Notice of Non-coverage for Certain Compounded Drugs
Posted February 13, 2023
A review by the Pharmacy Advisory Board of the Defense Health Agency (DHA) found compounded drugs, which traditionally accounted for a small proportion of pharmaceutical expenditures, grew to over $500 million by 2015. The dramatic increase was largely due to multiple fraudulent schemes related to drug compounding and billing.
To combat fraud and ensure patient safety, DHA adopted the Express Scripts Incorporated (ESI) Commercial Reject List. The ESI’s Commercial Reject List verifies that each ingredient is safe, effective, and covered by TRICARE. With the current implementation of the DHA’s new electronic health record, MHS GENESIS, only compounds recognized by ESI, covered for the indication prescribed, and approved for standardized use, will be compounded by National Capital Region (NCR) Market pharmacies.
As Walter Reed National Military Medical Center (WRNMMC) is a part of the NCR Market, we will no longer be authorized to maintain an independent formulary, and must adhere to the standardized TRICARE Uniform Formulary. On March 17, 2023, certain compounded medications will no longer be available at WRNMMC. A list of compounded drugs that are excluded from the TRICARE formulary, along with a list of possible therapeutic alternatives is available here.
If you wish to continue using a compound on the list, you will be required to obtain it from a retail pharmacy and will be responsible for any applicable copays or out-of-pocket costs. It is recommended that you contact TRICARE to discuss this process before paying any out-of-pocket costs as these may not be reimbursable.
Please contact your provider to discuss alternatives that are available at your military pharmacy at no cost. Information regarding compounds and the TRICARE pharmacy benefit can be found on the Military Health System website. Additional questions or concerns should be discussed with your health care provider or your local military pharmacy.
It is an honor to serve you, and we thank you for the opportunity to meet your health care needs.