Tricare Overseas Program Pharmacy Claims

[JimGant]

Anyone filed with Tricare Overseas Program (TOP) pharmacy claims for purchases from Thai pharmacies? Sounds like reimbursement, to some extent, is allowed, if the drug is on the Tricare allowable list (and, in most cases, is the generic). Haven't done it yet, but I do have some pills that would qualify for reimbursement. However, all my pharmacy receipts are hand written, and the following says that (just as from a US pharmacy) the particulars of the prescription and dosage need to be machine written. I guess this could be accomplished at many pharmacies here, if I gave them some time to do it before pickup. Anyway, anyone have experience with pharmacy filing to Tricare with your pills from over here? Thanx.

[lopburi3]

Can not answer as not covered by that but expect they only list requirements for a US prescription but if they allow others such rules would not be as strict.  Can say for my Blue Cross (and several other government plans) have had no problems with hand written receipts - but have been asked for detailed address on occasions as not always clear on cash type receipt.

 

Believe at least one local chain can provide machine typed receipts as recall getting from Save Drug located in some malls (old Carrefour as I recall) but they did not carry all medications (and it was many years ago). 

[pmarlin]

Why not use a thai hospital. You have see a doctor but TRICARE will reimburse 75% of that. Been doing that for over six years here and never had a problem with any type of medication. that also  goes for the wife.

[JimGant]

I'm sure someday I'll have to use a Thai hospital for a new ailment, but right now I'm just refilling at the local pharmacy all the maintenance medicines prescribed years ago in the States. Some of these are found in the generic form in Thailand, and are thus reimbursable by Tricare. Others, like Diovan (called Co-Diovan here) don't have the generic valsartan here, which is what Tricare would reimburse. Anyway, I won't go broke if I don't get reimbursed, but if I can get some of my fills partially reimbursed, why not. Just interested to hear from someone who has gone the pharmacy route filing with the Tricare Overseas Program (TOP).

[lopburi3]

A local version of valsartan is 

Valatan tab 160 mg		28's
Valatan tab 80 mg		28's

[JimGant]

Thanks, Lop. Since Valatan is unique to Thailand, I wonder how Tricare would treat it for insurance purposes? Since it's not on their formulary, they'll probably punt. But, since they won't reimburse Diovan either, if Valatan's cheaper, obviously that's the way to go (since, as best I can tell, it contains the same ingredient as Diovan -- with maybe a few different fillers).

[Pib]

Tricare requires a prescription to be written by a U.S. certified health care provider with DEA number.   DEA numbers are issued by the U.S. Drug Enforcement Agency. That's the chokepoint in getting prescriptions reimbursed.     

 

And when I say prescription I don't mean medicines issued when you visit a Thai doctor/hospital and the medicines are included on the bill...those are reimbursable as they were part of the outpatient/inpatient treatment.   When I say subscription I mean when you go to a local pharmacy to fill/refill a medicine.

 

I think the only U.S. certified doctor in Thailand able to write prescriptions which would meet Tricare reimbursement requirements is Dr Nick Walters at Mission Hospital in Bangkok.  The Tricare office at JUSMAGTHAI can give more info.

http://www.mission-hospital.org/en/component/k2/item/54-dr-nick-walters.html

 

[JimGant]

Quote

Tricare requires a prescription to be written by a U.S. certified health care provider with DEA number.   DEA numbers are issued by the U.S. Drug Enforcement Agency. That's the chokepoint in getting prescriptions reimbursed.     

The wording that I found says, " The prescription must be from an authorized, licensed health care provider." Are pharmacists "health care providers?" In some US States they are:

Quote

For example, in 2015, North Dakota Governor Jack Dalrymple signed into law 4 bills that expanded the role of pharmacists in the Peace Garden State and recognized them as health care providers:

http://www.pharmacytimes.com/publications/career/2016/pharmacycareers_february2016/the-state-of-provider-status-an-update-for-pharmacy-students

So, I bet if pressed by Tricare, they'd concede that Thai licensed pharmacists are "health care providers." Certainly they are in the most general of terminology.

 

But you won't be pressed by Tricare. You don't file the prescription with them, just the pharmacy's fill order form. And per the instructions, you can provide either the doctor's name, or his DEA number, on the fill order -- hand written, if you want. I'll use the US doctor I used to write the original prescriptions years ago. I thought I'd just use "Dr Feelgood," but I see from some old Safeway prescription receipts that they use the doctor's full name and address -- so will use my original doctor.

