TRICARE pharmacy copays to change in 2020

On Jan. 1, some copayments for prescription drugs will increase. If beneficiaries get their prescriptions through the TRICARE Pharmacy Home Delivery or at a retail network pharmacy, they’ll pay anywhere from $2 to $7 more starting Jan. 1. Congress made this change in the National Defense Authorization Act for Fiscal Year 2018.

There’s still no cost to fill prescriptions at military pharmacies. And these cost changes don’t apply to active duty service members (ADSMs). ADSMs still pay nothing for covered drugs at military and network pharmacies. Copayments for survivors of ADSMs are the same as the 2017 rates. Copayments remain the same for medically retired service members and their family members, too.

Prescription copayments vary based on pharmacy type. Also, they vary based on the drug category. TRICARE groups prescription drugs into one of four categories. This grouping is based on the medical and cost effectiveness of a drug compared to other drugs of the same type.

As outlined in the TRICARE Pharmacy Program Handbook, the drug categories include:

Generic formulary drugs: These drugs are widely available. Beneficiaries have the lowest out-of-pocket costs for these drugs.

Brand-name formulary drugs: These drugs are generally available. Plus, they offer the second lowest copayment.

Non-formulary drugs: These drugs may have limited availability. Beneficiaries have higher copayments for these drugs. Also, there’s generally an alternative formulary drug available. It’s often more cost effective, and equally or more clinically effective.

Non-covered drugs: TRICARE doesn’t cover these drugs. If beneficiaries choose to purchase a non-covered drug, they’ll pay 100 percent of the drug’s cost. These drugs are either not clinically effective, or as cost effective as other drugs offered. They may also pose a significant safety risk that may outweigh any potential clinical benefit.

Using home delivery, copayments for up to a 90-day supply of generic formulary drugs will increase from $7 to $10. For brand-name formulary drugs, copayments will increase from $24 to $29. Copayments for non-formulary drugs without medical necessity will increase from $53 to $60.

At a retail network pharmacy, copayments for up to a 30-day supply of generic formulary drugs will increase from $11 to $13. For brand-name formulary drugs, the increase is from $28 to $33. Non-formulary drugs will increase from $53 to $60.

At a non-network pharmacy, beneficiaries must pay the full price of the drug. After meeting the annual deductible, beneficiaries may submit a claim for partial reimbursement. Non-network pharmacy costs remain the same as previous years for TRICARE Prime beneficiaries.

With TRICARE Prime, a managed care option available in Prime Service Areas in the United States; you have an assigned primary care manager who provides most of your care.TRICARE Prime, beneficiaries pay a 50 percent cost-share after meeting their point-of-service deductible for covered drugs.

For all other health plans, non-network pharmacy costs are as follows:

Generic formulary drugs and brand-name formulary drugs will cost $33 or 20 percent of the total cost, whichever is more, after meeting the annual deductible.

Non-formulary drugs will cost $60 20 percent of the total cost, whichever is more, after meeting the annual deductible.