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TRICARE Compounded Medication Prior Authorization

TRICARE screens every ingredient of a compounded prescription, and when a compound fails that screening the prescriber can request coverage with this two-page Express Scripts form. It documents the active ingredients, diagnosis, route and why a commercially available product is not suitable. Express Scripts usually decides in about five days once it has all the paperwork.

Who completes it

The prescriber completes and signs all four steps: patient and physician information, the compound's active ingredients, an eleven-question clinical assessment, and the certification.

Submitting and payment

How to submit it
The prescriber calls or faxes Express Scripts, or the patient attaches the completed form to the prescription and mails it, or emails the form alone, to the TRICARE pharmacy prior authorization contacts printed on the form.
Who pays
Coverage approval lasts for the proposed duration of therapy or one year, whichever is less.

Good to know

  • Question 11 asks for evidence that each ingredient is lawfully marketed and proven safe and effective, that the compound suits the patient, and that no FDA-approved commercial product is appropriate.
  • The assessment asks which commercial products were tried, whether a national drug shortage applies, and whether the compound's route matches the FDA-approved route of its ingredients.
  • Before this form is needed, the pharmacist may remove or replace a failing ingredient, or the prescriber may choose a different drug, which usually takes 15 to 20 minutes.
  • The current version is dated 17 February 2021. If the request is denied, the beneficiary has 90 days to file a formal appeal.

Get the official form

Download the current version from the source each time; forms change without notice.

TRICARE Prior Authorization Request Form for Compounded Medications

Official pagePDF

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.

Frequently asked questions

How long does TRICARE take to approve a compounded medication?

TRICARE says the prior authorization step usually takes about five days after Express Scripts receives all paperwork. The earlier electronic ingredient screen takes seconds, and a pharmacist's ingredient change usually takes 15 to 20 minutes. Approvals last for the proposed duration or one year, whichever is less.

What evidence does the compounded medication form require?

Question 11 asks for evidence that each ingredient is lawfully marketed in the U.S. and proven safe and effective, that the compound is clinically appropriate for the patient, and that an FDA-approved commercial product is not appropriate because the patient needs a unique dosage form or concentration, or for another clinical reason.

Is a separate TRICARE form needed for each compound?

Yes. The form states that one form is required for each compounded product, and Step 2 lists that product's active ingredients. A patient with two different compounded prescriptions therefore needs two completed forms, each signed by the prescriber.