TRICARE Formulary

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.

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.

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).

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.

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.

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.

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.

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.

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.