TRICARE-For-Life

This item will be added to as information is available.  New information will be entered at the beginning of the article and dated.  More details about enrolling in Medicare Part B and updating your DEERS data may be found on TROA's Web site at http://www.troa.org/Legislative/HealthCare/TRICAREReady.asp

The Department of Defense has agreed to call the new health coverage for Medicare-eligible beneficiaries "TRICARE-For-Life".

21 MAY 2004

Part B Special Enrollment Period Coming
Some 90,000 Medicare-eligible military beneficiaries are not eligible for Tricare for Life and Tricare Senior Pharmacy services because they are not enrolled in Medicare Part B. The Medicare Prescription Drug, Improvement and Modernization Act of 2003 provides for a special, no-penalty enrollment period for them. The special period runs through Dec. 31, 2004, but the act did not specify a start date. According to the Military Officers Association of America (MOAA), Medicare must first publish guidelines in the Federal Register and provide a 60-day comment period. This would drag the open enrollment start to September or October. When it does kick off, the Center for Medicare and Medicaid Services plans to automatically enroll every Medicare-eligible beneficiary who is not currently enrolled in Part B, stated a MOAA official. Beneficiaries will receive notifications of enrollment offering them the chance to decline if they so choose.

7 May 2004

TRICARE Uniform Formulary Final Rule Published 3 MAY 2004.
Congress directed the DoD to establish a Uniform Formulary (UF) process which creates a new third-tier copay 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 make recommendations regarding which medications will be available at the third tier copay); and a new Beneficiary Advisory Panel (to review the Committee's recommendations).

The pharmacy benefit will continue to include all Food and Drug Administration approved pharmaceutical agents that require an authorized provider's prescription, unless otherwise excluded from TRICARE pharmacy benefit coverage by law.  It will also continue the current tiers of $3 for generic medications and $9 for brand name medications. There will be no drugs in the third ($22) tier until the appropriate committees have met to evaluate drugs in accordance with the Uniform Formulary Rule and the final approval has been made.  For further details see http://www.tricare.osd.mil/news/2004/news0411.cfm
(This information furnished by MOAA, Military Officers Assn of America)

TRICARE Retail Pharmacy Transitions
Beginning Jun 1, 2004, the TRICARE Retail Pharmacy program will be run by Express Scripts Inc.  Beneficiaries and caregivers are encouraged to close out outstanding paper claims from medications obtained prior to Jun 1, 2004.  Paper claims resulting from the use of non-network pharmacies or submitted for reimbursement of
out-of-pocket expenses not covered by other health insurance, should be submitted to the current claims processor of your Regional Managed Care support contractor until Aug 31, 2004.  After that date, Express Scripts Inc. will be responsible for any outstanding claims.

(This information furnished by MOAA, Military Officers Assn of America)

6 JUN 2003

Updates from the Tricare Management Activity

* Uniformed services retirees and their families are encouraged to check into the TRICARE Retiree Dental Program (TRDP). Benefits under the TRDP are enhanced under the new TRDP contract to form the most comprehensive dental benefits program ever available to uniformed services retirees and their family members. The new contract, administered by Delta Dental Plan of California, became effective May 1, 2003.

* TRICARE Provider Directory - The TRICARE Provider Directory Web site has been revamped to include basic descriptions that outline three TRICARE options (TRICARE Prime, Standard and Extra) and a link to a military treatment facility locator: http://www.tricare.osd.mil/providerdirectory/

* National Guard or activated reservists ordered to active duty for more than 30 days in support of a contingency operation or an active duty service member separating from active duty service under abnormal circumstances such as stop-loss or involuntary separation may be eligible for benefits under the Transitional Assistance Management Program (TAMP).  For more information consult the Tricare web site under "Transitional Health Care Benefits" at: http://www.tricare.osd.mil/factsheets/index.cfm?fx=show 

* These are links to updated Frequently Asked Questions posted on both TRICARE and Express Scripts Inc. web sites for the new Tricare Mail Order Pharmacy (TMOP) benefit:
http://www.tricare.osd.mil/pharmacy/tmop.cfm
http://www.express-scripts.com/custom/dod/tmopfaq/

10 January 2002

New TRICARE Mail Order Pharmacy to Open March 1, 2003

More than 400,000 military pharmacy mail order customers will be switched March 1, 2003, to a new TRICARE Mail Order Pharmacy program, according to the TRICARE Management Activity, Falls Church, VA.

