TRICARE Operations Manual 6010.59-M, April 1, 2015 TRICARE ...
Proof · 2020-06-22 · StockID = BOND20 Proof Page Plex = D Letter ID = LTR_FRMUNDOD_TOPICAL_1_002...
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StockID = BOND20 Proof Page Plex = D Letter ID = LTR_FRMUNDOD_TOPICAL_1_002 TRICARE is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved. © 2020 Express Scripts. All Rights Reserved. Express Scripts and "E" logo are trademarks of Express Scripts Strategic Development, Inc. All other trademarks are the property of their respective owners. CRP2006_003377.1 LT2006_003377 IMPORTANT NOTICE: A Change to your Prescription Drug Coverage Dear TRICARE Beneficiary: On August 26, 2020, the prescription drug you’re taking below, will no longer be covered by TRICARE. It has moved to a non-covered drug status and will no longer be available through military treatment facility pharmacies or the TRICARE mail order pharmacy If you continue to take the drug, you’ll be required to obtain the medication from a retail pharmacy and to pay 100% of its cost. BRYHALI If you are taking this drug, what Should You Do? If you are no longer taking the above drug, then you don’t need to do anything at this time. 1. Review the enclosed information called “Options for You and Your Doctor to Consider.” This document provides the drug that is no longer covered, preferred alternatives, and associated cost information. 2. Discuss this information with your doctor to see which of the following options is best for you: · Switch your prescription to a preferred alternative drug. · Continue your non-covered prescription by obtaining at a retail pharmacy and pay 100% of the cost of the drug Why the Change? The Defense Health Agency regularly reviews drugs and has determined the drug mentioned above has little to no clinical benefit compared to other drugs that are just as effective and cost less. Who Should You Contact If You Have Questions? If you have any questions about your pharmacy benefit or you need help, please visit express-scripts.com/TRICARE or call 877.363.1303. Sincerely, Jay Peloquin, PharmD, BCPS Director, Clinical Account Management Express Scripts Download the Express Scripts™ mobile app for free today! Our easy-to-use mobile app puts your TRICARE® prescription benefit in the palm of your hand. Follow us on social media! Add MilitaryRx on Facebook and Twitter for health tips, plan info and updates about your pharmacy benefit. 2020089154 - 1 John Q. Public 100 Any Street Any St. Apartments 7th Floor Any City, MO 55555-4444 LTR_FRMUNDOD_TOPICAL_1_002 June 12, 2020 202006120605940123 - DODA 0089154000001010100
Transcript of Proof · 2020-06-22 · StockID = BOND20 Proof Page Plex = D Letter ID = LTR_FRMUNDOD_TOPICAL_1_002...
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TRICARE is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved.© 2020 Express Scripts. All Rights Reserved. Express Scripts and "E" logo are trademarks of Express Scripts Strategic Development, Inc.
All other trademarks are the property of their respective owners. CRP2006_003377.1 LT2006_003377
IMPORTANT NOTICE:A Change to your Prescription Drug Coverage
Dear TRICARE Beneficiary:
On August 26, 2020, the prescription drug you’re taking below, will no longer be covered by TRICARE. Ithas moved to a non-covered drug status and will no longer be available through military treatment facilitypharmacies or the TRICARE mail order pharmacy If you continue to take the drug, you’ll be required toobtain the medication from a retail pharmacy and to pay 100% of its cost.
BRYHALI
If you are taking this drug, what Should You Do?
If you are no longer taking the above drug, then you don’t need to do anything at this time.
1. Review the enclosed information called “Options for You and Your Doctor to Consider.”This document provides the drug that is no longer covered, preferred alternatives, and associatedcost information.
2. Discuss this information with your doctor to see which of the following options is best for you:
· Switch your prescription to a preferred alternative drug.
· Continue your non-covered prescription by obtaining at a retail pharmacy and pay 100% of the costof the drug
Why the Change?The Defense Health Agency regularly reviews drugs and has determined the drug mentioned above haslittle to no clinical benefit compared to other drugs that are just as effective and cost less.
Who Should You Contact If You Have Questions?If you have any questions about your pharmacy benefit or you need help, please visitexpress-scripts.com/TRICARE or call 877.363.1303.
Sincerely,
Jay Peloquin, PharmD, BCPSDirector, Clinical Account ManagementExpress Scripts
Download the Express Scripts™ mobile app for free today! Our easy-to-use mobile app puts yourTRICARE® prescription benefit in the palm of your hand.
Follow us on social media! Add MilitaryRx on Facebook and Twitter for health tips, plan info andupdates about your pharmacy benefit.
2020089154 - 1
John Q. Public100 Any StreetAny St. Apartments7th FloorAny City, MO 55555-4444
LTR_FRMUNDOD_TOPICAL_1_002
June 12, 2020
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TRICARE is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved.© 2020 Express Scripts. All Rights Reserved. Express Scripts and "E" logo are trademarks of Express Scripts Strategic Development, Inc.
All other trademarks are the property of their respective owners. CRP2006_003377.1 LT2006_003377
Options for You and Your Doctor to ConsiderOn August 26, 2020, the drug listed below will be completely excluded from the TRICARE benefit. Anyprior authorization (PA) or medical necessity (MN) your drug currently has will no longer apply. You willpay 100% of the drug cost if you continue to fill your prescription of your non-covered drug. The costyou pay for your non-covered drug will not apply to your TRICARE catastrophic cap. Carefully read theinformation below to understand your options.
BRYHALI
Switch to a preferred drug.
Preferred Drug(s)
Military TreatmentFacility
Home DeliveryRetail Network
Pharmacy
Your cost(up to a 90-day supply)
Generic Drugs:
· Diclofenac 1% (Gel)
· Diclofenac 1.5%(Solution)
$0 $10 $39
Continue taking your current non-covered drug.
