Tip for Express Scripts PA form

Check the TRICARE formulary first at formulary.express-scripts.com/TRICARE

Tip for Express Scripts PA form

Medications filled at the MTF pharmacy have $0 cost — ask if yours is available there

Tip for Express Scripts PA form

TRICARE Home Delivery (mail-order) offers 90-day supplies at lower cost than retail

Military / TRICAREmoderateDoctor signature required

TRICARE Pharmacy Prior Authorization

Express Scripts PA form · Express Scripts (TRICARE pharmacy contractor)

Prior authorization for non-formulary medications or formulary drugs with utilization management requirements under TRICARE.

Form Details

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Where to Submit This Form

🌐

Submitted by the prescribing provider through Express Scripts

https://www.express-scripts.com/TRICARE/

Providers can submit prior authorization requests electronically.

🌐

Call Express Scripts

1-877-363-1303. Providers can call for prior authorization. Beneficiaries call 1-877-885-6242 for questions.

📠

Fax from the prescribing provider to Express Scripts

Fax: 1-877-895-1901

Filing Deadline

Must be approved before filling a non-formulary or restricted medication. Submit before the current prescription runs out.

Required Attachments

📎 Completed prior authorization form from Express Scripts
📎 Prescribing provider's clinical justification for the specific medication
📎 Documentation of previously tried formulary alternatives and results
📎 Relevant lab results or diagnostic information

Processing Time

Standard: 5-10 business days. Expedited/urgent: 24-72 hours.

What Happens Next

Express Scripts will approve or deny the request. If approved, the medication can be filled at any TRICARE pharmacy (MTF, network, or mail-order). If denied, the provider can request reconsideration or appeal.

Tips for This Form

✓ Check the TRICARE formulary first at formulary.express-scripts.com/TRICARE
✓ Medications filled at the MTF pharmacy have $0 cost — ask if yours is available there
✓ TRICARE Home Delivery (mail-order) offers 90-day supplies at lower cost than retail
✓ If denied, ask your provider to submit a clinical appeal with additional documentation

More Military / TRICARE Forms

TRICARE DoD/CHAMPUS Medical Claim

DD Form 2642 · Department of Defense

TRICARE medical claim form for beneficiaries seeking reimbursement when providers do not file claims directly. Must attach itemized bill on provider letterhead. Used by active duty, retirees, and family members.

TRICARE Enrollment (milConnect/DEERS)

Online enrollment · Defense Health Agency

Enrollment in TRICARE plan options (Prime, Select, etc.) through milConnect or DEERS update. Requires valid military ID.

DEERS Enrollment Application

DD Form 1172-2 · Department of Defense

Application for Department of Defense Common Access Card (CAC) or DEERS Enrollment. Establishes beneficiary status for TRICARE eligibility.

TRICARE Referral / Pre-Authorization Request

Contractor-specific · TRICARE managed care contractors

Referral or prior authorization for specialty care, certain procedures, and medications under TRICARE Prime. Not required for TRICARE Select.

Post-Deployment Health Assessment

DD Form 2796 · Department of Defense

Post-Deployment Health Assessment completed by service members within 30 days of returning from deployment. Screens for deployment-related health concerns including mental health, environmental exposures, and injuries.

Post-Deployment Health Reassessment

DD Form 2900 · Department of Defense

Post-Deployment Health Reassessment completed 90-180 days after return from deployment. Follow-up screening for emerging health issues including PTSD, TBI, and other delayed-onset conditions.

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Disclaimer: BeneFill™ provides form-filling assistance and informational guidance only. It is not affiliated with, endorsed by, or sponsored by the Express Scripts (TRICARE pharmacy contractor) or any government agency. The information provided is for general informational purposes and does not constitute legal, medical, financial, or tax advice. Always verify form requirements and submission details directly with the issuing agency.