Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); TRICARE; Implementation of Changes to the Pharmacy Benefits Program; Double Coverage With Medicare Part D

TRICARE eligible beneficiaries, who are entitled to Medicare Part A on the basis of age, disability, or end-stage renal disease, maintain their TRICARE eligibility when they are enrolled in the supplementary medical insurance program under Part B of Medicare. In general, in the case of medical or dental care provided to these individuals for which payment may be made under both Medicare and TRICARE, Medicare is the primary payer and TRICARE will normally pay the actual out-of-pocket costs incurred by the person. This final rule prescribes double coverage payment procedures and makes revisions to TRICARE rules to accommodate beneficiaries who are eligible under both Medicare and TRICARE, and who participate in Medicare's outpatient prescription drug program under Medicare Part D. These revisions are necessary because of the requirements contained in the Centers for Medicare and Medicaid Services (CMS) final rule for the Medicare Prescription Drug Benefit, Part D plans with other prescription drug coverage. This final rule also establishes requirements and procedures for implementation of the improvements to the TRICARE Pharmacy Benefits Program directed by section 714 of the Ronald W. Reagan National Defense Authorization Act (NDAA) for Fiscal Year (FY) 2005 (NDAA FY 05) (Pub. L.108-365). The rule clarifies that the cost-sharing requirements for Medicare-eligible beneficiaries may not be in excess of the cost- sharing requirements applicable to other retirees, their dependents, former spouses and survivors. Additionally, the rule authorizes the Department of Defense (DoD) Pharmacy and Therapeutics Committee (P&T) to make a separate and additional determination of the relative clinical and cost effectiveness of pharmaceutical agents that provide greater value than other uniform formulary agents in that therapeutic class. This rule also describes the transition process that will occur as the uniform formulary is developed and uniform service facilities move to a unifor