Drug Coverage

Drug Categories

Prescription drugs fall into four categories. These categories follow industry standards. They depend on the medical effectiveness and cost effectiveness of a drug compared to other similar drugs.

1. Generic formulary drugs
2. Brand-name formulary drugs
3. Non-formulary drugs
4. Non-covered drugs

A drug’s category may affect your pharmacy costs.

Generic Formulary Drugs

Generic drugs are just as potent, pure, safe, and reliable as brand-name drugs. The U.S. Food and Drug Administration requires that all generic drugs pass strict testing to prove they are the same.

Generic drugs have the lowest out-of-pocket costs to you.

Brand-Name Formulary Drugs

If you’re prescribed a brand-name drug, you’ll get a generic substitute, unless:

• There isn&rsquot a generic substitute.
• Express Scripts approves use of the brand-name drug.
• TRICARE determines the brand-name drug is a better value than its generic equivalent.

Express Scripts may approve a brand-name drug if your doctor:

• Completes a clinical review that says the brand-name drug should be used instead of the generic drug, and Express Scripts grants the approval.
• Calls Express Scripts to request the brand-name drug for you. 

Do you take a brand-name maintenance drug? You may be required to fill your prescription through TRICARE Pharmacy Home Delivery.

In general, you’ll pay more out-of-pocket for brand-name drugs than for generic drugs.

Non-Formulary Drugs

Non-formulary drugs are drugs that aren’t as clinically effective or cost-effective as other drugs in the same therapeutic clast. Covered non-formulary drugs have higher cost-shares than drugs in the generic formulary or brand-name formulary categories.

• Some non-formulary drugs are only covered through TRICARE Pharmacy Home Delivery.
• If your provider can establish medical necessity, you can get the non-formulary drugs at the formulary cost-share (or at no cost for active duty service members). 

Non-Covered Drugs

Prescription drugs and other products TRICARE doesn’t cover include:

• Excluded drugs listed in the non-covered category
• Drugs prescribed for cosmetic purposes
• Drugs used to treat a non-covered condition (such as prescription drugs for treatment of presbyopia)
• Fluoride preparations
• Homeopathic and herbal preparations
• Multivitamins (prenatal vitamins with a prescription are covered)
• Over-the-counter products, except for:
• Insulin and diabetes supplies
• Smoking cessation products covered by the smoking cessation benefit

You can get prescriptions filled for non-covered drugs, but you’ll have to pay the full cost of the drug. The amount you pay for the excluded drug won’t apply to your catastrophic cap.

Prior Authorization, Medical Necessity, and Step Therapy

Prior Authorization and Medical Necessity

Prior authorization is a routine process. We use it to make sure your prescription drug is safe, effective, medically necessary, and cost-effective.

You may need prior authorization for your prescription if it:

• Is specified by the DOD Pharmacy & Therapeutics Committee
• Is a brand-name prescription drug with a generic substitute
• Has age limits
• Is prescribed for an amount more than the normal limit

Medical necessity is a determination that a non-formulary drug is reasonable for the treatment of a certain medical condition.

You can check the TRICARE Formulary to see if your drug has prior authorization or medical necessity requirements.

How To Get Prior Authorization or Medical Necessity

• Search for your drug on the TRICARE Formulary.
• Download and print the form for your drug.
• Give the form to your provider to complete and send to Express Scripts.
  • Instructions are on the form.
  • You don’t need to send multiple forms.

Prior authorization approvals will apply to military pharmacies, home delivery, and network pharmacies. Medical necessity approvals apply to home delivery and network pharmacies.

Can’t find the form you need? Contact Express Scripts.

Step Therapy

You must use step therapy with certain prescription drugs. This means you must try a preferred drug as the first step in treating your medical condition.

The preferred drug is:

• Safe
• Clinically effective
• Cost-effective
• Often a generic drug

You can get non-preferred drugs, but only if the preferred drug isn’t effective or tolerated well This means you must try the preferred drug first.

If you’ve tried the preferred drug in the last 180 days, you’ll get automatic approval for the non-preferred drug. Once approved, there’s no expiration date

Certain Maintenance Drugs

All beneficiaries except active duty service members must refill certain brand-name maintenance drugs at a military pharmacy or through home delivery. This requirement only applies to prescriptions filled in the U.S. and U.S. territories.

