The Prescription Monitoring Program (PMP) is in place to support Military Treatment Facilities (MTFs) and the TRICARE® Managed Care Support Contractors (MCSCs) with the identification of beneficiaries who are potentially at risk for misuse of prescription drugs. The PMP provides the opportunity for restriction implementation to prevent or decrease the risk of overutilization.
On a quarterly basis, Express Scripts performs a review of MTF and retail pharmacy claims adjudicated within the prior six months to identify at risk TRICARE beneficiaries as candidates for enrollment in the PMP. Review criteria is pre-determined, including utilization patterns of controlled substances and/or other high risk medications. Express Scripts maintains the report logic and implements changes as needed to align with commercial best practices and Centers for Disease Control and Prevention (CDC) guidelines.
Identified beneficiaries are reported to the respective TRICARE MCSC or the MTF in which they are enrolled, based on the Primary Care Manager (PCM) assignment in the DEERS database, via the Prescription Monitoring Program Utilizer Report.
Restriction Requests
The reviewer at the MTF or MCSC may elect to enroll a beneficiary in the PMP and restrict certain prescription drugs to authorized provider(s) and/or pharmacy(ies). Restrictions are not limited to Express Scripts’ reports. MTF/MCSC points of contact may request restriction of any eligible beneficiary at any time.
The PMP Playbook for MTFs provides additional detail and recommended processes. MTFs may request a copy by emailing TRICARE111@express-scripts.com.
MTF Restriction Types
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Type I Lock: Restrict all medications
-
Type II Lock: Restrict controlled medications or selected drug schedule
- Type III Lock: Restrict specific medication or drug list
MCSC Restriction Types
- 100% Copay: Beneficiary is required to pay 100% cost share for controlled medications (DEA 2-5) at retail/TMOP pharmacies. NOTE: MTF Providers/Pharmacies do not receive system messages for patients on this restriction.
- DEA 2-5: Controlled medications are restricted to a selected provider
- Hospital/ER restriction is managed by the MCSC
System Messaging
Prescriptions that are out of compliance with the restriction will process or reject based on where the prescription is filled:
Retail/TMOP/MTF (MHS GENESIS)*
Reject with additional messaging dependent on the reject reason:
979 Locked Into Specific Prescriber(s)
980 Locked Into Specific Pharmacy(s)
MTF (CHCS)
Lock-in edit returned to the MTF pharmacy processing the claim:
PATIENT LOCKED IN TO PRESC/PHCY. CALL MTF HELPDESK FOR DETAIL 855-315-1921
*Retail claims cannot be overridden, however an MTF Pharmacist may enter a submission code to override the reject at their discretion.
Reporting
Express Scripts generates two reports for the MTFs and MCSCs pertaining to the PMP. Reports are generated the 15th of each month and available to MTFs via the MTF Provider Portal (provided by Express Scripts) and are sent directly to the MCSCs via Secure File Transfer Process.
To request access to PMP reporting or to update the PMP point of contact list, email the Express Scripts Prescription Monitoring Department: TRICARE111@express-scripts.com.
Express Scripts PMP Team Contact Information
Email: TRICARE111@express-scripts.com