Getting prior authorizations for TRICARE prescriptions: Your questions answered

Official Statements

• Defense Health Agency, November 12: “When you’re covered by a TRICARE health plan, you also have pharmacy coverage through the TRICARE Pharmacy Program. And as with any TRICARE health 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. Note: If you have coverage through the Uniformed Services Family Health Plan, you don’t have coverage through the TRICARE Pharmacy Program. The USFHP has its own pharmacy plan.”

• Defense Health Agency, November 12: “Prior authorization is a common term in the pharmacy industry,” said Melanie Richardson, Pharmacy Benefit Integration Branch, at the Defense Health Agency. “Prior authorization is a routine process to ensure your prescription drug is safe, 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.”

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

• Defense Health Agency, November 12: “A: The physician-led 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 additional coverage rules that may apply

• Defense Health Agency, November 12: “Drugs that require prior authorization may include but aren’t limited to:”

  • Prescription drugs specified by the Dod P&T Committee based on clinical effectiveness and widely accepted clinical guidelines
  • Brand-name drugs that have generic equivalents
  • Drugs subject to age or sex limitations
  • Non-preferred formulary drugs that have required preferred alternatives
  • Certain non-formulary drugs

  Q: What does prior authorization mean for me?

• Defense Health Agency, November 12: “A: Before filling certain prescriptions, https://militaryrx.express-scripts.com/, the TRICARE Pharmacy Program contractor, reviews and authorizes the medication. This review is based on the criteria set by the Dod P&T Committee and a prior authorization request submitted by your prescriber. If approved, your pharmacy can fill the prescription.”

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

• Defense Health Agency, November 12: “A: The https://www.express-scripts.com/frontend/open-enrollment/tricare/fst/#/ provides information about:”

  • Drugs that require prior authorization or have quantity limits
  • Coverage and copayments
  • Pharmacy forms
  • Options for filling prescriptions
  • Covered alternative drugs

• Defense Health Agency, November 12: “If your pharmacy rejects your prescription, you’ll need to get prior authorization. Does your provider use ePrescribe? They’ll be notified when your prescription needs prior authorization. To find out if your medication requires prior authorization, follow these steps:”

  • Use the https://www.express-scripts.com/frontend/open-enrollment/tricare/fst/#/ to locate your medication.
  • When searching, make sure to include your biological sex and age.
  • Click on “View Coverage” for the point of service you wish to get your prescriptions.
  • Download and print your drug’s prior authorization form.
  • Give the form to your provider to complete and send back to Express Scripts. Your provider can submit prior authorizations via mail, phone, fax, or through an electronic prior authorization request.

  Q: What’s an electronic prior authorization?

• Defense Health Agency, November 12: “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:”

  • At a military pharmacy
  • Through TRICARE Pharmacy Home Delivery
  • At a TRICARE retail network pharmacy

  Q: How long does the prior authorization process take?

• Defense Health Agency, November 12: “A: Some prior authorization approvals, such as those provided by ePA, can be instantaneous. Others may take up to 10 days after Express Scripts receives the request from your provider. Do you have the Express Scripts Pharmacy mobile app? If so, you can track the submission and status of prior authorizations.”

  Q: What happens if my prior authorization is denied?

• Defense Health Agency, November 12: “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. If denied, you and your provider will get a letter with instructions on your options. Other options include working with your provider to change to a different covered drug or paying out of pocket for your drug.”

  Q: With the TRICARE Pharmacy Program, where can I go to get my prescription filled?

• Defense Health Agency, November 12: “A: According to the TRICARE Pharmacy Program Handbook, you can fill your prescriptions in several ways, including:”

  • Military pharmacies
  • TRICARE Pharmacy Home Delivery
  • https://militaryrx.express-scripts.com/find-pharmacy
  • Non-network pharmacies

• Defense Health Agency, November 12: “There’s more to learn about the TRICARE Pharmacy Program. To make your pharmacy experience even easier, you can also:”

  • Sign up forsecure pharmacy services through https://militaryrx.express-scripts.com/ patient portal.
  • Download the free http://www.express-scripts.com/mobile/.
  • Search the https://www.express-scripts.com/frontend/open-enrollment/tricare/fst/#/.
  • Review your pharmacy costs.