Formulary & Co-Payments:
Johns Hopkins USFHP utilizes the TRICARE pharmacy formulary. The TRICARE pharmacy formulary is a list of generic and brand prescription drugs that are covered under the TRICARE benefit.
USFHP members are responsible for a portion of the cost of their medications. The TRICARE formulary contains three cost levels for USFHP members. The cost shares are as follows:
Generic Drugs: $5 – for up to 30 days supply and $0 – for up to 90 days supply
Preferred Brand Drugs: $17 – for up to 30 days supply and $13 – for up to 90 days supply
Non-preferred Brand Drugs: $44 – for up to 30 days supply and $43 – for up to 90 days supply
Providers can view the cost share for a medication using the TRICARE formulary search tool. Providers can also search for lower cost alternative medications to a medication they are currently prescribing.
This option allows USFHP members to fill prescriptions at any of the approximately 5,100 Rite Aid network pharmacies without having to submit a claim. You may fill prescriptions for up to a 90 day supply at any network pharmacy. The USFHP Pharmacy Program provides outpatient coverage to beneficiaries for medications that are approved for marketing by the U.S. Food and Drug Administration (FDA) and that generally require prescriptions. Other covered medications include:
- Compounded medications of which at least one ingredient is a legend drug
- Insulin syringes and needles
- Glucose test strips
Prescription medications used to treat conditions that are not currently covered by USFHP either by statute or regulation are likewise excluded from the pharmacy benefit.
Excluded medications include:
- Drugs prescribed for cosmetic purposes
- Fluoride preparations
- Food supplements
- Homeopathic and herbal preparations
- Over-the-counter products (except insulin and diabetic supplies)
- Smoking cessation products
- Weight reduction products
USFHP utilizes the TRICARE pharmacy formulary. The TRICARE formulary and pharmaceutical management policies are developed by the Department of Defense Pharmacy and Therapeutics Committee. The TRICARE formulary is a tiered, open formulary and includes generic drugs (Tier 1), preferred brand drugs (Tier 2), and non-preferred brand drugs (Tier 3). Additional information about the DoD Pharmacy and Therapeutics review and list of formulary drugs can be found at www.tricare.mil/uniformformulary.
The Department of Defense Pharmacy and Therapeutics Committee has established quantity limits for certain medications.
If a USFHP member's medical condition warrants use of quantities greater than listed quantity limit for their medication, Providers may submit a Prior Authorization request for use of the higher quantity. Providers must provide medical justification for use of the higher quantity. View the list of drugs subject to TRICARE Quantity Limits.
Generic Drugs Policy:
DoD’s policy on generic drugs require the pharmacy to substitute generic medications for brand-name medications when a generic equivalent is available. Brand-name drugs with a generic equivalent may be dispensed only if Providers submit a medical necessity request and approval is granted by USFHP. In those cases USFHP members will pay the brand-name co-payment. The form for establishing medical necessity can be found here.
Generic drugs are chemically identical to their branded counterparts. They are made with the same active ingredients, and produce the same effects as their brand name equivalents. The Food and Drug Administration (FDA) requires generic drugs to have the same quality, strength, purity, and stability as brand name drugs. Also, the FDA requires that all drugs, including generic drugs be safe and effective.
Although generic drugs are chemically identical to their branded counterparts, and are held to the same FDA standards for safety and performance as brand name drugs, they sell for 30-75 percent less. Additional information on generic drugs is available on the FDA web site.
Prior-authorization and Medical Necessity:
Some medications require prior authorization before they can be dispensed.
For a list of prior authorization drugs, please visit the TRICARE Pharmacy Prior Authorization Page.
To initiate a prior-authorization: Providers must complete and fax the Prior Authorization form to the Johns Hopkins Healthcare Pharmacy department at 410-424-4607. To download a copy of the Pharmacy Prior-Authorization form, click here.
Prior Authorization requests are reviewed within 48 hours of receipt by Johns Hopkins USFHP. Requests marked as “Urgent” are reviewed within 24 hours.
Medical Necessity for Non-Formulary Medications (at Formulary Co payments)
Medical necessity criteria are established by the DoD Pharmacy & Therapeutics (P&T) Committee for each non-formulary medication. If the medical-necessity criteria are met, the beneficiary may receive the non-formulary medication at a lower co-payment. Providers can establish medical necessity by completing and submitting the Pharmacy Prior-Authorization form.
Specialty medications are usually high-cost; self-administered; injectable, oral, or infused drugs that treat serious chronic conditions. These drugs typically require special storage and handling, and may not be readily available at a local pharmacy. Specialty medications may also have side effects that require pharmacist and/or nurse monitoring. Many specialty medications (oral and injectables) are available through the retail pharmacy network. However, some medications may not be available at retail because the medication’s manufacturer limits the medication to specific pharmacies. When providers submit a request for use of a restricted distribution drug, upon approval USFHP will forward the request to a contracted specialty pharmacy. The specialty pharmacy will coordinate delivery of the medication to patient’s home or physician office. S
Step therapy involves prescribing a safe, clinically effective, and cost-effective medication as the first step in treating a medical condition. The preferred medication is often a generic medication that offers the best overall value in terms of safety, effectiveness and cost. Non-preferred drugs are only prescribed if the preferred medication is ineffective or poorly tolerated.
Drugs subject to step therapy will be approved for first-time users only after they have tried one of the preferred agents on the DoD Uniform Formulary (e.g., currently a beneficiary must try omeprazole or Nexium before using any other proton pump inhibitor).
Note: If you filled a prescription for a step-therapy drug within 180 days prior to the implementation of step therapy, you will not be affected by step-therapy requirements an will not be required to switch medications.