Formulary Information- TRICARE Uniform Formulary Changes


This page is intended to provide MTFs with a single jumping off point for Uniform Formulary (UF) information, including changes to the Basic Core Formulary (BCF) and Extended Core Formulary (ECF). The table below provides links to multiple resources, organized by DoD P&T Committee meeting date and drug class. A list of definitions and timelines is available at the bottom of this page.

Nov 09 - Aug 09 - May 09 - Feb 09 - Nov 08 - Aug 08 - Jun 08 - Feb 08 - Nov 07 - Aug 07 - May 07 - Feb 07 - Nov 06 - Aug 06 - May 06 - Feb 06 - Nov 05 - Aug 05 - May 05 - Feb 05  -  Jul 04

Table of Uniform Formulary Decisions (including changes to the BCF & ECF)
Meeting Date
Drug or
Drug Class
Decision Date
Type of Action
Action
Resources / Comments
Nov 09 MS-DMDs

Interferon Beta-1b (Extavia)
  Recently FDA-Approved Agents
ECF
UF not ECF
NF
MTFs must have on formulary*
MTFs may have on formulary
MTFs must not have on formulary

interferon beta-1a IM (Avonex)

glatiramer (Copaxone)

interferon beta-1a SQ (Rebif)

interferon beta-1b (Betaseron)

Interferon Beta-1b (Extavia)

TRICARE Pharmacy Forms and Criteria page

Nov 09 Antidepressant-1 Agents

Bupropion HBr ER (Aplenzin)

Milnacipran (Savella)

Bupropion HCL ER (Wellbutrin XL)
  Recently FDA-Approved Agents
BCF
UF not BCF
NF
MTFs must have on formulary*
MTFs may have on formulary
MTFs must not have on formulary

bupropion SR (Wellbutrin SR)

citalopram (Celexa)

fluoxetine (generic)

sertraline (Zoloft)

trazodone (Desyrel)

Fluvoxamine (Luvox)

mirtazapine (Remeron)

nefazodone (Serzone)

paroxetine IR (Paxil)

venlafaxine IR/ER (Effexor, Effexor XR)

venlafaxine ER (Venlafaxine Extended Release)

bupropion HCL ER (Wellbutrin XL)

duloxetine (Cymbalta)

escitalopram (Lexapro)

fluoxetine 90-mg capsules (Prozac Weekly)

fluoxetine (Sarafem)

paroxetine CR (Paxil CR)

desvenlafaxine (Pristiq)

bupropion HBr ER (Aplenzin)

Milnacipran (Savella)


  • Bupropion HBr ER (Aplenzin) is approved for the treatment of major depressive disorder
  • Milnacipran (Savella) is an SNRI approved for the treatment of fibromyalgia
  • Bupropion HCL ER (Wellbutrin XL) was moved to UF (Nov 09 meeting)
  • TRICARE Pharmacy Forms and Criteria page

    Nov 09 Overactive Bladder Drugs (OAB)

    Oxybutynin topical gel (Gelnique)
      Recently FDA-Approved Agents
    BCF
    UF not BCF
    NF
    MTFs must have on formulary*
    MTFs may have on formulary
    MTFs must not have on formulary

    tolterodine SR (Detrol LA)

    oxybutynin SR (Ditropan XL)

    solifenacin (Vesicare)

    darifenacin (Enablex)

    oxybutynin IR

    tolterodine IR (Detrol)

    oxybutynin patch (Oxytrol)

    trospium (Sanctura)

    fesoterodine ER (Toviaz)

    oxybutynin topical gel (Gelnique)

    TRICARE Pharmacy Forms and Criteria page

    Nov 09 Narcotic analgesics

    Tapentadol (Nucynta)

    Tramadol ER (Ryzolt)

    Hydrocodone/Acetaminophen 5mg/500mg
      Recently FDA-Approved Agents

    BCF Change
    BCF
    UF not BCF
    NF
    MTFs must have on formulary*
    MTFs may have on formulary
    MTFs must not have on formulary

    High potency (Schedule II) single analgesic agents
    morphine sulfate 12-hour ER (MS Contin or generics) 15, 30, and 60 mg morphine sulfate IR 15 and 30 mg

    High potency (Schedule II) combos
    oxycodone / APAP 5/325 mg

    Lower potency single analgesic agents
    tramadol IR 50 mg

    Lower potency combos
    codeine/APAP 30/300 mg codeine/APAP elixir 12/120 mg per 5 mL

    High potency (Schedule II) single analgesic agents
    codeine fentanyl transdermal, transmuosal, buccal tablets
    hydromorphone
    levorphanol
    meperidine
    methadone
    morphine products (other than BCF selections)
    opium tincture opium/belladonna alkaloids (suppositories)
    oxycodone
    oxymorphone

    High potency (Schedule II) combos
    oxycodone/ASA
    oxycodone/APAP other than BCF selections

    Lower potency single analgesic agents
    buprenorphine injection
    butorphanol
    pentazocine/naloxone
    propoxyphene
    nalbuphine

    Lower potency combos
    codeine / APAP (other than BCF selections)
    codeine / ASA
    codeine / ASA / carisoprodoll
    codeine / caffeine / butalbital / APAP or ASA
    dihydrocodeine / caffeine / APAP or ASA
    hydrocodone / APAP (other than BCF selections)
    pentazocine / APAP propoxyphene / APAP
    propoxyphene / ASA / caffeine
    tramadol / APAP

    hydrocodone / APAP 5/500 mg

    High potency (Schedule II) single analgesic agents
    Tapentadol (Nucynta)

    Lower potency single analgesic agents
    tramadol ER (Ultram ER)
    tramadol ER (Ryzolt)


  • Hydrocodone / APAP 5/500mg was removed from BCF (Nov 09 meeting)
  • TRICARE Pharmacy Forms and Criteria page

    Nov 09 Renin-Angiotensin Antihypertensives (RAAs)

    Valsartan/amlodipine/hydrochlorothiazide (Exforge HCT)
      Recently FDA-Approved Agents
    BCF
    UF not BCF
    NF
    MTFs must have on formulary*
    MTFs may have on formulary
    MTFs must not have on formulary

    -

    valsartan/amlodipine/
    hydrochlorothiazide
    (Exforge HCT)

    irbesartan, eprosartan, olmesartan, valsartan and their HCTZ combinations (May 07)

    felodipine/enalapril (Lexxel) & verapamil/trandolapril (Tarka) (Feb 06)

    moexipril +/HCTZ, quinapril +/HCTZ, perindopril, ramipril (Aug 05)

    valsartan/amlodipine (Nov 07)


  • The DoD P&T Committee has reclassified ACE inhibitors, ACEI./CCB combinations, ARBs, ARB/CCB combinations, and newly approved drugs affecting the renin system into the RAA class.
  • TRICARE Pharmacy Forms and Criteria page

    Nov 09 Phosphodiesterase-5 (PDE-5) Inhibitors for Pulmonary Arterial Hypertension (PAH)   Drug Class Review
    BCF
    UF not BCF
    NF
    MTFs must have on formulary*
    MTFs may have on formulary
    MTFs must not have on formulary

    -

    sildenafil (Revatio)

    tadalafil (Adcirca)


  • PA is required for both sildenafil (Revatio) and tadalafil (Adcirca)
  • TRICARE Pharmacy Forms and Criteria page

    Nov 09 Contraceptives

    levonorgestrel 0.75mg (Next Choice; generic Plan B)
      BCF change
    BCF
    UF not BCF
    NF
    MTFs must have on formulary*
    MTFs may have on formulary
    MTFs must not have on formulary

    EE 20 mcg; 3 mg drospirenone (Yaz)
    EE 20 mcg; 0.1 mg levonorgestrel (Alesse, Levlite or equivt)
    EE 30 mcg; 3 mg drospirenone (Yasmin)
    EE 30 mcg; 0.15 mg levonorgestrel (Nordette or equiv; excludes Seasonale)
    EE 35 mcg; 1.0 mg norethindrone (Ortho-Novum 1/35 or equiv)
    EE 35 mcg; 0.25 mg norgestimate (Ortho-Cyclen or equiv)
    EE 25 mcg; 0.18/0.215/0.25 mg norgestimate (Ortho Tri-Cyclen Lo) EE 35 mcg; 0.18/0.215/0.25 mg norgestimate (Ortho Tri-Cyclen or equiv)
    0.35 mg norethindrone (Nor-QD, Micronor or equiv)

