Quantity Limits
TRICARE has established quantity limits on certain medications, which means that the Department of Defense (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. 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.
Non-formulary Drugs
The DoD Pharmacy and Therapeutics Committee may recommend to the Director of the TRICARE Management Activity that certain drugs be placed in the third, “non-formulary” tier. These medications include any drug in a therapeutic class determined to be not as relatively clinically effective or as cost-effective as other drugs in the same class. For an additional cost, third-tier drugs are available through the Mail Order Pharmacy or retail network pharmacies. You may be able to fill non-formulary prescriptions at formulary costs if your provider can establish medical necessity by completing and submitting the appropriate TRICARE pharmacy medical necessity form for the non-formulary medication. Forms and medical necessity criteria are available
online or by calling Express Scripts at 1-877-363-1303.
Note: If medical necessity is approved, ADSMs may receive non-formulary medications through the Mail Order Pharmacy or at retail network pharmacies at no cost. ADSMs may not fill a prescription for a non-formulary medication unless medical necessity is established.
To learn more about medications and common drug interactions, check for generic equivalents, or determine if a drug is classified as a non-formulary medication, visit the online
TRICARE formulary search tool.
For information on how to save money and make the most of your pharmacy benefit, visit
TRICARE's Pharmacy web portal or
Express Scripts' TRICARE 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, are difficult to administer, 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
- Monthly refill reminder calls
- Scheduled deliveries to your specified location
- Specialty consultation with nurse/pharmacist at any point during your therapy
These services are provided to you at no additional cost when you receive your medications through the Mail Order Pharmacy, and participation is voluntary. If you or your provider orders a specialty medication from the Mail Order Pharmacy, you will receive additional information from Express Scripts about the Specialty Medication Care Management program and how to get started.
Using the Mail Order Pharmacy to fill specialty medication prescriptions provides you with access to the Specialty Medication Care Management program benefits described above. 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, the Mail Order Pharmacy will ship your specialty medication to your home. For your convenience and safety, the Mail Order Pharmacy will contact you to arrange delivery before the medication is shipped.
Note: Some specialty medications may not be available through the Mail Order Pharmacy because the medication’s manufacturer limits the drug’s distribution to specific pharmacies. If you submit a prescription for a limited-distribution medication, the Mail Order Pharmacy 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 the Mail Order Pharmacy, visit
TRICARE's formulary search tool.
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