FALLS CHURCH, Va. – When you’re covered by a TRICARE health plan, you also have pharmacy coverage through the TRICARE Pharmacy Program. And as with any TRICARE plan, it’s important to know how this program works. You should be familiar with certain terms that can help you make the most of your pharmacy benefit.

One of those terms is prior authorization.

“Prior authorization is a common term in the pharmacy industry,” said U.S. Air Force Lt. Col. Leighcraft Shakes, deputy chief, Pharmacy Benefit Integration Branch at the Defense Health Agency. “Prior authorization is a routine process to ensure your prescription drug is medically necessary and cost effective.”

Keep in mind, prior authorization isn’t the same as pre-authorization. Pre-authorization is the process that TRICARE uses to approve medical care.

Note: If you have coverage through the US Family Health Plan, you don’t have coverage through the TRICARE Pharmacy Program. The USFHP has its own pharmacy plan.

Q: How does TRICARE determine which drugs require prior authorization?

A: The Department of Defense Pharmacy and Therapeutics Committee meets quarterly to determine which drugs:

Are included in the TRICARE pharmacy benefit
Identify those that require prior authorization
Establish any additional coverage rules that may apply

Drugs that require prior authorization may include but aren’t limited to:

Prescription drugs specified by the DOD P&T Committee based on clinical appropriateness and widely accepted clinical guidelines
Brand-name drugs that have generic equivalents
Drugs subject to age or sex limitations
Drugs prescribed in quantities that exceed standard limits

Q: What does prior authorization mean for me?

A: Before filling certain prescriptions, Express Scripts, the TRICARE Pharmacy Program contractor, reviews and authorizes the medication based on criteria developed by the DOD P&T Committee. Once approved, your pharmacist can fill the prescription.

Q: How do I know if my prescription needs prior authorization?

A: The TRICARE Formulary Search tool provides information about:

Drugs that require prior authorization or have quantity limits
Coverage and copayments
Pharmacy forms
Options for filling prescriptions
Common drug interactions

To find out if your medication requires prior authorization, follow these steps:

Use the TRICARE Formulary Search tool to locate your medication.
When searching, make sure to include your biological sex and age.
Download and print your drug’s prior authorization form.
Give the form to your provider to complete and send back to Express Scripts. They can submit prior authorizations via mail, phone call, or fax.

Q: What’s an electronic prior authorization?

A: An electronic prior authorization, or ePA, is a simple, secure way for your provider to submit prior authorization requests. They can electronically submit prior authorizations for prescriptions filled:

Q: How long does the traditional prior authorization process take?

A: Prior authorization approval takes about 10 days after Express Scripts receives the request from your provider.

Q: What happens if my prior authorization is denied?

A: Express Scripts will notify both you and your provider of the denial, the appeal process, and actions that can be taken to facilitate further review and consideration. Other options include working with your provider to change to a different covered drug or paying out of pocket for your drug.