1.4 Military, Veterans, & Worker's Compensation Programs

1.4 Military, Veterans, & Worker's Compensation Programs

Pharmacy technicians regularly process prescription claims for military service members, military retirees, disabled veterans, surviving family members, and employees injured on the job. These programs operate under distinct federal statutes, dedicated Pharmacy Benefit Managers (PBMs), and rigid administrative billing rules.

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|              SPECIALIZED GOVERNMENT & WORKER'S COMP PROGRAMS                |
|                                                                             |
|  +---------------------------+      +---------------------------+           |
|  |      TRICARE PROGRAMS     |      |    VETERANS AFFAIRS (VA)  |           |
|  | - Active Duty / Retirees  |      | - Direct VA Medical Ctr   |           |
|  | - Prime, Select, TFL      |      | - CHAMPVA (Dependents)    |           |
|  | - PBM: Express Scripts    |      | - VA MISSION Act / CCN    |           |
|  +---------------------------+      +---------------------------+           |
|                                                                             |
|  +-----------------------------------------------------------------------+  |
|  |                     WORKER'S COMPENSATION INSURANCE                   |  |
|  | - 100% Employer Funded / State Fee Schedules                          |  |
|  | - $0 Patient Cost-Sharing (Zero Copay / Zero Coinsurance)             |  |
|  | - Mandatory Fields: Date of Injury (DOI), Case #, Body Part Match     |  |
|  +-----------------------------------------------------------------------+  |
+-----------------------------------------------------------------------------+

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1. TRICARE Military Health System

TRICARE is the worldwide healthcare program for active duty uniformed service members, National Guard and Reserve members, military retirees, and their eligible family members, managed by the Defense Health Agency (DHA).

Primary TRICARE Plan Options

1. TRICARE Prime

• Managed Care Framework: Operates as an HMO-style model. Active Duty Service Members (ADSMs) are required to enroll in TRICARE Prime.
• Primary Care Manager (PCM): Beneficiaries are assigned a designated PCM at a military clinic/hospital or in the civilian network who coordinates care and issues required specialist referrals.
• Cost-Sharing: Active duty members pay $0 out-of-pocket for all medical care and prescription medications. Active duty family members and retirees pay low annual enrollment fees and nominal copays.

2. TRICARE Select

• Fee-for-Service Framework: Operates as a PPO-style model for military retirees and non-active duty family members.
• Provider Access: Members have freedom of choice to visit any TRICARE-authorized provider without a PCM referral. Beneficiaries are subject to annual deductibles and percentage-based cost-sharing (higher when utilizing non-network providers).

3. TRICARE For Life (TFL)

• Medicare Wraparound Coverage: Enacted for military retirees and their eligible dependents who are entitled to Medicare Part A and enrolled in Medicare Part B (typically age 65+).
• Payer Sequencing: Medicare is always the PRIMARY payer, and TRICARE For Life acts as the SECONDARY payer. TFL pays remaining Medicare Part A and Part B deductibles and 20% coinsurance for services covered by both programs, leaving beneficiaries with $0 out-of-pocket liability for covered care.

TRICARE Pharmacy Program (Express Scripts)

The TRICARE outpatient pharmacy benefit is centrally administered worldwide by Express Scripts (Routing: BIN: 003858, PCN: DODRX, RxGroup: DODRX). TRICARE utilizes a four-tiered pharmacy dispensing structure:

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|                 TRICARE PHARMACY DISPENSING TIERS & COPAYS                 |
|                                                                             |
|   1. Military Treatment Facility (MTF) Outpatient Pharmacies:               |
|      - Located on military bases / installations                            |
|      - Up to 90-day supply of formulary medications                         |
|      - $0.00 COPAYMENT (100% Free to all beneficiaries)                     |
|                                                                             |
|   2. TRICARE Home Delivery (Express Scripts Mail Order):                    |
|      - Up to 90-day supply delivered to home                                |
|      - Generic: $14 copay | Preferred Brand: $44 copay                      |
|                                                                             |
|   3. Retail Network Pharmacies (Commercial In-Network Retail):              |
|      - Up to 30-day supply                                                  |
|      - Generic: $16 copay | Preferred Brand: $48 copay                      |
|                                                                             |
|   4. Non-Network Retail Pharmacies:                                         |
|      - Patient pays 100% upfront and submits manual DD Form 2642            |
|      - Subject to high out-of-network deductibles and 20-50% coinsurance    |
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2. Veterans Affairs (VA) Healthcare, CHAMPVA, & VA MISSION Act

Healthcare and prescription benefits for honorably discharged military veterans are administered separately from TRICARE through the Department of Veterans Affairs (VA).

