[Federal Register Volume 83, Number 237 (Tuesday, December 11, 2018)]
[Rules and Regulations]
[Pages 63574-63578]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2018-26562]


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DEPARTMENT OF DEFENSE

Office of the Secretary

32 CFR Part 199

[DOD-2018-HA-0062]
RIN 0720-AB75


TRICARE Pharmacy Benefits Program Reforms

AGENCY: Office of the Secretary, Department of Defense (DoD).

ACTION: Interim final rule.

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SUMMARY: This interim final rule implements Section 702 of the National 
Defense Authorization Act for Fiscal Year 2018 (NDAA FY18). The law 
makes significant changes to the TRICARE Pharmacy Benefits Program, 
specifically it: Updates co-payment requirements; authorizes a new 
process for encouraging use of pharmaceutical agents that provide the 
best clinical effectiveness by excluding coverage for particular 
pharmaceutical agents that provide very little or no clinical 
effectiveness relative to similar agents and for giving preferential 
status to agents that provide enhanced clinical effectiveness; and 
authorizes special reimbursement methods, amounts, and procedures to 
encourage use or high-value products and discourage use of low-value 
products with respect to pharmaceutical agents provided as part of 
medical services from authorized providers.

DATES: This interim final rule is effective December 11, 2018. Comments 
must be received by February 11, 2019.

FOR FURTHER INFORMATION CONTACT: David W. Bobb, RPh, JD, Chief, 
Pharmacy Operations, Defense Health Agency (DHA), telephone (703) 681-
2890.

SUPPLEMENTARY INFORMATION: 

I. Executive Summary

A. Purpose of the Interim Final Rule

    This interim final rule implements Section 702 of the National 
Defense Authorization Act for Fiscal Year 2018 (NDAA FY18), which does 
three things: (1) It updates cost-sharing requirements for outpatient 
pharmaceutical prescriptions filled by retail pharmacies and the 
TRICARE mail order pharmacy program. (2) It authorizes a new Uniform 
Formulary process for encouraging use of pharmaceutical agents in the 
TRICARE Pharmacy Benefits Program that provide the best clinical 
effectiveness by excluding coverage for particular pharmaceutical 
agents that provide very little or no clinical effectiveness relative 
to similar agents and giving preferential status to agents that provide 
enhanced clinical effectiveness. (3) It authorizes special 
reimbursement methods, amounts, and procedures to encourage use of 
high-value products and discourage use of low-value products with 
respect to pharmaceutical agents provided as part of medical services 
from authorized providers. This interim final rule implements each of 
these three statutory changes. This is being issued as an interim final 
rule in order to implement expeditiously the reforms authorized by 
Section 702, as specifically authorized by subsection (b)(3) of that 
section. Based on that clear Congressional authority and intent, the 
Department finds that obtaining public comment in advance of issuing 
this rule is impracticable, unnecessary, and contrary to the public 
interest. Delaying expeditious implementation by waiting for public 
comments to this interim rule not only delays the significant cost 
savings to the government that will be realized through implementation 
but also continues to allow coverage of pharmaceutical agents that do 
not provide the best clinical effectiveness for beneficiaries. In 
addition, subsection (b)(3) of Section 702 states that ``in order to 
implement expeditiously the reforms authorized . . . (A) the Secretary 
of Defense may prescribe an interim final rule, (B) not later than one 
year after prescribing the interim final rule and considering public 
comments with respect to such interim final rule, by prescribing a 
final rule.'' Clearly Congressional intent is to implement the 
authorized reforms quickly. Nonetheless, DoD invites public comments on 
this rule and is committed to considering all comments and issuing a 
final rule as soon as practicable (but not later than one year after 
issuance of this interim final rule).

B. Legal Authority for the Regulatory Action

    This interim final rule is under the primary authority of 10 U.S.C. 
1074g, 1079 and 1086, and Section 702 of NDAA-18. Specifically, section 
702(b)(3) of NDAA-18 authorizes DoD to ``prescribe such changes to the 
regulations implementing the TRICARE program . . . by prescribing an 
interim final rule.'' TRICARE program regulations (32 CFR part 199) are 
issued under statutory authorities including 10 U.S.C. 1074g (the 
Pharmacy Benefits Program) and 10 U.S.C. 1079 and 1086 (TRICARE medical 
benefits). Section 702 of NDAA-18 amends both section 1074g and section 
1079 (the section 1079 amendment being automatically applicable to 
section 1086).

