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Decoding Prescriptions: Understanding key pharmacy terms and abbreviations

Pharmacy terminology can be confusing. To make the most of your TRICARE® pharmacy benefit, it is essential to understand some key pharmacy terms. The following is a list of some of the most common terms you may encounter.

Brand-name drug: medicine that is sold by a company under a specific name or trademark and is protected by a patent.

Copayment: a set dollar amount you pay out of your own pocket for your medicine. Your copay is set by your plan. It is usually paid at the time of service. The amount can vary by the type of medication (such as formulary or non-formulary) and place of service (using a Military Treatment Facility, Home Delivery or a retail pharmacy).

Compound drug: a drug that is created by a pharmacist mixing multiple ingredients together to create a prescription drug that is specific to a beneficiary’s needs. Express Scripts screens all TRICARE compound drug prescriptions to ensure each ingredient is safe, effective and covered by TRICARE.

Deductible: the total amount you must pay before your plan starts paying for part of your prescription costs. This amount varies by plan.

e-prescribing: a process doctors can use to send a prescription to a pharmacy using a secure computer network.

Explanation of Benefits (EOB): a statement sent to beneficiaries showing that claims were processed and the amount paid to providers.

Formulary: a list of generic and brand name prescription drugs that TRICARE covers.

Formulary Search Tool: an online tool you can use to:

  • locate pharmacies where you can get your prescription filled
  • see how much it costs
  • find out if your prescription requires a prior authorization (PA)
  • look up any medical necessity criteria
  • get these forms, if needed, for your prescription:
    • prior authorization form (PA)
    • medical necessity form

Generic drugs: a prescription or over-the-counter (OTC) medicine that has the same active ingredient as a brand-name version that’s on the market. Generic drugs often are a lower-cost option to their brand-name versions. They can be identical to the brand-name drug or a:

  • generic equivalent: it’s similar to the brand-name drug and has the same active ingredient, but has different inactive ingredients.
  • generic alternative: it has a different active ingredient from the brand-name drug, but a similar clinical effect on the body.

You can find out more about generic drugs from the US Food and Drug Administration.

Non-formulary: any drug in a therapeutic class determined to be not as clinically effective or as cost-effective as other drugs in the same class. Non-formulary medications for TRICARE may be either brand or generic drugs.

Maintenance medication: any medicine you have to take for three or more months to control symptoms or to prevent complications from a condition. Examples of conditions that might require long-term medicine include: high blood pressure, high cholesterol, diabetes, arthritis, heart conditions, and long-term pain.

Other Health Insurance (OHI): any non-TRICARE health insurance that is not considered a supplement. This insurance is acquired through an employer, entitlement program or other source. TRICARE pays last after all other health plans except Medicaid, TRICARE supplements, the Indian Health service or other programs or plans as identified by TRICARE.

Over-the-counter (OTC) drugs: OTC Drugs are medications sold Over the Counter and can be obtained without a prescription.

Point-of-service (POS) options: designated places that you can have your prescriptions filled. TRICARE beneficiaries have four service options:

  • Military pharmacies
  • TRICARE Pharmacy Home Delivery
  • Participating network pharmacy
  • Non-network pharmacy

Prior authorization: a process of reviewing certain medical, pharmacy, surgical and mental health care services to ensure the service is an effective treatment for the condition.

Specialty pharmacy: specialty medicine is used to treat complex and long-term conditions, and usually has to be stored or handled in special ways. People take specialty medicines for conditions, such as multiple sclerosis, rheumatoid arthritis, or hemophilia.

These are some of the most common pharmacy terms that will help you better understand your TRICARE benefit. If you have questions about your pharmacy benefit, you can contact Express Scripts Customer Service at 1-877-363-1303.




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