Applicable to military hospitals and clinics, also known as military treatment facilities, or MTFs.

1. Basic Core Formulary (BCF): Required to be available at all MTFs
2. Uniform Formulary (UF): May be available at an MTF, depending on local P&T Committee actions
3. Non-Formulary (NF): not available at an MTF without medical necessity
4. Complete Exclusion: not available at an MTF or through the TRICARE home delivery option. Patient pays full price for the drug at a retail network pharmacy.

Drugs determined to be excluded from the TRICARE Formulary as determined by regulatory policy, outside of P&T function

Applicable to retail network pharmacies and home delivery.

1. Tier 1: lowest copay, generally includes generic drugs
2. Tier 2: next highest copay, generally includes preferred branded drugs
3. Tier 3: highest copay, generally includes non-preferred drugs
4. Complete exclusion: not available at an MTF or through the TRICARE home delivery option. Patient pays full price for the drug at a retail network pharmacy.

• Conducted through ESI
• Patients requesting provider support for an appeal must submit a consent form to allow a provider to appeal on their behalf
• Providers should submit all relevant documentation (i.e. clinical data, guidelines, medical history) supporting the appeal request
• A clinical provider at ESI will make a determination for a patient’s case based on all submitted supporting documentation (Note: All information supporting a justification for appeal must be submitted in a timely manner to help prevent delays)
• TRICARE Operations Manual Chapter 12, 4.1.1: If the contractor’s reconsideration determination is less than fully favorable to the appealing party and the remaining amount in dispute is less than $50, no further appeal rights are available

• Conducted through the DHA’s Office of General Counsel
• Case information from ESI may be relayed to the second level appeals team
• New or additional information or updates supporting the justification for the appeal may also be submitted at this time
• The DHA’s Office of General Counsel, in conjunction with a physician, will make the best determination for the appeal based on all available information