Services will continue under the National Mail Order Pharmacy contract until Feb. 28, 2003. The next day, March 1, Express Scripts Inc. will provide services under the new TRICARE Mail Order Pharmacy program.  Express Scripts Inc. of Maryland Heights, Mo., won the $275 million, five-year contract in September to provide mail order pharmacy services for TRICARE beneficiaries.

Beneficiaries who have refills remaining on prescriptions on March 1 would be transferred to Express Scripts so they can continue ordering medications on time, with a few exceptions:  narcotics or other controlled substance prescriptions and compounded prescriptions -- those that are physically prepared by the pharmacy - cannot be transferred.

In early January, current users or the Mail Order Pharmacy should receive a post card announcing the new services. That will be followed by a mailing, which will include a registration form, a description of benefits and a brochure covering the TRICARE program.

Those eligible to use the current mail order program or the retail benefit are eligible to use the new TRICARE mail order program. New customers have to register for the program. Information will be provided through the TRICARE service centers, military treatment facilities pharmacy as well as their marketing points of contact.

The usual delivery time for medication is five to seven days. The easiest way for patients to ensure they don't run out of their medication is to have the provider write for up to a 90-day supply with up to three refills. The beneficiary can request a refill once 75 percent of the medication has been used.  About day 70 into their medication, you can request a refill.  That should provide a sufficient cushion.

Al medication is screened for potential drug interactions or therapeutic overlaps that could produce an adverse drug reaction.  Patients' complete beneficiary profiles are entered into the Pharmacy Data Transition Service, which enhances patient safety by keeping their medication records current, on file and readily available.

The new contract saves taxpayers' dollars because it calls for purchasing drug products at federal prices. Best federal prices are estimated to be at least 24 percent below average commercial wholesale prices.

The TRICARE Management Activity will manage the new contract. The current, national contract has been managed by the Defense Logistics Agency's Defense Supply Center in Philadelphia.

Patients can fill prescriptions three ways: by direct care at military treatment facilities, or the retail pharmacy network or the mail order program, Davies noted. The direct care system serves the bulk of the beneficiary population, he said. About 2.5 million beneficiaries use the retail pharmacy network because they don't have access to a military facility.

Most of the 400,000 beneficiaries who use the mail order program do so for chronic medication or maintenance medication needs.  Beneficiaries who have long-term medication needs should consider using the mail order program. It provides up to a 90-day supply of most medications for a single co-pay, whereas they only receive a 30-day supply for a single co- pay in the retail network pharmacy system..

Under the TRICARE Mail Order Pharmacy system, the co-pay for up to a 90-day supply for most medications is $9 for branded products or $3 for generics. Exceptions include controlled substances, and active duty members pay no co- pays.

For more information, including a complete section on the co-pay structure, visit the TRICARE Web site at http://www.tricare.osd.mil/. Reservists can check the site for details of their benefits under the program.

Beneficiaries can also use the Express Scripts Inc. Web site by clicking on the DoD seal at www.express-scripts.com after the site debuts on Jan. 15, 2003.

8 MAR 2002

TRICARE For Life (TFL) Claims Update

By the end of February, DoD had received over 7.6 million TFL claims and
had completed processing on more than 7 million of them, paying out over
$243 million in health care benefits.  Claims processing contractors
report that nearly all of the initial TFL claims “hiccups” either have
been resolved or will be by mid-March.  Here’s a recap of the status of
the main initial problems:

Electronic Claims Omission.  Approximately 13% of TFL beneficiaries were
inadvertently left out of TFL’s initial data exchange with Medicare.
Because Medicare was initially unaware that these people were TFL
beneficiaries, their Medicare claims were not forwarded to TFL.  This
group was re-entered into the electronic process by mid-December.  But the
affected beneficiaries needed to file a paper TRICARE claim to receive
reimbursement for doctor visits between October 1 and about December 7.
Status:  TFL contractors report they have already processed large numbers
of these paper claims, but there is no way to tell whether all of them
have been submitted.  Beneficiary Action Needed:  Affected beneficiaries
who had unpaid claims for visits during that period last fall must file a
paper TRICARE claim (Form DD2642), plus a copy of the Medicare Summary
Notice (MSN) for the relevant visit.

Expired ID Cards.  Many older beneficiaries who had let their military ID
cards expire had their initial TFL claims denied.  Status:  TFL is
centrally identifying and reprocessing all claims denied for this reason,
and will pay them until July.  The vast majority of corrected payments
will be completed by mid-March.  Beneficiary Action Needed:  Beneficiaries
with expired ID cards must renew them by July, or their subsequent TFL
claims will be denied.  Those who need help getting new ID cards can
contact the Defense Manpower Data Center Support Office at 1-800-538-9522.

