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TRICARE Formulary

View questions and answers about the TRICARE Formulary.

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TRICARE Formulary
Q1:

How do I appeal a denial from a prior authorization, quantity limit, age limit, or medical necessity request?

A:

When your medication is initially denied, you should receive the denial in writing. The letter will contain information on the appeals process. You can contact Express-Scripts Customer Service at 1-877-363-1303 for information regarding the appeals process. You can find more information on pharmacy appeals at https://www.tricare.mil/CoveredServices/Pharmacy/Appeals.

Q2:

How do I know if there is a generic medication available for my prescription?

A:

You can find out if a generic version of your prescription is available by looking it up on the Formulary Search Tool. In general, and FDA approved generic medication is required to be dispensed over the branded version. If your provider requests that a brand be dispensed instead of the generic they will need to call the Express-Scripts prior authorization line at 1-866-684-4488 to establish medical necessity or they can fill out the Brand over Generic Prior Authorization Request Form and fax it to Express-Scripts.

Q3:

Is my medication covered by TRICARE?

A:

You can find out if your medication is covered and what the copay will be by looking it up on the Formulary Search Tool.

The Formulary Search Tool lists any coverage rules (such as prior authorization or medical necessity) and copays at different points of service (military pharmacy, retail network pharmacy, or TRICARE mail order pharmacy).

Q4:

What if my medication shows as non-covered?

A:

You can find more information on non-covered drugs at https://tricare.mil/CoveredServices/Pharmacy/Drugs/MedsNotCovered.You can find more information on pharmacy appeals at https://www.tricare.mil/CoveredServices/Pharmacy/Appeals.

NOTE: In some cases medications (ex., injections, vaccines) may be covered as a medical benefit. Contact your TRICARE Regional Contractor for more information.

Q5:

What if it is medically necessary for me to receive a non-formulary medication rather than a formulary therapeutic alternative?

A:

Medical necessity does not need to be established for family members and retirees to receive a non-formulary drug at a retail network pharmacy or at the TRICARE mail order pharmacy. Non-formulary copays will apply.

If your provider considers it medically necessary for you to receive the non-formulary drug rather than a formulary therapeutic alternative, you may be able to pay a lower copay. Your provider may call the Express Scripts prior authorization line at 1-866-684-4488 to establish medical necessity, or they may fill out the medical necessity form that is linked to that medication on the Formulary Search Tool and fax it to Express-Scripts.

For active duty service members, medical necessity is required to receive a TRICARE non-formulary drug.

Military pharmacies do not typically stock or dispense non-formulary medications. If you are enrolled to the military clinic and referred out to a civilian provider who prescribes a non-formulary medication, contact your military pharmacy for options.

Medical necessity forms and prior authorization are separate forms and both may be required. If a prior authorization is listed in the "Notes" section of the Formulary Search Tool, the prior authorization must be approved before medical necessity requirements.

Q6:

Does my medication require a prior authorization?

A:

You can find out if your medication requires prior authorization by looking it up on the Formulary Search Tool. These will be listed under the "Notes" section. The copay listed is based on an approved prior authorization.

If a prior authorization is required, your provider can call the Express Scripts prior authorization line at 1-866-684-4488, submit a prior authorization electronically, or fill out the prior authorization form that is linked to that medication on the Formulary Search Tool and fax it to Express-Scripts.

Q7:

Is there an age restriction on my medication?

A:

You can find out if there are age restrictions on your medication by looking it up on the Formulary Search Tool. These will be listed under the "Notes" section.

If your provider wants to prescribe outside the age restrictions, they can call the Express Scripts prior authorization line at 1-866-684-4488 to request an override.

Q8:

Are there quantity limits on my medication?

A:

You can find out if there are quantity limits on your medication is covered by looking it up on the Formulary Search Tool. These will be listed under the "Notes" section.

If your provider wants to prescribe more than the quantity limit, they can call the Express Scripts prior authorization line at 1-866-684-4488 to request an override.

Q9:

How can I get reimbursement for a prescription if I paid full price or how can I get reimbursement for my other health insurance (OHI) copay?

A:

To request reimbursement for a prescription, you must file a claim. Information about the pharmacy claims process can be found at https://tricare.mil/CoveredServices/Pharmacy/Claims. You can also contact Express-Scripts Customer Service at 1-877-363-1303 for assistance.

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