The Military Health System's highest priority is the safety, health and well-being of our beneficiaries. Compound drugs are:
- A combination of two or more drugs
- Prepared by a pharmacist
- For an individual patient's needs
Some compound drugs contain ingredients the use of which is not supported by a widely recognized body of peer-reviewed clinical evidence.
We screen every ingredient in compound drug prescriptions to ensure they are safe, effective and appropriate for our beneficiaries.
Frequently Asked Questions
View questions and answers about TRICARE's compound drug policy.
Q1:
What is TRICARE's compound drug policy?
A:
TRICARE screens all ingredients in compound drugs to ensure they are safe, effective and medically necessary. TRICARE has established prior authorization review for compounds that don't meet the initial screening criteria.
Q3:
What if my compound prescription doesn't pass the initial screening?
A:
Your doctor can request prior authorization from Express Scripts. Requesting prior authorization allows Express Scripts and TRICARE to review each prescription on an individual basis, based on the criteria established by TRICARE. Your doctor must submit to Express Scripts:
- The diagnosis or condition that will be treated by the compound
- List of commercially available products tried in the past
- State if there is a national drug shortage for the commercially available product
- The estimated length of time you will need the compounded medication
Once Express Scripts receives the documentation, the request will be screened on these criteria:
- Has any ingredient been withdrawn from the market by the FDA for safety reasons?
- Are all ingredients lawfully marketed within the United States?
- Is there widely recognized evidence in the U.S. supporting that ingredient being safe and effective?
- Are the commercially available, FDA products inappropriate (e.g., inability to take a solid dosage form, dose based on age or weight) and/or a FDA-approved product that cannot be taken due to allergies or contraindication.
Q4:
What other evidence will TRICARE consider to determine if a compound drug prior authorization is allowed?
A:
In accordance with Sec. 704 of the FY 2015 National Defense Authorization Act, TRICARE will consider as evidence that a compound ingredient is safe and effective:
- Clinical trial published in refereed medical literature
- Formal technology assessments
- The positions of national medical policy organizations, national professional organizations or national expert opinion organizations
- Other validated evidence as the Secretary of Defense considers appropriate
Q8:
Will TRICARE beneficiaries be able to use non-network pharmacies to receive compound drugs?
A:
The normal TRICARE rules for non-network pharmacies will apply for compound drugs as for other drugs. Beneficiaries must pay up front and submit a claim to ESI for reimbursement. The claim will be subject to the same screening requirements as claims at a network pharmacy. Reimbursements are subject to deductibles or out-of-network cost shares, and copayments, which vary based on plan type and the sponsor’s status. >>Learn More
Q9:
What impact does the screen have on compound drugs for children?
A:
The screen will apply to all claims for compound drugs, including pediatric compounds, to ensure they are safe, effective and medically necessary. Most traditional pediatric compounds contain ingredients known to be safe and effective, so they will pass the electronic screen with no delay to the beneficiary.
If a prescription does not pass the initial screen, the pharmacist can contact the prescribing provider to discuss substituting an approved ingredient, getting a different prescription, or submitting a prior authorization request.
Q10:
Is the DHA responding to allegations of fraudulent practices by some compound drug companies?
A:
The DHA is actively investigating all cases of suspected fraud against the DOD related to compound drugs. We are collaborating with the appropriate federal and state law enforcement and licensing boards to pursue corrective action. DHA also initiated an audit of all compounding claims to determine if recoupment is justified in cases where possible violations of state or federal law resulted in inappropriate reimbursement.
We have received many reports from TRICARE beneficiaries regarding unsolicited attempts to obtain their personal identifying information and health information by offering them topical compound medications. The DHA, TRICARE and its contractors will never call and ask for personal identifying information or health information.
If beneficiaries are contacted in this fashion, the DHA strongly advises them to share NO information, and please immediately submit a Fraud-Line report to our Pharmacy Benefits contractor, Express Scripts. You can report the issue to Express Scripts (1-866-759-6139 or via email). Express Scripts can also flag your profile and reject attempts to bill for these medications. If you do receive unsolicited medication in the mail, you can refuse delivery.
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Presentation
Mar 20, 2015
.PDF |
425.49 KB
This presentation describes the DoD Uniform Formulary process and formulary considerations for compound medications.