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Editor’s Note: This article is part of the 2023-24 TRICARE Guide provided by insurance plans administered by the Association of Member Benefit Advisors (AMBA). A version of the guide appeared in the November 2023 issue of Military Officer magazine.

Tricare For Life Pharmacy Costs

A top priority in the second half of the 118th Congress is protecting TRICARE beneficiaries from excessive increases in pharmacy copayments.

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With the National Defense Authorization Act (NDAA) of FY 2018, Congress authorized the Department of Defense to begin costing prescription drugs beginning in 2028 to reflect changes in pharmacy program costs. Concerns that the Defense Health Agency could use this authority to implement excessive pay increases.

Next year, it will try to get legal protections in this government, consistent with past rules governing TRICARE pharmacy benefits.

The TRICARE For Life Act of FY 2001, the NDAA expanded TRICARE’s home delivery and retail pharmacy programs to Medicare-eligible retirees who were previously limited to filling prescriptions at local pharmacies.

The initial TRICARE pharmacy payments established by the Department of Defense followed the statutory objective and were aligned with the business plan criteria. Since then, Congress has enacted increases in pharmacy payments.

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Recently, Congress included a schedule in the FY 2018 NDAA with two-year increases in pharmacy payments through 2027. These increases increase TRICARE’s participation levels with other employer-sponsored plans.

The Kaiser Family Foundation (KFF) Employer Health Benefits Survey reports average copayments of $11.37 and $67 for Tier 1, Tier 2 and Tier 3 drugs. The TRICARE copayment at retail pharmacies is $14 for generic drugs, $38 for brand-name drugs, and $68 for non-formulary drugs for a 30-day supply.

Payment for a 90-day supply by mail is $12, $34, and $68 for generic, brand, and nonformula, respectively. Prescription drugs obtained at the MTF pharmacy do not have a co-payment.

Unlike many commercial plans, TRICARE does not have a separate item for certain drugs, such as biologics, that may be used to treat chronic conditions or certain types of cancer. Specialty drugs can be expensive and often require special administration, administration (eg, injections or infusions), and patient monitoring.

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KFF reports that approximately 61% of workers at large companies are in a health plan with at least one level of cost-sharing for specialty drugs only. The average copayment for specialty drugs in these plans is $103, and the average cost share is 25 percent.

She appreciates that the TRICARE drug program does not have a separate, more expensive line for specialty drugs, but is concerned about the future of TRICARE drug costs.

Learn more about TRICARE For Life, prepare for key deadlines, and understand plan options for you and your spouse.

Rodisoli is the Director of Government Relations for Health Affairs and also serves as Co-Chair of the Military Coalition Health Care Committee (TMC). She spent six years with the National Military Family Association, advocating for uniformed service families with a focus on health care and military caregivers. Our website uses cookies to provide a safer, faster and more personalized site experience. By using our site, you agree to our use of cookies. Read the privacy policy for more information.

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The TRICARE Toolkit provides insight and tips for navigating TRICARE benefits. Have a question or suggestion for a future column? Email beninfo@. Read other TRICARE Toolkit columns at /tricaretoolkit.

TRICARE pharmacy beneficiaries will see increased costs in 2024 as the Defense Health Agency implements prescription drug payments established by the National Defense Authorization Act (NDAA) in FY 2018.

The same law gives the Department of Defense the authority to adjust cost-sharing for 2028 and beyond to reflect changes in costs for pharmaceutical agents and prescription drugs. Discussions have already begun on Capitol Hill to create regulatory safeguards, with a legislative goal of limiting increases in the Defense Department’s prescription drug payments.

At retail pharmacies, beneficiaries will continue to pay the TRICARE copayment or the actual retail cost of the drug, whichever is lower. You can check the estimated retail cost of your prescription drugs using the Drug Cost tool.

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The TRICARE retail pharmacy and mail order programs were expanded to Medicare-eligible retirees in 2001 with the legislation that created TRICARE For Life (TFL). Until then, the only prescription drug benefit available to military retirees 65 and older was no-cost prescriptions at MTF pharmacies.

As Congress enacted reforms to the military health care system, it successfully blocked dozens of proposals that would have increased cost-sharing among beneficiaries, including the TFL enrollment fee and raising the catastrophic limit to $5,000.

It also opposed fee increases for survivors as well as medical retirees and their families. As a result, protections for these populations were included in the FY 2018 NDAA—their pharmacy copayments will remain the same next year.

There will also be no change for active-duty officers—they will have no out-of-pocket costs for drugs obtained from MTFs, retail pharmacies, or through mail order.

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Continues to work to rebuild the TRICARE pharmacy network, which has been reduced by approximately 25% due to reduced network requirements in the new TPharm5 contract, by working to provide reporting to obtain accurate beneficiary impact information. We appreciate the members who traveled to Washington, D.C. last month for our Defense in Action event and met with legislators to explain how discontinuing the pharmacy network will affect military families.

Please see the newsletter for updates on our advocacy efforts regarding TRICARE pharmacy benefits, including a call to action to share your views.

Rodisoli is the Director of Government Relations for Health Affairs and also serves as Co-Chair of the Military Coalition Health Care Committee (TMC). She spent six years with the National Military Family Association, advocating for uniformed service families with a focus on health care and military caregivers.

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