    0.75 mg levonorgestrel (Next Choice; generic Plan B)

    EE 20 mcg; 1.0 mg norethindrone
    EE 20 mcg; 1.0 mg norethindrone; ferrous fumarate
    EE 30 mcg; 0.3 mg norgestrel
    EE 30 mcg; 0.15 mg desogestrel
    EE 30 mcg; 1.5 mg norethindrone
    EE 30 mcg; 1.5 mg norethindrone; ferrous fumarate
    EE 35 mcg; 0.5 mg norethindrone
    EE 35 mcg; 1.0 mg ethynodiol diacetate
    Mestranol 50 mcg; 1 mg norethindrone
    EE 50 mcg; 1 mg ethynodiol diacetate
    EE 50 mcg; 0.5 mg norgestrel
    EE 35 mcg; 0.5/1.0 mg norethindrone
    EE 20/10 mcg; 0.15 mg desogestrel
    EE 30/40/30 mcg; 0.05/0.075/0.125 mg levonorgestrel
    EE 35 mcg; 0.5/1/0.5 mg norethindrone
    EE 35 mcg; 0.5/0.75/1 mg norethindrone
    EE 25 mcg; 0.1/0.125/0.15 mg desogestrel
    EE; norelgestromin transdermal (Ortho-Evra)
    EE; etonorgestrel vaginal ring (Nuvaring)
    104 mg/ 0.65mL depot medroxyprogesterone acetate injection (Depo-subq Provera 104)
    150 mg/mL depot medroxyprogesterone acetate injection
    1.5 mg levonorgestrel (Plan B One Step)

    EE 30 mcg; levonorgestrel 0.15 mg in special packaging for extended cycle use (Seasonale & equivalents, e.g., Jolessa, Quasense)
    EE 35 mcg; 0.4 mg norethindrone (Ovcon 35)
    EE 50 mcg; 1 mg norethindrone (Ovcon 50)
    EE 20/30/35 mcg; norethindrone 1 mg (Estrostep Fe)


  • The current qty limits of one fill per prescription with no refills remain for levonorgestrel 0.75mg (Next Choice;generic Plan B) and levonorgestrel 1.5mg (Plan B One Step)
  • TRICARE Pharmacy Forms and Criteria page

    Nov 09 Angiotensin Receptor Blockers (ARBs)

    telmisartan +/HCTZ (Micardis, Micardis HCT)
      BCF Change
    BCF
    UF not BCF
    NF
    MTFs must have on formulary*
    MTFs may have on formulary
    MTFs must not have on formulary

    -

    candesartan +/HCTZ (Atacand, Atacand HCT)

    losartan +/HCTZ (Cozaar, Hyzaar)

    telmisartan +/HCTZ (Micardis, Micardis HCT)

    irbesartan +/HCTZ (Avapro, Avalide)

    eprosartan +/HCTZ (Teveten, Teveten HCT)

    olmesartan +/HCTZ (Benicar, Benicar HCT)

    valsartan +/HCTZ (Diovan, Diovan HCT)


  • telmisartan +/HCTZ (Micardis, Micardis HCT) was removed from BCF (Nov 09 meeting)
  • TRICARE Pharmacy Forms and Criteria page

    Aug 09 Targeted Immunomodulatory Biologic (TIBs)

    golimumab (Simponi)
    21 Oct 09 Recently FDA-Approved Agents
    ECF
    UF not BCF
    NF
    MTFs must have on formulary*
    MTFs may have on formulary
    MTFs must not have on formulary

    adalimumab (Humira)

    alefacept (Amevive)

    anakinra (Kineret)

    etanercept (Enbrel)

    golimumab (Simponi)

    certolizumab (Cimzia)


  • No change to existing PA requirements for all TIB
  • No change to existing quantity limits for adalimumab (Humira), anakinra (Kineret), and etanercept (Enbrel)
  • See quantity limits for golimumab and certolizumab below
  • Efalizumab (Raptiva) removed from market in June 2009, no longer UF
  • TRICARE Pharmacy Forms and Criteria page

    Aug 09 Targeted Immunomodulatory Biologic (TIBs)

    certolizumab (Cimzia)
    21 Oct 09 Recently FDA-Approved Agents See Above

    TRICARE Pharmacy Forms and Criteria page

    Aug 09 BPH alpha blockers

    silodosin (Rapaflo)
    21 Oct 09 Recently FDA-Approved Agents
    BCF
    UF not BCF
    NF
    MTFs must have on formulary*
    MTFs may have on formulary
    MTFs must not have on formulary

    alfuzosin (Uroxatral)

    terazosin

    doxazosin

    tamsulosin (Flomax)

    silodosin (Rapaflo)


  • Trial of alfuzosin required for new starts (no alfuzosin, silodosin or tamsulosin prescription in last 180 days). Effective date 16 Apr 08 for tamsulosin; effective date 30 Dec 09 for silodosin
  • TRICARE Pharmacy Forms and Criteria page

    Aug 09 Narcolepsy/ADHD Agents

    armodafinil (Nuvigil)
    21 Oct 09 Recently FDA-Approved Agents
    BCF
    UF not BCF
    NF
    MTFs must have on formulary*
    MTFs may have on formulary
    MTFs must not have on formulary

    methylphenidate IR (Ritalin, Methylin, generics)

    methylphenidate ER tablets (Concerta)

    mixed amphetamine salts, ER (Adderall XR; generics)

    ADHD agents atomoxetine (Strattera)

    methylphenidate ER (Metadate CD, Ritalin LA, Methylin ER)

    mixed amphetamine salts, IR (Adderall, generics)

    dextroamphetamine IR and ER (Dexedrine, Dexedrine spansule, Dextrostat, generics)

    methamphetamine (Desoxyn)

    Narcolepsy agents modafinil (Provigil)

    armodafinil (Nuvigil)

    sodium oxybate (Xyrem)

    dexmethylphenidate IR and ER (Focalin, Focalin XR)

    methylphenidate patch (Daytrana)

    lisdexamfetamine dimesylate (Vyvanse)


  • PA required for modafinil and armodafinil. PAs will have 1 year expiration.
  • TRICARE Pharmacy Forms and Criteria page

    Aug 09 PDE-5 Inhibitors

    Addition of Step Therapy and addition of vardenafil to the BCF (previously was an ECF drug class).
    21 Oct 09 Drug Class Review
    BCF
    UF not BCF
    NF
    MTFs must have on formulary*
    MTFs may have on formulary
    MTFs must not have on formulary

    vardenafil (Levitra)

    -

    sildenafil (Viagra)

    tadalafil (Cialis)


  • No change to gender restrictions
  • PA required for males under 40 years of age for organic erectile dysfunction. Effective date 30 Dec 2009
  • Trial of vardenafil is required for new starts (no sildenafil, tadalafil or vardenafil prescription in last 180 days) Effective date 30 Dec 2009
  • TRICARE Pharmacy Forms and Criteria page

    Aug 09 Targeted Immunomodulatory Biologics (TIBs) 21 Oct 09 Quantity Limits
    Point of Service / Notes Adalimumab (Humira) Etanercept (Enbrel) Anakinra (Kineret) Alefacept (Amevive) Efalizumab (Raptiva) Golimumab (Simponi) Certolizumab (Cimzia)
    Retail Network 4 wks supply (2 packs of 2 syringes) 4 wks supply (based on instructions for use) 4 wks supply (1 pack of 28 syringes) 4 wks supply (1 pack 4 syringes) 4 wks supply (6 syringes) 4 wk supply (1 autoinjector) 4wk supply (3 packs of 2 syringes*)
    TMOP 8 wks supply (4 packs of 2 syringes) 8 wks supply (based on instructions for use) 8 wks supply (2 packs of 28 syringes) Not supplied through TMOP 8 wks supply (12 syringes) 8 wk supply (2 autoinjector) 8wk supply (3 packs of 2 syringes)
    Other Issues Crohns disease starter pack includes 6 pens for 1st 4 wks, no refills -- -- -- Not to exceed 200 mg/week 8 vials/ 4 wks 16 vials/ 8 wks   * accounts for loading dose

