TRICARE Mail Order Pharmacy

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TRICARE Mail Order Pharmacy

• LTC Don De Groff
• donald.degroff_at_amedd.army.mil

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TRICARE Retail Pharmacy Contract

• CDR Jill Pettit
• jill.pettit_at_amedd.army.mil

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TRICARE Retail Pharmacy (TRRx) Contract Objectives

• Consolidate retail pharmacy services under a
  single contract
• Streamline claims processing, network management
• Provide a portable benefit
• Consistent benefit interpretation across all
  regions
• Contract structure allows Government to
• Apply Federal Pricing as the basis for refunds
• 100 of refunds received by Government

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Key Contract Provisions

• Fixed price, performance based contract
• Claims processing fees
• Prior authorization and Medical Necessity review
• ESI pays pharmacies from a government account in
  accordance with its network agreements
• Contractor guarantees a reimbursement rate for
  generic and brand drugs
• Financial incentive if reimbursement rate
  achieved
• Financial dis-incentive if reimbursement rate not
  achieved
• Performance incentive for network management
• Full visibility of drug costs, administrative
  costs, refunds

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TRRx STATS(Nov 04)

• 5.7 million POS (pharmacy) claims
• 329,614 paper claims
• 54,505 pharmacies in network
• 67,040 calls to pharmacy help desk
• 56,353 calls to beneficiary help desk
• 1889 prior authorization reviews
• 868 medical necessity reviews

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TRRx Features

• Portability in 50 states, Guam, Puerto Rico, US
  Virgin Islands
• Beneficiary Services 24 x 7 x 365
• Pharmacy Help Desk Services 24 x 7 x 365
• TRRx Dedicated Staff
• ESI processes all claims

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TRRx Network

• 54,505 as of Nov 04 (43,000 under MCSCs)
• Guaranteed access standards
• Urban - 2 miles -- 90 of benes (91.0)
• Suburban - 5 miles -- 95 of benes (98.2)
• Rural - 15 miles 95 of benes (97.3)
• Specialty pharmacy services
• Compounded items
• Special distribution items/injectables
• Stable network no more than 10 decrease over
  life of the contract

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TRRx Claims Processing

• ESI processes all claims network, non-network
  (DD2642 claims), split billing (OHI)
• ALL paper claims processed to same standards as
  electronic (POS) claims
• Includes specialty drugs, compounded items

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TRRx Formulary Today

• Open
• TRRx benefit exclusions
• smoking cessation products, cosmetic drugs,
  weight control drugs, OTCs
• branded products when generic available
• some injectables (eg Xolair, Synergis, Synvisc,
  etc)
• Covers some supplies/injectables
• diabetic supplies, spacers, diaphragms

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TRRx under Uniform Formulary

• Same benefit exclusions
• Branded products when generic equivalent
  available
• Non-formulary drugs
• Established by DoD PT committee
• Available at third tier cost share
• 22.00 per 30 day supply
• Available at second tier cost share with approved
  medical necessity
• 9.00 per 30 day supply
• Not available at MTF

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Prior Authorization

• DoD PT designates drugs requiring PA
• Establishes PA criteria for TMOP/TRRx
• PAs approved for one year
• PDE5 Inhibitors Enbrel
• Fertility injectables Growth Hormone
• Humira Kineret
• Lamisil Penlac
• Raptiva Sporanox

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Types of Medical Necessity

• 1 - Required for prescriptions exceeding quantity
  limits established by DoD PT
• 2 - Required for certain benefit exclusions
  (prenatal vitamins)
• 3 - Required for brand name drug when generic is
  available
• 4 - Under Uniform Formulary - required to receive
  non-formulary drug at second tier (9.00) cost
  share
• Criteria developed by DoD PT
• Approval good until end of TRRx contract

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Prior Auth/Medical Necessity Portability

• Prior Authorizations (good for one year)
• MTF ? TRRx ? TMOP
• Cannot seed CHCS with PA drugs
• Medical Necessity (good for life of contract)
• MTF ? TRRx ? TMOP
• Only Type 4 MN approvals transfer from MTF
  to TRRx and TMOP

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Who Pays the TRRx Bill? (How the money flows!)
Treasury Department Issues Appropriation Warrant
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TRRx Accounting

• TRRx ? Accrual fund (Medicare eligible)
• Non-accrual fund (TRICARE eligible)
• MTFs are NOT billed for Rxs filled in TRRx for
  MTF enrolled beneficiaries

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Beneficiary Preference or Cost Shifting?
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The Top 20 Hit Parade (by cost)
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The Top 20 Hit Parade (by of Rxs)
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TMOP UPDATE

• 4 Ws and an H
• Express-Scripts Inc (ESI)
• Mail Service
• Tempe Arizona
• 1 March 2003
• PDTS as adjudication engine

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Statistics

• Current Workload
• Prescription Returns and Reasons
• Possible Future Increase
• Number of Calls and Top Call Drivers
• OHI, OHI, OHI

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Unique Features

• Robotics
• Replenishment Only
• Re-baseline Feature
• GPI Switching

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New Territory

• OIF
• Navy Deployment
• Smoking Cessation
• P2/P4
• Multi-Ingredient Compound Feature
• Data Mining through Business Objects
• Drug Diversion

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TMOP Contracting Officer RepresentativeLTC Don
De Groffdonald.degroff_at_amedd.army.milTRRx
Contracting Officer RepresentativeCDR Jill
Pettitjill.pettit_at_amedd.army.mil