TRICARE Prime Handbook

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Covered Services, Limitations, and Exclusions


Pharmacy Services

TRICARE offers comprehensive prescription drug coverage and several options for filling your prescriptions. To have a prescription filled, you’ll need a written prescription and a valid uniformed services identification (ID) or Common Access Card (CAC). Refer to the TRICARE: Summary of Beneficiary Costs flyer or www.tricare.mil/pharmacy for pharmacy cost information.

Military Treatment Facility Pharmacy
Prescriptions may be filled (up to a 90-day supply for most medications) at an MTF pharmacy at no cost as long as the medication is on the MTF formulary. You should contact the MTF to find out what is on the formulary and for specific details about filling prescriptions at the MTF pharmacy.

TRICARE Mail Order Pharmacy
The mail-order pharmacy is your least expensive option when not using the MTF. You may receive up to a 90-day supply for most medications delivered to your home for a small copayment. Refills may be requested by mail, phone, or online. Express Scripts, Inc. (ESI) administers the mail-order pharmacy, and registering is easy.
  1. Register online. Complete the registration form and follow the instructions available at
    Express Scripts.
  2. Register by phone. Call 1-866-363-8667
  3. Register by mail. Download the form at Express Scripts and mail it to: P.O. Box 52150, Phoenix, AZ 85072-9954. Include the written prescription and the appropriate copayment when you mail your registration.

For faster processing of your mail-order prescription, you can register before placing your first order. Once you are registered, your provider can fax or call in your prescriptions.

ESI will send your medications directly to your home within about 14 days after receiving your
prescription. If you have prescription drug coverage from another health insurance plan, you can use the mail-order pharmacy if the medication is not covered under the other plan or if you exceed the dollar limit of coverage under the other plan.

TRICARE Retail Pharmacy Network
You may have prescriptions filled (up to a 30-day supply) at any pharmacy in the TRICARE retail pharmacy network for a small copayment. ESI also administers the retail pharmacy network. For more information or to locate a TRICARE network pharmacy, call 1-866-DoD-TRRX (1-866-363-8779) or visit Express Scripts.

Note: Network pharmacies are available in the United States, Guam, Puerto Rico, and the U.S. Virgin Islands.

Non-Network Pharmacies
Filling prescriptions at a non-network pharmacy is the most expensive option. You may have to pay for the total amount first and then file a claim with ESI to receive a partial reimbursement after your deductible is met. (For more information about pharmacy claims, see the Claims section.)

Note: Non-active duty beneficiaries are using the POS option at non-network pharmacies.

Quanity Limits and Prior Authorization
TRICARE has established quantity limits on certain medications, which means that the DoD will only pay for up to a specified quantity per 30-, 60-, or 90-day supply. Quantity limits are applied to ensure the medications are safely and appropriately used. Exceptions to established quantity limits may be made if the prescribing provider is able to justify medical necessity.

Some drugs require prior authorization from ESI. For a general list of prescription drugs that are covered under TRICARE and for drugs requiring prior authorization or having quantity limits, visit www.tricare.mil/pharmacy or call toll-free 1-866-DoD-TRRX (1-866-363-8779) or
1-866-DoD-TMOP (1-866-363-8667).

Generic Drug Use Policy
It is DoD policy to use generic medications, instead of brand-name medications, whenever possible. Brand-name drugs that have a generic equivalent may be dispensed only if the prescribing physician is able to justify medical necessity for use of the brand-name drug in place of the generic equivalent. If a generic equivalent drug does not exist, the brand-name drug will be dispensed at the brand-name copayment. If you insist on having a prescription filled with a brand-name drug that is not considered medically necessary, and when a generic equivalent is available, you will be responsible for paying the entire cost of the prescription out of pocket.

Non-formulary Drugs
Any drug in a therapeutic class determined to be not as relatively clinically effective or not as cost-effective as other drugs in the class may be recommended for placement in the third, “non-formulary” tier. Any drug placed into the third tier is available to beneficiaries from the mail-order or retail pharmacies, but at a higher cost. You may be able to have non-formulary prescriptions filled at formulary costs if your provider can establish medical necessity.

To learn more about any medication and common drug interactions, to check for generic equivalents, or to determine if a drug is classified as a non-formulary medication, visit the online TRICARE Formulary Search Tool.

For information on how to save money and make the most of your pharmacy benefit, visit www.tricare.mil/pharmacy, or call 1-877-DoD-MEDS (1-877-363-6337).

 

        
Maternity Services
Prenatal care is important, and we strongly recommend that those who are pregnant, or who anticipate becoming pregnant, seek appropriate medical care. TRICARE Prime covers maternity care, including prenatal care, delivery, and postpartum care. Newborns are covered separately.

Maternity Ultrasounds
TRICARE covers maternity ultrasounds when medically necessary. Such situations include:
  • Estimating gestational age
  • Evaluating fetal growth
  • Conducting a biophysical evaluation for fetal well-being
  • Evaluating a suspected ectopic pregnancy
  • Defining the cause of vaginal bleeding
  • Diagnosing or evaluating multiple gestations
  • Confirming cardiac activity
  • Evaluating maternal pelvic masses or uterine abnormalities
  • Evaluating suspected hydatiform mole
  • Evaluating the fetus's condition in late registrants for prenatal care
A physician is not obligated to perform ultrasonography on a patient who is a low risk and has no medical indications.

Some providers offer patients routine ultrasound screening as part of the scope of care after 16-20
weeks of gestation. TRICARE does not cover routine ultrasound screening. Only maternity ultrasound with a valid medical indication that constitutes medical necessity is covered by TRICARE. Browse Humana Military's Web site for additional details on maternity ultrasound coverage.

If TRICARE coverage ends during pregnancy, TRICARE will not cover any remaining maternity costs unless your family qualifies for other TRICARE health coverage or has purchased the Continued Health Care Benefit Program (CHCBP).

To ensure your newborn is covered by TRICARE, see “Having a Baby or Adopting a Child” in the Life Events section.

      
Dental Options
Active duty service members receive dental care from military dental treatment facilities. For all other beneficiaries, TRICARE offers two dental programs—the TRICARE Dental Program (TDP) and the TRICARE Retiree Dental Program (TRDP). Each program is administered by a separate dental contractor and has its own monthly premiums and cost-shares.

TRICARE Dental Program
The TDP is a voluntary dental insurance program available to eligible active duty family members and to members of the National Guard and Reserve and/or their families. United Concordia Companies, Inc., (United Concordia) currently administers the program. For information about the TDP, visit the TDP Web site or call United Concordia toll-free at 1-800-866-8499.

TRICARE Retiree Dental Program
The TRDP is a voluntary dental insurance program available to retired service members and their eligible family members. Delta Dental Plan of California (Delta Dental) currently administers the program. For information about the TRDP, visit the TRDP Web site or call Delta Dental toll-free at
1-888-838-8737.

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Last Reviewed: July 11, 2008