Non-Covered Drug(s)
Military TreatmentFacility
Home DeliveryRetail Network
Pharmacy
Your cost
· Diclofenac 1.3% (Patch)
· Flector (Patch)
· Pennsaid 2% (Pump)
NOT AVAILABLE NOT AVAILABLE 100% of the cost ofthe drug.
LTR_FRMUNDOD_TOPICAL_1_002202006120605940123 - DODA
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e Plex
= D
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TRICARE is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved.© 2020 Express Scripts. All Rights Reserved. Express Scripts and "E" logo are trademarks of Express Scripts Strategic Development, Inc.
All other trademarks are the property of their respective owners. CRP2006_003377.1 LT2006_003377
IMPORTANT NOTICE:A Change to your Prescription Drug Coverage
Dear TRICARE Beneficiary:
On August 26, 2020, the prescription drug you’re taking below, will no longer be covered by TRICARE. Ithas moved to a non-covered drug status and will no longer be available through military treatment facilitypharmacies or the TRICARE mail order pharmacy If you continue to take the drug, you’ll be required toobtain the medication from a retail pharmacy and to pay 100% of its cost.
FLECTOR
If you are taking this drug, what Should You Do?
If you are no longer taking the above drug, then you don’t need to do anything at this time.
1. Review the enclosed information called “Options for You and Your Doctor to Consider.”This document provides the drug that is no longer covered, preferred alternatives, and associatedcost information.
2. Discuss this information with your doctor to see which of the following options is best for you:
· Switch your prescription to a preferred alternative drug.
· Continue your non-covered prescription by obtaining at a retail pharmacy and pay 100% of the costof the drug
Why the Change?The Defense Health Agency regularly reviews drugs and has determined the drug mentioned above haslittle to no clinical benefit compared to other drugs that are just as effective and cost less.
Who Should You Contact If You Have Questions?If you have any questions about your pharmacy benefit or you need help, please visitexpress-scripts.com/TRICARE or call 877.363.1303.
Sincerely,
Jay Peloquin, PharmD, BCPSDirector, Clinical Account ManagementExpress Scripts
Download the Express Scripts™ mobile app for free today! Our easy-to-use mobile app puts yourTRICARE® prescription benefit in the palm of your hand.
Follow us on social media! Add MilitaryRx on Facebook and Twitter for health tips, plan info andupdates about your pharmacy benefit.
2020089154 - 2
PAUL G. SANDERS1100 GATESHEAD LNMATTHEWS, NC 28105-2507
LTR_FRMUNDOD_TOPICAL_1_002
June 12, 2020
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TRICARE is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved.© 2020 Express Scripts. All Rights Reserved. Express Scripts and "E" logo are trademarks of Express Scripts Strategic Development, Inc.
All other trademarks are the property of their respective owners. CRP2006_003377.1 LT2006_003377
Options for You and Your Doctor to ConsiderOn August 26, 2020, the drug listed below will be completely excluded from the TRICARE benefit. Anyprior authorization (PA) or medical necessity (MN) your drug currently has will no longer apply. You willpay 100% of the drug cost if you continue to fill your prescription of your non-covered drug. The costyou pay for your non-covered drug will not apply to your TRICARE catastrophic cap. Carefully read theinformation below to understand your options.
FLECTOR
Switch to a preferred drug.
Preferred Drug(s)
Military TreatmentFacility
Home DeliveryRetail Network
Pharmacy
Your cost(up to a 90-day supply)
Generic Drugs:
· Diclofenac 1% (Gel)
· Diclofenac 1.5%(Solution)
$0 $10 $39
Continue taking your current non-covered drug.
Non-Covered Drug(s)
Military TreatmentFacility
Home DeliveryRetail Network
Pharmacy
Your cost
· Diclofenac 1.3% (Patch)
· Flector (Patch)
· Pennsaid 2% (Pump)
NOT AVAILABLE NOT AVAILABLE 100% of the cost ofthe drug.
LTR_FRMUNDOD_TOPICAL_1_002202006160606238369 - DODA
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= D
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TRICARE is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved.© 2020 Express Scripts. All Rights Reserved. Express Scripts and "E" logo are trademarks of Express Scripts Strategic Development, Inc.
All other trademarks are the property of their respective owners. CRP2006_003377.1 LT2006_003377
IMPORTANT NOTICE:A Change to your Prescription Drug Coverage
Dear TRICARE Beneficiary:
On August 26, 2020, the prescription drug you’re taking below, will no longer be covered by TRICARE. Ithas moved to a non-covered drug status and will no longer be available through military treatment facilitypharmacies or the TRICARE mail order pharmacy If you continue to take the drug, you’ll be required toobtain the medication from a retail pharmacy and to pay 100% of its cost.
FLECTOR
If you are taking this drug, what Should You Do?
If you are no longer taking the above drug, then you don’t need to do anything at this time.
1. Review the enclosed information called “Options for You and Your Doctor to Consider.”This document provides the drug that is no longer covered, preferred alternatives, and associatedcost information.
2. Discuss this information with your doctor to see which of the following options is best for you:
· Switch your prescription to a preferred alternative drug.
· Continue your non-covered prescription by obtaining at a retail pharmacy and pay 100% of the costof the drug
Why the Change?The Defense Health Agency regularly reviews drugs and has determined the drug mentioned above haslittle to no clinical benefit compared to other drugs that are just as effective and cost less.
Who Should You Contact If You Have Questions?If you have any questions about your pharmacy benefit or you need help, please visitexpress-scripts.com/TRICARE or call 877.363.1303.