C. Summary of Major Provisions of the Interim Final Rule

    The major provisions of the interim final rule are the following.
    1. Updating Cost-Sharing. Under the authority of section 
1074g(a)(6), as amended by Section 702(a) of NDAA FY18, we are amending 
32 CFR 199.21(i) to cross reference the statutory changes.
    2. Uniform Formulary Changes. Based on section 1074g(a)(10), as 
added by Section 702(b)(1) of NDAA FY 18, we are changing the Uniform 
Formulary process under 32 CFR 199.21(e) by authorizing the exclusion 
of any pharmaceutical agent that provides very little or no clinical 
effectiveness relative to similar agents, and preferential status for 
pharmaceutical agents that have enhanced clinical effectiveness 
relative to similar agents.
    3. Pharmaceutical Agents as Part of Medical Services. Based on 10 
U.S.C. 1079(q), as added by Section 702(b)(2) of NDAA FY18, we are 
changing provisions of 32 CFR 199.14 to authorize the adoption of 
special reimbursement methods, amounts and procedures to encourage the 
use of high value products and discourage the use of low value 
products--both relative to similar agents--in connection with 
pharmaceutical agents provided as part of outpatient medical services 
covered by TRICARE.

II. Provisions of Interim Final Rule

A. Updating Co-Payments

    The interim final rule amends 32 CFR 199.21(i)(2), which is the 
paragraph of the TRICARE regulation that governs cost-sharing amounts 
under the Pharmacy Benefits Program. The amended language simply cross 
references the statutory specifications on cost-sharing, including the 
table set forth in 10 U.S.C. 1074g(a)(6)(A). This table lists cost 
sharing amounts for the years 2018 through 2027 for generic, formulary, 
and non-formulary pharmaceutical agents dispensed by retail network 
pharmacies and the mail order pharmacy program. Two exceptions are that 
there is a $0 cost-share for vaccines/immunizations authorized as 
preventive care for eligible beneficiaries and provided by

[[Page 63575]]

retail network pharmacies and a $0 cost-share for smoking cessation 
pharmaceutical agents covered under the smoking cessation program. 
Another special rule under the statute is that for survivors of members 
who die on active duty and for disability retirees and their families, 
cost-sharing increases will not apply, and the 2017 amounts will remain 
in effect. The interim final rule also provides that for any year after 
2027, the cost-sharing amounts will reflect changes in the costs of 
pharmaceutical agents and prescription dispensing, calculated 
separately for generic, formulary, and non-formulary drugs in each 
applicable point of service.

B. Uniform Formulary Changes

    The interim final rule amends 32 CFR 199.21(e)(3) to provide that 
the Pharmacy and Therapeutics Committee may recommend and the Director 
may, after considering the comments and recommendations of the 
Beneficiary Advisory Panel, approve special uniform formulary actions 
to encourage use of pharmaceutical agents that provide the best 
clinical effectiveness to covered beneficiaries and DoD, including 
consideration of better care, healthier people, and smarter spending. 
Such special actions may operate as exceptions to the normal rules and 
procedures. Specifically, the Pharmacy and Therapeutics Committee may 
recommend complete or partial exclusion from the pharmacy benefits 
program of any pharmaceutical agent the Director determines provides 
very little or no clinical effectiveness relative to similar agents--
i.e., other pharmaceutical agents in the same drug class--to covered 
beneficiaries and DoD. A partial exclusion under this paragraph may 
take the form (as one example) of a limitation on the clinical 
conditions, diagnoses, or indications for which the pharmaceutical 
agent may be prescribed. (As an example of this, off-label uses of a 
pharmaceutical agent may be disallowed.) A partial exclusion may be 
implemented through preauthorization or other means recommended by the 
Pharmacy and Therapeutics Committee. In the case of a partial 
exclusion, a pharmaceutical agent may be available on the non-formulary 
tier of the uniform formulary for limited purposes and for other 
purposes be excluded. In addition, the Pharmacy and Therapeutics 
Committee may recommend to the Director giving preferential status--
based on a determination of enhanced clinical effectiveness relative to 
other agents in the same drug class--to any non-generic pharmaceutical 
agent of the uniform formulary by treating it for purposes of cost-
sharing as a generic product.

