How Drugs Become Covered by TRICARE
Step 1: Food and Drug Administration approves the drug
Before TRICARE can cover a drug, the Food and Drug Administration (FDA) has to approve it. The FDA approves a drug after it proves safe and effective for its intended use, and when the drug’s benefits outweigh potential risks.
Step 2: Department of Defense Pharmacy and Therapeutics Committee reviews the drug
This committee develops and maintains the TRICARE Formulary. Every quarter, it reviews new drugs approved by the FDA. It also checks on previously marketed drugs. The committee recommends what new drugs to add to the TRICARE Formulary. It also recommends what category the drug should be in.
Step 3: The Beneficiary Advisory Panel reviews the recommendations
This panel reviews and provides independent recommendations on the TRICARE Formulary to the director of the Defense Health Agency (DHA).
Step 4: Defense Health Agency Director provides a final decision
The DHA Director approves or rejects the recommendations. If approved, the drug is placed into one of four categories.
Step 5: Drug is categorized
The category a drug is placed into determines how it will be available and the cost. The categories include:
• Generic formulary drugs. Widely available and offers the lowest out-of-pocket costs.
• Brand-name formulary drugs. Generally available and has moderate out-of-pocket costs. Some drugs may require prior authorization.
• Non-formulary drugsA drug in a therapeutic class that isn’t as clinically or cost-effective as other drugs in the same class. You pay a higher cost share for these drugs.. May have limited availability and has higher out-of-pocket costs. The drugs may require prior authorization
• Non-covered drugs. Not covered by TRICARE and has the highest out-of-pocket costs (you pay 100 percent of the drug's cost). You may have other health insuranceHealth insurance you have in addition to TRICARE, such as Medicare or an employer-sponsored health insurance. TRICARE supplements don’t qualify as "other health insurance." that provides coverage. Your payment doesn't go towards your annual TRICARE catastrophic cap.
Last Updated 3/22/2019