Sincerely,
Jay Peloquin, PharmD, BCPSDirector, Clinical Account ManagementExpress Scripts
Download the Express Scripts™ mobile app for free today! Our easy-to-use mobile app puts yourTRICARE® prescription benefit in the palm of your hand.
Follow us on social media! Add MilitaryRx on Facebook and Twitter for health tips, plan info andupdates about your pharmacy benefit.
2020089154 - 3
PATRICIA M. YOUNG1101 19TH STWHEATLAND, WY 82201-2417
LTR_FRMUNDOD_TOPICAL_1_002
June 12, 2020
202006160606238372 - DODA
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02
TRICARE is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved.© 2020 Express Scripts. All Rights Reserved. Express Scripts and "E" logo are trademarks of Express Scripts Strategic Development, Inc.
All other trademarks are the property of their respective owners. CRP2006_003377.1 LT2006_003377
Options for You and Your Doctor to ConsiderOn August 26, 2020, the drug listed below will be completely excluded from the TRICARE benefit. Anyprior authorization (PA) or medical necessity (MN) your drug currently has will no longer apply. You willpay 100% of the drug cost if you continue to fill your prescription of your non-covered drug. The costyou pay for your non-covered drug will not apply to your TRICARE catastrophic cap. Carefully read theinformation below to understand your options.
FLECTOR
Switch to a preferred drug.
Preferred Drug(s)
Military TreatmentFacility
Home DeliveryRetail Network
Pharmacy
Your cost(up to a 90-day supply)
Generic Drugs:
· Diclofenac 1% (Gel)
· Diclofenac 1.5%(Solution)
$0 $10 $39
Continue taking your current non-covered drug.
Non-Covered Drug(s)
Military TreatmentFacility
Home DeliveryRetail Network
Pharmacy
Your cost
· Diclofenac 1.3% (Patch)
· Flector (Patch)
· Pennsaid 2% (Pump)
NOT AVAILABLE NOT AVAILABLE 100% of the cost ofthe drug.
LTR_FRMUNDOD_TOPICAL_1_002202006160606238372 - DODA
Sto
ckID
= B
ON
D20
Proof
Pag
e Plex
= D
Letter ID
= L
TR
_F
RM
UN
DO
D_T
OP
ICA
L_1_0
02
TRICARE is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved.© 2020 Express Scripts. All Rights Reserved. Express Scripts and "E" logo are trademarks of Express Scripts Strategic Development, Inc.
All other trademarks are the property of their respective owners. CRP2006_003377.1 LT2006_003377
IMPORTANT NOTICE:A Change to your Prescription Drug Coverage
Dear TRICARE Beneficiary:
On August 26, 2020, the prescription drug you’re taking below, will no longer be covered by TRICARE. Ithas moved to a non-covered drug status and will no longer be available through military treatment facilitypharmacies or the TRICARE mail order pharmacy If you continue to take the drug, you’ll be required toobtain the medication from a retail pharmacy and to pay 100% of its cost.
FLECTOR
If you are taking this drug, what Should You Do?
If you are no longer taking the above drug, then you don’t need to do anything at this time.
1. Review the enclosed information called “Options for You and Your Doctor to Consider.”This document provides the drug that is no longer covered, preferred alternatives, and associatedcost information.
2. Discuss this information with your doctor to see which of the following options is best for you:
· Switch your prescription to a preferred alternative drug.
· Continue your non-covered prescription by obtaining at a retail pharmacy and pay 100% of the costof the drug
Why the Change?The Defense Health Agency regularly reviews drugs and has determined the drug mentioned above haslittle to no clinical benefit compared to other drugs that are just as effective and cost less.
Who Should You Contact If You Have Questions?If you have any questions about your pharmacy benefit or you need help, please visitexpress-scripts.com/TRICARE or call 877.363.1303.
Sincerely,
Jay Peloquin, PharmD, BCPSDirector, Clinical Account ManagementExpress Scripts
Download the Express Scripts™ mobile app for free today! Our easy-to-use mobile app puts yourTRICARE® prescription benefit in the palm of your hand.
Follow us on social media! Add MilitaryRx on Facebook and Twitter for health tips, plan info andupdates about your pharmacy benefit.
2020089154 - 4
MARGHERITA SPILLANE1102 KENNEBEC ST APT 2COXON HILL, MD 20745-3318
LTR_FRMUNDOD_TOPICAL_1_002
June 12, 2020
202006160606238373 - DODA
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00
00
40
10
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ON
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Proof
Pag
e Plex
= D
Letter ID
= L
TR
_F
RM
UN
DO
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OP
ICA
L_1_0
02
TRICARE is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved.© 2020 Express Scripts. All Rights Reserved. Express Scripts and "E" logo are trademarks of Express Scripts Strategic Development, Inc.
All other trademarks are the property of their respective owners. CRP2006_003377.1 LT2006_003377
Options for You and Your Doctor to ConsiderOn August 26, 2020, the drug listed below will be completely excluded from the TRICARE benefit. Anyprior authorization (PA) or medical necessity (MN) your drug currently has will no longer apply. You willpay 100% of the drug cost if you continue to fill your prescription of your non-covered drug. The costyou pay for your non-covered drug will not apply to your TRICARE catastrophic cap. Carefully read theinformation below to understand your options.
FLECTOR
Switch to a preferred drug.
Preferred Drug(s)
Military TreatmentFacility
Home DeliveryRetail Network
Pharmacy
Your cost(up to a 90-day supply)
Generic Drugs:
· Diclofenac 1% (Gel)
· Diclofenac 1.5%(Solution)
$0 $10 $39
Continue taking your current non-covered drug.
