TRICARE October 2026 Provider Pulse

Review TRICARE Policy Manual Updates

The Defense Health Agency has revised the TRICARE policy governing medical claims that include drugs and biologics. Revision C-56 to Chapter 8, Section 9.2 clarifies coverage, cost-sharing, prior authorization, and utilization management responsibilities for drugs and biologics billed under the medical benefit (as opposed to the TRICARE Pharmacy [TPharm] benefit).

Who and What This Policy Covers

This policy applies to drugs and biologics administered by a TRICARE-authorized provider (including home health agencies), and to infusion or injectable drug therapy (even if self-administered and delivered in the home) when the drug is unavailable from the TPharm program.

Self-administered drugs dispensed by a retail, mail-order, or market/military medical treatment facility pharmacy fall under Section 9.1, not this policy.

Covered categories include:

• Legend drugs and vitamins, including prenatal vitamins. Legend vitamins may be cost-shared only when used to treat a specific medical condition; prenatal vitamins that require a U.S. prescription may be cost-shared.
• Drugs and biologics grandfathered by the Federal Food, Drug, and Cosmetic Act of 1938 (cost-shared as if FDA-approved)
• FDA-approved drugs and biologics, including immunizations and vaccines (see Chapter 7 for preventive and well-childcare)
• Insulin and related supplies for known diabetics, even if a prescription is not required by state law
• Self-administrable infusion or injectable drugs that are unavailable from the TPharm program

Coverage and Cost-Sharing Criteria

A drug or biologic may be cost-shared under this policy only when all the following are met:

1. It is FDA-approved for marketing (if approval is required) or holds an FDA Emergency Use Authorization. Coverage ends when the EUA ends unless the product is otherwise approved or cleared by the FDA.
2. It is prescribed for its labeled indication by a provider acting within the scope of licensure.
3. It is furnished in accordance with all applicable state laws and licensing requirements.
4. It is medically or psychologically necessary or provided as part of well-child or preventive care.
5. It is not otherwise excluded.

Off-Label Use

TriWest, as the contractor, provides approval for off-label reimbursement. An off-label use may be approved when medically necessary and supported by medical literature, national organizations, or technology assessment bodies demonstrating the use is safe, effective, and consistent with nationally accepted standards of practice (unless use is specifically prohibited by the TPM).

Orphan Drugs

Drugs and biologics with an FDA orphan drug designation and marketing approval may be cost-shared when used to treat a rare disease or condition as defined at 32 CFR 199.2.

Home Infusion and Injectable Therapy - Prior Authorization Required

When injectable or infusion drug therapy is medically necessary and home delivery/administration is appropriate, TriWest will provide prior authorization to a TRICARE-authorized pharmacy so the drug can be fulfilled under the pharmacy benefit (per Sections 9.1 and 20.1). Providers should initiate prior authorization before home administration.

Utilization Management - DEA Schedule II-V Prescriber Designation

Beneficiaries are required to designate a single prescriber to manage all prescriptions for DEA Schedule II-V medications. Prescriptions written by a provider other than the designated prescriber will be denied authorization for dispensing through network retail pharmacies, and claims filled at non-network retail pharmacies will be denied reimbursement. Claims are also screened for potential over-utilization and substance abuse by the TRICARE Operations Manual, Chapter 28.

Key Exclusions

The following are not cost-shared under this policy:

• Drugs or biologics prescribed or furnished by a member of the patient's immediate family or a household member
• Over-the-counter products, including compounded OTC preparations
• Investigational drugs with FDA "Group C" designation (medical care related to their use may be cost-shared only when it would have been provided in the absence of the Group C drug)
• Orphan drugs without marketing approval made available on a compassionate-use basis
• Treatment Investigational New Drugs (related medical care may be cost-shared when medically warranted and consistent with accepted standards of practice)

Reimbursement

Reimbursement for drugs and biologics on medical claims is described in the TRICARE Reimbursement Manual and depends on provider type, beneficiary category, and the presence of Other Health Insurance.

Action Items for Providers

• Verify whether a drug should be billed under the medical benefit (this policy) or the pharmacy benefit (Section 9.1) before submitting a claim.
• Obtain prior authorization for home infusion/injectable therapy prior to administration.
• Include supporting medical literature with off-label reimbursement requests.
• Confirm the beneficiary's designated prescriber before writing DEA Schedule II-V prescriptions.

Inactive Providers Will No Longer Appear in TRICARE Provider Directory

To meet Defense Health Agency contract requirements and improve beneficiary search results, TriWest will begin suppressing inactive TRICARE providers from the public TRICARE West Region provider directory. Providers designated as “suppressed” will remain part of the network, but will not appear in the online directory.

This process is intended to enhance directory accuracy and make it easier for beneficiaries to locate actively participating providers.

If an inactive provider wishes to be listed again, they may request reinstatement at any time by emailing providerdataupdates@triwest.com with the subject line: Stop Directory Suppression. Providers should include the name, address and NPI1 number in the body of the email to ensure a solid match.

Register for November TRICARE Mental Health Readiness Training

Mental health providers are invited to participate in the November TRICARE Provider Readiness Designation Training. Providers who complete the required coursework and earn the TPRD designation will be identified in the TRICARE Directory as having specialized knowledge of military culture, ethics, and evidence based treatment approaches.

This free, two day CE opportunity includes six required courses and offers 14 CE credits for psychologists and social workers. All TRICARE mental health providers are welcome.

November Training Details

• Dates: November 17–18, 2026
• Time: 0900–1730 ET

Required Courses Include:

• Assessing Military Clients for Trauma and PTSD
• Ethical Considerations for Working with Military Members and Veterans
• Military Culture: Enhancing Clinical Competence
• Addressing Suicide with Military Connected Patients
• An Overview of Sleep Disorders Common in Military Members
• The Use of Screening Tools

By completing this training, providers strengthen their clinical readiness for working with military connected populations and gain enhanced visibility within the TRICARE network. You can register for this training with the Uniformed Services University.

Meet TRICARE Referral and Pre Authorization Requirements

Providers who provide healthcare to our nation’s military members and their families while participating in the Department of War TRICARE program must comply with all referral and pre-authorization requirements. These prerequisites can be found here:

• TRICARE policy requirements
• TriWest TRICARE Provider Handbook

Providers are responsible for obtaining a pre-authorization for services that require them (see the Prior Authorization List). Failure to do so will result in a 10% payment reduction during claims processing. Network providers could have a greater penalty depending on the provider’s network contract.

Important! Payment reduction penalties cannot be passed onto the beneficiary.

Review these policies and procedures routinely as changes may occur due to contract modifications. Additionally, TriWest assesses pre-authorization requirements annually to ensure adherence to TRICARE policy and evaluates medical and mental healthcare trends for appropriate utilization of care.

TRICARE Provider Handbook Updates

There are no updates to the TRICARE Provider Handbook this month.