Generic Drug Use Policy
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 the brand-name drug is medically necessary and after Express Scripts grants approval. If your patient requires a brand-name medication that has a generic equivalent, you must obtain prior authorization. Otherwise, the patient may be responsible for the entire cost of the medication.
If a generic-equivalent drug does not exist, the brand-name drug is dispensed at the brand-name cost.
Uniform Formulary Drugs and Non-Formulary Drugs
In 2005, DoD established a uniform formulary, which is a list of covered generic and brand-name drugs. The formulary also contains a third tier of medications that are designated as “non-formulary.” 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 a higher copayment, third-tier drugs are available through TRICARE Pharmacy Home Delivery or retail network pharmacies. A beneficiary may be able to fill a non-formulary prescription at formulary costs if the provider can establish medical necessity by completing and submitting the appropriate TRICARE Pharmacy medical necessity form to Express Scripts for the non-formulary medication. To download the form, visit the
DoD Pharmacoeconomic Center web site.
- ADSMs: If medical necessity is approved, ADSMs may receive non-formulary medications through TRICARE Pharmacy Home Delivery or at retail network pharmacies at no cost.
- All other eligible beneficiaries: If medical necessity is approved, the beneficiary may receive the non-formulary medication at the formulary cost through TRICARE Pharmacy Home Delivery or at retail network pharmacies.
For medical necessity to be established, at least one of the following criteria must be met for each available formulary alternative:
- 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.
Call Express Scripts at 1-877-363-1303 or visit
DoD's Pharmacoeconomic Center web site for forms and medical-necessity criteria. 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.
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 (e.g., 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 step therapy implementation, the beneficiary 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 DoD P&T Committee".
Medicare-Eligible Beneficiaries
Medicare-eligible beneficiaries are able to use the TRICARE Pharmacy Program if they have both Medicare Part A and Part B. If they do not have both Medicare Part A and Part B, they may only access pharmacy benefits at MTFs.* Medicare-eligible beneficiaries are also eligible for Medicare Part D prescription drug plans. However, beneficiaries do not need to enroll in a Medicare Part D plan to keep their TRICARE Pharmacy Program benefits.
* Exceptions exist for certain beneficiaries, including ADSMs and ADFMs. Please see “TRICARE For Life” earlier in this section for more information.
You may direct eligible beneficiaries who inquire about Medicare Part D coverage to visit the
TRICARE web site. However, for the most up-to-date information on the Medicare Part D prescription drug benefit, beneficiaries should call Medicare at 1-800-MEDICARE (1-800-633-4227) or visit the
Medicare web site.
Pharmacy Data Transaction Service
The Pharmacy Data Transaction Service (PDTS) is a centralized data repository that records information about DoD beneficiaries’ prescriptions. PDTS allows providers to access complete patient medication histories, helping to increase patient safety by reducing the likelihood of adverse drug interactions, therapeutic overlaps, and duplicate treatments. PDTS conducts an online prospective drug-utilization review (a clinical screening) in real time against a beneficiary’s complete medication history for each new or refilled prescription before it is dispensed to the patient. Regardless of where a beneficiary fills a prescription, prescription information is stored in a robust central data repository and is available to authorized PDTS providers, including TRICARE Pharmacy Home Delivery, MTF pharmacies, MTF providers, and TRICARE retail network pharmacies.
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 local pharmacies. Specialty medications may also have side effects that require pharmacist and/or nurse monitoring. The Specialty Medication Care Management program is structured to improve the beneficiary’s 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 beneficiaries get the most benefit from their medications
- Monthly refill reminder calls
- Scheduled deliveries to beneficiaries’ specified locations
- Specialty consultation with a nurse or pharmacist at any point during therapy
These services are provided to beneficiaries at no additional cost when they receive their medications through TRICARE Pharmacy Home Delivery, and participation is voluntary. If you or your patient orders a specialty medication from TRICARE Pharmacy Home Delivery, Express Scripts sends the patient additional information about the Specialty Medication Care Management program and how to get started.
Beneficiaries enrolled in the Specialty Medication Care Management program have access to pharmacists 24 hours a day, seven days a week. The specialty clinical team reaches out to the beneficiaries’ physicians, as needed, to address beneficiary issues, such as side effects or disease exacerbations. If any of your patients currently fill specialty medication prescriptions at retail pharmacies, the specialty clinical team will provide brochures detailing the program as well as prepopulated enrollment forms.
If a patient requires specialty pharmacy medications, you may fax the prescription to TRICARE Pharmacy Home Delivery at 1-877-895-1900. TRICARE Pharmacy Home Delivery ships medications to the beneficiary’s home. Faxed prescriptions must include the following ID information: patient’s full name, date of birth, address, and ID number.
Note: Some specialty medications may not be available through TRICARE Pharmacy Home Delivery because the manufacturer limits the drug’s distribution to specific pharmacies. If you submit a prescription for a limited-distribution medication, TRICARE Pharmacy Home Delivery either forwards the prescription to a pharmacy of the patient’s choice that can fill it or provides the patient with instructions about where to send the prescription. To determine if a specialty medication is available through TRICARE Pharmacy Home Delivery, visit the
TRICARE Formulary Search Tool.
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