C. Pharmaceutical Agents as Part of Medical Services

    The interim final rule amends 32 CFR 199.14(a)(6) and (j)(1) to 
provide that TRICARE may adopt special reimbursement methods, amounts, 
and procedures to encourage the use of high-value pharmaceutical agents 
as part of medical services furnished in a hospital outpatient setting 
or as part of any other medical services provided to TRICARE 
beneficiaries. Although TRICARE generally follows Medicare's 
reimbursement methodology when practicable for such medical services 
which include medically necessary administration of drugs, Section 
702(b)(2) of NDAA FY18 authorizes the adoption of special reimbursement 
methods when determined appropriate to encourage the use of high-value 
pharmaceutical agents and discourage the use of low-value agents. For 
example, Medicare's reimbursement formula for physician-administered 
drugs paid under Part B is Average Sales Price (ASP) + 6%. Medicare and 
TRICARE reimburse providers ASP + 6 percent for the drug regardless of 
the price a provider pays for the drug.
    Both Medicare and TRICARE acknowledge that such payment for 
physician-administered drugs does not incentivize high-value clinically 
driven, low cost drugs. To the contrary, the payment methods for 
physician-administered drugs using the ASP plus 6 percent raises many 
concerns including that it may encourage the use of more expensive 
drugs because the 6% add-on generates more revenue for more expensive 
drugs without regard to the relative clinical value of the product 
compared to other products in the same drug class. In order to remove 
the incentive for using higher priced products that have no higher 
clinical value, TRICARE may utilize the authority provided by the NDAA-
18 to restructure--at least for certain selected drug classes, or 
categories of pharmaceuticals (identified in coordination with the 
Pharmacy and Therapeutics Committee, or other entities as described in 
the implementing instructions)--the reimbursement amount. For example, 
TRICARE is evaluating established the ASP add-on as a percentage 
(likely 6 percent) of the median value of all drugs in a particular 
class, rather than attaching the 6% add-on to the ASP of a particular 
drug. The specific modifications to drug pricing for physician-
administered drugs authorized by this IFR and NDAA FY18 shall be 
published in TRICARE's implementing instructions (manuals) as approved 
by the Director, DHA, and shall be published on the health.mil website. 
The amendment to Sec.  199.14(j)(1) will authorize this.

III. Regulatory Procedures

Interim Final Rule Justification

    This is being issued as an interim final rule in order to implement 
expeditiously the reforms authorized by Section 702, as specifically 
authorized by subsection (b)(3) of that section. Based on that clear 
Congressional authority and intent, the Department finds that obtaining 
public comment in advance of issuing this rule is impracticable, 
unnecessary, and contrary to the public interest.
Executive Order (E.O.) 13771, ``Reducing Regulation and Controlling 
Regulatory Costs''
    E.O. 13771 seeks to control costs associated with the government 
imposition of private expenditures required to comply with Federal 
regulations and to reduce regulations that impose such costs. 
Consistent with the analysis of transfer payments under OMB Circular A-
4, this interim final rule does not involve regulatory costs subject to 
E.O. 13771. Rather, this interim final rule affects only health care 
reimbursement payments under the TRICARE program. Aside from the 
``housekeeping'' change to the regulation to incorporate the updated 
copayment amounts enacted by Congress, the interim final rule makes two 
changes to the program: a new authority under the Uniform Formulary 
process and revised payment authority for pharmaceutical agents as part 
of medical services.
Executive Order 12866, ``Regulatory Planning and Review'' and Executive 
Order 13563, ``Improving Regulation and Regulatory Review''
    Executive Orders 13563 and 12866 direct agencies to assess all 
costs and benefits of available regulatory alternatives and, if 
regulation is necessary, to select regulatory approaches that maximize 
net benefits (including potential economic, environmental, public 
health and safety effects, distribute impacts, and equity). Executive 
Order 13563 emphasizes the importance of quantifying both costs and 
benefits, of reducing costs, of harmonizing rules, and of promoting 
flexibility. This interim final rule has been designated a 
``significant regulatory action,'' although not economically 
significant, under section

[[Page 63576]]

