All services associated to discharges involving pediatric bone marrow transplants . All companies related to CHAMPUS coated solid organ transplantations for which there is no DRG project. The CHAMPUS DRG-based cost system will use the identical DRGs utilized in probably the most just lately obtainable grouper for the Medicare Prospective Payment System, except as needed to acknowledge distinct characteristics of CHAMPUS beneficiaries and as described in directions issued by the Director, OCHAMPUS. An quantity in dispute is required for an antagonistic determination to be appealed beneath the provisions of this part, besides as set forth or additional explained in ยง 199.10, and .
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The Uniformed Services might establish extra procedures, in keeping with this part, for the effective administration of the supplemental care program in their respective services. A reconsidered dedication that might be last in cases involving sole-function PROs under paragraph of this part will not be final in reference to multi-function PROs. Rather, in such instances (other than any case which is appealable beneath paragraph of this section), an opportunity for a second reconsideration shall be offered. The second reconsideration might be offered by OCHAMPUS or one other contractor independent of the multi-function PRO that performed the review.
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Generics are multisource products that must comprise the same active components, are of the same dosage form, route of administration and are equivalent in power or concentration. Information to ascertain scientific necessity for use of a non-formulary pharmaceutical agent could additionally be provided with the prescription submitted to the TMOP contractor. Information to determine clinical necessity to be used of a non-formulary pharmaceutical agent must be provided to TRICARE for prescriptions submitted to a retail network pharmacy. Subject to paragraphs and of this section, formulary pharmaceutical brokers can be found under the Pharmacy Benefits Program from all points of service recognized in paragraph of this section. The DoD Pharmacy and Therapeutics Committee will evaluate the relative medical effectiveness of pharmaceutical agents inside a therapeutic class by considering information about their safety, effectiveness, and medical consequence. Special packages established underneath this part that are not a part of the TRICARE Select program are not, until specifically supplied in this part, obtainable to members in the CHCBP.