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Frequently Asked Questions

Your Plan Coverage

If I meet my Catastrophic Cap requirement for the year, will I still be charged a copayment for a non-formulary medication?

No. After your cap is met, no copayments will be charged for your medications until the following fiscal year (beginning October 1).

What does it mean if my pharmacist says "prior authorization" is needed?

Prior Authorization means that additional information is needed to determine if your plan sponsor will cover the drug. It's typically reserved for high-risk or high-cost medications. If prior authorization is needed, ask your doctor to contact us.

Why isn't my prescription covered under my plan?

Your plan sponsor determines which prescription drugs are covered. Express Scripts does not decide this for you. We follow your plan sponsor's coverage guidelines and process your prescription claims accordingly.

Do some prescription drugs cost more or have additional requirements for coverage?

Yes. Some drugs are considered non-formulary or non-preferred medications and can be either brand or generic drugs. These drugs are covered at the non-formulary copayment listed above. However, your doctor can submit evidence of medical necessity for these drugs, and if the evidence of medical necessity is approved, your copayment will be reduced to the formulary (brand) copayment. The TRICARE website provides more information about medical necessity for non-formulary medications

Other drugs are covered only if you receive prior authorization. These drugs require evidence of medical necessity by the health care provider who prescribed the medication. If the prior authorization is approved, these drugs will be covered at the formulary (brand) copayment. The TRICARE website provides more information about prior authorization requirements

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