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Military Health System

Important Notice about Pharmacy Operations

Change Healthcare Cyberattack Impact on MHS Pharmacy Operations. Read the statement to learn more. 

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Information for Providers

Pharmacy & Therapeutics Committee Meetings

The Defense Health Agency’s Formulary Management Branch conducts quarterly P&T meetings (February, May, August, November) to assess:

  • New FDA approved drugs and drug classes for TRICARE outpatient formulary status. TRICARE outpatient formulary status is based on four tiers:
    • Basic Core Formulary
    • Uniform Formulary
    • Non-Formulary
    • Complete Exclusion
  • TRICARE utilization management and pharmacy-related economic data
  • TRICARE copays
  • Medical necessity criteria
  • Prior authorization criteria

Meeting minutes are publicly posted after:

 

Formulary Terminology

TRICARE Formulary Tier Status

 

Not Covered

 

Copay Tier

Formulary Tools

The TRICARE Formulary Search Toolgoes to formulary search tool website includes information for drugs. This includes:

  • Formulary status
  • Prior authorization forms
  • Medical necessity forms
  • Quantity limits
  • Directions for submission of forms are listed at the top of each individual form
  • Forms are processed through Express Scripts, Inc.goes to ESI webpage, the pharmacy contractor for the TRICARE Health Plan

Learn More about the TRICARE Formulary.

Express Scripts Provider Tools

Express Scripts is an online pharmacy and the pharmacy benefit manager for TRICARE.

Provider resources are available and they include:

  • MTF Provider Portal for online prescription management
  • Prescription monitoring program for identification of beneficiaries who are potentially at risk for misuse of prescription drugs

Appeals Process for Prior Authorization Denials

Active Duty Appeals

  • Active duty beneficiary appeals must be routed through the active duty service member’s local military hospital or clinic.
  • Contact the local military facility pharmacy to start the process.

All Other Appeals

Non-active duty beneficiaries will follow the processes outlined below:

 

First level appeal

 

Second level appeal

Formulary Change Requests

Requests for changes to the TRICARE outpatient formulary (e.g. formulary status, prior authorization criteria):

  • Contact the local military facility pharmacy to start the process.
  • Initial requests must be routed through the local military hospital's Pharmacy and Therapeutics Committee
  • May only be submitted by medical providers
  • Must have a Formulary Change Request (DHA Form 111) submitted with the request
  • Must include reliable supporting evidence for the requested change

A determination will be made by the military hospital’s P&T Committee to address the requested change locally or escalate the request to the DHA’s Formulary Management Branch for further consideration.

Last Updated: July 11, 2023
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