Quantity Limits for Certain Medications
TRICARE has established quantity limits on certain medications, which means that the DoD will only pay for up to a specified, limited amount of medication each time you fill a prescription. Quantity limits are often applied to ensure medications are used safely and appropriately. Exceptions to established quantity limits may be made if the prescribing provider is able to justify medical necessity.
Prior Authorization
Some drugs require prior authorization from Express Scripts. Medications requiring prior authorization may include, but are not limited to, prescription drugs specified by the DoD Pharmacy and Therapeutics Committee, brand-name medications with a generic equivalent, medications with age limitations, and medications prescribed for a quantity exceeding normal limits. For a general list of prescription drugs that are covered under TRICARE, and for drugs that require prior authorization or that have quantity limits, visit
TRICARE's online formulary search tool. If you do not have Internet access, call 1-877-363-1303 to inquire about a specific drug.
Generic Drug Use Policy
Generic drugs are medications approved by the U.S. Food and Drug Administration (FDA) and clinically equivalent to brand-name medications. Generic drugs provide the same safe, effective treatment as brand-name drugs and help save you money. It is DoD policy to use generic medications instead of brand-name medications whenever possible. A brand-name drug with a generic equivalent may be dispensed only after the prescribing physician completes a clinical assessment that indicates use of the brand-name drug is medically necessary and after Express Scripts grants approval. If a generic-equivalent drug does not exist, the brand-name drug will be dispensed at the brand-name copayment. If you fill a prescription 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.
Prescribers may call the Express Scripts Prior Authorization line at 1-866-684-4488 to submit a request for a brand name drug to be dispensed in lieu of a generic, or a completed
Brand over Generic Prior Authorzation Request Form may be faxed to 1-866-684-4477.
Non-formulary Drugs
The DoD has established a uniform formulary, which is a list of covered generic and brand-name drugs. This formulary also contains a third tier of medications that are non-formulary. Prescriptions for non-formulary drugs are dispensed at a higher cost to beneficiaries.
Non-formulary medications include any drug in a therapeutic class determined to be not as clinically effective or as cost-effective as other drugs in the same class. For an additional cost, all non-formulary drugs are available through TRICARE Pharmacy Home Delivery and most are available through retail network pharmacies. You may be able to fill non-formulary prescriptions at formulary costs if your provider establishes medical necessity by completing and submitting the appropriate TRICARE pharmacy medical-necessity form.
Forms and medical-necessity criteria are available online or by calling Express Scripts at 1-877-363-1303.
If medical necessity is approved, ADSMs may receive non-formulary medications through TRICARE Pharmacy Home Delivery or at retail network pharmacies at no cost. ADSMs may not fill a prescription for a non-formulary medication unless medical necessity is established. For all other eligible beneficiaries, if medical necessity is approved, beneficiaries may receive the non-formulary medication at the formulary cost through TRICARE Pharmacy Home Delivery or at retail network pharmacies.
Note: Non-formulary drugs are generally not available at MTFs.
To learn more about medications and common drug interactions, check for generic equivalents, or to determine if a drug is a non-formulary medication, visit the
TRICARE Formulary Search Tool.
For information on how to save money and make the most of your pharmacy benefit, visit
TRICARE's Pharmacy Program or the
Express Scripts web site.
Specialty Medication Care Management
Specialty medications are usually high-cost; self-administered; injectable, oral, or infused drugs that treat serious chronic conditions (e.g., multiple sclerosis, rheumatoid arthritis, hepatitis C). These drugs typically require special storage and handling and are not readily available at your local pharmacy. Specialty medications may also have side effects that require pharmacist and/or nurse monitoring.
The Specialty Medication Care Management program is structured to improve your health through continuous health evaluation, ongoing monitoring, assessment of educational needs, and management of medication use. This program provides:
- Access to proactive, clinically based services for specific diseases designed to help you get the most benefit from your medicine
- Refill reminder calls
- Scheduled deliveries to your specified location
- Specialty consultation with a nurse or pharmacist at any point during your therapy
These services are provided to you at no additional cost when you receive your medications through TRICARE Pharmacy Home Delivery, and participation is voluntary. If you or your provider orders a specialty medication from TRICARE Pharmacy Home Delivery, you will receive additional information from Express Scripts about the Specialty Medication Care Management program and how to get started.
Using TRICARE Pharmacy Home Delivery to fill specialty medication prescriptions provides you with access to the Specialty Medication Care Management program benefits described. You may submit a specialty medication prescription by mail or your provider may submit it by fax. If you are currently using another pharmacy to fill your specialty medication prescription, you can contact the Member Choice Center at 1-877-363-1433 to switch to the Specialty Medication Care Management program. With specific mailing instructions from you or your provider, TRICARE Pharmacy Home Delivery will ship your specialty medication to your home. For your convenience and safety, the home delivery program will contact you to arrange delivery before the medication is shipped.
Note: Some specialty medications may not be available through TRICARE Pharmacy Home Delivery because the medication’s manufacturer limits the drug’s distribution to specific pharmacies. If you submit a prescription for a limited-distribution medication, the home delivery program will either forward your prescription to a pharmacy of your choice that can fill it or will provide you with instructions about where to send the prescription to have it filled. To determine if your specialty medication is available through TRICARE Pharmacy Home Delivery, visit the
TRICARE Formulary Search Tool.
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