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News | April 19, 2022

Pre-Authorization and Medical Necessity for Prescription Drugs: What You Need to Know

By TRICARE Communications

Prescription drugs are tools meant to support your overall health. TRICARE has procedures to make sure you get the right prescription drug to treat your condition. You must sometimes work with your doctor to get approval for coverage of certain drugs. Two examples of this are pre-authorization (also known as prior authorization) and medical necessity.
 
“TRICARE uses pre-authorization and medical necessity to make sure your prescription drug is safe, effective, medically necessary, and cost effective,” said U.S. Public Health Service Cmdr. Teisha Robertson, a pharmacist with the Defense Health Agency’s Pharmacy Operations Division. “If you don’t get pre-authorization approval when it’s required, TRICARE may not cover your prescription. Without a medical necessity form, you’ll pay a higher cost for your prescription drug.”
 
Here are some facts about pre-authorization and medical necessity to help you through the process.
 
Pre-authorization
As outlined in the TRICARE Pharmacy Program Handbook, you may need pre-authorization for your prescription if it:  
Express Scripts, the TRICARE pharmacy contractor, sometimes needs more information from your doctor about your prescription before it can be covered by your plan. Express Scripts uses this information to help control costs. They also must make sure the medication is an effective treatment. Express Scripts works with your doctor on these reviews.
 
To find out if your prescription needs pre-authorization, you can go to the TRICARE Formulary Search Tool. Enter the name of your prescription drug in the search tool. If the drug requires pre-authorization, a form will be available for you to download by clicking “Coverage rules apply.” Otherwise, the form won’t appear.
 
Keep in mind, only your doctor can submit the form. They can do this online by following the instructions on the form. Express Scripts will update you on the status of your form. You can also log in to your Express Scripts account or Express Scripts mobile app at any time to check the status. Your approval will apply to network pharmacies, TRICARE Pharmacy Home Delivery, and military pharmacies.
 
Medical necessity
Some drugs require proof from your doctor of medical necessity. Your TRICARE plan has a list of generic and brand-name drugs that TRICARE covers. It’s called the formulary list. TRICARE also covers non-formulary drugs, but at a higher copayment. If evidence of medical necessity is approved for these drugs, you can get your non-formulary drug at the formulary cost, which will be a lower copayment. Medical necessity is also required for active duty service members to get the non-formulary drug at no cost.
 
How can you find out if your prescription drug needs medical necessity? You can find this by looking it up on the TRICARE Formulary Search Tool. As with pre-authorization, only your doctor can submit the form. Your medical necessity approval will apply to network pharmacies, TRICARE Pharmacy Home Delivery, and military pharmacies.
 
Keep in mind, coverage for some non-formulary drugs requires you to use home delivery. You can check the online search tool to confirm.
 
Find more information about pre-authorization and medical necessity on the TRICARE website. If you can’t find a form you need or have questions, reach out to Express Scripts.
 
Remember, you can always check the TRICARE Formulary Search Tool to see how much you’ll pay out of pocket for your prescriptions. You can also check out the TRICARE Pharmacy Program Handbook for everything you need to know about your pharmacy benefit.
 
Would you like the latest TRICARE news sent to you by email? Visit the TRICARE Subscriptions page today, and create your personalized profile to get benefit updates, news, and more.
 
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