TRICARE's pharmacy benefit requires substitution of FDA A-rated generics, so a prescriber who wants a TRICARE patient to receive the brand-name drug completes this one-page Express Scripts request. It asks whether the patient tried the generic and what happened, or why the generic cannot be used. An approval has no expiration date and covers prescriptions filled through the TRICARE pharmacy program.
The prescriber completes and signs all three steps: patient and physician information, the clinical questions about the generic, and the certification signature.
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Brand over Generic Prior Authorization Request Form
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The form states that this prior authorization has no expiration date. It applies to prescriptions filled through the Department of Defense TRICARE pharmacy program, which Express Scripts administers for mail order and retail fills.
Whether the patient has tried the generic. If yes, describe the patient's experience with it; if no, give patient-specific clinical justification for why the A-rated generic cannot be used. The prescriber then certifies the answers are correct and signs and dates the form.
Yes. The prescriber may call or fax Express Scripts, but the patient can also attach the completed form to the prescription and mail it to Express Scripts, or email the form alone. The prescriber's signature is still required.