As of May 1, 2015, TRICARE changed coverage rules for compounded drugs. Compound drugs are:
A combination of two or more drugs, prepared by a pharmacist for a patient’s individual needs.
The new rules will require that each ingredient in the compound:
- Is covered by TRICARE
- Is safe and effective
- Doesn’t exceed the cost standard
- Is being filled by a network pharmacy
- Note - not all network pharmacies compound drugs
Many compounded drugs that have been covered in the past will no longer be covered.
Example of compounded drugs that could be covered:
If the compound drug—or any ingredient in it—doesn’t meet the coverage requirements above, you can ask your doctor about:
- Hormones creams
- Pain creams
- Basically any compound that contains a non-TRICARE covered active or inactive cream ingredient (including bulk compounding powders and inactive bulk powders or bases)
- A covered drug that comes in tablet form but not liquid form and the patient cannot swallow tablets.If the pharmacist takes the covered tablet and compounds it into a liquid form this would be covered
- Keep in mind this is extremely rare as most medications now either come in liquid form or can be crushed or chewed
- Note - coverage would not be granted if a liquid or chewable form is already covered by TRICARE as a non-compound
If the compound drug or any ingredient in it doesn't meet the above coverage requirements, you may ask your doctor about:
- Prescribing a TRICARE covered medication instead of a compound
- Remove or substitute the non-covered ingredient with a TRICARE covered ingredient
- If neither of these options are possible, your doctor can fill out a prior authorization form, but this does not guarantee coverage.
- If the prior authorization is approved you can get the compound
- If prior authorization is not approved then coverage will not be granted
- If you still want the compound you will need to pay out of pocket
- Note - you can appeal this decision to USFHP within 90 days.
Want to learn more? Visit the Defense Health Agency's (DHA) web site.