FALLS CHURCH, Va. –
Have you ever wondered how a service, drug, or treatment becomes a TRICARE benefit? As drugs and technology continue to develop, TRICARE coverage evolves along with them.
It’s important to know that U.S. law governs TRICARE benefits. If the law allows TRICARE to cover a treatment or drug, the Defense Health Agency reviews the proposed benefit to make sure it’s:
“It takes many teams to add a new TRICARE benefit. Congress sets the rules for coverage. Health care experts evaluate whether a proposed benefit is safe and effective. Policymakers outline the rules for using the benefit,” said Elan Green, chief, Medical Benefits and Reimbursement Branch, TRICARE Health Plan, at the Defense Health Agency. “This process ensures the longevity and success of the TRICARE health plan.”
Want to learn more about this process? Keep reading.
Medical treatments
Before TRICARE can add a new benefit, the law or the
Code of Federal Regulations must allow it. Sometimes, the law doesn’t allow TRICARE to cover certain services. DHA doesn’t have the ability to change the law. Only Congress can expand what TRICARE covers.
When deciding whether to cover a service, DHA considers:
- Changes to federal law
- Changes in national health care coverage
- Advances in medical science
- Denials brought to DHA’s attention through the appeals process
- Input from providers or military leadership
TRICARE only covers treatments that are:
- Medically necessary
- Proven
This means TRICARE doesn’t cover experimental treatments.
Experts review all clinical data. Sometimes, DHA creates a pilot program or demonstration to get more information before deciding whether to add it as a TRICARE benefit.
Once DHA approves a new benefit, it will:
- Develop policies about the benefit
- Identify funding within the budget
- Update the TRICARE Manuals
- Update contracts with the regional contractors
New prescription coverage
There’s a different process for approving coverage for prescription drugs that you get at an outpatient pharmacy (military pharmacy, retail pharmacy, or home delivery). When a private company develops a new drug, the
U.S. Food and Drug Administration determines if the drug is safe and effective before approving it. TRICARE never covers drugs the FDA hasn’t approved.
Even when a drug is FDA-approved, DHA still needs to decide if it will become a TRICARE benefit.
All TRICARE-covered drugs are on a list called the TRICARE Formulary. The Pharmacy and Therapeutics Committee is responsible for recommending drugs for the formulary. Every quarter, they review new drugs approved by the FDA. They make recommendations based on a comparison of the other drugs already available.
The committee’s mission is to provide appropriate drug therapy in a uniform, consistent, and equitable way. The committee has voting members from across the Department, including:
A second group of professionals also gives input on what drugs TRICARE should cover. This group, the Beneficiary Advisory Panel, gives independent suggestions to the DHA director. It includes:
The DHA director makes a final decision. The DHA then places the drug into one of four categories, as described in the TRICARE Pharmacy Program Handbook:
There are many steps involved in approving new TRICARE benefits. But each step helps ensure that TRICARE-covered treatments are proven, safe, and effective. This process enables TRICARE’s resources to support the health needs of millions of service members, retirees, and family members. Want to learn more? Check out How a Benefit Becomes Covered. Or, watch “How a Benefit Gets Covered” on the TRICARE YouTube channel for a quick overview.
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