TRICARE Prior (Rx) Authorization Form

A TRICARE prior authorization form is a document to be completed by a prescribing physician requesting a specific type of medication for their patient which is otherwise not covered by their TRICARE plan. TRICARE is a civilian health care program for military personnel and their dependents, therefore the Department of Defense (D0D) only authorizes drug therapy for patients if it is the most effective, efficient, and fiscally responsible option. If the physician believes that a certain brand of medication will help their patients condition, they may choose to prescribe this brand over the generic product. Alternatively, if the physician doubts the capability of a generic or brand-name product, they may choose to request prior authorization for compounded medications. This form is only used if the patient’s condition has not improved after trying generic or commercially-available brands of medications and are seeking alternative treatment. Once filled-in, the TRICARE prior authorization form should be signed and dated by the prescribing physician and faxed (or mailed) to TRICARE for evaluation.

How to Write

Step 1 – Enter the name, address, sponsor ID#, and DoB of the patient. Enter the name, address, phone, and fax numbers of the prescribing physician.

Step 2 – Document the active ingredient(s) in the requested compound medication.

Step 3 – Answer questions (1.) through (5.) involving information concerning the diagnosis, administration, and reasoning for this particular drug prescription. Question number (6.) asks if the patient has tried other treatments; select yes or no. Provide a list of all the medications previously used by the patient in section (7.) if you selected “yes”. Go to number (8.) if you selected “no”.

Step 4 – Question number (8.) asks if the reason for requesting the drug in question is because of a shortage of a commercial product. Answer yes or no.

Step 5 – Question number (9.) asks if the prescribed route of administration matches the FDA-approved route of administration of the compounded ingredients. Answer yes or no.

Step 6 – Section 10 offers space to include any other information to help support your request. Select no if you do not wish to include additional information.

Step 7 – Include additional information in the space provided and attach documents proving that the ingredients in this drug are lawfully marketed in the U.S., that the compound is appropriate for the patient, and that an FDA-approved commercially-available product is not appropriate.

Step 8 – Sign at the bottom and include the current date.