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VA Co-pay and Tricare Express Scripts

Military Authority Member
David Ballard July 30th, 2012

I am retired US Military and recieve all of my medical care at the Roudebush VA Medical Center in Indianapolis, IN facility.

I have Medicare parts A and B.

I have Tricare for Life.

I recieve retired pay.

I am 40% Disabled.

I have, at present, 14 prescriptions from the VA with a $8.00/month co-pay equaling $122.00/Month.



My question is this, what is the best method to get these prescriptions covered by Express Script? I do not know how Medicare and Tricare split their processing. All know is I must have Medicare Part B to keep and maintain Tricare which has included prescription coverage and there is not one bit of information/guidance with my senario. I know I am not the only person in this situation, I do know if I pay something then I should have coverage.



David Ballard

Cell 317-605-0397


Replies

Military Authority Member
Jason Van Steenwyk August 1st, 2012

Hello, and thanks for writing. I'm Jason Van Steenwyk, the financial editor for Military.com, and I'll be looking into your question for you.

The more general answer is that Medicare is the primary payor, and TRICARE For Life, or TFL, pays costs that are left over.

So if you had Medicare Part D, the Prescription Drug Plan, or if you had a Medicare Advantage plan that included prescription drug coverrage, it would likely fall under Medicare auspices.

But since you dont have Medicare Part D, then it falls under your TRICARE coverage.

There are some things about your prescriptions that are going to be fact-specific. That is, only you can answer. Specifically, your copay structure is going to be different depending on the exact drugs you are taking. Here's why:

TRICARE has published a uniform co-pay guide that establishes different co-pays depending on whether your prescription is a generic, if it's included on the formulary, or if it's a non-formulary drug.

Your copay also differs based on how you get the prescription filled.

Here is the copay structure under Express-Script:

Home Delivery (Up to a 90 day supply)
Generic: $0
Formulary: $9
Non-Formulary: $25

Retail Pharmacy (30 day supply)
Generic: $5
Formulary: $12
Non-Formulary: $25

Not sure if your drug is on the formulary? Use this search tool:

http://pec.ha.osd.mil/formulary_search.php

As you can see, some of these categories have no co-pay at all, while other categories have higher co-pays than you are paying the VA. So if all your meds are on the formulary and you get them filled at a pharmacy, your co-pay could be up to $168 per month. That's a 12 dollar co-pay times 14 meds. That's for a 30 day supply. So if you need to go through a pharmacy, that's a money loser for you unless most of your meds are generics with a 5 dollar copay.

If you switch to home delivery, you can see that the copay for formulary meds is 9 dollars. But look closer... that's for a 90 day supply, not 30. So you're better off using Home Delivery, 90 day supply.

Even if everything you take is non-formulary, it's close to a wash with the VA copay: 25 dollars per med every 3 months for Express-Script vs. 8 dollars per month, or 24 dollars every three months, for the VA.

So it may make sense, for simplicity's sake, to channel everything through express script.

For the Express Scripts website, go here: http://www.express-scripts.com/TRICARE/

Hope that helps!~

Jason

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