TRICARE Adds Medications to Uniform Formulary

TRICARE has a Uniform Formulary , a standardized list of prescription medications. Beginning in October, 17 medications are being added to the list as non-formulary medications and they will be covered under the retail network pharmacy and TRICARE Mail Order Pharmacy programs, but at the higher cost-share. Non-formulary medications can be obtained for the lower formulary cost-share only when your provider establishes medical necessity and writes the prescription.

Non-formulary medications are not available through the military treatment facility pharmacy and there is a $22 copay for these prescriptions filled through either the TRICARE retail network or Mail Order Pharmacy.

Determining Medical Necessity

If you are taking any of the third-tier (non-formulary) medications, you should consult with your provider about changing to a first-tier (generic) or second-tier (brand name) medication—either of those options will allow you to use the available lower cost-shares through the TRICARE Pharmacy Program.

Your non-formulary prescription cost can be reduced if your provider establishes medical necessity. With medical necessity, the non-formulary drugs can be filled at the $9 formulary copay using network retail pharmacies or the Mail Order Pharmacy.

In general, medical necessity can be established for non-formulary medications when at least one 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

Filling prescriptions at a non-network pharmacy may be subject to deductibles, higher cost-shares and copays.

The Non-Formulary drugs and their effective dates:

• October 24, 2007
  • Prevacid
  • Zegerid
  • Protonix
  • Aciphex
  • Avodart
• November 21, 2007
  • Antara
  • Tricor
  • Omacor
  • Welchol
  • Avapro
  • Avalide
  • Benicar
  • Benicar HCT
  • Diovan
  • Diovan HCT
  • Teveten
  • Teveten HCT