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Provider Handbook
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Uniform Formulary Drugs
Prior Authorizations
Quantity Limits
Pharmacy Costs |
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Uniform Formulary Drugs |
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The DoD has established a uniform formulary consisting of generic and brand-name drugs, as well as a third tier of medications that are designated as “non-formulary.”
Prescriptions for non-formulary drugs can be dispensed, but at a higher cost to beneficiaries (unless the prescribing physician can establish medical necessity).
For a complete list of non-formulary drugs, as well as the formulary medication alternative(s), visit the TRICARE Web site. The non-formulary list is normally updated on a quarterly basis.
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Medical Necessity for Non-Formulary Medications (at Formulary Costs) |
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A non-formulary medication can be provided at the formulary cost if the provider supplies information showing that there is a medical necessity to use the non-formulary medication instead of any of the therapeutic alternatives that are on the uniform formulary.
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- ADSMs: If medical necessity is approved, ADSMs may receive non-formulary medications at retail network pharmacies and through the mail-order pharmacy at no cost. ADSMs may not fill prescriptions for a non-formulary medication, unless it is determined to be medically necessary.
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- All other eligible beneficiaries: 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.
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Generally, in order for medical necessity to be established, one or more of the criteria listed must be met for all of the available formulary alternatives:
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- The use of the formulary alternative is contraindicated.
- The patient experiences, or is likely to experience, significant adverse effects from the formulary alternative, and the patient is reasonably expected to tolerate the non-formulary medication.
- The formulary alternative results in therapeutic failure, and the patient is reasonably expected to respond to the non-formulary medication.
- The patient previously responded to a non-formulary medication and changing to a formulary alternative would incur unacceptable clinical risk.
- There is no formulary alternative.
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Providers may call the TRRx 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. Once the request is approved, you will receive a “letter of medical necessity,” which the beneficiary must present with the prescription at the pharmacy. Medical necessity criteria and appropriate forms for each non-formulary medication are also available on the TRICARE Pharmacy Web site.
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Prior Authorizations |
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In addition to brandname drugs with generic equivalents, the DoD has identified several other medications that require prior authorization before they may be prescribed. For a complete list of these medications and for instructions on obtaining prior authorization, visit the TRICARE Web site.
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Quantity Limits |
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The DoD has established quantity limits for certain medications. Exceptions to established quantity or days’ supply limits can be made if you are able to justify medical necessity. Visit the TRICARE Pharmacy Web site for a complete list of quantity limits for specific medications. |
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Pharmacy Costs |
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Visit TRICARE's Pharmacy Web site for additional information about TRICARE’s prescription drug coverage. |
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