Excess Charges Payment.  3 to 4 percent of TFL beneficiaries visit doctors
who do not “accept Medicare assignment.”   Providers who don’t accept
assignment may charge up to 115 percent of the Medicare-allowable charge.
TFL will cover this extra 15-percent charge.  However, the TRICARE claims
processors initially didn’t get the word, and initially denied the extra
payment.  Status:  TFL had identified and made corrected payments for all
of the previously underpaid claims as of mid-February.  Beneficiary Action
Needed:  None.

OHI Indicator.  Some members who canceled other health insurance (OHI) in
conjunction with switching to TFL coverage and advised TFL of the
cancellation had initial TFL claims denied because the Medicare claim
system still indicated their OHI was active.  (By law, the OHI must pay
first.)  In some cases, this was a simple processing delay.  In others,
the other insurance company delayed notifying Medicare to avoid missing
any delayed claims for medical visits before the cancellation.  Status:
TFL processes have been changed to override the Medicare OHI indication if
the beneficiary has notified DoD of the OHI cancellation, either by mail
or by phone.  Erroneously denied claims are being centrally identified and
reprocessed.  Over 160,000 previously denied claims had been corrected and
reprocessed by the end of February.  Beneficiary Action Needed:  None.

Beneficiary Notification Failure.  Members who canceled their OHI but who
did not notify TFL of such cancellation also may have their claims denied
as discussed in the previous paragraph.  Status:  TFL can’t correct the
problem unless they are made aware of the cancellation.  Beneficiary
Action Needed:  If notified that your TFL claim was denied for this
reason, call the TFL call center toll-free at 1-888-363-5433.  The call
center can provide a phone number for your state/region that you can call
to update your TFL records to show your OHI has been canceled.  Your claim
then can be reprocessed automatically.

TMA leaders report that TFL claim denial rates are dropping.  Initially
30%, the rate is now down to 23%, and this trend should continue with
correction of initial processing problems.

The single most frequent reason for a denied claim (almost half of all
denials) is that something in Medicare or TFL files shows the beneficiary
has other health insurance (OHI).  Despite intensive efforts by TMA, TROA
and many others, only 63% of TFL- eligibles have told DoD of their intent
to retain or drop any Medigap insurance coverage they may have had.

If you previously used other insurance, your claims history with Medicare
or TRICARE usually will still reflect that you have OHI unless you report
its cancellation date.  And if the TRICARE system understands you still
have Medicare supplemental insurance coverage, your claim will be denied.

Another problem may occur if you have decided to keep your OHI and don’t
tell DoD.  In some cases, this can cause TFL to make a duplicate payment
to your doctor (i.e., in addition to the payment from your other policy)
that later may have to be recouped.  This results in administrative
problems for DoD, for your doctor, and for you.  These administrative
problems could result in TFL getting a bad name with providers and that
could hurt all military beneficiaries.

The success of the program depends on TFL beneficiaries doing their part
to make sure that the claims processors have accurate information about
their coverage.  So it is important for you if you are a Medicare-eligible
member to confirm to DoD whether you have OHI and, if so, whether you plan
to cancel or retain it, and the effective date of any planned
cancellation.

Last summer DoD sent a TFL mailing to all 1.4 million
Medicareeligible uniformed services retirees, family members and
survivors requesting that they respond with their OHI intentions.   If you
didn’t respond to the mailing, it is not too late to update your files.
You should call DoD today and furnish this important information toll free
at 888-363-5433.

Contacting DoD has no effect on your current Medicare supplement.  If you
wish to make any changes to your existing supplemental coverage, you will
still have to contact your insurance carrier to make those arrangements.
You are under no obligation to cancel your Medicare supplement, but you do
need to communicate your intentions to DoD to guard against having a
claims problem.

If you need additional TFL information visit the TRICARE Web site at
http://www.tricare.osd.mil/ or call toll free 888-DOD-LIFE (888-363-5433)
for assistance with resolution of any claims problems.
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“© 2002 The Retired Officers Association.  Used with permission.”
Copyright © 2002, The Retired Officers Association (TROA), all rights
reserved. Part or all of this message may be retransmitted for information
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this notice.