    TRICARE Pharmacy Forms and Criteria page

    Aug 09 Mometasone 110 mcg (Asmanex Twisthaler) 21 Oct 09 Quantity Limits

    Quantity Limit:
    Retail: 2 inhalers/30 days
    Mail Order: 6 inhalers/90 days

    TRICARE Pharmacy Forms and Criteria page

    Aug 09 Fluticasone 50. 100, and 250mcg (Flovent Diskus) 21 Oct 09 Quantity Limits

    Quantity Limit:
    Retail: 1 inhaler/30 days
    Mail Order: 3 inhalers/90 days

    TRICARE Pharmacy Forms and Criteria page

    Aug 09 Fluoxetine 90mg (Prozac Weekly) 21 Oct 09 Quantity Limits

    Quantity Limit:
    Retail: 4 caps /28 days
    Mail Order: 12 caps/84 days

    TRICARE Pharmacy Forms and Criteria page

    Aug 09 Tramadol ER tab 100,200, and 300mg (Ryzolt) 21 Oct 09 Quantity Limits

    Quantity Limit:
    Retail: 30 tabs /30 days
    Mail Order: 90 tabs/90 days

    TRICARE Pharmacy Forms and Criteria page

    May 09 Antiemetics

    granisetron patch (Sancuso)
    17 Aug 09 Recently FDA-Approved Agents
    BCF
    UF not BCF
    NF
    MTFs must have on formulary*
    MTFs may have on formulary
    MTFs must not have on formulary

    promethazine (oral and rectal)

    Granisetron (Kytril)

    ondansetron (Zofran)

    dronabinol (Marinol)

    meclizine (Antivert)

    prochlorperazine (Compazine)

    scopolamine

    thiethylperazine

    trimethobenzamide

    nabilone (Cesamet)

    aprepitant (Emend)

    dolasetron (oral) (Anzemet)

    granisetron patch (Sancuso)

    TRICARE Pharmacy Forms and Criteria page

    May 09 Antidepressant-1 Agents

    venlafaxine ER (Venlafaxine Extended Release)
    17 Aug 09 Recently FDA-Approved Agents
    BCF
    UF not BCF
    NF
    MTFs must have on formulary*
    MTFs may have on formulary
    MTFs must not have on formulary

    bupropion SR (Wellbutrin SR)

    citalopram (Celexa)

    fluoxetine (generic)

    sertraline (Zoloft)

    trazodone (Desyrel)

    Fluvoxamine (Luvox)

    mirtazapine (Remeron)

    nefazodone (Serzone)

    paroxetine IR (Paxil)

    venlafaxine IR/ER (Effexor, Effexor XR)

    venlafaxine ER (Venlafaxine Extended Release)

    bupropion ER (Wellbutrin XL)

    duloxetine (Cymbalta)

    escitalopram (Lexapro)

    fluoxetine 90-mg capsules (Prozac Weekly)

    fluoxetine (Sarafem)

    paroxetine CR (Paxil CR)

    desvenlafaxine (Pristiq)

    TRICARE Pharmacy Forms and Criteria page

    May 09 Proton Pump Inhibitors (PPI)

    dexlansoprazole DR(Kapidex)
    17 Aug 09 Recently FDA-Approved Agents
    BCF
    UF not BCF
    NF
    MTFs must have on formulary*
    MTFs may have on formulary
    MTFs must not have on formulary

    omeprazole (generic

    omeprazole; excludes Prilosec 40 mg)

    esomeprazole (Nexium)

    omeprazole (Prilosec 40 mg)

    lansoprazole (Prevacid)

    omeprazole/sodium bicarbonate (Zegerid)

    pantoprazole (Protonix)

    rabeprazole (Aciphex)

    dexlansoprazole DR(Kapidex)

    TRICARE Pharmacy Forms and Criteria page

    May 09 Nasal Allergy Drugs (NADs)

    azelastine sucralose (Astepro)
    17 Aug 09 Recently FDA-Approved Agents
    BCF
    UF not BCF
    NF
    MTFs must have on formulary*
    MTFs may have on formulary
    MTFs must not have on formulary

    fluticasone propionate (generics)

    azelastine (Astelin)

    mometasone furoate (Nasonex)

    flunisolide (Nasarel, generics),

    ipratroprium nasal spray (Atrovent nasal)

    beclomethasone dipropionate (Beconase AQ),

    budesonide (Rhinocort Aqua),

    ciclesonide (Omnaris)

    fluticasone furoate (Veramyst),

    olopatadine HCI (Patanase),

    triamcinolone acetonide (Nasacort AQ)

    azelastine sucralose (Astepro)

    TRICARE Pharmacy Forms and Criteria page

    May 09 Overactive Bladder Drugs (OAB)

    fesoterodine ER (Toviaz)
    17 Aug 09 Recently FDA-Approved Agents
    BCF
    UF not BCF
    NF
    MTFs must have on formulary*
    MTFs may have on formulary
    MTFs must not have on formulary

    oxybutynin IR

    tolterodine SR (Detrol LA)

    oxybutynin SR (Ditropan XL)

    solifenacin (Vesicare)

    darifenacin (Enablex)

    tolterodine IR (Detrol)

    oxybutynin patch (Oxytrol)

    trospium (Sanctura)

    fesoterodine ER (Toviaz)

    TRICARE Pharmacy Forms and Criteria page

    May 09 Antilipidemic-II Agents (LIP-2)

    fenofibrate acid(Trilipix)
    17 Aug 09 Recently FDA-Approved Agents
    BCF
    UF not BCF
    NF
    MTFs must have on formulary*
    MTFs may have on formulary
    MTFs must not have on formulary

    fenofibrate meltdose (Fenoglide)

    gemfibrozil

    fenofibrate IDD-P (Triglide)

    non-micronized fenofibrate (Lofibra, generics)

    micronized fenofibrate (Lofibra, generics; excludes Antara)

    cholestyramine/ aspartame & cholestyramine/sucrose (Questran, Questran Light, generics)

    colestipol (Colestid, generics)

    fenofibrate nanocrystallized (Tricor)

    fenofibrate micronized (Antara)

    omega-3 fatty acids (Omacor)

    colesevelam (Welchol)

    fenofibrate acid(Trilipix)

    TRICARE Pharmacy Forms and Criteria page

    May 09 ondansetron (Zofran) 24 mg tablets 17 Aug 09 Quantity Limits

    Quantity Limit:
    Retail: 1 tab/ RX
    Mail Order: 3 tab/ RX

    TRICARE Pharmacy Forms and Criteria page
    May 09 dasatinib (Sprycel) 100 mg tablets 17 Aug 09 Quantity Limits

    Quantity Limit:
    Retail: 60 caps/30 days
    Mail Order: 90 caps/45 days

    TRICARE Pharmacy Forms and Criteria page
    May 09 budesonide (Pulmicort Respules) nebulizer soln 1 mg/ml 17 Aug 09 Quantity Limits

    Quantity Limit:
    Retail: 60ml (30 ampules)/30 days
    Mail Order: 180ml (90 ampules)/90 days

    TRICARE Pharmacy Forms and Criteria page
    May 09 cromolyn (Intal) inhaler 8.1 gm 17 Aug 09 Quantity Limits

    Quantity Limit:
    Retail: 3 inhalers/30 days
    Mail Order: 9 inhalers/90 days

    TRICARE Pharmacy Forms and Criteria page
    May 09 azelastine (Astelin) nasal spray 17 Aug 09 Quantity Limits

    Quantity Limit:
    Retail: 2 bottles/30 days
    Mail Order: 6 bottles/90 days

    TRICARE Pharmacy Forms and Criteria page
    May 09 azelastine with sucralose (Astepro) nasal spray 17 Aug 09 Quantity Limits

    Quantity Limit:
    Retail: 2 bottles/30 days
    Mail Order: 6 bottles/90 days

    TRICARE Pharmacy Forms and Criteria page
    May 09 metaproterenol nebulizer solution 17 Aug 09 Quantity Limits

    Quantity Limit:
    Retail: 200 amps/30 days
    Mail Order: 600 amps/90 day

    TRICARE Pharmacy Forms and Criteria page
    May 09 ipratropium/albuterol (Combivent) inhaler 14.7 gm 17 Aug 09 Quantity Limits

    Quantity Limit:
    Retail: 2 inhaler/30 days
    Mail Order: 6 inhaler/90 days

    TRICARE Pharmacy Forms and Criteria page
    May 09 methylnaltrexone SQ Injection (Relistor) 17 Aug 09 Quantity Limits

    Quantity Limit:
    Retail and Mail Order: no refills

    TRICARE Pharmacy Forms and Criteria page
    May 09 fentanyl citrate buccal lozenges (Actiq) 17 Aug 09 Advisory Edit

    Fentanyl citrate buccal lozenges (Actiq) added to the fentanyl patch advisor edit for strong opioid nave patients.

