeks to provide comments on the decisions. The primary role of the BAP is to provide a beneficiary perspective in the process and to address the potential impacts of the P&T Committee's recommendations on beneficiaries' needs.

The BAP is made up of 15 appointees: seven, who as retirees, are beneficiary advocates. ROA is included in this group, with CAPT Marshall Hanson, USNR (Ret.), director of Naval Services, appointed as a member to this panel.

Two other members on the BAP are professional experts: one a pharmacist and the other a research physician. Five other members are representatives from the TRICARE mail order pharmacy, and health-care contract providers. The voting chairman is from the TRICARE Management Activity staff.

The P&T committee meetings will be closed, as proprietary information about pricing and drug formulas will be reviewed. The BAP meetings will be public, the first not yet scheduled. Details will be published in a future ROA weekly e-newsletter.

TRICARE and TRICARE for Life provide an open formulary, a system in which the availability of drugs is based on their status as generic, preferred, or non-preferred pharmaceuticals. Pharmacy benefits are also managed through the amount of co-payments, with different, or tiered, price structures for various drugs.

A closed formulary, as offered by many civilian HMOs and health-care plans, is a system that offers a limited set of selected pharmaceutical products, with other non formulary drugs made available only by waiver or exemption. However, not all medications are available through TRICARE.

The most common products that are not covered include those for ending smoking, weight loss, or cosmetic purposes (such as balding and wrinkle cessation) as well as over-the-counter products. Some over-the-counter exceptions are alcohol swabs, needles and syringes for home-use injectable drugs, glucose test strips, insulin and insulin syringes, lancets and spacers for inhalers.

Other brand name prescriptions need prior authorization before they can be filled. TRICARE favors generic prescriptions, or has approved other brand name drugs within a therapeutic class. If a physician believes that there is a medical necessity for a specific brand-name drug, prior authorization may be necessary.

For a list of prescription drugs not covered or requiring pre-authorization under the DoD TRRx program, please call 1-866-DOD-TRRX (1-866-363-8779). A useful Web site is http://www. pec.ha.osd.mil/PA_Criteria_and_forms. htm.

Prescriptions filled by the TRICARE Mail Order Pharmacy cost $3 for up to a 90-day supply of a generic medication; $9 for up to a 90-day supply of a brand name formulary medication; and $22 for up to a 90-day supply of a non formulary medication. If prescriptions are filled through the retail network, the co-payments are the same, but only for a 30-day supply.

Prescriptions continue to be at no cost at military treatment facilities, but drug availability may not be as extensive as in the network. Tier-one and -two drugs are available through MTF pharmacies. Tier-three drugs will not be available at MTFs. For a complete list of available drugs, contact your nearest MTF in person or by phone.

Beneficiaries using a non network pharmacy pay either $9 or 20 percent of the total cost of the prescription, whichever amount is greater, for both generic and brand-name formulary medications, and $22 or 20 percent, whichever amount is greater, for up to a 30-day supply of non-formulary medications. Applicable deductibles for non-network pharmacy use must first be met.

The uniform formulary is not intended to hinder access to the variety of pharmaceutical drugs that are available to TRICARE beneficiaries. P&T committee members are fully aware of the significance of prescription drugs to the quality of life for many military retirees, and the impassioned response if access to a drug is denied. ROA will be an advocate in the process to ensure that your options are upheld.

Note: The "To Your Health" column is often a summary from various Web sites. Sources include DoD releases and TRICARE Management Activity Web sites. This month, further information is provided by the RAND Corporation and the Military Officers Association of America (MOAA).

            TRICARE               Network            Non-Network
            Mail Order            Mail Order         Retail
            Pharmacy              Retail Pharmacy    Pharmacy

RX          90-day supply of      30-day supply of   30-day supply
Amount      most non-narcotic     medication         of medication
            drugs or a 30-day
            supply of a narcotic
            prescription

Co-         $3 for generic        $3 for generic     20 percent of the
payment     $9 for brand name     $9 for brand name  cost of the drugs,
            $22 for               $22 for            or $9, whichever
            non-formulary         non-formulary      is greater

Deductible  None                  None               $150 per year

            Military
            Treatment
            Facility Pharmacy

RX          Varies by facility
Amount      (often 30-day supply).

Co-         No cast for generic and
payment     tier-two brand- name
            drugs (if available).
            No non-formulary drugs

Deductible  None

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