Prior authorizations

Medications requiring prior authorization may include, but are not limited to, prescription drugs specified by the DoD Pharmacy and Therapeutics Committee, brand name medications with generic equivalents, medications with age limitations and medications prescribed for quantities exceeding normal limits. See the general list of TRICARE-covered prescription drugs requiring prior authorization

  • ADSMs: If medical necessity is approved, ADSMs may receive non-formulary medications through TRICARE Pharmacy Home Delivery or at retail network pharmacies at no cost
  • All other eligible beneficiaries: If medical necessity is approved, the beneficiary may receive the non-formulary medication at the formulary cost through TRICARE Pharmacy Home Delivery or at retail network pharmacies

For medical necessity to be established, at least one of the following criteria must be met for each available formulary alternative:

  • Use of the alternative is contraindicated
  • The patient experiences, or is likely to experience, significant adverse effects from the alternative medicine, and the patient is reasonably expected to tolerate the non-formulary medication
  • The alternative results in therapeutic failure 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 incur unacceptable clinical risk
  • There is no acceptable alternative
Learn more about medications and common drug interactions, check for generic equivalents or determine if a drug is classified as a non-formulary medication