Non-Covered Drug(s)
Military TreatmentFacility
Home DeliveryRetail Network
Pharmacy
Your cost
· Diclofenac 1.3% (Patch)
· Flector (Patch)
· Pennsaid 2% (Pump)
NOT AVAILABLE NOT AVAILABLE 100% of the cost ofthe drug.
LTR_FRMUNDOD_TOPICAL_1_002202006160606238373 - DODA
Sto
ckID
= B
ON
D20
Proof
Pag
e Plex
= D
Letter ID
= L
TR
_F
RM
UN
DO
D_T
OP
ICA
L_1_0
02
TRICARE is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved.© 2020 Express Scripts. All Rights Reserved. Express Scripts and "E" logo are trademarks of Express Scripts Strategic Development, Inc.
All other trademarks are the property of their respective owners. CRP2006_003377.1 LT2006_003377
IMPORTANT NOTICE:A Change to your Prescription Drug Coverage
Dear TRICARE Beneficiary:
On August 26, 2020, the prescription drug you’re taking below, will no longer be covered by TRICARE. Ithas moved to a non-covered drug status and will no longer be available through military treatment facilitypharmacies or the TRICARE mail order pharmacy If you continue to take the drug, you’ll be required toobtain the medication from a retail pharmacy and to pay 100% of its cost.
DICLOFENAC EPOLAMINE
If you are taking this drug, what Should You Do?
If you are no longer taking the above drug, then you don’t need to do anything at this time.
1. Review the enclosed information called “Options for You and Your Doctor to Consider.”This document provides the drug that is no longer covered, preferred alternatives, and associatedcost information.
2. Discuss this information with your doctor to see which of the following options is best for you:
· Switch your prescription to a preferred alternative drug.
· Continue your non-covered prescription by obtaining at a retail pharmacy and pay 100% of the costof the drug
Why the Change?The Defense Health Agency regularly reviews drugs and has determined the drug mentioned above haslittle to no clinical benefit compared to other drugs that are just as effective and cost less.
Who Should You Contact If You Have Questions?If you have any questions about your pharmacy benefit or you need help, please visitexpress-scripts.com/TRICARE or call 877.363.1303.
Sincerely,
Jay Peloquin, PharmD, BCPSDirector, Clinical Account ManagementExpress Scripts
Download the Express Scripts™ mobile app for free today! Our easy-to-use mobile app puts yourTRICARE® prescription benefit in the palm of your hand.
Follow us on social media! Add MilitaryRx on Facebook and Twitter for health tips, plan info andupdates about your pharmacy benefit.
2020089154 - 5
JAMES W. MITCHELL11095 GOAT VALLEY CVARLINGTON, TN 38002-8456
LTR_FRMUNDOD_TOPICAL_1_002
June 12, 2020
202006160606238379 - DODA
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Pag
e Plex
= D
Letter ID
= L
TR
_F
RM
UN
DO
D_T
OP
ICA
L_1_0
02
TRICARE is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved.© 2020 Express Scripts. All Rights Reserved. Express Scripts and "E" logo are trademarks of Express Scripts Strategic Development, Inc.
All other trademarks are the property of their respective owners. CRP2006_003377.1 LT2006_003377
Options for You and Your Doctor to ConsiderOn August 26, 2020, the drug listed below will be completely excluded from the TRICARE benefit. Anyprior authorization (PA) or medical necessity (MN) your drug currently has will no longer apply. You willpay 100% of the drug cost if you continue to fill your prescription of your non-covered drug. The costyou pay for your non-covered drug will not apply to your TRICARE catastrophic cap. Carefully read theinformation below to understand your options.
DICLOFENAC EPOLAMINE
Switch to a preferred drug.
Preferred Drug(s)
Military TreatmentFacility
Home DeliveryRetail Network
Pharmacy
Your cost(up to a 90-day supply)
Generic Drugs:
· Diclofenac 1% (Gel)
· Diclofenac 1.5%(Solution)
$0 $10 $39
Continue taking your current non-covered drug.
Non-Covered Drug(s)
Military TreatmentFacility
Home DeliveryRetail Network
Pharmacy
Your cost
· Diclofenac 1.3% (Patch)
· Flector (Patch)
· Pennsaid 2% (Pump)
NOT AVAILABLE NOT AVAILABLE 100% of the cost ofthe drug.
LTR_FRMUNDOD_TOPICAL_1_002202006160606238379 - DODA
Sto
ckID
= B
ON
D20
Proof
Pag
e Plex
= D
Letter ID
= L
TR
_F
RM
UN
DO
D_T
OP
ICA
L_1_0
02
TRICARE is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved.© 2020 Express Scripts. All Rights Reserved. Express Scripts and "E" logo are trademarks of Express Scripts Strategic Development, Inc.
All other trademarks are the property of their respective owners. CRP2006_003377.1 LT2006_003377
IMPORTANT NOTICE:A Change to your Prescription Drug Coverage
Dear TRICARE Beneficiary:
On August 26, 2020, the prescription drug you’re taking below, will no longer be covered by TRICARE. Ithas moved to a non-covered drug status and will no longer be available through military treatment facilitypharmacies or the TRICARE mail order pharmacy If you continue to take the drug, you’ll be required toobtain the medication from a retail pharmacy and to pay 100% of its cost.
DICLOFENAC EPOLAMINE
If you are taking this drug, what Should You Do?
If you are no longer taking the above drug, then you don’t need to do anything at this time.
1. Review the enclosed information called “Options for You and Your Doctor to Consider.”This document provides the drug that is no longer covered, preferred alternatives, and associatedcost information.
2. Discuss this information with your doctor to see which of the following options is best for you:
· Switch your prescription to a preferred alternative drug.