     
    May 09 fentanyl citrate buccal tablets (Fentora) 17 Aug 09 Advisory Edit

    Fentanyl citrate buccal tablets (Fentora) added to the fentanyl patch advisor edit for strong opioid nave patients

     
    Feb 09 Self-Monitored Blood Glucose System (SMBGS) 12 May 09 Recently FDA-Approved Agents TRUE test strips: No change in BCF or NF items

    BCF
    UF not BCF
    NF
    MTFs must have on formulary*
    MTFs may have on formulary
    MTFs must not have on formulary

    Precision Xtra

    Accu-check Aviva
    Freestyle Lite
    Ascensia Contour
    TRUE test

    All others

    TRICARE Pharmacy Forms and Criteria page

    Feb 09 Pulmonary I Agents - Inhaled Corticosteroids (ICS) 12 May 09 Drug Class Review
    BCF
    UF not BCF
    NF
    MTFs must have on formulary*
    MTFs may have on formulary
    MTFs must not have on formulary

    fluticasone DPI (Flovent Diskus)
    fluticasone HFA MDI (Flovent HFA)
    mometasone DPI (Asmanex Twisthaler)

    budesonide inhalation solution (Pulmicort respules, generic)

    Beclomethasone HFA MDI (Qvar)
    budesonide DPI (Pulmicort Flexhaler)
    ciclesonide HFA MDI (Alvesco)
    flunisolide CFC MDI (Aerobid, Aerobid M)
    triamcinolone CFC MDI (Azmacort)

    TRICARE Pharmacy Forms and Criteria page

    Feb 09 Pulmonary I Agents - Long-Acting Beta Agonists (LABAs) 12 May 09 Drug Class Review
    BCF
    UF not BCF
    NF
    MTFs must have on formulary*
    MTFs may have on formulary
    MTFs must not have on formulary

    salmeterol DPI (Serevent Diskus)
    albuterol inhalant solution generic

    formoterol DPI (Foradil Aerolizer)
    arformoterol inhalation solution (Brovana)

    formoterol inhalation solution (Perforomist)

    TRICARE Pharmacy Forms and Criteria page

    Feb 09 Pulmonary I Agents - Inhaled Corticosteroid/Long-Acting Beta Agonist Combinations (ICS/LABA Combinations) 12 May 09 Drug Class Review
    BCF
    UF not BCF
    NF
    MTFs must have on formulary*
    MTFs may have on formulary
    MTFs must not have on formulary

    fluticasone/salmeterol DPI (Advair Diskus)
    fluticasone/salmeterol HFA (Advair HFA)

    budesonide/formoterol (Symbicort)

    No NF ICS/LABA combinations

    TRICARE Pharmacy Forms and Criteria page

    Feb 09 Nasal Allergy Drugs 12 May 09 Quantity Limits

    ciclesonide (Omnaris ) Quantity Limit:
    Retail: 2 bottles/30 days
    Mail Order: 6 bottles/90 days

    TRICARE Pharmacy Forms and Criteria page
    Feb 09 Nasal Allergy Drugs 12 May 09 Quantity Limits

    olopatadine (Patanase) Quantity Limit:
    Retail: 2 bottles/30 days
    Mail Order: 6 bottles/90 days

    TRICARE Pharmacy Forms and Criteria page
    Feb 09 Pulmonary I Agents - Inhaled Corticosteroid/Long-Acting Beta Agonist Combinations (ICS/LABA Combinations) 12 May 09 Quantity Limits

    fluticasone/salmeterol Oral HFA MDI (Advair HFA ) Quantity Limit:
    Retail: 1 inhaler/30 days
    Mail Order: 3 inhalers/90 days

    TRICARE Pharmacy Forms and Criteria page
    Nov 08 Short-Acting Beta Agonists (SABAs) 02 Feb 09 Drug Class Review
    BCF
    UF not BCF
    NF
    MTFs must have on formulary*
    MTFs may have on formulary
    MTFs must not have on formulary

    albuterol HFA (Ventolin HFA),
    albuterol inhalant solution generic (does not include brand Accuneb) and 0.5% (2.5 mg/0.5mL multi-dose vial)

    albuterol HFA (Proventil HFA,
    Proair HFA), levalbuterol HAF
    (Xopenex HFA), levalbuterol
    nebulizer solution (Xopenex),
    albuterol nebulizer solution
    (Accuneb)

    pirbuterol inhaler
    (Maxair), metaproterenol
    inhaler, metaproterenol
    nebulizer solution

    TRICARE Pharmacy Forms and Criteria page

    Nov 08 Nasal Allergy Drugs (NADS) 02 Feb 09 Drug Class Review
    BCF
    UF not BCF
    NF
    MTFs must have on formulary*
    MTFs may have on formulary
    MTFs must not have on formulary

    fluticasone propionate (generics),
    azelastine (Astelin)

    mometasone furoate
    (Nasonex), flunisolide
    (Nasarel, generics),
    ipratroprium nasal spray
    (Atrovent nasal)

    beclomethasone dipropionate
    (Beconase AQ), budesonide
    (Rhinocort Aqua), ciclesonide
    (Omnaris), fluticasone
    furoate (Veramyst),
    olopatadine HCI (Patanase),
    and triamcinolone acetonide
    (Nasacort AQ)

    TRICARE Pharmacy Forms and Criteria page

    Nov 08 Antiemetics 02 Feb 09 Utilization Management

    palonsetron (Aloxi) quantity limit established as 1 capsule/fill in TRRx and TMOP
    granisetron transdermal (Sancuso Patch) quantity limit established as 1 patch/fill in TRRx and TMOP

     
    Nov 08 Pulmonary I Agents Inhaled Corticosteroids 02 Feb 09 Utilization Management

    ciclesonide (Alvesco) quantity limit established as 2 inhalers/30 days in TRRx; 6 inhalers/90 days in TMOP

     
    Nov 08 Renin-Angiotensin Antihypertensives 02 Feb 09 Non-Formulary Agents for Re-Evaluation

    Ramipril reclassified as generic on the UF. No longer Non-formulary.

