Injectable Medication/Infusion Reference Guide
Injectable medications may be dispensed in a provider’s office or by a home health agency and may require a physician or health care professional’s administration. Under the West Region contract, these injectable drugs may also require prior authorization by TriWest Healthcare Alliance. Please refer to the list of injectable medications requiring prior authorization.
To request prior authorization for the injectable medications listed below, please download the appropriate form from www.triwest.com under the "Find a Form" tab. Please fill out the form completely and legibly and fax it to TriWest at 1-866-269-5892, along with any relevant clinical information.
After review and upon approval, the requesting provider will be faxed an approval letter when TriWest has his/her fax number on file; otherwise the provider will be sent the approval letter by mail. The beneficiary will also be sent an approval letter by mail. Allow five business days for TriWest to process the request. If the prescription is urgent, please mark the authorization request "urgent" and the authorization will be handled promptly.
Most injectable medications are available at an Express Scripts Inc. (ESI) affiliated retail pharmacy under the TRICARE Retail Pharmacy (TRRx) program or the TRICARE Mail Order Pharmacy (TMOP) program.
Please note that covered injectable medications and prior authorization requirements may vary between the TRRx and TMOP programs. If TriWest receives a request for a drug that may be obtained from ESI by way of the TRRx or TMOP programs, the requesting provider will be sent a letter from TriWest directing the provider to contact ESI.
As a reminder, home infusion drugs must now be billed using the appropriate J-code (or J3490 if no J code exists) along with a specific National Drug Code (NDC) for pricing. In addition, the provider should make certain that the units billed represent the units of the NDC. This change requires home infusion drugs to be paid at the lesser of the billed amount or 95% of the average wholesale price (AWP). Contractual discounts may also apply.
| Important Contact Information | Telephone Numbers, Websites |
|---|---|
| TriWest HealthCare Alliance | Call: 1-888-TRIWEST (1-888-874-9378) Fax Forms: 1-866-269-5892 |
| Formulary search tool - Type in the brand name or generic name of the drug, and the tool will indicate if it is available through a retail pharmacy. | Drug Compare for the TRICARE Pharmacy Benefit |
| Formulary Frequently Asked Questions | Frequently Asked Questions on TRICARE Pharmacy |
| Retail Express Scripts (ESI)/ TRICARE Retail Pharmacy (TRRx) |
Call: 1-866-684-4488 doctor's line Fax: 1-866 684-4477 doctor's line http://www.express-scripts.com/TRICARE |
| Mail Order TRICARE Mail Order pharmacy (TMOP) |
Call: 1-877-283-3858 Fax: 1-877-895-1900 http://www.tricare.mil/pharmacy/tmop.cfm |
| Speak to an ESI pharmacist | Call: 1-866-363-8667 |
| Express Scripts Customer Service - for Beneficiaries | Beneficiary Website: http://member.express-scripts.com/dodCustom/welcome.do |