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Obtaining Prior Authorization for Prescriptions
     


If you’ve ever had questions about how to obtain prior authorization for prescriptions, what forms are required and where to get them, the following is a guide for obtaining authorization through TRICARE.

Medications Requiring Prior Authorization
Prior authorization and/or validation of medical necessity may be required for prescription coverage under several circumstances, including:
  • Certain medications as designated by the Department of Defense (DoD) Pharmacy and Therapeutics Committee
  • Medications that have the potential for inappropriate use
  • Medications used for conditions not covered by TRICARE
  • Medications with more cost-effective equivalents having similar or better clinical effectiveness, available on the Uniform Formulary
  • Brand-name medications with generic equivalents
  • Medications with quantity limits when a greater amount is needed
  • Medications with age and/or gender limitations
  • Active duty service members who require a medication designated non-formulary (Tier 3) under the DoD Uniform Formulary
To determine formulary status, copayment, availability, prior authorization, and quantity or age/gender limits for specific medications, use the DoD Formulary Search Tool.

To validate medical necessity for a brand-name medication when a generic equivalent is available or to justify exceptions to quantity limits or age/gender limits, call 1-866-684-4488 for prescriptions to be filled through a TRICARE network retail pharmacy or include relevant clinical information with prescriptions to be filled through the TRICARE Mail Order Pharmacy.

Non-Formulary (Tier 3) Medications and Military Status
Designation of a medication as “non-formulary,” also known as Tier 3 under the Uniform Formulary, impacts active duty service members (ADSMs) differently than active duty family members (ADFMs), retired service members and their family members, and other TRICARE-eligible individuals.

TRICARE will not cover a non-formulary (Tier 3) medication for an ADSM (who pays no copayment) unless it is determined to be medically necessary in lieu of all similar alternatives on the Uniform Formulary. 

ADFMs, retired service members and their families may obtain non-formulary (Tier 3) medications at the $22 Tier 3 copayment without medical necessity determination.  However, they may receive a non-formulary (Tier 3) medication at the $9 formulary (Tier 2) copayment if it is determined to be medically necessary in lieu of all similar alternatives on the Uniform Formulary.

Forms and Contact Numbers
Prior authorization and medical necessity criteria and forms are accessible via the DoD Formulary Search Tool Web site. These forms apply only to prescriptions filled through retail network pharmacies or the mail-order program. Military treatment facility (MTF) pharmacies may follow different procedures. Please contact the MTF for details.

At the top of each form, there is information on where to send the completed form. For assistance in completing prior authorization or medical necessity forms, please call 1-866-684-4488.


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Last Reviewed: July 18, 2008