3(f) of Executive Order 12866. Accordingly, this rule has been reviewed 
by the Office of Management and Budget (OMB).
    The economic effect of these changes is limited to government 
reimbursements to health care providers/suppliers that under Circular 
A-4 are not considered as costs imposed on the economy. The expected 
reduction in government payments to pharmaceutical companies is based 
on some predicted increase in use of higher value medications and a 
corresponding decrease in the use of lower value medications in drug 
classes where different drugs have comparable clinical effect. The 
expected value of this shift in use of some medications--i.e., the 
quantity of the transfer payments--is $30 million per year.
    An initial analysis identified a sample group of candidate drugs 
that do not offer additional therapeutic benefit over other formulary 
items. By comparing the current costs to those of a lower-priced 
comparator and assuming similar utilization rates, the average cost 
avoidance was $1.5M/drug/year, with a more conservative cost avoidance 
of $1M/drug/year. When fully implemented, this new process could 
average 30 drugs per year at a conservative cost avoidance of $1M/drug/
year.
Congressional Review Act, 5 U.S.C. 804(2)
    Under the Congressional Review Act, a major rule may not take 
effect until at least 60 days after submission to Congress of a report 
regarding the rule. A major rule is one that would have an annual 
effect on the economy of $100M or more or have certain other impacts. 
This final rule is not a major rule under the Congressional Review Act.
Public Law 96-354, ``Regulatory Flexibility Act'' (RFA), (5 U.S.C. 601)
    The Regulatory Flexibility Act requires that each Federal agency 
analyze options for regulatory relief of small businesses if a rule has 
a significant impact on a substantial number of small entities. For 
purposes of the RFA, small entities include small businesses, nonprofit 
organizations, and small governmental jurisdictions. This interim final 
rule is not an economically significant regulatory action, and it will 
not have a significant impact on a substantial number of small 
entities. Therefore, this rule is not subject to the requirements of 
the RFA.
Public Law 104-4, Sec. 202, ``Unfunded Mandates Reform Act''
    Section 202 of the Unfunded Mandates Reform Act of 1995 also 
requires that agencies assess anticipated costs and benefits before 
issuing any rule whose mandates require spending in any one year of 
$100M in 1995 dollars, updated annually for inflation. That threshold 
level is currently approximately $140M. This interim final rule will 
not mandate any requirements for state, local, or tribal governments or 
the private sector.
Public Law 96-511, ``Paperwork Reduction Act'' (44 U.S.C. Chapter 35)
    This rulemaking does not contain a ``collection of information'' 
requirement, and will not impose additional information collection 
requirements on the public under Public Law 96-511, ``Paperwork 
Reduction Act'' (44 U.S.C. chapter 35).
Executive Order 13132, ``Federalism''
    This interim final rule has been examined for its impact under E.O. 
13132, and it does not contain policies that have federalism 
implications that would have substantial direct effects on the States, 
on the relationship between the national Government and the States, or 
on the distribution of powers and responsibilities among the various 
levels of Government. Therefore, consultation with State and local 
officials is not required.

List of Subjects in 32 CFR Part 199

    Claims, Dental health, Health care, Health insurance, Individuals 
with disabilities, Mental health, Mental health parity, Military 
personnel.

    For the reasons stated in the preamble, the DoD amends 32 CFR part 
199 as set forth below:

PART 199--CIVILIAN HEALTH AND MEDICAL PROGRAM OF THE UNIFORMED 
SERVICES (CHAMPUS)

0
1. The authority citation for part 199 continues to read as follows:

    Authority:  5 U.S.C. 301; 10 U.S.C. chapter 55.

0
2. Section 199.14 is amended by revising paragraphs (a)(6)(i)(I) and 
(a)(6)(ii), and by adding paragraph (j)(1)(xi), to read as follows:


Sec.  199.14   Provider reimbursement methods.

