As you write prescriptions to be filled under either of the national TRICARE pharmacy programs— TRICARE Retail Pharmacy (TRRx) Network and TRICARE Mail Order Pharmacy (TMOP)—keep in mind that certain drugs have special requirements.

For example, some drugs require prior authorization from Express Scripts, Inc. (ESI), the contractor for both TMOP and TRRx, while non-formulary medications and quantities beyond established quantity limits are subject to medical necessity review.

You can ensure your patients get the proper medications in a timely manner by following these guidelines.

When to Request Prior Authorization

Prescriptions for the following types of medications require prior authorization before they will be filled:
 

• Medications that have prior authorization criteria established by the DoD Pharmacy and Therapeutics Committee. The list of these medications, along with prior authorization forms and instructions, are available online. Medications on the list include Cialis®, Enbrel®, fertility drugs, growth hormone and Lamisil®, among others.
   
• Brand name medications with generic equivalents. DoD policy is to dispense a generic equivalent to a brand name medication when possible. If you believe the brand name medication is clinically required for your patient, contact customer service for TMOP (toll-free 1-866-363-8667) or TRRx (toll-free 1-866-363-8779) to initiate the review process. ESI will review the information you submit and determine if the brand name medication is clinically required for your patient.
   
• Medications with age limitations. Topical Tretinoin products (e.g., Retin-A®) require prior authorization for patients 36 years of age or older to verify that the product is clinically required to treat a condition other than wrinkles, age spots or other cosmetic conditions related to the normal aging process. Prenatal vitamins for patients 46 years of age or older require prior authorization to verify that the vitamins are required due to pregnancy. Viagra®, Cialis and Levitra® require prior authorization for men under the age of 50.
   
• Lipid-lowering medications other than Zocor (TMOP only). Due to a national pharmaceutical contract for statins, Zocor® (simvastatin) is the preferred “high-potency” statin in TMOP. TMOP will not dispense the following medications unless you provide information showing it is clinically required to use that product in place of Zocor:
   
  
  • AltoprevTM (lovastatin extended release)
  • Caduet® (amlodipine/atorvastatin)
  • Crestor® (rosuvastatin)
  • Lescol® (fluvastatin)
  • Lescol® XL (fluvastatin extended release)
  • Lipitor® (atorvastatin)
  • Vytorin® (ezetimibe/simvastatin)

This requirement applies only to TMOP. Prior authorization is not required to fill prescriptions for these medications at retail network pharmacies. 

If you wish to prescribe a non-formulary medication instead of any of the therapeutic alternatives on the Uniform Formulary, you must prove medical necessity. Medical necessity criteria, forms and instructions for non-formulary medications are available on the TRICARE Web site.

In addition, the DoD Pharmacy and Therapeutics Committee has established quantity limits on certain medications, which means that DoD will pay only for up to a specified quantity per 30-, 60- or 90-day period. Some medications also have limitations on the days supply of medication that may be dispensed to a patient at one time. Exceptions can be made if the prescribing physician is able to justify medical necessity.

A variety of drugs in the following categories are subject to quantity limits:
 

• Antiemetics
• Antimigraine drugs
• Controlled substances
• Erectile dysfunction agents
• Fertility agents
• Miscellaneous
• Nasal inhalers
• Oral inhalers and inhalant solutions
• Topicals

For a complete listing of drugs that require prior authorization or are subject to medical necessity review or quantity limits, check the Formulary Search Tool.

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Last Reviewed: February 7, 2007