 

Now, to have my pharmacist prepare a fill receipt that looks pretty much like the Safeway prescription receipts acceptable by Tricare, at least in the past. Will see what happens.

 

Oh, Pib, I've got one year to file. If I wait until next fiscal year (Oct) to file, will that be against next year's deductible -- or because the fill date is this fiscal year, will it be against this year's deductible. I've forgotten how that works... Thanx.

 

 

[JimGant]

Ah, Express Scripts gives the more restrictive language Pib talks about:

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By law, only prescriptions written by prescribers licensed in the United States, District of Columbia or a U.S. territory are considered valid. For controlled substances, the prescriber must provide his or her individual DEA number. Prescribers can't write prescriptions for family members.

Well, this will be stretching a fine point. All my medicines are maintenance medicines written by my US doctor. That these prescriptions were written over a year ago invalidates them, strictly speaking. But, I think I'll push on, knowing there's nothing unethical about getting a reimbursement. Strange that the law effectively cuts out of the pattern from pharmacies Tricare eligible expats. Oh well.

[Pib]

2 hours ago, JimGant said:

 

Oh, Pib, I've got one year to file. If I wait until next fiscal year (Oct) to file, will that be against next year's deductible -- or because the fill date is this fiscal year, will it be against this year's deductible. I've forgotten how that works... Thanx.

 

 

It goes against the year service was provided.  Say you just filed (Jun 17)  a claim for medical services provided in Sep 16 (FY16), the claim would be processed against your FY16 records/deductible/etc; not against the current FY17 coverage year.

[Pib]

Jim,

Really getting a subscription reimbursed requires:  (1) the prescription to have been written by a U.S. certified health care provider, and (2) the subscription receipt to provide the required information like in your earlier post.  

 

While you may get a local pharmacy to provide all the required info on a receipt (I pretty sure all of the pharmacies I use would just laugh at me....all I get is a typical receipt like when buying something at Lotus or no receipt at all).   And my local private hospital here in Bangkok the wife and I have used for 9 years does not fill subscriptions unless it's part of an office visit to the hospital (i.e., seeing the doc) which of course runs up the cost of paying for a doctor visit just to say get three months worth of meds.  And even then the receipt does not provide details such as number of pills, strength, drug name....it just says medicines.  And the meds cost significantly more than at a pharmacy.   But since it's part of a visit to a hospital/doc the reimbursement for medicines issued does not require the level of detail like when filling a subscription at a pharmacy.   Medication issued as part of a hospital/doctor visit are just handled differently in the info required.

 

Now, regarding Home Delivery of medications like you may have been using the Tricare/Express Scripts delivery method when in the States, once gain you run up again the prescription must be written by a U.S.-licensed provider and they will only mail to an APO address.

 

https://tricare.mil/overseas-pharmacy

 

Quote

 

TRICARE Pharmacy Home Delivery

To use home delivery overseas, you:

• Must get your prescription from a U.S.-licensed provider
• Must use your APO/FPO address
• Should use the embassy address if you’re assigned to an embassy and don’t have an APO/FPO address
• Can’t use private foreign addresses
• Can’t use APO/FPO addresses for refrigerated drugs

There may be local restrictions, including:

• Home delivery to APO/FPO addresses is subject to local customs laws.
• Prescription drugs sent to APO/FPO addresses may be seized by customs authorities.
• If your prescriptions are seized, contact Express Scripts at 1-877-363-1303. Or look up your local toll-free number to find out other ways to get your prescription filled.
• Home delivery isn’t available in Germany.

You can avoid problems overseas by getting your prescriptions filled at a military pharmacy or a local overseas retail pharmacy.

 

 

 

Now, I've never tried to get reimbursement for the wife and my meds which probably costs us around $50/month.  Never tried due to the requirements we've already talked about....primarily the U.S. certified health care provider and pharmacy receipt requirements.  Plus when considering the annual deductible must be met ($150 for each of us totaling up to $300) plus our 25% cost share our daily med requirements just haven't reached a level of me wanting to try to claim them considering the very specific receipt requirements.   Just reaching that $300 deductible takes 6 months worth of meds.  