· Continue your non-covered prescription by obtaining at a retail pharmacy and pay 100% of the costof the drug
Why the Change?The Defense Health Agency regularly reviews drugs and has determined the drug mentioned above haslittle to no clinical benefit compared to other drugs that are just as effective and cost less.
Who Should You Contact If You Have Questions?If you have any questions about your pharmacy benefit or you need help, please visitexpress-scripts.com/TRICARE or call 877.363.1303.
Sincerely,
Jay Peloquin, PharmD, BCPSDirector, Clinical Account ManagementExpress Scripts
Download the Express Scripts™ mobile app for free today! Our easy-to-use mobile app puts yourTRICARE® prescription benefit in the palm of your hand.
Follow us on social media! Add MilitaryRx on Facebook and Twitter for health tips, plan info andupdates about your pharmacy benefit.
2020089154 - 6
EILEEN A. BERNING12753 W VISTA PASEO DRLITCHFIELD PARK, AZ 85340-5523
LTR_FRMUNDOD_TOPICAL_1_002
June 12, 2020
202006160606238600 - DODA
00
89
15
40
00
00
60
10
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0
Sto
ckID
= B
ON
D20
Proof
Pag
e Plex
= D
Letter ID
= L
TR
_F
RM
UN
DO
D_T
OP
ICA
L_1_0
02
TRICARE is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved.© 2020 Express Scripts. All Rights Reserved. Express Scripts and "E" logo are trademarks of Express Scripts Strategic Development, Inc.
All other trademarks are the property of their respective owners. CRP2006_003377.1 LT2006_003377
Options for You and Your Doctor to ConsiderOn August 26, 2020, the drug listed below will be completely excluded from the TRICARE benefit. Anyprior authorization (PA) or medical necessity (MN) your drug currently has will no longer apply. You willpay 100% of the drug cost if you continue to fill your prescription of your non-covered drug. The costyou pay for your non-covered drug will not apply to your TRICARE catastrophic cap. Carefully read theinformation below to understand your options.
DICLOFENAC EPOLAMINE
Switch to a preferred drug.
Preferred Drug(s)
Military TreatmentFacility
Home DeliveryRetail Network
Pharmacy
Your cost(up to a 90-day supply)
Generic Drugs:
· Diclofenac 1% (Gel)
· Diclofenac 1.5%(Solution)
$0 $10 $39
Continue taking your current non-covered drug.
Non-Covered Drug(s)
Military TreatmentFacility
Home DeliveryRetail Network
Pharmacy
Your cost
· Diclofenac 1.3% (Patch)
· Flector (Patch)
· Pennsaid 2% (Pump)
NOT AVAILABLE NOT AVAILABLE 100% of the cost ofthe drug.
LTR_FRMUNDOD_TOPICAL_1_002202006160606238600 - DODA
Sto
ckID
= B
ON
D20
Proof
Pag
e Plex
= D
Letter ID
= L
TR
_F
RM
UN
DO
D_T
OP
ICA
L_1_0
02
TRICARE is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved.© 2020 Express Scripts. All Rights Reserved. Express Scripts and "E" logo are trademarks of Express Scripts Strategic Development, Inc.
All other trademarks are the property of their respective owners. CRP2006_003377.1 LT2006_003377
IMPORTANT NOTICE:A Change to your Prescription Drug Coverage
Dear TRICARE Beneficiary:
On August 26, 2020, the prescription drug you’re taking below, will no longer be covered by TRICARE. Ithas moved to a non-covered drug status and will no longer be available through military treatment facilitypharmacies or the TRICARE mail order pharmacy If you continue to take the drug, you’ll be required toobtain the medication from a retail pharmacy and to pay 100% of its cost.
DICLOFENAC EPOLAMINE
If you are taking this drug, what Should You Do?
If you are no longer taking the above drug, then you don’t need to do anything at this time.
1. Review the enclosed information called “Options for You and Your Doctor to Consider.”This document provides the drug that is no longer covered, preferred alternatives, and associatedcost information.
2. Discuss this information with your doctor to see which of the following options is best for you:
· Switch your prescription to a preferred alternative drug.
· Continue your non-covered prescription by obtaining at a retail pharmacy and pay 100% of the costof the drug
Why the Change?The Defense Health Agency regularly reviews drugs and has determined the drug mentioned above haslittle to no clinical benefit compared to other drugs that are just as effective and cost less.
Who Should You Contact If You Have Questions?If you have any questions about your pharmacy benefit or you need help, please visitexpress-scripts.com/TRICARE or call 877.363.1303.
Sincerely,
Jay Peloquin, PharmD, BCPSDirector, Clinical Account ManagementExpress Scripts
Download the Express Scripts™ mobile app for free today! Our easy-to-use mobile app puts yourTRICARE® prescription benefit in the palm of your hand.
Follow us on social media! Add MilitaryRx on Facebook and Twitter for health tips, plan info andupdates about your pharmacy benefit.
2020089154 - 7
MELANIE S. CHRISTENSEN1277 E 100 SLOGAN, UT 84321-4974
LTR_FRMUNDOD_TOPICAL_1_002
June 12, 2020
202006160606238601 - DODA
00
89
15
40
00
00
70
10
10
0
Sto
ckID
= B
ON
D20
Proof
Pag
e Plex
= D
Letter ID
= L
TR
_F
RM
UN
DO
D_T
OP
ICA
L_1_0
02
TRICARE is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved.© 2020 Express Scripts. All Rights Reserved. Express Scripts and "E" logo are trademarks of Express Scripts Strategic Development, Inc.
All other trademarks are the property of their respective owners. CRP2006_003377.1 LT2006_003377
Options for You and Your Doctor to ConsiderOn August 26, 2020, the drug listed below will be completely excluded from the TRICARE benefit. Anyprior authorization (PA) or medical necessity (MN) your drug currently has will no longer apply. You willpay 100% of the drug cost if you continue to fill your prescription of your non-covered drug. The costyou pay for your non-covered drug will not apply to your TRICARE catastrophic cap. Carefully read theinformation below to understand your options.
