Information for Providers

Pharmacy & Therapeutics Committee Meetings

The Defense Health Agency’s Formulary Management Branch conducts quarterly P&T meetings (February, May, August, November) to assess:

  • New FDA approved drugs and drug classes for TRICARE outpatient formulary status. TRICARE outpatient formulary status is based on four tiers:
    • Click to closeBasic Core FormularyThe Basic Core Formulary (BCF) is a list of medications required to be on formulary at all full-service military treatment facilities (MTFs). BCF medications are intended to meet the majority of the primary care needs of DoD beneficiaries.Basic Core Formulary
    • Uniform Formulary
    • Non-Formulary
    • Complete Exclusion
  • TRICARE utilization management and pharmacy-related economic data
  • TRICARE copays
  • Medical necessity criteria
  • Prior authorization criteria
  • Prior authorization bypass drugs and criteria

Meeting minutes are publicly posted after:

Formulary Terminology

Applicable to military hospitals and clinics, also known as military treatment facilities, or MTFs.

  1. Click to closeBasic Core FormularyThe Basic Core Formulary (BCF) is a list of medications required to be on formulary at all full-service military treatment facilities (MTFs). BCF medications are intended to meet the majority of the primary care needs of DoD beneficiaries.Basic Core Formulary (BCF): Required to be available at all MTFs
  2. Uniform Formulary (UF): May be available at an MTF, depending on local P&T Committee actions
  3. Non-Formulary (NF): not available at an MTF without medical necessity
  4. Complete Exclusion: not available at an MTF or through the TRICARE home delivery option. Patient pays full price for the drug at a retail network pharmacy.

Drugs determined to be excluded from the TRICARE Formulary as determined by regulatory policy, outside of P&T function

Applicable to retail network pharmacies and home delivery.

  1. Tier 1: lowest copay, generally includes generic drugs
  2. Tier 2: next highest copay, generally includes preferred branded drugs
  3. Tier 3: highest copay, generally includes non-preferred drugs
  4. Complete exclusion: not available at an MTF or through the TRICARE home delivery option. Patient pays full price for the drug at a retail network pharmacy.

Formulary Tools

The TRICARE Formulary Search Toolgoes to formulary search tool website includes information for drugs. This includes:

  • Formulary status
  • Prior authorization forms
  • Medical necessity forms
  • Quantity limits
  • Directions for submission of forms are listed at the top of each individual form
  • Forms are processed through Express Scripts, Inc.goes to ESI webpage, the pharmacy contractor for the TRICARE Health Plan

Learn More about the TRICARE Formulary.

Express Scripts Provider Tools

Express Scripts is an online pharmacy and the pharmacy benefit manager for TRICARE.

Provider resources are available and they include:

  • MTF Provider Portal for online prescription management
  • Prescription monitoring program for identification of beneficiaries who are potentially at risk for misuse of prescription drugs

Appeals Process for Prior Authorization Denials

Active Duty Appeals

All Other Appeals

Non-active duty beneficiaries will follow the processes outlined below:

  • Conducted through ESI
  • Patients requesting provider support for an appeal must submit a consent form to allow a provider to appeal on their behalf
  • Providers should submit all relevant documentation (i.e. clinical data, guidelines, medical history) supporting the appeal request
  • A clinical provider at ESI will make a determination for a patient’s case based on all submitted supporting documentation (Note: All information supporting a justification for appeal must be submitted in a timely manner to help prevent delays)
  • TRICARE Operations Manual Chapter 12, 4.1.1: If the contractor’s reconsideration determination is less than fully favorable to the appealing party and the remaining amount in dispute is less than $50, no further appeal rights are available
  • Conducted through the DHA’s Office of General Counsel
  • Case information from ESI may be relayed to the second level appeals team
  • New or additional information or updates supporting the justification for the appeal may also be submitted at this time
  • The DHA’s Office of General Counsel, in conjunction with a physician, will make the best determination for the appeal based on all available information

Formulary Change Requests

Requests for changes to the TRICARE outpatient formulary (e.g. formulary status, prior authorization criteria):

  • Contact the local military facility pharmacyGoes to the MTF Locator to start the process.
  • Initial requests must be routed through the local military hospital's Pharmacy and Therapeutics Committee
  • May only be submitted by medical providers
  • Must have a Formulary Change Request (DHA Form 111) submitted with the request
  • Must include reliable supporting evidence for the requested change

A determination will be made by the military hospital’s P&T Committee to address the requested change locally or escalate the request to the DHA’s Formulary Management Branch for further consideration.