Showing Medical Necessity Can Save You Money
Understanding TRICARE’s Uniform Formulary process can help you save money on your cost-shares when filling prescriptions for non-formulary medications.
The Uniform Formulary (UF) process established a new cost-share of $22 per prescription for medications that are designated as non-formulary under the UF regulation. This cost-share is applied at both mail order and retail pharmacies.
Prescriptions designated as non-formulary may be covered by TRICARE as formulary only if the prescription is considered medically necessary. If medical necessity is determined, active duty Service members may obtain non-formulary medications through any pharmacy point of service at a $0 cost-shareand non-active duty Service members (spouses, dependents, or retirees) may receive these medications at the $9 formulary cost-share at retail network pharmacies and the mail order plan.
Determining Medical Necessity
Medical necessity must be approved in order to receive cheaper cost-shares. In general, medical necessity can be established when
one or more of the following criteria is met for ALL of the available formulary alternatives:
- The use of the formulary alternative is not advisable.
- The patient experiences, or is likely to experience, significant adverse effects from the formulary alternative, and the patient is reasonably expected to tolerate the non-formulary medication.
- The formulary alternative will not bring the patient to a therapeutic level, and the patient is reasonably expected to respond to the non-formulary medication.
- The patient previously responded to a non-formulary medication and changing to a formulary alternative would result in unacceptable risk.
- There is no formulary alternative.
Save Even More with TMOP
If you are currently prescribed non-formulary medications and have received medical necessity approval, you can save even more money
by filling your prescriptions through TRICARE’s Mail Order Pharmacy (TMOP). The mail order pharmacy delivers a 90-day supply
of prescription medications directly to your door step with a cost-share savings of up to 66 percent.
TriWest Healthcare Alliance does not administer the TMOP program. To enroll in the TRICARE Mail Order Pharmacy or for more information, please visit www.expressscripts.com/TRICARE.