It is Department of Defense policy to fill prescriptions with generic drugs when available. You are urged to prescribe both generic
and brand-name medications which are on the approved formulary. However, TRICARE will cover a non-formulary medication at the formulary copayment if you can provide information demonstrating medical necessity for the non-formulary medication.
In order for a non-formulary medication to be considered medically necessary, it must meet one or more of the criteria listed below for all of the available formulary alternatives: 

• The formulary alternative iscontraindicated.
• The patient is reasonably expected to have a more favorable outcome with the non-formulary alternative.
• The formulary alternative causes therapeutic failure.
• The patient previously responded to a non-formulary medication and changing to a formulary medication would pose a non-favorable clinical risk.
• There is no formulary alternative available.

• The prescription is written by an MTF provider.
• Medical necessity has been established for the medication.

Furthermore, MTFs have the option of filling a non-MTF provider’s prescription for a non-formulary medication if medical necessity has been established; however, the MTF is not required to do so.

Active duty service members pay no copayments for non-formulary medications through any pharmacy; however, they may only fill prescriptions for non-formulary medications when deemed medically necessary 
 

Non-formulary medications are also available to non-active duty service members and their families. Once medical necessity has been established, these spouses, dependents and retirees may fill their non-formulary prescriptions at retail network pharmacies or through TRICARE’s mail-order pharmacy for the applicable $9 formulary copayment.
 

  
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Created: September 6, 2007