Prescription Plan Rules & Coverage

The TRICARE Formulary is a list of brand-name and generic drugs available through the TRICARE pharmacy benefit. Some drugs are covered but not preferred, and are categorized as Non-Formulary. These drugs have a higher copayment and generally are only available via home delivery.

You can use the TRICARE Formulary Search Tool to search for specific drugs and to see whether they are available through the TRICARE pharmacy benefit and if they are, what you will pay. The TRICARE Formulary Search Tool will also advise as to any quantity or day supply limitations associated with the drug in question.

If your medication is not on the Uniformed Services Formulary, you will be charged the non-formulary price unless your doctor’s medical necessity waiver is approved. Download the form for your medication and your doctor can complete and submit it to us.

  1. Go to Prescriptions and select Find a Pharmacy.
  2. Enter a ZIP code or city and state. Be sure to include a comma between the city name and the state abbreviation.

You can use the Express Scripts app on your mobile device for turn-by-turn directions to the pharmacy you choose.

Yes. When you fill a prescription at an in-network retail pharmacy, tell the pharmacist if you have TRICARE coverage in addition to your OHI. Your pharmacist will submit your prescription to both insurance plans at the same time. Letting your pharmacist know you have two prescription plans means:

  • Minimal out-of-pocket expenses for you
  • Never paying more than the TRICARE copayment
  • No need to submit paper claims
  • Reduced or eliminated up-front costs

To get reimbursed by TRICARE:

  1. Keep the receipt for your medication. You will need to file a claim with TRICARE for reimbursement within one year from the date your prescription was filled.
  2. Fill out the Patient's Request for Medical Payment (DD 2642) form.
  3. Submit this form along with your OHI explanation of benefits and your receipt to:

Express Scripts Inc.

P.O. Box 52132

Phoenix, AZ 85082

Use the Formulary Search Tool to find out about the medication you need:

  1. Go to the Benefits menu and select Covered Medications.
  2. Follow the instructions in the Formulary Search Tool to look up a medication.

The results will give you details about the medications covered, strength, form, whether there’s a generic option, and whether there are any restrictions or extra requirements.

You can choose how to get your maintenance medications. Most plans allow you to choose to get your medications from a Military Treatment Facility, a retail network pharmacy, or through TRICARE Home Delivery Pharmacy Program. But, some plans require you to use delivery for certain medications. We’ll alert you if your medication has restrictions on your pharmacy location.

Express Scripts Pharmacy® offers delivery of up to a 90-day supply of your medication to any location. You can track your order online or through the Express Scripts mobile app. We also offer an optional 3-month payment plan. And, you have access to an Express Scripts pharmacist at any time, 24/7.

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

In general, no. You can use TRICARE home delivery only if:

  • Your other health insurance (OHI) does not include pharmacy benefits
  • The medication you need is not covered by your OHI
  • You have met your catastrophic cap.

If you meet one of these three conditions, here’s how to submit your prescription to for home delivery:

  1. Ask your doctor or provider to write a prescription for up to a 90-day supply of medication.
  2. Include a copy of an explanation of benefits (EOB) showing your OHI did not pay for the medication.
  3. Send this information, along with your prescription, to:

Express Scripts

P.O. Box 52150

Phoenix, AZ 85072-9954

To view your coverage information, log in:

  1. Go to Prescriptions and select Price a Medication.
  2. Enter the name of the medication you want to price and click Search.
  3. Select the medication you’re looking for and enter your dosage amount. Price a Medication will show you if your medication is covered by your plan and how much it costs.

A network pharmacy is a pharmacy that accepts TRICARE copayment. TRICARE will pay for part or all of your medication’s cost from a network pharmacy. Military Treatment Facilities and Express Scripts Pharmacy® are network pharmacies. But, not all retail pharmacies are network pharmacies.

Beneficiaries can file a claim for a partial reimbursement of the cost of their medication when filling at a non-network pharmacy. Learn more.

To submit a pharmacy claim online, log in to your account and navigate to the ‘Benefits’ menu option and select ‘Forms’.

Be sure to have your prescriber information handy, a photocopy of your pharmacy receipt and the phone number for the pharmacy you filled your prescription.

By law, your other health insurance (OHI) must be the primary payer for your prescriptions and TRICARE is the secondary payer. TRICARE becomes the primary payer only when:

  • A drug is not covered by your OHI, but is covered by TRICARE

OR

  • Your OHI coverage is exhausted for the benefit year

Go to Benefits and select Benefits Overview. Then, choose the links for the benefits you’d like to review.

If this information seems different from what you expected, check your plan's benefits on the TRICARE website.

Prior Authorization Form: Your prescription may need prior authorization to assure appropriate use for high-risk or high-cost drugs. Prior Authorization criteria are used to make sure your medication is safe, cost effective, and medically necessary.

Your doctor may need to fill out a prior authorization if your drug is generally used for a certain health condition, has the potential to be misused, or has an age or quantity limit.

Medical Necessity Form: Your doctor can complete a medical necessity form if you take non-formulary drugs, which are often a higher cost. If your doctor can establish medical necessity for these drugs, you can get the drug at the formulary (brand) copayment.

Brand Name Request Form: A generic drug contains the same chemical as the brand-name drug but has a lower copayment. If your doctor determines it is medically necessary for you to take the brand-name drug over the generic version, your doctor can request through the Brand Name Request Form. You may pay additional costs for the brand-name drug.

National Guard and Reserve members with line-of-duty care should contact the Military Medical Support Office at (888)647-6676.

To find the claim form:

  1. Go to TRICARE forms.
  2. Follow their instructions to submit the reimbursement claim form.

Yes. This is required under your TRICARE plan. There are two options to submit information about your OHI:

  1. Log in and go to Account, then select Other Health Insurance. Click the Add OHI button to update your OHI information.

Or

  1. Complete the TRICARE OHI form.
  2. Mail the form to the address shown on page 1.

If you have questions about the form, please call Express Scripts at (877)363-1303.

No. These do not count as Other Health Insurance (OHI). But, Medicare Part D programs do count as OHI.

To get reimbursed, you must submit a paper claim. It must be postmarked within one year from the date you filled the medication.

You must submit these forms with your claim:

  • Explanation of Benefits (EOB) form from your OHI provider
  • Prescription receipts
  • TRICARE DoD/CHAMPUS Claim Form – Patient’s Request for Medical Payment (DD Form 2462)

To find the claim form:

  1. Go to TRICARE forms.
  2. Download the TRICARE Claim Form (DD Form 2462).
  3. Mail your completed form to the Express Scripts address on the website.

The Formulary Search Tool is fast and easy to use. It can help you determine where to fill your prescription (e.g. at the military pharmacy, Home Delivery, or a retail pharmacy) and for what cost. In addition, the tool allows you or your doctor to:

  • Download required forms (prior authorization (PA) and medical necessity (MN);
  • Understand copayments; and
  • Look for alternatives if your medication has a generic equivalent or is not covered.

If you can’t find the answer to your question, please contact us.