Effective October 1, 2015, the Department of Defense (DoD) Tricare program has adopted the commercial exclusions list for compounds under the Compound Management Program implemented by the DoD in May 2015. These exclusions include select classes of solid dose forms such as tablets and capsules in addition to the already excluded agents and bulk powders. Compound claims that are not covered should reject with a 70 (Product/Service Not Covered). Pharmacies have the option of resubmitting non covered claims using the “08” Clarification Code to accept non-payment for non-covered ingredients or resubmitting with a covered ingredient.
While Pharmacies should be able to rely upon the point-of-sale messaging to determine coverage, in order to avoid subsequent recoupment attempts by PBMs, pharmacies should become familiar with the common indications exclusions list. Frier Levitt regularly advises Pharmacies on claims submission and reimbursement issues. If your pharmacy has questions regarding Tricare coverage of compounds or the claims submission process, contact Frier Levitt.
