TRICARE Prior Authorization for Prescriptions Guide
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## Quick answer Some medications require TRICARE's permission before your pharmacist can fill them. This "prior authorization" (PA) confirms that a drug is medically necessary, safe, and cost-effective for your specific condition. If your doctor doesn't submit the PA and get approval from Express Scripts, TRICARE will not pay for the drug, leaving you to pay the full retail price.
Details
### Why is Prior Authorization required? TRICARE uses a "Formulary" (a list of covered drugs) managed by the Defense Health Agency. Prior authorization is usually required for: * High-cost specialty drugs. * Medications with significant safety concerns or potential for misuse. * Drugs that are only effective for specific medical conditions. * Brand-name drugs when a generic equivalent is available.
### How the process works 1. **Check the Formulary:** Use the [TRICARE Formulary Search Tool](https://www.express-scripts.com/tform) to see if your medication requires "PA." 2. **Doctor Submission:** Your healthcare provider must submit clinical justification to Express Scripts. They usually do this via a specific form or an electronic portal (Surescripts or CoverMyMeds). 3. **Review Period:** Express Scripts typically reviews the request within 2 to 5 business days. 4. **Notification:** Both you and your doctor will receive a letter or notification of the decision. If approved, the authorization usually lasts for one year, though it can vary by medication.
### What if it's denied? If the PA is denied, you have two options: * **Medical Necessity Appeal:** Your doctor can argue that the TRICARE-preferred alternative would be ineffective or cause an adverse reaction. * **Alternative Medication:** You can switch to a drug on the formulary that does not require PA or has already been vetted for your condition.
### Costs and Copays (2026 Rates) If you have an approved PA, your costs depend on where you fill the script and your beneficiary status. For 2026, typical costs for a 90-day supply via TRICARE Home Delivery are: * **Generic:** $16 * **Brand-name:** $43 * **Non-formulary:** $92 (Requires medical necessity)
*Note: Active Duty Service Members (ADSMs) have $0 copays for covered drugs at any pharmacy.*
### Pharmacy Network Locations The PA requirement applies regardless of where you get your medicine: * **Military Pharmacies:** $0 copay, but check if they stock the drug. * **TRICARE Home Delivery:** Managed by Express Scripts. * **Retail Network Pharmacies:** Such as Walgreens or CVS. * **Non-Network Pharmacies:** You will pay the full price upfront and file a claim for partial reimbursement (not recommended).
## Who this affects Prior authorization rules apply to all beneficiaries using the TRICARE pharmacy benefit, including: * Active Duty Service Members (ADSMs). * Active Duty Family Members (ADFMs). * National Guard and Reserve members (and their families). * Retirees and their families. * TRICARE For Life (TFL) beneficiaries (TRICARE is secondary to Medicare, but is the primary payer for most prescription drugs).
## Sources * **TRICARE.mil Pharmacy Coverage:** https://www.tricare.mil/pharmacy * **Express Scripts TRICARE Portal:** https://militaryrx.express-scripts.com/ * **TRICARE Formulary Search Tool:** https://www.express-scripts.com/tform * **Defense Health Agency (DHA) Pharmacy Operations:** https://health.mil/Military-Health-Topics/Access-Cost-Quality-and-Safety/Access-to-Healthcare/Pharmacy-Program/Manuals-and-Forms