WE DO NOT HAVE A BIN NUMBER
WE REIMBURSE THE INSURED FOR THEIR RX ONCE THEY HAVE MET THEIR DEDUCTIBLE
The supplement plans cover prescription drug co-pays left behind by TRICARE/CHAMPVA. In most cases, our supplement will only cover the item if it was approved and partially reimbursed by TRICARE.
However if a retail pharmacy prescription purchase was denied by TRICARE because the drug is a brand name maintenance drug on this list, we will still accept the claim and reimburse up to $24 for a 30-day fill or up to $72 for a 90-day fill. TRICARE will not usually pay for these brand name maintenance medications unless filled via mail order or dispensed at a Military Treatment Facility. To add value to our supplement plans, we will reimburse (at least partially) for these drugs even though they are denied by TRICARE. When we process these “exception” claims, we will use CPT code RXE. RXE stands for prescription exception.
The member must submit receipts to us so that we may reimburse any eligible charges. See the claims section for more details.
As of 07/01/2021 our insureds who fill their RX at Rite Aid pharmacies will have to pay up front and then file a claim with us for reimbursement. Please review the letter we are sending the insureds to explain this process.
NOTE: Starting on June 28, 2017, TRICARE will no longer include the drug Nexium in the preferred, or formulary drug list and it will no longer be available in military hospitals and clinics. In order to prepare for the changes, patients are currently being asked to switch to one of the following three preferred alternatives that have been shown to have effective results:
- Omeprazole
- Pantoprazole
- Rabeprazole
Your doctor may determine that the preferred alternatives are not right for the member and that Nexium is medically necessary. To be medically necessary means it is appropriate, reasonable, and adequate for your condition. In those cases, TRICARE will continue to cover the cost of Nexium, minus the $20 copay for a 90-Day supply of home delivery and $24 copay for a 30-Day supply via a retail outlet. On or after June 28, 2017, your doctor must submit a prior authorization and a reason why Nexium is medically necessary via the Express Scripts doctor line for you to refill your prescription. For patients who continue to use Nexium with prior authorization but WITHOUT a doctor’s medical necessity determination, the non-formulary copay cost will be $49 for a 90-Day supply via home pharmacy delivery or $50 for a 30-Day supply via a retail outlet.
BRAND NAME MAINTENANCE DRUG LIST:
How Members May File Claims for Network and Home Delivery Prescriptions (not CHAMPVA)
The member must submit a claim form. The member must also include one of the following:
(1) a copy of the prescription drug co-payment receipt showing the name of the drug, date filled, referring doctor, NDC product number and co-payment amount, or
(2) a print-out of prescription drug charges from the pharmacy, and
(3) The Tricare EOB.
How Members May File Claims for Non-Network Prescriptions (not CHAMPVA)
The member must submit a claim form. The member must also include a copy of the TRICARE EOB and a copy of the prescription drug receipt (showing the name of the drug, date filled, referring doctor’s name, NDC product number and billed amount).
How CHAMPVA Members May File for Prescriptions
CHAMPVA Supplement insureds must submit the CHAMPVA EOB to receive reimbursement of the co-pay paid at the pharmacy. The member will receive the CHAMPVA EOB in the mail. Please ask the insured if they will get a print out from the pharmacy, and fax to 1.800.310.5514 along with the primary EOB.