     
    Aug 08 Antidepressant-1 24 Oct 08 New Drug Review

    desvenlafaxine (Pristiq) Designated as non-formulary under UF

    MTFs must not have on formulary effective: 07 Jan 09 (60 days)
    NF designation and retail/mail copay changes effective: 07 Jan 09 (60 days)

    Formulary management sheet

    MN Criteria (TRICARE Pharmacy site)
    Aug 08 Calcium Channel Blockers 24 Oct 08 New Drug Review

    nisoldipine (Sular geomatrix) Designated as non-formulary under UF

    MTFs must not have on formulary effective: 07 Jan 09 (60 days)
    NF designation and retail/mail copay changes effective: 07 Jan 09 (60 days)

    Formulary management sheet

    MN Criteria (TRICARE Pharmacy site)
    Aug 08 Overactive Bladder Agents 24 Oct 08 Drug Class Review
    BCF
    UF not BCF
    NF
    MTFs must have on formulary*
    MTFs may have on formulary
    MTFs must not have on formulary

    oxybutynin ER (Ditropan XL, generics)
    tolterodine ER (Detrol LA)

    darifenacin (Enablex)
    oxybutynin IR (Ditropan, generics)
    oxybutynin patch (Oxytrol)
    solifenacin (Vesicare)
    tolterodine ER (Detrol LA)
    trospium ER (Sanctura XR)

    tolterodine IR (Detrol)
    trospium IR (Sanctura)

    MN Criteria (TRICARE Pharmacy site)

    MN form (Word version) posted on RxNet for MTF use

    MN form (PDF version) on TRICARE Pharmacy site

    BCF listing

    Aug 08 Self-Monitoring Blood Glucose Test Systems Test Strips 24 Oct 08 Drug Class Review See Feb 09 Formulary management sheet
    Aug 08 Antiemetics 24 Oct 08 Utilization Management

    Odansetron oral tablets. QL changed to 60 tablets per 30 days or 180 tablets per 90 days.

    TRICARE Pharmacy Forms and Criteria page
    Jun 08 Antilipidemic Agents II

    27 Aug 08

    New Drug Review
    BCF
    UF not BCF
    NF
    MTFs must have on formulary*
    MTFs may have on formulary
    MTFs must not have on formulary

    fenofibrate meltdose (Fenoglide)

    gemfibrozil

    fenofibrate IDD-P (Triglide)
    non-micronized fenofibrate (Lofibra, generics)
    micronized fenofibrate (Lofibra, generics; excludes Antara)
    cholestyramine/ aspartame & cholestyramine/sucrose (Questran, Questran Light, generics)
    colestipol (Colestid, generics)

    fenofibrate nanocrystallized (Tricor)

    fenofibrate micronized (Antara)

    omega-3 fatty acids (Omacor)

    colesevelam (Welchol)

    Formulary management sheet

    MN Criteria (TRICARE Pharmacy site)

    MN form (Word version) posted on RxNet for MTF use

    MN form (PDF version) on TRICARE Pharmacy site

    BCF listing

    Jun 08 Osteoporosis Agents 27 Aug 08 Basic / Extended Core Formulary (BCF/ECF) Review
    BCF
    UF not BCF
    NF
    MTFs must have on formulary*
    MTFs may have on formulary
    MTFs must not have on formulary
    alendronate (Fosamax) ibandronate (Boniva)

    raloxifene (Evista)
    risedronate (Actonel )

    calcitonin salmon nasal spray (Miacalcin)

     

    Formulary management sheet

    MN Criteria (TRICARE Pharmacy site)

    MN form (Word version) posted on RxNet for MTF use

    MN form (PDF version) on TRICARE Pharmacy site

    BCF listing

    Jun 08 Triptans 27 Aug 08 Basic / Extended Core Formulary (BCF/ECF) Review
    BCF
    UF not BCF
    NF
    MTFs must have on formulary*
    MTFs may have on formulary
    MTFs must not have on formulary
    rizatriptan (Maxalt)
    sumatriptan oral and one injectable formulation, when multi-source generics are available


    eletriptan (Relpax)
    sumatriptan (Imitrex)
    sumatriptan / naproxen (Treximet)
    zolmitriptan (Zomig)

    almotriptan (Axert)
    frovatriptan (Frova)
    naratriptan (Amerge)

     

    Formulary management sheet

    MN Criteria (TRICARE Pharmacy site)

    MN form (Word version) posted on RxNet for MTF use

    MN form (PDF version) on TRICARE Pharmacy site

    BCF listing

    Jun 08

    Adrenergic Blocking Agents

    nebivolol (Bystolic)

    27 Aug 08 New Drug Review

    nebivolol (Bystolic) Designated as non-formulary under UF


    MTFs must not have on formulary effective: 29 Oct 08 (60 days)
    NF designation and retail/mail copay changes effective: 29 Oct 08 (60 days)

    Formulary managemnt sheet

    MN form (PDF version) on TRICARE Pharmacy site

    Jun 08

    Newer Antihistamines

    levocetirizine (Xyzal)

    27 Aug 08 Basic / Extended Core Formulary (BCF/ECF) Review

    levocetirizine (Xyzal) Designated as non-formulary under UF


    MTFs must not have on formulary effective: 29 Oct 08 (60 days)
    NF designation and retail/mail copay changes effective: 29 Oct 08 (60 days)

    MTFs required to carry at least one single ingredient agent from the newer antihistamine class (loratadine, cetirizine, or fexofenadine) on their local formulary, including at least one dosage form suitable for pediatric use

    Formulary management sheet

    MN Criteria

    MN form (PDF version) on TRICARE Pharmacy site

    Jun 08

    Leukotriene Modifiers

    zileuton ER (Zyflo CR)

    27 Aug 08 New Drug Review

    zileuton ER (Zyflo CR) Designated as non-formulary under UF

    MTFs must not have on formulary effective: 29 Oct 08 (60 days)
    NF designation and retail/mail copay changes effective: 29 Oct 08 (60 days)

    Formulary management sheet

    MN Criteria

    MN form (PDF version) on TRICARE Pharmacy site

    Jun 08

    Renin Angiotensin Antihypertensives

    olmesartan/amlodipine (Azor)

    27 Aug 08 New Drug Review

    olmesartan/amlodipine (Azor) Designated as non-formulary under UF

    MTFs must not have on formulary effective: 29 Oct 08 (60 days)
    NF designation and retail/mail copay changes effective: 29 Oct 08 (60 days)

    Formulary management sheet

    MN Criteria

    MN form (PDF version) on TRICARE Pharmacy site

    Jun 08

    Antilipidemic Agents I

    simvastatin / niacin release (Simcor)

    27 Aug 08 New Drug Review

    simvastatin / niacin release (Simcor) Designated as formulary on UF

    MTFs may have on formulary

    Formulary management sheet
    Jun 08

    Glaucoma Agents

    brimonidine 0.02% / timolol maleate 0.05% (Combigan)

    27 Aug 08 New Drug Review

    brimonidine 0.02% / timolol maleate 0.05% (Combigan) Designated as formulary on UF

    MTFs may have on formulary

    Formulary management sheet
    Jun 08

    Renin Angiotensin Antihypertensives

    aliskiren / hydrochlorothiazide (Tekturna HCT)

    27 Aug 08 New Drug Review

    aliskiren / hydrochlorothiazide (Tekturna HCT) Designated as formulary on UF

    MTFs may have on formulary

    Formulary management sheet
    Jun 08

    Targeted Immunomodulatory Biologics (TIBs)

    Adalimumab (Humira)

    27 Aug 08 New Indication Adalimumab (Humira) received an additional indication from the FDA for children aged 4 to 17 years to reduce the signs and symptoms of moderate to severely active polyarticular JIA.

    TRICARE Pharmacy Forms and Criteria page

    Formulary management sheet

    Letter to MTF

    Jun 08

    Phosphodiesterase type 5 inhibitors (PDE5s)

    tadalafil (Cialis)

    2.5mg and 5 mg

    27 Aug 08 Quantity Limit

    tadalafil (Cialis) 2.5mg and 5 mg

    Quantity Limit: 6 tabs/30 days; 18 tabs/90 days

    TRICARE Pharmacy Forms and Criteria page
    Jun 08

    Triptans

    sumatriptan / naproxen (Treximet)

    27 Aug 08 Quantity Limit

    sumatriptan / naproxen (Treximet)

    Quantity Limit: 9 tabs/30 days; 27 tabs/90 days

    TRICARE Pharmacy Forms and Criteria page
    Jun 08

    Antiemetics

    aprepitant (Emend) 40 mg

    27 Aug 08 Quantity Limit

    aprepitant (Emend) 40 mg

    Quantity Limit: 1 cap/prescription fill at the retail and mail order points of service.

