The Department of Defense published an Interim Final Rule in the Federal Register on September 3, 2020 with two provisions which directly impact payment for drugs on TRICARE inpatient and outpatient claims.
The first provision is that TRICARE will adopt the payment criteria and formulas for new technology add-on payments (NTAP) as outlined in CMS Inpatient Prospective Payment System (IPPS) Final Rule. This is a new payment provision and will be made retroactive to January 1, 2020. In the future, TRICARE will adopt CMS’s effective date of October 1 of each year. This is listed as a permanent change. For a tool listing the FY2020 and FY2021 drugs eligible for CMS NTAP payments (and now applying to TRICARE), see: NTAP Tool.
The second provision is a temporary provision where TRICARE, for the first time, will cover not just the care associated with administration of an investigational drug, but the investigational drug itself, when the investigational drug is for the treatment of COVID–19 or its associated sequelae. This use may be authorized in any setting for which the FDA allows treatment use of an investigational drug under expanded access to proceed.
The change under this provision is temporary for the duration of the President’s national emergency for the COVID–19 outbreak, but the drug may continue to be covered beyond the national emergency if the course of treatment was started prior to the end of the national emergency.
TRICARE indicated that it intends to use this national emergency period to re-evaluate their current exclusion on coverage of treatment INDs and may revise the regulation to cover investigational drugs for treatment use under expanded access for all indications if appropriate after they evaluate the costs, benefits, risks, and other considerations. Coverage for investigational drugs may impact both inpatient and outpatient TRICARE claims as the charges may contribute to outlier payments and there may be additional separate reimbursement on outpatient claims depending upon the cost incurred by the facility.
TRICARE has 9.4 million beneficiaries who receive healthcare in a network of civilian providers and military hospitals and clinics. TRICARE beneficiaries are the men and women of the Armed Forces and their families including active duty and retirees, as well as National Guard and Reserve members
- The Finance Teamwill want to review all FY2020 CMS NTAP-eligible drugs to determine if any were used on TRICARE inpatients with claim dates on or after January 1, 2020. The appropriate ICD-10-PCS codes should be added if not already on the claim and rebilled to TRICARE.
- The Finance Teamwill want to include TRICARE accounts in any edits or monitoring for FY2021 NTAP drugs (similar to their current process for Medicare), to ensure that appropriate ICD-10-PCS codes are added to the claim.
- ThePharmacy and P&T Committeeshould include Medicare and TRICARE data when evaluating NTAP-designated drugs for formulary status.