+-----------------------------------------------------------------------------+
|                      VA HEALTHCARE SYSTEM VS. CHAMPVA                       |
|                                                                             |
|   FEATURE               VA HEALTHCARE SYSTEM          CHAMPVA               |
|   --------------------  ----------------------------  --------------------  |
|   Eligible Enrollee     Discharged Military Veteran   Spouse & Dependents   |
|   Delivery Site         VA Medical Centers / CMOP     Retail Pharmacies     |
|   Formulary             VA National Formulary (VANF)  Commercial PBM Payer  |
|   Payer Priority        Primary for Veteran Care      Always Secondary Payer|
|   Funding Source        Direct Federal Budget (VHA)   Federal VA Trust Fund |
+-----------------------------------------------------------------------------+

Veterans Health Administration (VHA)

• Direct Healthcare Delivery: The VA provides direct clinical care through VA Medical Centers (VAMCs) and Community-Based Outpatient Clinics (CBOCs).
• Prescription Fulfillment: Prescriptions written by VA clinicians are fulfilled primarily through internal VAMC outpatient pharmacies or the automated Consolidated Mail Outpatient Pharmacy (CMOP) system.
• Formulary Controls: Medications are selected from the VA National Formulary (VANF). Non-formulary items require strict clinical justification through the VA formulary exception process.

CHAMPVA (Civilian Health and Medical Program of the VA)

• Target Population: A comprehensive healthcare program for the spouses, surviving spouses, and dependent children of veterans who are rated 100% permanently and totally disabled from a service-connected condition, or who died from a service-connected disability or while on active duty.
• Secondary Payer Mandate: By federal statute, CHAMPVA is ALWAYS SECONDARY to all other health insurance (including Medicare, commercial group health plans, and HMOs), with the sole exceptions of Medicaid and state CHAMPVA supplemental policies.
• Pharmacy Billing: Retail community pharmacies bill CHAMPVA prescription claims through its contracted PBM (MedImpact) using designated BIN/PCN parameters, submitting primary explanation of benefits (EOB) payment details.

VA MISSION Act & Community Care Network (CCN)

Enacted in 2018, the VA MISSION Act established the Veterans Community Care Network (CCN). When a VA facility cannot provide timely clinical care (e.g., appointment wait time exceeds 20 to 28 days, or average drive time exceeds 30 to 60 minutes), the VA authorizes the veteran to receive care from participating private community providers:

• Urgent Care Pharmacy Benefit: Enrolled veterans can access contracted in-network retail community pharmacies for urgent medical needs. The pharmacy can dispense up to a 14-day supply of urgent/emergent medications with $0 patient out-of-pocket cost by billing through the VA CCN third-party administrator (e.g., Optum Public Sector or TriWest) with no prior authorization required.

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3. Worker's Compensation Insurance

Worker's Compensation is a system of state-mandated employer insurance designed to provide medical care, rehabilitation, and lost wage replacement to employees who suffer occupational injuries or work-related illnesses.

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|                   WORKER'S COMPENSATION CORE PILLARS                        |
|                                                                             |
|   1. ZERO PATIENT OUT-OF-POCKET EXPENSE:                                    |
|      - Patient copayments, coinsurance, and deductibles are ILLEGAL ($0).   |
|      - Balance billing the injured worker is strictly prohibited by law.    |
|                                                                             |
|   2. TOTAL EXCLUSION OF STANDARD HEALTH INSURANCE:                          |
|      - Work injuries CANNOT be billed to Commercial, Medicare, or Medicaid. |
|      - Worker's Comp carrier is 100% liable for all causally related care.  |
|                                                                             |
|   3. CLAIM ADJUDICATION PREREQUISITES:                                      |
|      - Date of Injury (DOI) (NCPDP Field 434-DY)                            |
|      - Worker's Comp Claim / Case Number                                    |
|      - Matching Injured Body Part (Direct Causation Link)                   |
|      - Insurance Carrier / Third-Party Administrator (TPA)                  |
+-----------------------------------------------------------------------------+

Required Claim Elements & NCPDP Fields

To adjudicate a Worker's Compensation prescription claim electronically, the pharmacy management system requires specific data fields that differ significantly from standard commercial billing:

• Date of Injury (DOI): Submitted in NCPDP Field 434-DY. The DOI transmitted on the claim must match the official injury date recorded on the employer's First Report of Injury (FROI) filed with the state Worker's Compensation board.
• Worker's Comp Claim Number: The unique claim/case identifier assigned by the insurance carrier or Third-Party Administrator (TPA) (e.g., Sedgwick, Gallagher Bassett, Broadspire, CorVel, Travelers).
• Employer Name and Address: Recorded to verify active employment at the time of the incident.
• Injury Causation / Body Part Match: The medication must directly treat the accepted medical condition and body part. For example, if the accepted claim is for an acute lumbar spine strain, an NSAID (meloxicam) or muscle relaxant (cyclobenzaprine) will adjudicate; an unrelated prescription for an inhaler or insulin will reject.

State Fee Schedules & Adjuster Authorizations

• Fee Schedules: Pharmacy reimbursement is governed by state-legislated Worker's Compensation fee schedules (typically formulated as Average Wholesale Price [AWP] plus a percentage, plus a regulated dispensing fee).
• Claims Adjuster Authorizations: For high-dollar medications, extended days' supply (beyond 30 days), off-formulary compounds, or brand-name specialty agents, the pharmacy must obtain written authorization from the assigned claims adjuster before dispensing.