FALLS CHURCH, Va. – Do you have a new prescription you need to fill? Or maybe you’ve been taking the same drug for years. It’s helpful to know some key terms to get your medications affordably.
“Your medical needs and your health plan can affect what you pay at the pharmacy,” said Air Force Lt. Col. Leighcraft A. Shakes, TRICARE Pharmacy Contract Support Chief at the Defense Health Agency. “It’s important to understand how TRICARE covers different types of drugs. It’ll help you make sure you get what you need—at the right price.”
Get started with this list of key terms.
Formulary
Formulary drugs are drugs that TRICARE covers. They’re widely available. There are two categories:
- Generic formulary drugs
- Brand-name formulary drugs
Generic formulary drugs covered by the TRICARE pharmacy benefit work the same as brand-name drugs. They provide the same treatment at a lower cost. When available, TRICARE usually fills prescriptions with generic-equivalent drugs.
Want to know which drugs TRICARE covers? The TRICARE Formulary Search Tool is a tool you can use to learn more about the formulary. It has information about:
- Coverage and copayments
- Pharmacy forms
- Options for filling prescriptions
Drugs that TRICARE doesn’t cover are called non-covered drugs. If TRICARE doesn’t cover a drug, ask your provider about a similar formulary drug. Otherwise, you’ll pay the full cost. Then, you’ll need to file a claim for reimbursement. You’ll have to pay applicable cost-shares, copayments, deductibles, and other costs.
Non-formulary
Covered non-formulary drugs are drugs that may cost more than other drugs in the same therapeutic drug class. All are available through TRICARE Pharmacy Home Delivery for an extra cost.
They aren’t usually available at military pharmacies. But you can ask your local military pharmacy if it has them. You can also find most of these drugs at TRICARE retail network pharmacies.
You may get non-formulary drugs if your provider determines that you have medical necessity. Not sure if this applies to you? You can ask your provider for more information.
Want to find your medication's formulary status? Check the TRICARE Formulary Search Tool.
Specialty
Specialty drugs treat complex chronic conditions. They often require special storage and handling. They aren’t widely available at retail pharmacies. These drugs may have side effects or dosing regimens that your provider must monitor.
Note: Specialty drugs usually cost more than generic and brand-name drugs. You can download a list of TRICARE specialty drugs.
Maintenance
Maintenance drugs treat chronic conditions. These can include drugs to control blood pressure or cholesterol. They’re taken regularly over a longer period.
Refills and renewals
Are you out of a medication? Getting another supply is easy. But it’s important to know the difference between refills and renewals.
A refill means you can order a new supply of your medication when you’re running low. In this case, you don’t have to go through your provider to get a new supply. Instead, you can use the MHS GENESIS Patient Portal to request refills from your military pharmacy.
Are you trying to refill a prescription at a TRICARE retail network pharmacy? If so, you should check with the pharmacy for details. Some non-formulary drugs are covered only through TRICARE Pharmacy Home Delivery or military pharmacies.
Have you used up all the refills for your prescription? You’ll need to get a new prescription for the same drug. This means you need to contact your provider to ask for a renewal. You can do this at a scheduled appointment.
You can also request renewals through the MHS GENESIS Patient Portal. (Note: In some cases, you may need to see your provider first.)
Knowing pharmacy terms and options helps you maintain your health. It also helps you manage out-of-pocket costs. For more information, visit the TRICARE Pharmacy Program or check out the TRICARE Pharmacy Program Overview Fact Sheet.
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