DICLOFENAC EPOLAMINE
Switch to a preferred drug.
Preferred Drug(s)
Military TreatmentFacility
Home DeliveryRetail Network
Pharmacy
Your cost(up to a 90-day supply)
Generic Drugs:
· Diclofenac 1% (Gel)
· Diclofenac 1.5%(Solution)
$0 $10 $39
Continue taking your current non-covered drug.
Non-Covered Drug(s)
Military TreatmentFacility
Home DeliveryRetail Network
Pharmacy
Your cost
· Diclofenac 1.3% (Patch)
· Flector (Patch)
· Pennsaid 2% (Pump)
NOT AVAILABLE NOT AVAILABLE 100% of the cost ofthe drug.
LTR_FRMUNDOD_TOPICAL_1_002202006160606238601 - DODA
Sto
ckID
= B
ON
D20
Proof
Pag
e Plex
= D
Letter ID
= L
TR
_F
RM
UN
DO
D_T
OP
ICA
L_1_0
02
TRICARE is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved.© 2020 Express Scripts. All Rights Reserved. Express Scripts and "E" logo are trademarks of Express Scripts Strategic Development, Inc.
All other trademarks are the property of their respective owners. CRP2006_003377.1 LT2006_003377
IMPORTANT NOTICE:A Change to your Prescription Drug Coverage
Dear TRICARE Beneficiary:
On August 26, 2020, the prescription drug you’re taking below, will no longer be covered by TRICARE. Ithas moved to a non-covered drug status and will no longer be available through military treatment facilitypharmacies or the TRICARE mail order pharmacy If you continue to take the drug, you’ll be required toobtain the medication from a retail pharmacy and to pay 100% of its cost.
FLECTOR
If you are taking this drug, what Should You Do?
If you are no longer taking the above drug, then you don’t need to do anything at this time.
1. Review the enclosed information called “Options for You and Your Doctor to Consider.”This document provides the drug that is no longer covered, preferred alternatives, and associatedcost information.
2. Discuss this information with your doctor to see which of the following options is best for you:
· Switch your prescription to a preferred alternative drug.
· Continue your non-covered prescription by obtaining at a retail pharmacy and pay 100% of the costof the drug
Why the Change?The Defense Health Agency regularly reviews drugs and has determined the drug mentioned above haslittle to no clinical benefit compared to other drugs that are just as effective and cost less.
Who Should You Contact If You Have Questions?If you have any questions about your pharmacy benefit or you need help, please visitexpress-scripts.com/TRICARE or call 877.363.1303.
Sincerely,
Jay Peloquin, PharmD, BCPSDirector, Clinical Account ManagementExpress Scripts
Download the Express Scripts™ mobile app for free today! Our easy-to-use mobile app puts yourTRICARE® prescription benefit in the palm of your hand.
Follow us on social media! Add MilitaryRx on Facebook and Twitter for health tips, plan info andupdates about your pharmacy benefit.
2020089154 - 8
AGATHA JUNDT1524 N 21ST STBISMARCK, ND 58501-2931
LTR_FRMUNDOD_TOPICAL_1_002
June 12, 2020
202006160606238821 - DODA
00
89
15
40
00
00
80
10
10
0
Sto
ckID
= B
ON
D20
Proof
Pag
e Plex
= D
Letter ID
= L
TR
_F
RM
UN
DO
D_T
OP
ICA
L_1_0
02
TRICARE is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved.© 2020 Express Scripts. All Rights Reserved. Express Scripts and "E" logo are trademarks of Express Scripts Strategic Development, Inc.
All other trademarks are the property of their respective owners. CRP2006_003377.1 LT2006_003377
Options for You and Your Doctor to ConsiderOn August 26, 2020, the drug listed below will be completely excluded from the TRICARE benefit. Anyprior authorization (PA) or medical necessity (MN) your drug currently has will no longer apply. You willpay 100% of the drug cost if you continue to fill your prescription of your non-covered drug. The costyou pay for your non-covered drug will not apply to your TRICARE catastrophic cap. Carefully read theinformation below to understand your options.
FLECTOR
Switch to a preferred drug.
Preferred Drug(s)
Military TreatmentFacility
Home DeliveryRetail Network
Pharmacy
Your cost(up to a 90-day supply)
Generic Drugs:
· Diclofenac 1% (Gel)
· Diclofenac 1.5%(Solution)
$0 $10 $39
Continue taking your current non-covered drug.
Non-Covered Drug(s)
Military TreatmentFacility
Home DeliveryRetail Network
Pharmacy
Your cost
· Diclofenac 1.3% (Patch)
· Flector (Patch)
· Pennsaid 2% (Pump)
NOT AVAILABLE NOT AVAILABLE 100% of the cost ofthe drug.
LTR_FRMUNDOD_TOPICAL_1_002202006160606238821 - DODA
Sto
ckID
= B
ON
D20
Proof
Pag
e Plex
= D
Letter ID
= L
TR
_F
RM
UN
DO
D_T
OP
ICA
L_1_0
02
TRICARE is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved.© 2020 Express Scripts. All Rights Reserved. Express Scripts and "E" logo are trademarks of Express Scripts Strategic Development, Inc.
All other trademarks are the property of their respective owners. CRP2006_003377.1 LT2006_003377
IMPORTANT NOTICE:A Change to your Prescription Drug Coverage
Dear TRICARE Beneficiary:
On August 26, 2020, the prescription drug you’re taking below, will no longer be covered by TRICARE. Ithas moved to a non-covered drug status and will no longer be available through military treatment facilitypharmacies or the TRICARE mail order pharmacy If you continue to take the drug, you’ll be required toobtain the medication from a retail pharmacy and to pay 100% of its cost.