If you get your certain maintenance drug at a network pharmacy:

• One time: Express Scripts will send you a letter telling you that you need to switch.
• Two times: Express scripts will send you another letter about switching.
• Three times: You’ll pay 100% of the drug’s cost.

Search the list below to see if you have a prescription for a maintenance drug that must be filled through home delivery or at a military pharmacy.

Download the Maintenance Drug List

Specialty Drugs

Specialty drugs:

• Are usually self-administered, high-cost, injectable, or oral drugs
• Can require clinical training to administer
• Treat chronic conditions (for example, cancer, multiple scleroses, rheumatoid arthritis, hepatitis C)
• May need special storage and handling
• Aren’t available from many retail pharmacies

Do you have a prescription for a specialty drug on the specialty drug list? You must get it filled through:

• An in-network retail pharmacy. This includes Accredo, a specialty pharmacy serving TRICARE beneficiaries with complex and chronic health conditions.
• TRICARE Pharmacy Home Delivery, including specialty pharmacy services provided by Accredo.
• A military pharmacy. You can check with your local military pharmacy to see if they stock your drug and if so, how to switch.

Download the Specialty Drug List

Learn more about your options for filling specialty drug prescriptions.

Note: Some specialty drugs may be limited by the manufacturer to certain retail pharmacies. See the TRICARE Formulary Search Tool for more information.

Home Delivery for Specialty Drugs

Accredo provides specialty pharmacy services if you fill eligible specialty drug prescriptions through TRICARE Pharmacy Home Delivery. Accredo gives you access to the following:

• Get expert advice from specialty-trained pharmacists and nurses available 24/7.
• Receive condition-specific support from clinicians.
• Schedule delivery of your specialty drugs to your home or office on a day that works for you at no additional cost.
• Manage your specialty medications and set refill reminders.

Over-the-Counter Drugs and Supplies

OTC Drugs

Typically, TRICARE doesn’t cover over-the-counter drugs, except for the following. 

• Your usual pharmacy copayments or cost-shares may apply.
• TRICARE doesn’t cover OTC drugs outside of the U.S. and U.S. territories.
• Visit the TRICARE Formulary Search Tool to learn more.

OTC Supplies

TRICARE covers the following OTC supplies:

• Insulin products
• Certain blood glucose strips
• Urine glucose test strips
• Blood and urine ketone/acetone test strips
• Syringes and needles used for injectable medications
• Lancets
• Inhaler spacers
• Diaphragms

There are some limitations. Visit the TRICARE Formulary Search Tool to learn more.

TRICARE may cover some medical supplies and devices not listed here. Contact your regional contractor for more information.

Compound Drugs

Compound drugs are a combination of two or more drugs. They’re prepared by a pharmacist for a patient’s individual needs.

Screening Process for Compound Drugs

Step 1: Electronic Screen

Express Scripts screens each ingredient to make sure:

• TRICARE covers it.
• It’s safe and effective.
• It’s medically necessary.

This step usually takes less than five seconds to complete.

Step 2: Required if the Compound Doesn’t Pass Step 1

If the compound drug—or any ingredient in it—doesn’t pass the first step, your pharmacist can:

• Remove the non-covered ingredient or replace it with a covered ingredient.
• Contact your doctor to request a different drug to treat your condition.

This step happens while you wait at the pharmacy. It may take 15 to 20 minutes.

Step 3: Prior Authorization

Your doctor can request prior authorization for the compound drug if they can’t substitute an ingredient or prescribe a different drug for you. This allows Express Scripts to individually review your prescription to make sure it’s safe, effective, and medically necessary.

To request prior authorization:

• Download the TRICARE Prior Authorization Request Form for Compounded Medications or contact Express Scripts to get the form.
• Give it to your doctor to complete and submit to Express Scripts. (Instructions are on the form.)

This step usually takes about five days from when Express Scripts gets all the necessary paperwork.

If your compound drug doesn’t get approved, you have 90 days to request a formal appeal.