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  • Brand Over Generic Prior Authorization Request Form

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Brand over Generic Prior Authorization Request Form To be completed and signed by the prescriber. To be used only for prescriptions which are to be filled through the Department of Defense (DoD) TRICARE.

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Prior authorization ensures that you get the prescription drug that is right for you and that is covered by your benefit. If it's determined that your plan doesn't cover the drug you were prescribed, you can ask your doctor about getting another prescription that is covered.

Humana Military, Health Net Federal Services, and International SOS Assistance extended some already-approved referrals and authorizations that expire(d) between March 1, 2020 and June 30, 2020. This automatic extension is for an extra 180 days from the expiration date. You don't need to take action.

DD FORM 2876, JUL 2016 PREVIOUS EDITION IS OBSOLETE. TRICARE PRIME OPTION DESIRED: TRICARE Prime: Active duty service members have to enroll in TRICARE Prime. (Enrollment is not automatic.)

A: You can contact your PCM. Your PCM will then work with your TRICARE contractor for the referral and/or authorization. Your contractor will try to refer you to a military hospital or clinic first. If that option isn't available, the contractor will refer you to a network provider in your region.

East: Humana Military (1-800-444-5445) West: Health Net (1-844-866-9378) USFHP: Brighton Marine Health Center (1-800-818-8589) CHRISTUS Health (1-800-678-7347) Johns Hopkins Medicine (1-800-808-7347) Martin's Point Health Care (1-888-674-8734)

All Other Beneficiaries Enrolled in a TRICARE Prime Plan You must have prior authorization for all specialty care. Your primary care manager gets your referral and prior authorization at the same time.

To view or check the status of a referral or authorization: Go to your regional contractor's website. If not already registered for secure services, you'll need to register first, then sign in.

Search for your drug on the TRICARE Formulary Search Tool. Download and print the form for your drug. Give the form to your provider to complete and send back to Express Scripts. Instructions are on the form. ... Your authorization approval will apply to network pharmacies and home delivery.

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© Copyright 1997-2025
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232