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Pharmacies & Medications

Pharmacy & Formulary

Quick Links:

USFHP Pharmacy Formulary
Copay Tier
Generic Substitution
Prior Authorization, Quantity Limits, and Step Therapy
Pharmacy Network
Drug Safety Information
Pharmacy Compounded Drugs
Specialty Medications
Medical Injectable Drugs

USFHP Pharmacy Formulary

Johns Hopkins 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). The Formulary is updated on a regular basis including Tier changes and utilization management requirements. Review the changes that will be made to the formulary.

Covered Medications:

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/products include:

  • Compounded medications of which at least one ingredient is a legend drug
  • Insulin
  • Insulin syringes and needles
  • Glucose test strips
  • Lancets

Non-Covered Medications:

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
  • Multivitamins
  • Over-the-counter products (except insulin and diabetic supplies)
  • Weight reduction products

Copay Tier

USFHP members are responsible for a portion of the cost of their medications. The TRICARE formulary contains three copay tiers (cost share tiers) for USFHP members.

The cost share tiers are as follows:

Generic Drugs:

$10 – for up to 30 days' supply and $0 – for up to 90 days' supply

Preferred Brand Drugs:

$24 – for up to 30 days' supply and $20 – for up to 90 days' supply

Non-preferred Brand Drugs:

$50 – for up to 30 days' supply and $46 – 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.

Formulary

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 here. The Formulary is updated on a regular basis including Tier changes and utilization management requirements. To review the changes that will be made to the formulary, click here.

Generic Substitution Policy

DoD’s policy on generic drugs requires pharmacies 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 the prescriber submits a medical necessity request and approval is granted by the JHHC USFHP Pharmacy Review Department. In those cases, USFHP members will pay the brand-name copayment. View the form for establishing medical necessity.   

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 website.

Prior Authorization & Medical Necessity

Prior Authorization:

Some medications require prior authorization before they can be dispensed. 

To determine if a drug requires prior authorization and view any applicable criteria, please search the TRICARE formulary tool

To initiate a prior-authorization: Providers must download the Johns Hopkins USFHP Pharmacy Prior-Authorization form, complete and fax the form to the Johns Hopkins Healthcare Pharmacy Review department at 410-424-4607.

Medical Necessity for Non-Formulary Medications (at Formulary Copayments):

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. The provider can establish medical necessity by completing and submitting the Johns Hopkins Pharmacy Review department’s Prior-Authorization form.

Quantity Limits:

The Department of Defense Pharmacy and Therapeutics Committee has established quantity limits for certain medications.  Quantity Limits detail may be found on the TRICARE formulary tool.

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. Download a copy of the Pharmacy Prior-Authorization form, complete and fax the Prior Authorization form to the Johns Hopkins Healthcare Pharmacy department at 410-424-4607.

Step Therapy:

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.

Note: A member who has filled a prescription for a step-therapy drug within 180 days prior to the implementation of step therapy, will not be affected by step-therapy requirements and will not be required to switch medications. Please note that the coverage terms of this prescription benefit are subject to change

To determine if a drug requires Step Therapy and view any applicable criteria, please search  the TRICARE formulary tool

If a provider determines that a step therapy requirement is not appropriate for a member, the Pharmacy Prior Authorization Form may be submitted for review. 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. Download a copy of the Pharmacy Prior-Authorization form.

Pharmacy Network

The Johns Hopkins USFHP Plan allows retail prescription processing at any of the approximately 5,100 Rite Aid pharmacies in the United States. Prescriptions may be filled for up to a 90 day supply at any network pharmacy. For members who prefer to utilize a mail order program, the Rite Aid Pharmacy at Wyman Park provides this service. The contact information, directions, and request form for the mail order prescription fills can be found here.

Drug Safety Information

To view information on a drug, including how to take the medication, the possible side effects and drug interactions, click here and search by drug name to see the drug’s side effects, precautions, drug interactions and how to use the medication. 

Pharmacy Compounded Drugs

To ensure safety and effectiveness of compound drug claims and to manage cost, some compound medications when rejected at the pharmacy may require prior authorization. The provider may complete the Compound Prior Authorization Form and fax to the Johns Hopkins Healthcare Pharmacy department at 410-424-4607 for review. The provider must provide clinical documentation to support the request and demonstrate that an FDA approved commercially-available product is not clinically appropriate for the member.

Specialty Medications

Specialty medications are usually high-cost prescription medications used to treat complex 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 provider monitoring.  Some specialty medications may require prior authorization or may not be available to you at a Rite Aid because the medication's manufacturer limits the medication to specific pharmacies through limited distribution practices. When a provider submits a request for use of a specialty medication, upon authorization approval, the JHHC USFHP Pharmacy Review Department will forward the request to a contracted specialty pharmacy and notify the provider. The specialty pharmacy will coordinate delivery of the medication to the patient's home or physician office.

Medical Injectable Drugs

Certain medical injectable medications require prior authorization. Please refer to the to the Tricare Formulary search tool to view prior authorization criteria.

To request prior authorization for applicable medical injectable drugs, use the medical injectable PA form.