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DoD TRICARE Management Activity 2007 Rx Benefit Innovation Award Problem Identification More than 9 million active and retired U.S. military personnel and their families have drug benefit coverage through the Department of Defense (DoD) TRICARE system. Of the 6 million who use the TRICARE pharmacy benefit, a significant portion also have drug benefit coverage from another source, such as second career employment or spouse’s employment. By law, all pharmacy claims for these beneficiaries must be paid first by the Other Health Insurance (OHI). Historically, this meant beneficiaries needed to pay the OHI copay at the pharmacy and then file a paper claim to get their TRICARE reimbursement. The DoD wanted to reduce this hassle factor for beneficiaries and save on claims processing fees by implementing electronic coordination of benefits. Target Audience TRICARE beneficiaries with drug benefit coverage from multiple sources and 56,000 retail pharmacies in the nationwide TRICARE network are the target audiences for this DoD drug benefit solution. Objectives The goal was to develop and implement a COB program to minimize the need for millions of TRICARE beneficiaries to incur reimbursable out-of-pocket expense and then file paper claims for reimbursement. To accomplish its goal, the TRICARE Management Activity (TMA) had to achieve the following:
Solution TMA organized a multi-functional group that included the DoD’s Pharmacy Data Transaction Service, Express-Scripts, and the National Council of Prescription Drug Programs to develop the technology solutions. In seven months, the team invested more than 2,000 hours in software development, testing, and integration to create an electronic COB system that allows pharmacists to have both the primary payer claim and the TRICARE claim coordinated and adjudicated at the point of sale. By collaborating with leaders in the National Association of Chain Drug Stores, TMA was able to obtain widespread pharmacy participation in TRICARE’s electronic COB. The TMA also conducted an extensive communication campaign to make TRICARE beneficiaries aware of the COB capability and benefits. Results DoD’s electronic COB program was launched in April 2006. In the next eight months, more than 350,000 TRICARE beneficiaries used the service and over 1 million prescriptions were processed electronically with TRICARE as the secondary payer. Nearly 95% of the beneficiaries who used electronic COB at point of sale were able to obtain their prescriptions with no out-of-pocket expense. Since inception of the program, the number of TRICARE claims processed through the electronic COB program has increased an average of 15% each week. This real-time, online technology solution is significantly reducing the hassle factor for TRICARE beneficiaries and generating an estimated savings of $1 million annually for the DoD in reduced claims processing fees.
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Copyright 2007 Pharmacy Benefit Management Institute, LP
