Reimbursement for Injectable Drugs, Home Infusion Drugs and Vaccines
Thursday, February 13, 2020
revised March 9, 2020
TRICARE covers most drugs and immunizations administered in a provider's office or in a home infusion setting. For medications administered non-orally, the type of drug and how it’s administered will determine how claims are paid. TRICARE’s reimbursement for injectable drugs, home infusion drugs and vaccines follows Medicare’s reimbursement guidelines. This pricing, including TRICARE’s recently updated vaccine reimbursement policy, is outlined below.
Per the TRICARE Reimbursement Manual, Chapter 1, Section 15, paragraph 3.3:
Injectable and home infusion (other than vaccines)
- Except for home infusion, drugs administered other than orally, including chemotherapy drugs, are priced using the TRICARE Injectable Drugs/Biological CHAMPUS Maximum Allowable Charge (CMAC) rates file.
- Drugs that do not appear on the TRICARE Injectable Drugs/Biological CMAC rates file are priced at the lesser of billed charges or 95% of the average wholesale price (AWP).
- Home infusion drugs (except those infused through durable medical equipment [DME]) that are not available under TRICARE’s pharmacy benefit are priced at the lesser of billed charges or 95% of the AWP.
- Effective Jan. 1, 2017, drugs (including home infusion drugs) infused through DME are priced at TRICARE Injectable Drugs/Biological CMAC rates + 6%. The equipment must meet TRICARE’s definition of DME (TRICARE Policy Manual, Chapter 8, Section 2.1).
Home infusion therapy requires prior authorization for all beneficiaries except those with other health insurance. Visit our Home Infusion Therapy benefit page for details.
- Vaccines provided under the State Vaccine Program (SVP) are priced based on the vaccine price list for each SVP program.
- Vaccines that appear on the Medicare Average Sale Price (ASP) list or the Centers for Disease Control and Prevention (CDC) Private Sector Vaccine Price List are reimbursed based on the allowable amount provided in the TRICARE Injectable Drugs/Biological CMAC rates file, which includes the 6% add on.
- For dates of service Aug. 15–Oct. 31, 2019, rates are per the July 2019 CDC fee schedule.
- For dates of service Nov. 1, 2019–Jan. 31, 2020, rates are per the September 2019 CDC fee schedule.
- The January 2020 CDC fee schedule took effect Feb. 1, 2020.
- Vaccines that do not appear on the TRICARE Injectable Drugs/Biological CMAC rates file are priced at the lesser of billed charges or 95% of the average wholesale price (AWP).
Medicare updates its pricing file on a quarterly basis. Visit www.cms.gov and www.ReimbursementCodes.com for Medicare pricing resources. For TRICARE network providers, HNFS will use the contracted rate to calculate allowed amounts.