    TRICARE Pharmacy Forms and Criteria page
    Feb 08 Antibiotics 30 Apr 08 Basic / Extended Core Formulary (BCF/ECF) Review

    Clarify BCF listing: “Amoxicillin oral (200 mg and 500 mg capsules; 250/5 mL and 400 mg/5mL suspension)”

     
    Feb 08 Antibiotics 30 Apr 08 Basic / Extended Core Formulary (BCF/ECF) Review Clarify BCF listing: “Cephalexin oral (200 mg and 500 mg capsules; 250/5 mL suspension)”  
    Feb 08 Antibiotics 30 Apr 08 Basic / Extended Core Formulary (BCF/ECF) Review Clarify BCF listing: “Doxycycline hyclate (100 mg tablets or capsules)”  
    Feb 08 Antibiotics 30 Apr 08 Basic / Extended Core Formulary (BCF/ECF) Review Clarify BCF listing: “Nitrofurantoin oral (50 mg macrocrystals; 100 mg monohydrate/macrocrystals)”  
    Feb 08 Antifungals 30 Apr 08 Basic / Extended Core Formulary (BCF/ECF) Review Clarify BCF listing: “Nystatin”, (remove “Does not include Mycostatin Pastille”)  
    Feb 08 Asthma agents, inhaled 30 Apr 08 Basic / Extended Core Formulary (BCF/ECF) Review Clarify BCF listing: “remove (Does not include HFA products)”  
    Feb 08 Contraceptives 30 Apr 08 Basic / Extended Core Formulary (BCF/ECF) Review

    Clarify BCF listing: “Specify hormonal content only, remove reference to product name unless designated non-formulary”

    Examples:

    • Monophasics with 30 mcg EE; 0.15 mg levonorgestrel (excludes Seasonale)
    • Monophasics with 20 mcg EE; 0.1 mg levonorgestrel
    Formulary management sheet
    Feb 08 Cough and Cold Preparations 30 Apr 08 Basic / Extended Core Formulary (BCF/ECF) Review Remove BCF listing for chlorpheniramine 8 mg/ pseudoephedrine 120 mg SR  
    Feb 08 Miscellaneous Migraine Medications 30 Apr 08 Basic / Extended Core Formulary (BCF/ECF) Review Remove BCF listing for isometheptene 65 mg / dichloralphenazone 100 mg / acetaminophen 325 mg (Midrin)  
    Feb 08 Miscellaneous Respiratory Medications 30 Apr 08 Basic / Extended Core Formulary (BCF/ECF) Review Clarify BCF listing: Change insect sting kit, injection to “Epinephrine auto-injection”  
    Feb 08 Ophthalmic Antibiotic and Combinations 30 Apr 08 Basic / Extended Core Formulary (BCF/ECF) Review Remove BCF listing for Sulfacetamide sodium ophthalmic ointment  
    Feb 08 Proton Pump Inhibitors 30 Apr 08 Basic / Extended Core Formulary (BCF/ECF) Review Clarify BCF listing to esomeprazole (Nexium) 20 and 40 mg capsules  
    Feb 08 Targeted Immunomodulatory Biologics (TIBs)

    30 Apr 08

     

    PA

    The FDA-approved plaque psoriasis indication will be added to the PA for Humira

    TRICARE Pharmacy Forms and Criteria page

    Formulary management sheet

    Letter to MTFs

    Feb 08
      Targeted Immunomodulatory Biologics (TIBs)
    30 Apr 08 Quantity Limit

    Point of Service / Notes

    Adalimumab
    (Humira)

    Etanercept
    (Enbrel)

    Anakinra
    (Kineret)

    Alefacept
    (Amevive)

    Efalizumab
    (Raptiva)

    Retail Network

    4 wks supply
    (2 packs of 2 syringes)

    4 wks supply (based on instructions for use)

    4 wks supply
    (1 pack of 28 syringes)

    4 wks supply
    (1 pack 4 syringes)

    4 wks supply
    (6 syringes)

    TMOP

    8 wks supply (4 packs of 2 syringes)

    8 wks supply (based on instructions for use)

    8 wks supply
    (2 packs of 28 syringes)

    Not supplied through TMOP

    8 wks supply
    (12 syringes)

    Other Issues

    Crohn’s disease
    starter pack includes
    6 pens for 1st 4 wks,
    no refills

    --

    --

    --

    Not to exceed 200 mg/week
    8 vials/ 4 wks
    16 vials/ 8 wks

    TRICARE Pharmacy Forms and Criteria page

    Formulary management sheet

    Letter to MTF

    Feb 08 Renin-Angiotensin Antihypertensives (RAAs) 30 Apr 08 MN Committee recommended that medical necessity be approved for children between the ages of 6 and 16 years who have failed to respond adequately to treatment with losartan, or who have experienced adverse effects to losartan MN Criteria (TRICARE Pharmacy site)
    Feb 08 Synthetic tetrahydrobiopterin 30 Apr 08 Quantity Limit Kuvan (sapropterin) tab will have a QL of 45 days supply in the TMOP and a 30 days supply in the TRRx (no multiple fills for multiple co-pays)  
    Feb 08 ACE inhibitors 30 Apr 08 Non-Formulary Agents for Re-Evaluation Quinapril and Quinapril/HCTZ reclassified as generic on the UF  
    Nov 07 Targeted Immunomodulatory Biologics 13 Feb 08 Class review Extended Core Formulary class. ECF selection effective 13 Feb 08.
    NF designations & retail/mail copay changes effective 18 Jun 08.
    MTF implementation period 13 Feb 08 - 18 Jun 08 (120 days)
    ECF
    UF not ECF
    NF
    MTFs must have on formulary*
    MTFs may have on formulary
    MTFs must not have on formulary
    adalimumab (Humira)
    alefacept (Amevive)
    efalizumab (Raptiva)
    anakinra (Kineret)
    etanercept (Enbrel)
    *Based on scope of care at individual MTF. Must be on formulary if any otherTIB is on formulary.
    • No change to existing PA requirements for adalimumab (Humira), anakinra (Kineret), efalizumab (Raptiva), and etanercept (Enbrel).
    • No change to existing quantity limits for adalimumab (Humira), anakinra (Kineret), and etanercept (Enbrel).

    Formulary management sheet

    MN Criteria (TRICARE Pharmacy site)

    MN form (Word version) not yet posted on RxNet for MTF use

    MN form (PDF version) not yet posted on TRICARE Pharmacy site

    ECF listing

    Nov 07 Alefacept (Amevive) 13 Feb 08 PA PA required. Effective date: 18 Jun 08 (120-day implementation period) TRICARE Pharmacy Forms and Criteria page
    Nov 07 BPH alpha blockers 13 Feb 08 Class review Basic Core Formulary class. BCF selections effective 13 Feb 08.
    Tamsulosin remains non-formulary under the UF.
    PA (step therapy) will apply to tamsulosin effective 16 Apr 08 (see below)
    BCF
    UF not BCF
    NF
    MTFs must have on formulary
    MTFs may have on formulary
    MTFs must not have on formulary
    alfuzosin (Uroxatral)
    terazosin
    doxazosin tamsulosin (Flomax)

    Formulary management sheet

    MN Criteria (TRICARE Pharmacy site)

    MN form (Word version) posted on RxNet for MTF use

    MN form (PDF version) on TRICARE Pharmacy site

    BCF listing

    Nov 07

    Tamsulosin

    13 Feb 08 PA PA required. Trial of alfuzosin required for new starts (no alfuzosin or tamsulosin prescription in last 180 days). Effective date 16 Apr 08 (60-day implementation period)

    TRICARE Pharmacy Forms and Criteria page

    Formulary management sheet

    Nov 07 Adrenergic Beta-blocking agents 13 Feb 08 Class review Basic Core Formulary class. No changes to UF status. BCF selections effective 13 Feb 08.
    BCF
    UF not BCF
    NF
    MTFs must have on formulary
    MTFs may have on formulary
    MTFs must not have on formulary

    atenolol
    carvedilol
    metoprolol tartrate
    metoprolol succinate ER

    acebutolol
    atenolol/chlorthalidone
    betaxolol
    bisoprolol +/HCTZ
    carvedilol ER
    labetalol
    nadolol +/bendroflumethiazide
    penbutalol
    propranolol +/HCTZ, propranolol ER
    timolol +/HCTZ

    -

    Formulary management sheet

    BCF listing

    Nov 07 Amlodipine 13 Feb 08 UF status change UF status of amlodipine changed from non-formulary to formulary effective 13 Feb 08. For UF status of other agents in this therapeutic class (Calcium Channel Blockers), see results from the May 05 meeting.

