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TRICARE Non-Federal Ceiling Price Retail PA Form

Drug makers must give TRICARE discounted prices on retail prescriptions, and products whose makers decline are placed in a special non-formulary class. A TRICARE patient who fills one of these drugs at a retail network pharmacy without preauthorization pays the full cost. This one-page Express Scripts form lets the prescriber justify retail filling instead of home delivery.

Who completes it

The prescriber completes and signs all three steps: patient and physician details, the drug requested with three clinical questions and an explanation for every Yes, and the certification.

Submitting and payment

How to submit it
For initial review, 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
Without approval the beneficiary pays 100 percent of the cost at a retail pharmacy, but can still get up to a 90-day supply through TRICARE home delivery at the non-formulary cost-share.

Good to know

  • The three questions ask whether formulary agents are contraindicated, whether getting the drug through home delivery would harm the patient, and whether an A-rated generic of a brand product would be detrimental.
  • Active duty service members must still submit the form for initial review even if coverage will not be approved; reconsideration then happens at the appropriate military treatment facility.
  • The form's criteria apply only to retail network pharmacies, not to any other point of service such as home delivery or military pharmacies.
  • The latest revision is dated 27 June 2012, and the form covers prescriptions filled through the TRICARE Retail Pharmacy Program (TRRx).

Get the official form

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

TRICARE Prior Authorization Request Form for Medications Subject to Non-Federal Ceiling Price Requirements Filled at Network Retail Pharmacies

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.

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Frequently asked questions

What is a non-Federal Ceiling Price drug under TRICARE?

A drug whose manufacturer chose not to provide the discounted prices the law requires for DoD beneficiaries' retail prescriptions. Such products can be placed in a special non-formulary class, and patients pay the full cost at retail pharmacies unless the prescriber obtains preauthorization with this form.

Can the patient avoid the full retail cost without this form?

Yes, through home delivery. The beneficiary can fill the prescription through the TRICARE Mail Order Pharmacy, also called Home Delivery, for up to a 90-day supply at the current non-formulary cost-share. The form is for cases where retail filling is needed.

Do active duty members need to submit the non-FCP form?

Yes. Even when coverage will not be approved under the form's criteria, the request for an active duty service member must first go to the TRICARE pharmacy contractor for initial review. Reconsideration is then allowed at the appropriate military treatment facility.