Subject: Philippine Tricare Immunization Claims

Philippine TRICARE Users [6/7/12]

The following is forwarded from the U.S. Military Retirees of the Philippines Group for those affected:

Lt. James ‘EMO”Tichacek USN (Ret)
Associate Director & Editor/Publisher RAO Baguio Bulletin


In March, 2012 during a Tricare meeting in Cebu a retiree described an instance where he had gotten immunizations for his family. The immunizations were performed in the Doctor’s office and the vaccines came from the Doctor’s stock of vaccines, (which are only sold to medical professional, not to the general public).

Due to the September 2011 change to purchases of pharmaceuticals policy for the Tricare Philippines, Tricare ordered WPS to deny all claims for pharmaceuticals that were not purchased from a Tricare certified pharmacy or a Tricare certified hospital pharmacy. This policy change was made in order to stop the practice of doctors prescribing medicines and then filling the prescription in-house.

Unfortunately the policy change, as the Cebu retiree explained, had the effect of causing immunization claims to be denied if the vaccines were purchased from the doctor/clinic resulting in the loss of legitimate reimbursement to beneficiaries.

We asked for retirees to provide us with claim examples for which the claim was for in-office immunizations and were denied because the vaccines were purchased from the doctor/clinic. We received numerous examples with the corresponding claim numbers and presented these to a Tricare representative.

Based on the examples that you, the retirees provided us, Tricare, (TMA), has agreed that the denial for in-office immunizations and vaccinations using drugs that are not normally self-administered should be reimbursable. The following is a copy of the email we received today concerning this new policy change to the September 2011 pharmaceutical policy. The email is reprinted with the permission of the author, but we have redacted the authors name and identifying information.

Please wait about 60 days to see if your claim has been reprocessed before contacting WPS to have a claim re-opened under the new policy.

Mr. Fournier,

I just wanted to let you know that I've received preliminary notification that our efforts to overturn the denial of injectable medication/immunization claims for Code 398 (pharmacy charges cannot be paid when the facility is not qualified to dispense pharmacy services) was successful. WPS has reportedly run a report and identified more than 100 claims that need to be adjusted/paid. The IT programming is being reviewed, and the adjustments should be taking place in 2-3 weeks. I may get more details next week.

Thank you for your assistance with this matter. While the September 2011 pharmacy policy change prohibited reimbursement for pharmaceuticals purchased from a provider other than a certified retail pharmacy or certified hospital pharmacy, it wasn't intended to apply to vaccinations and other injectable medicines that typically must be administered by a physician in his/her office. While I was undoubtedly making some headway with this matter, the specific examples you provided to back me up were very helpful in successfully pushing this fix through.