    Formulary management sheet

    BCF listing

    Nov 07 Amlodipine 13 Feb 08 BCF change Amlodipine added to BCF effective 13 Feb 08. Formulary management sheet
    Nov 07 Ethinyl estradiol 20 mcg/levonorgestrel 0.09 mg for continuous use (Lybrel) 13 Feb 08 New Drug Review

    New drug in previously reviewed class: Contraceptives (May 06)
    Designated as non-formulary under UF; MTFs must not have on formulary effective 16 Apr 08.
    NF designation and retail/mail copay changes effective 16 Apr 08 (60 days)

    Contraceptives formulary management sheet

    MN Criteria (TRICARE Pharmacy site)

    MN form (Word version) not yet posted on RxNet for MTF use

    MN form (PDF version) on TRICARE Pharmacy site

    BCF listing

    Nov 07 Lisdexamfetamine dimesylate (Vyvanse) 13 Feb 08 New Drug Review

    New drug in previously reviewed class: Attention Deficit Hyperactivity Disorder (ADHD)/Narcolepsy agents (Nov 06) . Designated as non-formulary under UF; MTFs must not have on formulary effective 16 Apr 08.
    NF designation and retail/mail copay changes effective 16 Apr 08 (60 days)

    Formulary management sheet

    MN Criteria (TRICARE Pharmacy site)

    MN form (Word version) not yet posted on RxNet for MTF use

    MN form (PDF version) on TRICARE Pharmacy site

    BCF listing
    Nov 07 Valsartan/amlodipine (Exforge) 13 Feb 08 New Drug Review

    New drug in Renin-Angiotensin Antihypertensive (RAA) class. The DoD P&T Committee has reclassified ACE inhibitors, ACEI./CCB combinations, ARBs, ARB/CCB combinations, and newly approved drugs affecting the renin system into the RAA class.
    Designated as non-formulary under UF; MTFs must not have on formulary effective 16 Apr 08.
    NF designation and retail/mail copay changes effective 16 Apr 08 (60 days)

    Other non-formulary RAAs include: irbesartan, eprosartan, olmesartan, valsartan and their HCTZ combinations (May 07)felodipine/enalapril (Lexxel) & verapamil/trandolapril (Tarka) (Feb 06); moexipril +/HCTZ, quinapril +/HCTZ, perindopril, ramipril (Aug 05)

    Formulary management sheet

    MN Criteria
    (TRICARE Pharmacy site)

    MN form (Word version) not yet posted on RxNet for MTF use

    MN form (PDF version) on TRICARE Pharmacy site

    BCF listing
    Nov 07 Rosiglitazone (Avandia) and rosiglitazone / metformin (Avandamet) 13 Feb 08 BCF change Rosiglitazone (Avandia) & rosiglitazone/metformin (Avandamet) removed from BCF  
    Nov 07 Meloxicam 13 Feb 08 BCF change BCF listing for meloxicam oral clarified to meloxicam tablets only  
    Nov 07 Cyclobenzaprine 13 Feb 08 BCF change BCF listing for "cyclobenzaprine oral; does not include 5 mg strength" clarified to "cyclobenzaprine IR tablets, 5 and 10 mg"  
    Nov 07 Oxycodone 5 mg /acetaminophen 325 mg 13 Feb 08 BCF change BCF listing for "oxycodone 5 mg/acetaminophen 325 mg" clarified to "oxycodone/acetaminophen 5 mg/325 mg tablets"  
    Nov 07 Methylphenidate IR 13 Feb 08 BCF change BCF listing clarified to methylphenidate IR (excludes Methylin oral solution and chewable tablets)  
    Nov 07 Formoterol fumarate (Perforomist) 13 Feb 08 Quantity Limit QL for newly approved agent - In the retail network: 60 unit dose vials per 30 days. In the TMOP: 180 unit dose vials per 90 days. TRICARE Pharmacy Forms and Criteria page
    Aug 07 Newer Anthistamines 17 Oct 07 Class review Basic Core Formulary class. BCF selections effective 17 Oct 07.
    NF designations & retail/mail copay changes effective 16 Jan 08.
    MTF implementation period 17 Oct 07 - 16 Jan 08 (90 days).
    BCF
    UF not BCF
    NF
    MTFs must have on formulary
    MTFs may have on formulary
    MTFs must not have on formulary

    At least one single ingredient agent (loratadine, cetirizine, or fexofenadine), including at least one dosage form suitable for pediatric use

    Acrivastine/PSE (Semprex-D)
    Cetirizine +/ PSE (Zyrtec, Zyrtec D)
    Fexofenadine +/ PSE (generic Allegra, Allegra D)

    Loratadine +/ PSE (added to UF for purposes of the TRICARE OTC demonstration project)

    Desloratadine +/ PSE (Clarinex, Clarinex D)

    Formulary management sheet

    MN Criteria (TRICARE Pharmacy site)

    MN form (Word version) posted on RxNet for MTF use

    MN form (PDF version) on TRICARE Pharmacy site

    BCF listing

    Aug 07 Leukotriene Modifiers 17 Oct 07 Class review Basic Core Formulary class. BCF selections effective 17 Oct 07.
    NF designations & retail/mail copay changes effective 16 Jan 08.
    MTF implementation period 17 Oct 07 - 16 Jan 08 (90 days).
    BCF
    UF not BCF
    NF
    MTFs must have on formulary
    MTFs may have on formulary
    MTFs must not have on formulary

    montelukast (Singulair) tabs, chewable tabs, oral granules

    zafirlukast (Accolate)

    zileuton (Zyflo)

    Formulary management sheet

    MN Criteria (TRICARE Pharmacy site)

    MN form (Word version) posted on RxNet for MTF use

    MN form (PDF version) on TRICARE Pharmacy site

    BCF listing

    Aug 07 Growth Stimulating Agents 17 Oct 07 Class review Extended Core Formulary class. ECF selections effective 17 Oct 07.
    NF designations & retail/mail copay changes effective 19 Dec 07.
    MTF implementation period 17 Oct 07- 19 Dec 07 (60 days).
    ECF
    UF not ECF
    NF
    MTFs must have on formulary*
    MTFs may have on formulary
    MTFs must not have on formulary

    Somatropin products (growth hormone):

    Norditropin /
    Norditropin Nordiflex

    Somatropin products (growth hormone):
       Nutropin / Nutropin AQ
       Serostim
       Tev-tropin
       Zorbtive

    Insulin-like growth factor-1 (IGF-1) product
      
    Mecasermin (Increlex)

    Somatropin products (growth hormone):
        Genotropin
        Humatrope
        Omnitrope
        Saizen

    *Based on scope of care at individual MTF. Must be on formulary if any other growth stimulating agent is on formulary.

