The Department of Defense has established a “uniform formulary” consisting of generic and brand-named drugs, as well as a third tier of medications that are designated as “non-formulary.”

If you prescribe a medication that is on the non-formulary list and medical necessity is not established, the non-formulary medication will be dispensed at the non-formulary cost-share ($22). However, if you provide an explanation of the prescription’s medical necessity, you will help your patients save money.

Your patient can fill the prescription at formulary cost—a substantial savings—if you can supply information to Express Scripts, Inc. (ESI) showing there is a medical necessity for a non-formulary medication instead of any of the other therapeutic alternatives that are on the uniform formulary.

         
Active Duty Service Members (ADSMs)

If medical necessity is approved, the beneficiary may receive the non-formulary medication at the formulary cost at retail network pharmacies and through the mail-order pharmacy.

Each non-formulary medication has its own medical necessity criteria and form. Visit the TRICARE Pharmacy Web site for medical necessity criteria and appropriate forms for each non-formulary medication.

You may also call ESI’s TRICARE Retail Pharmacy Prior Authorization Line at 1-866-684-4488 for a medical necessity waiver form. You will be asked to complete and submit a Prior Authorization Request Form to ESI. Once your request is approved, you will receive a “letter of medical necessity” that your patient must present with the prescription at the pharmacy.

  
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Military treatment facilities (MTFs) across the South region rely on Humana Military network specialists and facilities for the timely return of consult reports. Consult reports are requested on all MTF referred beneficiaries.

Consult reports include office visit consultations, evaluation and treatment notes, procedure notes, results and discharge summaries where applicable. Reminder faxes and phone calls go out to Humana Military network providers on a daily basis based upon the known appointment date for the beneficiaries in question.

Every effort is made to retrieve the consult report within 10 days of the patient encounter. This is to ensure speedy follow-up by the MTF provider to facilitate effective continuity of care.

Humana Military offers a single fax line that is dedicated to consult reports. This fax line is secured and managed by staff members who are responsible for logging all reports and forwarding the information on to the appropriate MTF. This fax method has proven to be efficient for timely processing, effective for provider offices and reliable for tracking patient information. Please be sure to look for the Humana Military-dedicated fax number on all referral confirmations sent to your office location for MTF beneficiaries.

We appreciate your attention to the consult report returns procedures and your swift responses on behalf of our TRICARE beneficiaries.

  
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Updated: November 15,  2007