* * * * *
    (a) * * *
    (6) * * *
    (i) * * *
    (I) Drugs administered other than by oral method. Drugs 
administered other than by oral method provided on an outpatient basis 
by hospitals are paid on the same basis as drugs administered other 
than by oral method covered by the allowable charge method under 
paragraph (j)(1) of this section.
* * * * *
    (ii) Outpatient services subject to OPPS--(A) General. Outpatient 
services provided in hospitals subject to Medicare OPPS as specified in 
42 CFR 413.65 and 42 CFR 419.20 will be paid in accordance with the 
provisions outlined in sections 1833t of the Social Security Act and 
its implementing Medicare regulation (42 CFR part 419) subject to 
exceptions as authorized by this paragraph (a)(6)(ii).
    (B) Under the above governing provisions, TRICARE will recognize to 
the extent practicable, in accordance with 10 U.S.C. 1089(j)(2), 
Medicare's OPPS reimbursement methodology to include specific coding 
requirements, ambulatory payment classifications (APCs), nationally 
established APC amounts and associated adjustments (e.g., discounting 
across geographical regions and outlier calculations).
    (C) While TRICARE intends to remain as true as possible to 
Medicare's basic OPPS methodology, there will be some deviations 
required to accommodate TRICARE's unique benefit structure and 
beneficiary population as authorized under the provisions of 10 U.S.C. 
1079(j)(2).
    (D) TRICARE is also authorized to deviate from Medicare's basic 
OPPS methodology to establish special reimbursement methods, amounts, 
and procedures to encourage use of high-value products and discourage 
use of low-value products with respect to pharmaceutical agents 
provided as part of medical services from authorized providers. 
Therefore, drugs administered other than oral method provided on an 
outpatient basis by hospitals are paid on the same basis as drugs 
administered other than oral method covered by the allowable charge 
method under paragraph (j)(1) of this section.
    (E) Temporary transitional payment adjustments (TTPAs). Temporary 
transitional payment adjustments will be in place for all hospitals, 
both network and non-network, in order to buffer the initial decline in 
payments upon implementation of TRICARE's OPPS.
    (1) For network hospitals. The temporary transitional payment 
adjustments will cover a four-year period. The four-year transition 
will set higher payment percentages for the ten Ambulatory Payment 
Classification

[[Page 63577]]

(APC) codes 604-609 and 613-616, with reductions in each of the 
transition years. For non-network hospitals, the adjustments will cover 
a three year period, with reductions in each of the transition years. 
For network hospitals, under the TTPAs, the APC payment level for the 
five clinic visit APCs would be set at 175 percent of the Medicare APC 
level, while the five ER visit APCs would be increased by 200 percent 
in the first year of OPPS implementation. In the second year, the APC 
payment levels would be set at 150 percent of the Medicare APC level 
for clinic visits and 175 percent for ER APCs. In the third year, the 
APC visit amounts would be set at 130 percent of the Medicare APC level 
for clinic visits and 150 percent for ER APCs. In the fourth year, the 
APC visit amounts would be set at 115 percent of the Medicare APC level 
for clinic visits and 130 percent for ER APCs. In the fifth year, the 
TRICARE and Medicare payment levels for the 10 APC visit codes would be 
identical.
    (2) For non-network hospitals. Under the TTPAs, the APC payment 
level for the five clinic and ER visit APCs would be set at 140 percent 
of the Medicare APC level in the first year of OPPS implementation. In 
the second year, the APC payment levels would be set at 125 percent of 
the Medicare APC level for clinic and ER visits. In the third year, the 
APC visit amounts would be set at 110 percent of the Medicare APC level 
for clinic and ER visits. In the fourth year, the TRICARE and Medicare 
payment levels for the 10 APC visit codes would be identical.
    (3) An additional temporary military contingency payment adjustment 
(TMCPA) will also be available at the discretion of the Director, 
Defense Health Agency (DHA), or a designee, at any time after 
implementation to adopt, modify and/or extend temporary adjustments to 
OPPS payments for TRICARE network hospitals deemed essential for 
military readiness and deployment in time of contingency operations. 
Any TMCPAs to OPPS payments shall be made only on the basis of a 
determination that it is impracticable to support military readiness or 
contingency operations by making OPPS payments in accordance with the 
same reimbursement rules implemented by Medicare. The criteria for 
adopting, modifying, and/or extending deviations and/or adjustments to 
OPPS payments shall be issued through TRICARE policies, instructions, 
procedures and guidelines as deemed appropriate by the Director, DHA, 
or a designee. TMCPAs may also be extended to non-network hospitals on 
a case-by-case basis for specific procedures where it is determined 
that the procedures cannot be obtained timely enough from a network 
hospital. For such case-by-case extensions, ``Temporary'' might be less 
than three years at the discretion of the DHA Director, or designee.
* * * * *
    (j) * * *
    (1) * * *
    (xi) Pharmaceutical agents utilized as part of medically necessary 
medical services. In general, the TRICARE-determined allowed amount 
shall be equal to an amount determined to be appropriate, to the extent 
practicable, in accordance with the same reimbursement rules as apply 
to payments for similar services under Medicare. Under the authority of 
10 U.S.C. 1079(q), in the case of any pharmaceutical agent utilized as 
part of medically necessary medical services, the Director may adopt 
special reimbursement methods, amounts, and procedures to encourage the 
use of high-value products and discourage the use of low-value 
products, as determined by the Director. For this purpose, the Director 
may obtain recommendations from the Pharmaceutical and Therapeutics 
Committee under Sec.  199.21 or other entities as the Director, DHA 
deems appropriate with respect to the relative value of products in a 
class of products subject to this paragraph. Among the special 
reimbursement methods the Director may choose to adopt under this 
paragraph is to reimburse the average sales price of a product plus a 
percentage of the median of the average sales prices of products in the 
product class or category. The Director shall issue guidance regarding 
the special reimbursement methods adopted and the appropriate 
reimbursement rates.
* * * * *