FLECTOR
If you are taking this drug, what Should You Do?
If you are no longer taking the above drug, then you don’t need to do anything at this time.
1. Review the enclosed information called “Options for You and Your Doctor to Consider.”This document provides the drug that is no longer covered, preferred alternatives, and associatedcost information.
2. Discuss this information with your doctor to see which of the following options is best for you:
· Switch your prescription to a preferred alternative drug.
· Continue your non-covered prescription by obtaining at a retail pharmacy and pay 100% of the costof the drug
Why the Change?The Defense Health Agency regularly reviews drugs and has determined the drug mentioned above haslittle to no clinical benefit compared to other drugs that are just as effective and cost less.
Who Should You Contact If You Have Questions?If you have any questions about your pharmacy benefit or you need help, please visitexpress-scripts.com/TRICARE or call 877.363.1303.
Sincerely,
Jay Peloquin, PharmD, BCPSDirector, Clinical Account ManagementExpress Scripts
Download the Express Scripts™ mobile app for free today! Our easy-to-use mobile app puts yourTRICARE® prescription benefit in the palm of your hand.
Follow us on social media! Add MilitaryRx on Facebook and Twitter for health tips, plan info andupdates about your pharmacy benefit.
2020089154 - 9
ALICE K. HECKE1903 NORMAL PARK DRHUNTSVILLE, TX 77340-4932
LTR_FRMUNDOD_TOPICAL_1_002
June 12, 2020
202006160606239040 - DODA
00
89
15
40
00
00
90
10
10
0
Sto
ckID
= B
ON
D20
Proof
Pag
e Plex
= D
Letter ID
= L
TR
_F
RM
UN
DO
D_T
OP
ICA
L_1_0
02
TRICARE is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved.© 2020 Express Scripts. All Rights Reserved. Express Scripts and "E" logo are trademarks of Express Scripts Strategic Development, Inc.
All other trademarks are the property of their respective owners. CRP2006_003377.1 LT2006_003377
Options for You and Your Doctor to ConsiderOn August 26, 2020, the drug listed below will be completely excluded from the TRICARE benefit. Anyprior authorization (PA) or medical necessity (MN) your drug currently has will no longer apply. You willpay 100% of the drug cost if you continue to fill your prescription of your non-covered drug. The costyou pay for your non-covered drug will not apply to your TRICARE catastrophic cap. Carefully read theinformation below to understand your options.
FLECTOR
Switch to a preferred drug.
Preferred Drug(s)
Military TreatmentFacility
Home DeliveryRetail Network
Pharmacy
Your cost(up to a 90-day supply)
Generic Drugs:
· Diclofenac 1% (Gel)
· Diclofenac 1.5%(Solution)
$0 $10 $39
Continue taking your current non-covered drug.
Non-Covered Drug(s)
Military TreatmentFacility
Home DeliveryRetail Network
Pharmacy
Your cost
· Diclofenac 1.3% (Patch)
· Flector (Patch)
· Pennsaid 2% (Pump)
NOT AVAILABLE NOT AVAILABLE 100% of the cost ofthe drug.
LTR_FRMUNDOD_TOPICAL_1_002202006160606239040 - DODA
Sto
ckID
= B
ON
D20
Proof
Pag
e Plex
= D
Letter ID
= L
TR
_F
RM
UN
DO
D_T
OP
ICA
L_1_0
02
TRICARE is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved.© 2020 Express Scripts. All Rights Reserved. Express Scripts and "E" logo are trademarks of Express Scripts Strategic Development, Inc.
All other trademarks are the property of their respective owners. CRP2006_003377.1 LT2006_003377
IMPORTANT NOTICE:A Change to your Prescription Drug Coverage
Dear TRICARE Beneficiary:
On August 26, 2020, the prescription drug you’re taking below, will no longer be covered by TRICARE. Ithas moved to a non-covered drug status and will no longer be available through military treatment facilitypharmacies or the TRICARE mail order pharmacy If you continue to take the drug, you’ll be required toobtain the medication from a retail pharmacy and to pay 100% of its cost.
FLECTOR
If you are taking this drug, what Should You Do?
If you are no longer taking the above drug, then you don’t need to do anything at this time.
1. Review the enclosed information called “Options for You and Your Doctor to Consider.”This document provides the drug that is no longer covered, preferred alternatives, and associatedcost information.
2. Discuss this information with your doctor to see which of the following options is best for you:
· Switch your prescription to a preferred alternative drug.
· Continue your non-covered prescription by obtaining at a retail pharmacy and pay 100% of the costof the drug
Why the Change?The Defense Health Agency regularly reviews drugs and has determined the drug mentioned above haslittle to no clinical benefit compared to other drugs that are just as effective and cost less.
Who Should You Contact If You Have Questions?If you have any questions about your pharmacy benefit or you need help, please visitexpress-scripts.com/TRICARE or call 877.363.1303.
Sincerely,
Jay Peloquin, PharmD, BCPSDirector, Clinical Account ManagementExpress Scripts
Download the Express Scripts™ mobile app for free today! Our easy-to-use mobile app puts yourTRICARE® prescription benefit in the palm of your hand.
Follow us on social media! Add MilitaryRx on Facebook and Twitter for health tips, plan info andupdates about your pharmacy benefit.