 

After filing claims for around 9 years so far, the great majority of Tricare claims get reimbursed without any thing getting disallowed.  But each year when I fill the claim for the wife's annual mammogram which is reimbursed at 100% regardless of deductible/copay (i.e., deductible/copay does not come into play), it always "initally" gets reimbursed at 75% and the $150 deductible may come into play also.  This is even after I've included with the claim wording along with separate memo and other flashing light to bring to the claim processors attention this is her annual mammogram it still gets reimbursed at 75% plus the deductible is in play.  I then call Tricare WPS or email them "saying you messed up again (but in nice words)"....they say yea, you are right.  They then initiate an adjustment and the claim get reimbursed at 100% without the deductible in play about 3 weeks later.   It almost like the Ground Hog Day movie...happens over and over.  

 

And another example is one line entry on every hospital receipt from my hospital has a charge for a couple hundred baht and it described as "Other Services."  It's an administrative charge I thing.  First few years worth of claims that line item was always allowed/reimbursed by Tricare....then one day they started disallowing it.  I called and talked to them about it saying it was a valid hosptial charge for admin, supplies or something....I couldn't say specifically for what.   Tricare was diallowing since "Other Services" was not descriptive enough.   Anyway they did an adjustment to allow that line item and I got reimbursed.  I took note info learned from that  phone call and the "five digit code" the Tricare claim processor used to describe/code the line item on the adjusted claim.  Now, whenever I file a claim I annotate the Other Services line item to say Other Services/Supplies and enter the five digit code in parenthesis after that....it is always now allowed/reimbursed.   Just one of those little tricks of the trade you pick after filing X-amount of claims, getting a few thing disallowed, and having to talk to Tricare to work it out...figure out what makes Tricare happy.  

 

I've been pretty satisfied with Tricare claims processing...I always file online...years back my claims  would process withing 10-14 days of filing...but starting a few years ago it changed to 21-28 days.  But years back they also only reimbursed by check which took a couple of weeks to get to you after the claim processed.  But now you can get Direct Deposit reimbursement...as soon as the claim is processed they do a DD to your bank account.

 

Yea, so far, so good with Tricare.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

[lopburi3]

39 minutes ago, Pib said:

And my local private hospital here in Bangkok the wife and I have used for 9 years does not fill subscriptions unless it's part of an office visit to the hospital (i.e., seeing the doc) which of course runs up the cost of paying for a doctor visit just to say get three months worth of meds.  And even then the receipt does not provide details such as number of pills, strength, drug name....it just says medicines.

Actually you ask for a detail receipt from cashier and each test, procedure or medication will be listed with full name, size, amount and price on an A4 page which hospital will stamp with there seal.  This is used for anyone using outside insurance and they all know about and can easily provide.  Another document they do not routinely provide is a medical certificate but just ask and doctor will fill out with full reason for exam and results - this is also handy for insurance.

Edited June 9, 2017 by lopburi3

[Pib]

I get a medical certificate and a detailed receipt (English or Thai)...it's just the degree of detail will vary from hospital to hospital I expect.  Oh, yea, several official looking stamps also.   

[lopburi3]

If it just says medications it sounds like a normal cash receipt - not a detailed receipt (you have to ask for this/you also get the cash receipt with expense by catagory).

[pmarlin]

The TRICARE pharmacy rules do not apply for overseas claims. Been under Tricare overseas program for years and  and never had a problem as long as I used a Hospital and a Hospital pharmacy. Of course you have to see a doctor first at the hospital.  All my receipts that I use for my TRICARE  claims list out-patients medicine with the cost. During the last six years only had a couple of problems and they were quickly resolved using the message function  on the TRICARE Overseas  website.  So far TRICARE has been good to me and my wife.

[Pib]

Yeap, like I said in my earlier post no problem getting reimbursed by Tricare for medications issued during a visit to a hospital/doctor....but of course you then have that hospital/doc cost on top of the medications cost where the visit costs would normally far exceed an medicines cots.   I've never had Tricare disallow payment of any medicines listed on the receipt for a hospital/doctor visit which of course included other charges Nursing Charge, Health Profession Fees (i.e., the Doc fees).

 

Yesterday I visited my local private hospital the wife and I have used for 9 years for a hand problem.   As a result of this visit one medication was issued...20 tablets Colcine with each tablet being 0.6mg in strength.   One tablet a day is to be taken.  On the primary hospital receipt  (in English) which I will use for the Tricare claim it just says Medicines and a total cost for the medicine....that has always worked from Tricare reimbursement.

