Glossary
Non-Formulary Drugs
Drugs not on the TRICARE preferred list — highest copay tier, often requires Medical Necessity approval.
Also known as: tier 3, non-formulary
Quick answer
Non-formulary drugs are FDA-approved drugs that TRICARE has not placed on the preferred (uniform) formulary, usually because a clinically equivalent formulary alternative exists. They are covered at the highest copay tier and typically require a Medical Necessity submission to access at the lower brand-formulary copay.
Why it matters
Non-formulary status is the single biggest pharmacy cost driver. With a Medical Necessity approval, a non-formulary drug can be repriced to the brand-formulary tier — often saving the beneficiary substantial money each month.
Why this matters at age 65
Newly retired beneficiaries sometimes show up at retail with a non-formulary drug not realizing the cost difference. Run all medications through the formulary search tool before retirement.
When you'll encounter it
When a prescription is denied at point of sale or fills at a much higher copay than expected.
Impact on Medicare
None directly. Some Medicare Part D plans may cover the same drug at a different tier — but switching off TRICARE Pharmacy is rarely the right answer.
Impact on TRICARE For Life
Triggers the highest TRICARE copay tier and frequently requires Medical Necessity. Available only at Home Delivery and retail network — not at MTF.
Impact on Medicare Advantage
An MA-PD plan may place the same drug on a lower tier. Compare per-drug pricing before assuming MA-PD is cheaper.
Military-specific context
Express Scripts publishes Medical Necessity criteria and forms on militaryrx.express-scripts.com. Most prescribers can complete the form in under 10 minutes if the clinical history supports it.
Common misconceptions
- "Non-formulary means TRICARE won't cover it." — Covered — just at the highest tier. Medical Necessity approval drops the cost to the brand-formulary tier.
Common mistakes to avoid
- Paying the non-formulary copay for months without asking the prescriber to file Medical Necessity.
- Switching to a Part D plan to cover one non-formulary drug — usually a worse total outcome.
Real-world scenario: A retiree's rheumatologist prescribes a non-formulary biologic.
First fill is denied at the pharmacy. The rheumatologist's office submits Medical Necessity documentation. Within 72 hours the drug is approved at the formulary tier — copay drops by hundreds per month.
What should I do?
- 1If a drug fills at an unexpectedly high cost, check whether it is non-formulary.
- 2Ask the prescriber to submit Medical Necessity documentation through Express Scripts.
- 3Reassess every 12 months — formulary changes can move drugs back to preferred status.
Questions people commonly ask
- What is Medical Necessity and how do I request it?
- Why is my prescription suddenly more expensive?
Continue learning
— suggested by the knowledge graph- Prescription drug coverage under TRICARE For LifeWhy TFL beneficiaries use TRICARE Pharmacy (Express Scripts), not Medicare Part D — and how the four pharmacy options compare.
- What is TRICARE For Life? The complete guide for retired militaryThe Medicare-wraparound benefit you earned through service — what it covers, who qualifies, what it costs, and how it activates.
- How Medicare and TRICARE For Life work togetherThe exact mechanics of who pays first, who pays second, and what you owe — for every common care scenario.
- Understanding Original Medicare (Parts A & B) for veteransExactly what Part A and Part B cover, what they cost in 2026, and why both are required to keep TRICARE For Life.
- Brand-Name DrugsFDA-approved drugs sold under a manufacturer's proprietary name — middle copay tier on the TRICARE formulary.
- Generic DrugsChemically identical, FDA-approved equivalents of brand-name drugs — the lowest copay tier under TRICARE Pharmacy.
- Non-Network PharmacyA civilian pharmacy that is NOT contracted with Express Scripts — highest cost and usually requires you to pay up front and file a claim.
- TRICARE Home DeliveryTRICARE's mail-order pharmacy through Express Scripts — 90-day supplies of maintenance medications at the lowest retail-equivalent copay.
- TRICARE Retail Network PharmacyCivilian pharmacies (chains and independents) contracted with Express Scripts to fill TRICARE prescriptions at network copays.
- Creditable Drug CoveragePrescription drug coverage that CMS certifies is at least as good as standard Medicare Part D — including TRICARE Pharmacy and VA Pharmacy.
- Express ScriptsThe pharmacy benefit manager that administers the TRICARE Pharmacy Program, including TFL home-delivery and retail-network prescriptions.
- What are the TRICARE Pharmacy copays for retirees?MTF pharmacy: $0. Home Delivery (90-day): low. Retail network (30-day): higher. Non-network: highest and requires a paper claim. Exact amounts adjust annually.
- What if my drug isn't on the TRICARE formulary?Non-formulary drugs cost more. Your doctor can request a medical-necessity exception so it's covered at the formulary copay.
- How much does Medicare Part B cost?Most people pay the standard Part B premium (roughly $185/month in 2026). Higher-income retirees pay IRMAA on top. Lower-income retirees may qualify for help paying it.
- Who pays first, Medicare or TRICARE For Life?Medicare pays first for any service it covers. TFL pays second. The claim usually crosses over automatically — you should never pay out of pocket up front.
- Should I enroll in Medicare Part D?No, for almost every TFL beneficiary. TRICARE Pharmacy (Express Scripts) is creditable coverage and cheaper than most Part D plans. Adding Part D usually costs more without adding benefit.
Related glossary terms
Related Official Resources
Continue learning straight from the source. Every link below goes to an official government or DoD resource.
Last reviewed January 2026 against the 2026 Medicare & You and TRICARE For Life handbooks.