Generic Drug Use Policy
It is a mandatory Department of Defense (DoD) policy to use generic-equivalent medications when available instead of brand-name medications. If a generic-equivalent drug does not exist, the brand-name drug will be dispensed at the brand-name cost.
Prior Authorization for Brand-Name Medications
Brand-name drugs that have a generic equivalent may be dispensed only if the prescribing physician is able to clinically justify the use of the brand-name drug in place of the generic equivalent. If you feel a brand-name medication (for which a generic equivalent is available) is clinically necessary, you must receive prior authorization before the patient can have the prescription filled at government expense. Otherwise, the beneficiary may be responsible for the entire cost of the medication. For prior authorization approval, call the TRICARE pharmacy contractor, Express Scripts, Inc., at 1-866-684-4488. Note: After November 4, 2009, call 1-877-363-1303.
Uniform Formulary Drugs
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
TRICARE's non-formulary drug list. The non-formulary list is normally updated on a quarterly basis.
Medical Necessity for Non-Formulary Medications (at Formulary Costs)
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.
- 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.
- 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.
In order for medical necessity to be established, one or more of the following criteria must be met for all of the available formulary alternatives:
- 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.
To obtain medical necessity approval for a non-formulary medication, the provider will need to complete and submit a medical necessity form to Express Scripts, Inc.
Prior Authorizations
In addition to brand-name drugs with generic equivalents, the DoD Pharmacy and Therapeutics Committee has identified 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
TRICARE's Pharmacy Prior Authorization list.
Step Therapy
Step therapy involves prescribing a safe, clinically effective, and cost-effective medication as the first step in treating a medical condition. The preferred medication is often a generic medication that offers the best overall value in terms of safety, effectiveness, and cost. Non-preferred drugs are only prescribed if the preferred medication is ineffective or poorly tolerated.
Drugs subject to step therapy will only be approved for first-time users after they have tried one of the preferred agents on the DoD Uniform Formulary. (Example: Currently, a patient must try omeprazole or Nexium® prior to using any other proton pump inhibitor.) Note: If a beneficiary filled a prescription for a step-therapy drug within 180 days prior to when the drug became subject to step therapy, he or she will not be affected by step-therapy requirements and will not be required to switch medications.
For a complete list of medications subject to step therapy, see “
Medications Identified by the Department of Defense Pharmacy and Therapeutics Committee".
Quantity Limits
DoD has established quantity limits for certain medications. However, exceptions to established quantity or days’ supply limits can be made if you are able to justify medical necessity. Visit
TRICARE's Medication Quantity Limits information for a complete list of quantity limits for specific medications.
Forms
Prior authorization and medical necessity criteria and forms are accessible via
TRICARE's Formulary Search Tool. These forms apply only to prescriptions filled through retail network pharmacies or the Mail Order Pharmacy. MTF pharmacies may follow different procedures. 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, call
1-866-684-4488.
Note: After November 4, 2009, call
1-877-363-1303.
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