0
3. Section 199.21 is amended by adding paragraph (e)(3), and by 
revising paragraphs (i)(2)(ii), (iv), and (x), to read as follows:


Sec.  199.21  TRICARE Pharmacy Benefits Program.

* * * * *
    (e) * * *
    (3) Special rules for best clinical effectiveness. (i) Under the 
authority of 10 U.S.C. 1074g(a)(10), the Pharmacy and Therapeutics 
Committee may recommend and the Director may, after considering the 
comments and recommendations of the Beneficiary Advisory Panel, approve 
special uniform formulary actions to encourage use of pharmaceutical 
agents that provide the best clinical effectiveness to covered 
beneficiaries and DoD, including consideration of better care, 
healthier people, and smarter spending. Such special actions may 
operate as exceptions to the normal rules and procedures under 10 
U.S.C. 1074g(a)(2), (5) and (6) and the related provisions of this 
section.
    (ii) Actions under paragraph (e)(3)(i) of this section may include 
a complete or partial exclusion from the pharmacy benefits program of 
any pharmaceutical agent the Director determines provides very little 
or no clinical effectiveness relative to similar agents to covered 
beneficiaries and DoD. A partial exclusion under this paragraph may 
take the form (as one example) of a limitation on the clinical 
conditions, diagnoses, or indications for which the pharmaceutical 
agent may be prescribed. A partial exclusion may be implemented through 
any means recommended by the Pharmacy and Therapeutics Committee, 
including but not limited to preauthorization under paragraph (k) of 
this section. In the case of a partial exclusion, a pharmaceutical 
agent may be available on the non-formulary tier of the uniform 
formulary for limited purposes and for other purposes be excluded.
    (iii) Actions under paragraph (e)(3)(i) of this section may also 
include giving preferential status to any non-generic pharmaceutical 
agent of the uniform formulary by treating it for purposes of cost-
sharing as a generic product.
* * * * *
    (i) * * *
    (2) * * *
    (ii) For pharmaceutical agents obtained from a retail network 
pharmacy, the cost share will be as provided in 10 U.S.C. 1074g(a)(6), 
except that there is a $0 cost-share for vaccines/immunizations 
authorized as preventive care for eligible beneficiaries.
* * * * *
    (iv) For pharmaceutical agents obtained under the TRICARE mail 
order program, the cost share will be as provided in 10 U.S.C. 
1074g(a)(6), except that there is a $0 cost-share for smoking cessation 
pharmaceutical agents covered under the smoking cessation program.
* * * * *
    (x) For any year after 2027, the cost-sharing amounts under this 
paragraph shall be equal to the cost-sharing amounts for the previous 
year adjusted by an amount, if any, determined by the Director to 
reflect changes in the costs of pharmaceutical agents and prescription 
dispensing, rounded to the nearest dollar. These cost changes, if any, 
will consider costs under the

[[Page 63578]]

TRICARE pharmacy benefits program calculated separately for each of the 
following categories based on prescriptions filled in the most recent 
period for which TRICARE cost data are available, updated to the 
current year, if necessary, by appropriate industry data:
    (A) Generic drugs in the retail point of service;
    (B) Formulary drugs in the retail point of service;
    (C) Generic drugs in the mail order point of service;
    (D) Formulary drugs in the mail order point of service;
    (E) Non-formulary drugs.
* * * * *

    Dated: December 3, 2018.
Shelly E. Finke,
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 2018-26562 Filed 12-10-18; 8:45 am]
 BILLING CODE 5001-06-P