The Senate Armed Services Committee (SASC) report for its version of the FY 2022 National Defense Authorization Act (NDAA) includes language directing DoD to establish an appeals process for TRICARE coverage of Tier 4/non-covered drugs – a change sought by MOAA to reduce beneficiaries’ financial risk and improve their access to effective drug treatments.
MOAA greatly appreciates the SASC’s response; although directive report language is not legally binding, agency officials generally regard it as a congressional mandate and respond accordingly.
The SASC language directs the Defense Health Agency (DHA) to establish a medical necessity and prior authorization process to allow a beneficiary to request coverage of a Tier 4 drug at the same co-pay or cost-share as a non-formulary drug. It requests a briefing to the Senate and House Armed Services Committees on the appeals process no later than Feb. 1, 2022.
The FY 2018 NDAA authorized DoD to exclude from the TRICARE pharmacy program any prescription drug that provides little or no clinical effectiveness over other covered drugs. These drugs are known as Tier 4 (non-covered). Since the establishment of Tier 4, MOAA has advocated for an appeals process on the basis of medical necessity. And because charges for drugs in this tier don’t count against the catastrophic cap, beneficiaries can be exposed to significant costs if their prescription is moved to this tier.
We also have worked to get a specific drug, Dexilant, reinstated to the TRICARE formulary. Even with the pending appeals process, our efforts on Dexilant will continue given beneficiary feedback and our research on Dexilant coverage policies, which indicate TRICARE is out of step with commercial plans and other government payers.
We will request an implementation update from DHA and will provide more information as soon as it is available. Thank you to the many MOAA members who shared their stories about the impact of Tier 4 – your contributions played a critical role in our advocacy efforts. Continue to share these details on your use of the TRICARE pharmacy program by emailing firstname.lastname@example.org.
Have More Questions About Your Health Care Benefit?
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