tricare formulary cialis

Benefits

TRICARE Pharmacy Program

TRICARE provides a world-class pharmacy benefit to all eligible Uniformed Services members, retirees, and their families. Eligible beneficiaries may fill prescription medications at military treatment facility pharmacies; through the TRICARE Pharmacy Home Delivery option; at TRICARE retail network pharmacies; and at non-network pharmacies. TRICARE has a mandatory generic drug policy, which has been in place for more than 10 years, requiring that prescriptions be filled with a generic product if one is available. As with most prescription drug plans, beneficiaries enjoy a significant cost savings by asking their doctors to prescribe the generic equivalent of a brand-name drug.

You must refill select maintenance drugs through home delivery via TRICARE's home-delivery pharmacy, Express Scripts. You can also refill maintenance drugs at military pharmacies. This doesn't apply to active duty service members. Maintenance drugs are those you use on a regular basis for chronic health conditions (e.g. high cholesterol, blood pressure). These do not include medications needed for a sudden illness or infection. See our webpage explaining how to fill maintenance medications using TRICARE.

How to Fill Prescriptions

TRICARE offers several convenient ways for you to have prescriptions filled depending on your family's specific needs. You can have prescriptions filled at any of these pharmacies, based on your specific situation, and you can use more than one option at a time.

While each option is available worldwide, some may be limited outside of the United States.

• Military Pharmacy: Least expensive option with no out-of-pocket costs
• TRICARE Pharmacy Home Delivery: Safe, convenient and the most cost-effective option when a military pharmacy is not available
• TRICARE Network Pharmacy: Fast and convenient. more than 60,000 network pharmacies in the United States and U.S. Territories
• Non-Network Pharmacy: Most expensive option

You do not need to file pharmacy claims if you have prescriptions filled at a military pharmacy, through TRICARE Pharmacy Home Delivery, or at a TRICARE retail network pharmacy. However, if you fill a prescription at a non-network pharmacy in the United States or U.S. territories, you must pay the full price of your prescription and file a claim with TRICARE for reimbursement.

Military Pharmacy

A military pharmacy is the least expensive option for filling prescriptions. At a military pharmacy, you may receive up to a 90-day supply of most medications at no cost. Most military pharmacies accept prescriptions written by both civilian and military providers. Non-formulary medications generally are not available at military pharmacies. To check the availability of a particular drug, contact the nearest military pharmacy in person or by phone.

TRICARE Pharmacy Home Delivery

TRICARE Pharmacy Home Delivery is your least expensive option when not using a military pharmacy. There is no cost for TRICARE Pharmacy Home Delivery for active duty service members. For all other beneficiaries, there is no cost to receive up to a 90-day supply of generic medications. Copayments apply for brand-name and non-formulary medications (up to a 90-day supply). Home delivery is best suited for maintenance medications you take on a regular basis. Prescriptions are delivered to you with free standard shipping, and refills can be ordered easily online, by phone, or by mail. Home delivery also provides you with convenient notifications about your order status, refill reminders, and assistance in renewing expired prescriptions.

TRICARE Pharmacy Home Delivery is only available overseas if you have an APO/FPO address or are assigned to a U.S. Embassy or State Department. You must have a prescription written by a U.S. licensed provider. Refrigerated medications cannot be shipped to APO/FPO addresses. Beneficiaries residing in Germany cannot use the home delivery option due to country-specific legal restrictions. In the Philippines, you are required to use TRICARE certified pharmacy providers.

TRICARE Retail Pharmacy Network

Another option for filling your prescriptions is through a TRICARE retail network pharmacy. You may fill prescriptions and pay one copayment for each 30-day supply when you present your written prescription along with your uniformed services identification card to the pharmacist. This option allows you to fill your prescriptions at network pharmacies without having to submit a claim. You have access to a network of more than 57,000 retail pharmacies in the United States and the U.S. territories of Guam, the Northern Mariana Islands, Puerto Rico, and the U.S. Virgin Islands. Currently, there are no TRICARE retail network pharmacies in American Samoa.

Non-Network Pharmacies

A "non-network pharmacy" is a retail pharmacy that is not part of the TRICARE network. Filling prescriptions at non-network pharmacies is the most expensive option and is not recommended. Beneficiaries may have to pay for the total amount first and file a claim to receive a partial reimbursement.

TRICARE Pharmacy Copayments In the U.S.
(Including Puerto Rico, Guam, Virgin Islands)

The side effect of Cialis

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Here is the language from a Medicare publication on coverage of drugs under Part D:

By law, Part D can’t pay for drugs when they would be covered under Part A or Part B. In addition, these drugs can’t be included in basic Part D coverage: Drugs when used for treatment of sexual or erectile dysfunction, unless such agents are used to treat a condition, other than sexual or erectile dysfunction, for which the agents have been approved by the FDA.

Because the FDA approved this drug for treatment of BPH, a Part D plan should cover it. The drug probably won't show up on formularies as approved. It's likely an individual will have to get prior authorization.

Here is the prior auth language I found in one company's information:

Cialis may be considered medically necessary when the following criteria are met:

• Enlarged prostate AND bothered by symptoms for at least 50 percent of the time over one month.
• Moderate to severe uncontrolled symptoms due to benign prostatic hyperplasia (BPH) with an American Urological Association Symptom Index (AUA-SI) > 8.
• Failure (defined less than 50% improvement of symptoms after 3 month trial), to two different combination therapies consisting of (options listed).

The policy also spells out criteria for continued use of the medication.

I suggest contacting the plan to find out about the prior authorization requirements.

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Last Updated 11/14

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