Frequently Asked Questions
What is the Uniform Formulary?
On April 1, 2004, TRICARE announced the Uniform Formulary Final rule. This rule outlines requirements for a new formulary process and copayment structure called the "Uniform Formulary" under the direction of the 2000 National Defense Authorization Act, Section 701.
As part of this new process, the DoD Pharmacy & Therapeutics (P&T) Committee, composed of pharmacists and doctors, reviews and evaluates FDA-approved prescription medications to determine their relative clinical and cost effectiveness. The committee then recommends whether a drug should be considered generic, formulary, or non-formulary.
Drugs that are equally effective but cost more compared to other drugs in the same class may be recommended for placement in the non-formulary category.
Previously, most medications were grouped into two categories: generic or brand name. Under the new process, any drug placed into the third category (non-formulary) will be available to beneficiaries at a higher copayment.
What is the copayment structure under the Uniform Formulary?
Effective Feb. 1, 2016, the copayment structure under the Uniform Formulary is as follows:
- Home Delivery (Up to a 90 day supply)
- Generic: $0
- Formulary: $20
- Non-Formulary: $49
- Retail Pharmacy (30 day supply)
- Generic: $10
- Formulary (Brand): $24
- Non-Formulary: $50
The TRICARE website provides more information on TRICARE prescription copayments.
How can I find out which drugs are considered non-formulary?
Non-formulary drugs can be found on the Non-Formulary Medications section of the TRICARE website. You can also use the TRICARE formulary tool to verify formulary status before sending in your prescription.
How can I continue paying the formulary copayment for my non-formulary medication?
If you are taking a non-formulary medication, talk with your doctor about formulary alternatives. To review therapeutic alternatives to non-formulary drugs, visit the Uniform Formulary section of the TRICARE website.
In addition, you may be able to obtain your non-formulary medication for the formulary (brand) copayment through Home Delivery or at a retail network pharmacy if your doctor provides clinical evidence that it is medically necessary for you to use the non-formulary drug instead of a formulary drug.
How do I obtain medical necessity approval?
Doctors can begin the medical necessity process by submitting a medical necessity form available on the Non-Formulary Medications section of the TRICARE website. Your doctor should then submit the form and prescription using one of the following options:
- Fax to Express Scripts toll-free at 866.684.4477 (overseas doctors use 602-586-3915)
- Mail to:
- Express Scripts
- PO Box 52150
- Phoenix, AZ 85072.
If approved, future refills of your non-formulary medication will be charged at the formulary copayment. Please note that an approval notification will not be sent to you.
Once medical necessity is established, will my approval expire?
No. After medical necessity is established, the approval will be valid for as long as you require the medication.
If I obtain medical necessity for a non-formulary drug under TRICARE Pharmacy Home Delivery, will the same override work at a retail pharmacy?
Yes. It is best to establish medical necessity under the program you will be using, however, the override will work in both the Home Delivery and the retail programs.
My prescription and medical necessity form have been sent to Express Scripts. How will I know if medical necessity approval was granted?
If the form was approved, your prescription will be processed at the formulary copayment and shipped to you. If denied, you will receive a notification letter.
You may also check the status by calling the Contact Center at 877.363.1303, which is open 24 hours a day. A patient care advocate will be happy to provide you with an update if one is available. Please allow approximately three days if faxed or seven days if mailed before calling the Contact Center.
If I previously obtained medical necessity approval for a non-formulary medication, will it be grandfathered?
Yes. If you previously obtained a medical-necessity approval before the medication was considered non-formulary, you will not be required to reestablish medical necessity under the new criteria approved by the Director of TRICARE.