2020089154 - 10
WILLIAM P. POWER1904 CUPSTID STCAYCE, SC 29033-1507
LTR_FRMUNDOD_TOPICAL_1_002
June 12, 2020
202006160606239041 - DODA
00
89
15
40
00
01
00
10
10
0
Sto
ckID
= B
ON
D20
Proof
Pag
e Plex
= D
Letter ID
= L
TR
_F
RM
UN
DO
D_T
OP
ICA
L_1_0
02
TRICARE is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved.© 2020 Express Scripts. All Rights Reserved. Express Scripts and "E" logo are trademarks of Express Scripts Strategic Development, Inc.
All other trademarks are the property of their respective owners. CRP2006_003377.1 LT2006_003377
Options for You and Your Doctor to ConsiderOn August 26, 2020, the drug listed below will be completely excluded from the TRICARE benefit. Anyprior authorization (PA) or medical necessity (MN) your drug currently has will no longer apply. You willpay 100% of the drug cost if you continue to fill your prescription of your non-covered drug. The costyou pay for your non-covered drug will not apply to your TRICARE catastrophic cap. Carefully read theinformation below to understand your options.
FLECTOR
Switch to a preferred drug.
Preferred Drug(s)
Military TreatmentFacility
Home DeliveryRetail Network
Pharmacy
Your cost(up to a 90-day supply)
Generic Drugs:
· Diclofenac 1% (Gel)
· Diclofenac 1.5%(Solution)
$0 $10 $39
Continue taking your current non-covered drug.
Non-Covered Drug(s)
Military TreatmentFacility
Home DeliveryRetail Network
Pharmacy
Your cost
· Diclofenac 1.3% (Patch)
· Flector (Patch)
· Pennsaid 2% (Pump)
NOT AVAILABLE NOT AVAILABLE 100% of the cost ofthe drug.
LTR_FRMUNDOD_TOPICAL_1_002202006160606239041 - DODA
Sto
ckID
= B
ON
D20
Proof
Pag
e Plex
= D
Letter ID
= L
TR
_F
RM
UN
DO
D_T
OP
ICA
L_1_0
02
TRICARE is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved.© 2020 Express Scripts. All Rights Reserved. Express Scripts and "E" logo are trademarks of Express Scripts Strategic Development, Inc.
All other trademarks are the property of their respective owners. CRP2006_003377.1 LT2006_003377
IMPORTANT NOTICE:A Change to your Prescription Drug Coverage
Dear TRICARE Beneficiary:
On August 26, 2020, the prescription drug you’re taking below, will no longer be covered by TRICARE. Ithas moved to a non-covered drug status and will no longer be available through military treatment facilitypharmacies or the TRICARE mail order pharmacy If you continue to take the drug, you’ll be required toobtain the medication from a retail pharmacy and to pay 100% of its cost.
FLECTOR
If you are taking this drug, what Should You Do?
If you are no longer taking the above drug, then you don’t need to do anything at this time.
1. Review the enclosed information called “Options for You and Your Doctor to Consider.”This document provides the drug that is no longer covered, preferred alternatives, and associatedcost information.
2. Discuss this information with your doctor to see which of the following options is best for you:
· Switch your prescription to a preferred alternative drug.
· Continue your non-covered prescription by obtaining at a retail pharmacy and pay 100% of the costof the drug
Why the Change?The Defense Health Agency regularly reviews drugs and has determined the drug mentioned above haslittle to no clinical benefit compared to other drugs that are just as effective and cost less.
Who Should You Contact If You Have Questions?If you have any questions about your pharmacy benefit or you need help, please visitexpress-scripts.com/TRICARE or call 877.363.1303.
Sincerely,
Jay Peloquin, PharmD, BCPSDirector, Clinical Account ManagementExpress Scripts
Download the Express Scripts™ mobile app for free today! Our easy-to-use mobile app puts yourTRICARE® prescription benefit in the palm of your hand.
Follow us on social media! Add MilitaryRx on Facebook and Twitter for health tips, plan info andupdates about your pharmacy benefit.
2020089154 - 11
GILBERT E. MCGAULEYPO BOX 205WELAKA, FL 32193-0205
LTR_FRMUNDOD_TOPICAL_1_002
June 12, 2020
202006160606241044 - DODA
00
89
15
40
00
01
10
10
10
0
Sto
ckID
= B
ON
D20
Proof
Pag
e Plex
= D
Letter ID
= L
TR
_F
RM
UN
DO
D_T
OP
ICA
L_1_0
02
TRICARE is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved.© 2020 Express Scripts. All Rights Reserved. Express Scripts and "E" logo are trademarks of Express Scripts Strategic Development, Inc.
All other trademarks are the property of their respective owners. CRP2006_003377.1 LT2006_003377
Options for You and Your Doctor to ConsiderOn August 26, 2020, the drug listed below will be completely excluded from the TRICARE benefit. Anyprior authorization (PA) or medical necessity (MN) your drug currently has will no longer apply. You willpay 100% of the drug cost if you continue to fill your prescription of your non-covered drug. The costyou pay for your non-covered drug will not apply to your TRICARE catastrophic cap. Carefully read theinformation below to understand your options.
FLECTOR
Switch to a preferred drug.
Preferred Drug(s)
Military TreatmentFacility
Home DeliveryRetail Network
Pharmacy
Your cost(up to a 90-day supply)
Generic Drugs:
· Diclofenac 1% (Gel)
· Diclofenac 1.5%(Solution)
$0 $10 $39
Continue taking your current non-covered drug.
Non-Covered Drug(s)
Military TreatmentFacility
Home DeliveryRetail Network
Pharmacy
Your cost
· Diclofenac 1.3% (Patch)
· Flector (Patch)
· Pennsaid 2% (Pump)
NOT AVAILABLE NOT AVAILABLE 100% of the cost ofthe drug.
LTR_FRMUNDOD_TOPICAL_1_002202006160606241044 - DODA
