What is medical necessity?

Doctor with chart and patient

You deserve the right medication for you and your plan.

Your TRICARE plan has a list of generic and brand name drugs and supplies that TRICARE covers called the formulary list.

The TRICARE formulary list is:

  • Updated quarterly.
  • Developed by the Department of Defense (DOD) Pharmacy and Therapeutics (P&T) Committee.

You pay a higher cost share for non-formulary drugs than drugs in the generic formulary or brand-name formulary categories. Some non-formulary drugs are only covered through home delivery.

There are times when a doctor believe a non-formulary drug is a medical necessity. If your provider can establish medical necessity and it is approved, it allows you to get the non-formulary drug at the formulary cost share; however, it is not necessary for you to get the non-formulary drug. Medical necessity is required for active duty service members to get the non-formulary drug at no cost share.

To prove medical necessity, your doctor must send a Medical Necessity Form to Express Scripts. You can find the form with your medication's information in the Formulary Search Tool.

We’re happy to work with your doctor to get you the right medications for managing your health. We’ll let you and your doctor know the status of a medical necessity request upon determination.

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