 

I decided to ask for a "detailed" receipt as the last time I asked for one was several years ago in support of the wife's annual mammogram claim.  Wanted to see how the detailed receipt described medications.  The detailed receipt for the medication issued was combination Thai and English and the core identifying information consisted of a 5 digit code used only for the hospital database I expect, name of the medication, number of tablets, and total cost.

 

Now if that had been a "prescription refill" vs medications issued during a hospital/doc visit the detailed receipt is missing some the key data required by the OP's #1 post where things like the drug "strength" which must be "printed" on the receipt.  And things missing that could be "handwritten" on the receipt (but were not) were most of the things in the OP's post like prescription number, number of day's supply, doctor's name or DEA number, Pharmacist's Signature, etc.  And since the Pharmacist's signature is required I expect the handwritten entries should be the pharmacist, but hey, anyone to write that in after the fact.  Yea, getting precription refills at overseas pharmacy under Tricare Overseas is more challenging that if a person was on Tricare Prime and/or active duty...just different requirements.  Heck, in the P.I. there are even more restrictions on Tricare claims/reimbursement due to claim fraud that went on in the past....I feel lucky those restrictions don't apply to most countries like Thailand.

 

Like parlin  my Tricare claim experience with Tricare has been pretty good except for a few minor things that were initially disallowed.  And the wife's annual mammogram 100% reimbursement issue they always do not get right and I have to go back to them via telephone or email to work it out...then the adjusted claim they initiate fixes things.  But when the dust settled so far we have always had every item on the receipts allowed/reimbursed.

 

Also, the basic Tricare 75% reimbursement really works out to around 78% for me, since Tricare uses a Cash/Note exchange which gives you about 1.5% more "dollars" reimbursement during the claim processing and I always pay with my credit card that gives 1.5% cash back.....those two 1.5 percents effectively give me an extra 3% reimbursement.

 

[JimGant]

On 6/11/2017 at 8:53 AM, pmarlin said:

The TRICARE pharmacy rules do not apply for overseas claims. Been under Tricare overseas program for years and  and never had a problem as long as I used a Hospital and a Hospital pharmacy. Of course you have to see a doctor first at the hospital.

Maintenance medicines are normally covered by Tricare in up-to 90 day increments (now including pharmacies, which used to be restricted to 30 day fills). Not practical to visit a doctor every 90 days just to get maintenance meds; and, while an annual visit/checkup makes sense, not sure a year's supply of meds would be covered (or even provided). But, maybe so......

 

I emailed the Singapore office for TOPs with the following:

 

Quote

The following statement says I can't be reimbursed for prescription fills in Thailand at a pharmacy -- unless the prescription is written by a US doctor:

"By law, only prescriptions written by prescribers licensed in the United States, District of Columbia or a U.S. territory are considered valid. For controlled substances, the prescriber must provide his or her individual DEA number. Prescribers can't write prescriptions for family members."

My prescriptions are solely from Thai doctors. However, I saw this exception in relation to Germany:

"Can I fill prescriptions written by my German doctor?
Yes, as long as the doctor is a Tricare-authorized provider. The prescription must be written in English using American trade names."

Question: Are there any Tricare-authorized providers in Thailand? If so, any in Chiang Mai.

And, if not: Confirm I can't be reimbursed for drug fills at Thai pharmacies, unless I have current prescriptions written by a US licensed doctor

Their answer:

Quote

If you are ordering from Express Scripts, they would require prescriptions from an US licensed doctor.

Otherwise, if you wish to purchase the prescribed medication through the local pharmacy, it will be on pay and claim basis.

Meanwhile, you may refer to the link below on prescriptions:

https://tricare.mil/CoveredServices/Pharmacy/FillPrescriptions

Indeed, the link provided says only prescriptions for mail order require a US licensed doctor. For fills at military facilities abroad, or non network pharmacies, the following applies:

"The prescription must be from an authorized, licensed health care provider." (And, as previously discussed, a licensed Thai pharmacist would appear to qualify.)

 

So, at least from this guidance, sounds like you certainly could file a claim for Thai pharmacy issued pills. The main stumbling block could be to get the Thai pharmacy to write the prescription data in acceptable format.