25 Jan 2002

TRICARE FISCAL YEAR CATASTROPHIC CAP REDUCED FOR RETIREES, THEIR FAMILY MEMBERS AND SURVIVORS

The TRICARE fiscal year "catastrophic cap" has been reduced from $7,500 to $3,000 for uniformed services retirees, their family members and survivors. The cap is the maximum amount of out-of-pocket costs these beneficiaries are required to pay for medical care during a fiscal year (Oct. 1 through Sept. 30).

For active duty family members, the catastrophic cap remains $1,000 per fiscal year.

The catastrophic cap reduction is retroactive to Oct. 1, 2000. Retirees, their family members and survivors who have paid more than $3,000 out-of-pocket for TRICARE-covered services are eligible for reimbursement. The managed care support contractors (MCSC's) will search their files and identify beneficiaries due refunds.

Beneficiaries who have saved their receipts and choose to initiate a request for reimbursement, may do so by contacting their regional claims processor for guidance on where to submit their receipts and claims.

It is not necessary for beneficiaries to resubmit claims already paid by
TRICARE to qualify for reimbursement of the amount paid over the catastrophic cap.

For retirees, their family members and survivors enrolled in TRICARE Prime, there is an enrollment year cap. The enrollment year cap begins on the anniversary date of enrollment in TRICARE Prime, and applies to all enrollees. Catastrophic caps, both fiscal year and enrollment year combined, will not exceed $3,000 in a given 12-month period for retirees, their family members and survivors, and $1,000 for family members of active duty members.
Once the catastrophic cap and enrollment year cap (combined) are met by TRICARE Prime enrollees, TRICARE will pay up to the TRICARE allowable amount for all covered services (excluding point-of-service charges which do not count toward the catastrophic cap).

For beneficiaries who are not enrolled in TRICARE Prime, TRICARE will pay up to the TRICARE allowable amount for all covered services for the remainder of the fiscal year after the fiscal year cap is met.

Retirees, family members, and survivors remain responsible for the cost of all services and treatments received which are not TRICARE covered benefits.

Some beneficiaries mistakenly believe that the $3,000 catastrophic cap is the ceiling on the amount that TRICARE will cover for a family during any given year, however the opposite is true. The cap will protect retirees, their family members and survivors from paying more than $3,000 out-of pocket for medical care.

For additional information on catastrophic cap reduction, beneficiaries are encouraged to contact the nearest TRICARE service center or military treatment facility beneficiary counseling and assistance coordinators for assistance.
TRICARE benefit information is also available on the Military Health
System/TRICARE Web site at http://www.tricare.osd.mil , or by calling 1-888-DoD-LIFE (1-888-363-5433).

--End –

7 DEC 2001

TFL Covers Excess Charges of Non-Medicare Providers.  Healthcare providers who don’t accept Medicare assignment may charge up to 115% of the limits set in law, and TRICARE For Life (TFL) will cover these “excess charges.”  But some initial TFL claims for care from non-participating providers were not properly paid for the excess charges.  The contractors who process TFL claims have corrected their procedures and are taking action to provide supplemental payments for those affected.

16 NOV 2001

2 NOV 2001

19 OCT 2001

Testimony of PRESCRIPTION DRUG ordering.

The TFL prescription plan coverage began 1 APR 2001, but if you had coverage under a Medigap policy, which I did, TFL would not activate.  The Medical coverage kicked in 1 OCT 2001 and I cancelled my Medigap policy effective 30 SEP 2001.  It was necessary for me to get DEERS (1-888-363-5433 to tell Merc-Medco that I was covered by TFL) and on 17 OCT 2001 I was able to order refills on line.  Four items that cost me $60 under my old plan were $24 under TFL.  I will let you know if I do not get the medicine now.  Ha! S/ J. Claud

The FY2001 National Defense Authorization Act (NDAA) lowered the
ANNUAL CATASTROPHIC CAP (the maximum out-of-pocket expense for TRICARE covered medical bills in a fiscal year) for retirees and their families.  The cap was reduced from $7,500 per family to $3,000. Beginning December 15, funds will become available to reimburse beneficiaries whose out-of-pocket TRICARE expenses (from 1 Oct. 2000 to 30 Sept. 2001) were between $3,000 and $7,500.

28 SEP 2001

TFL Question of the Week.  Is the 1 October start-up of TRICARE
For Life at risk because funding or other considerations associated with the recent terrorist attacks or America’s response to them? 

The short answer is “No.”

14 September 2001

TFL Question of the Week:

I received TRICARE-For-Life mailings from two different TRICARE contractors. Which one am I supposed to fill out? 

The short answer: Complete and return them both to be on the safe side.