    Formulary management sheet

    MN Criteria (TRICARE Pharmacy site)

    MN form (Word version) posted on RxNet for MTF use

    MN form (PDF version) on TRICARE Pharmacy site

    ECF listing

    Aug 07 Fluticasone furoate nasal spray (Veramyst) 17 Oct 07 New Drug Review New drug in previously reviewed class: Nasal Corticosteroids (Nov 05)
    Designated as non-formulary under UF (effective 19 Dec 07); MTFs must not have on formulary effective 19 Dec 07.
    Formulary management sheet (updated Oct 07)

    MN Criteria (TRICARE Pharmacy site)

    Revised MN form (Word version) posted on RxNet for MTF use

    MN form (PDF version) on TRICARE Pharmacy site

    BCF listing
    Aug 07 Aliskiren (Tekturna) 17 Oct 07 New Drug Review

    New drug in Renin-Angiotensin Antihypertensive (RAA) class. The DoD P&T Committee has reclassified ACE inhibitors,ACEI/CCB combinations, ARBs, ARB/CCB combinations, and newly approved drugs affecting the renin system into the RAA class.
    Designated as formulary on UF; MTFs may have on formulary

    Aug 07 Quetiapine (Seroquel) 17 Oct 07 BCF change BCF listing for "quetiapine" clarified to: "quetiapine tablets, immediate and extended release"
    Aug 07 Risperidone (Risperdal) 17 Oct 07 BCF change BCF listing for "risperidone oral; does not include orally disintegrating tablets (Risperdal Redi-tabs)" clarified to: "risperidone tablets and solution, does not include orally disintegrating tablets"
    Aug 07 Alendronate 70 mg / vit D 2800 IU (Fosamax Plus D) 17 Oct 07 BCF change BCF listing for "alendronate 70 mg / vit D 2800 IU (Fosamax Plus D) changed to specify new product with higher strength of vitamin D – “alendronate 70 mg/vitamin D 5600 IU tablets”
    Aug 07 Guaifenesin 600 / pseudoephedrine 120 mg ER oral 17 Oct 07 BCF change Removed from BCF
    Aug 07 Fluticasone furoate (Veramyst) 17 Oct 07 Quantity Limit QL for newly approved agent - In the retail network:1 inhaler per 30 days. In the TMOP: 3 inhalers per 90 days. TRICARE Pharmacy Forms and Criteria page
    Aug 07 Rizatriptan tablets and orallly disintegrating tablets (Maxalt, Maxalt MLT) 17 Oct 07 Quantity limit QL changed to 12 tablets per 30 days or 36 tablets per 90 days. TRICARE Pharmacy Forms and Criteria page
    Aug 07 Budesonide / formoterol oral inhaler (Symbicort) 17 Oct 07 Quantity Limit QL for newly approved agent - In the retail network:1 inhaler per 30 days. In the TMOP: 3 inhalers per 90 days. TRICARE Pharmacy Forms and Criteria page
    May 07 Antilipidemics II
    (LIP-2s)
    24 Jul 07 Class review Basic Core Formulary class. BCF selections effective 24 Jul 07.
    NF designations & retail/mail copay changes effective 24 Jul 07.
    MTF implementation period 24 Jul 07 - 21 Nov 07 (120 days).
    BCF
    UF not BCF
    NF
    MTFs must have on formulary
    MTFs may have on formulary
    MTFs must not have on formulary

    gemfibrozil

    IDD-P fenofibrate (Triglide)

    non-micronized fenofibrate (Lofibra, generics)
    micronized fenofibrate (Lofibra, generics; excludes Antara)
    cholestyramine/ aspartame & cholestyramine/sucrose (Questran, Questran Light, generics)
    colestipol (Colestid, generics)

    micronized fenofibrate (Antara),
    nanocrystallized fenofibrate (Tricor),
    colesevelam (Welchol)
    prescription omega-3 fatty acids (Lovaza, formerly Omacor)*

    *name change July 07

    Formulary management sheet

    MN Criteria (TRICARE Pharmacy site)

    MN form (Word version) posted on RxNet for MTF use

    MN form (PDF version) on TRICARE Pharmacy site

    BCF listing

    May 07 5-Alpha Reductase Inhibitors (5-ARIs) 24 Jul 07 Class review Basic Core Formulary class. BCF selections effective 24 Jul 07.
    NF designations & retail/mail copay changes effective 24 Jul 07.
    MTF implementation period 24 Jul 07 - 24 Oct 07 (90 days).
    BCF
    UF not BCF
    NF
    MTFs must have on formulary
    MTFs may have on formulary
    MTFs must not have on formulary
    finasteride (Proscar, generics)
    -
    dutasteride (Avodart)

    Formulary management sheet

    MN Criteria (TRICARE Pharmacy site)

    MN form (Word version) posted on RxNet for MTF use

    MN form (PDF version) on TRICARE Pharmacy site

    BCF listing

    May 07 Angiotensin Receptor Blockers (ARBs) 24 Jul 07 Class review Basic Core Formulary class. BCF selections effective 24 Jul 07.
    NF designations & retail/mail copay changes effective 24 Jul 07.
    MTF implementation period 24 Jul 07 - 21 Nov 07 (120 days).
    BCF
    UF not BCF
    NF
    MTFs must have on formulary
    MTFs may have on formulary
    MTFs must not have on formulary
    telmisartan +/HCTZ (Micardis, Micardis HCT) candesartan +/HCTZ (Atacand, Atacand HCT)

    losartan +/HCTZ
    (Cozaar, Hyzaar)

    irbesartan +/HCTZ (Avapro, Avalide)
    eprosartan +/HCTZ (Teveten, Teveten HCT)
    olmesartan +/HCTZ (Benicar, Benicar HCT)
    valsartan +/HCTZ (Diovan, Diovan HCT)

    Formulary management sheet

    MN Criteria (TRICARE Pharmacy site)

    MN form (Word version) posted on RxNet for MTF use

    MN form (PDF version) on TRICARE Pharmacy site

    BCF listing

    May 07 Proton Pump Inhibitors (PPIs) 24 Jul 07 Class review Basic Core Formulary class. BCF selections effective 24 Jul 07.
    NF designations & retail/mail copay changes effective 24 Jul 07.
    MTF implementation period 24 Jul 07 - 24 Oct 07 (90 days).
    PA (step therapy) will apply for all PPIs other than omeprazole (Prilosec, generics) or esomeprazole (Nexium) effective  24 Oct 07.
    BCF
    UF not BCF
    NF
    MTFs must have on formulary
    MTFs may have on formulary
    MTFs must not have on formulary

    omeprazole (generic omeprazole; excludes Prilosec 40 mg)
    esomeprazole (Nexium)

    omeprazole (Prilosec 40 mg) lansoprazole (Prevacid)
    omeprazole/sodium bicarbonate (Zegerid)
    pantoprazole (Protonix)
    rabeprazole (Aciphex)

    Formulary management sheet

    MN Criteria (TRICARE Pharmacy site)

    MN form (Word version) posted on RxNet for MTF use

    MN form (PDF version) on TRICARE Pharmacy site

    BCF listing

    May 07

    lansoprazole
    omeprazole/sodium bicarbonate
    pantoprazole
    rabeprazole

    24 Jul 07 PA PA required. Trial of omeprazole (Prilosec, generics) or esomeprazole (Nexium) required for new starts (no PPI prescription in last 180 days). Effective date: 24 Oct 07 ((90-day implementation period) TRICARE Pharmacy Forms and Criteria page
    May 07 Terbinafine 1% cream (Lamisil AT) 24 Jul 07 New Drug Review

    Reviewed as new drug in previously reviewed drug class: Topical antifungals. Designated as formulary on UF for purposes of the OTC Demonstration Project.

     
    May 07 Mometasone nasal spray (Nasonex) 24 Jul 07 Quantity limit QL changed to 34 gm (2 inhalers) per 30 days in the retail network and 102 gm (6 inhalers) per 90 days in TMOP. TRICARE Pharmacy Forms and Criteria page
    May 07 Ipratropium nasal spray (Atrovent) 24 Jul 07 Quantity limit

    QL changed to:
    0.03% strength: 60 mL (2 inhalers) per 30 days in the retail network and 180 mL (6 inhalers) per 90 days in TMOP.
    0.06% strength: 45 mL (3 inhalers) per 30 days in the retail network and 135 mL (9 inhalers) per 90 days in TMOP.

    TRICARE Pharmacy Forms and Criteria page
    May 07 Arformoterol (Brovana) 24 Jul 07 Quantity Limit QL for newly approved agent - In the retail network: 60 unit dose vials per 30 days. In the TMOP: 180 unit dose vials per 90 days TRICARE Pharmacy Forms and Criteria page
    May 07 Lapatinib (Tykerb) 24 Jul 07 Quantity Limit QL for newly approved agent - In the retail network: 150 tabs per 30 days with a days supply limit of 30 days (no multiple fills for multiple copays). In the TMOP: 225 tabs per 45 days, with a days supply limit of 45 days. TRICARE Pharmacy Forms and Criteria page
    May 07 Vorinostat (Zolinza) 24 Jul 07 Quantity Limit QL for newly approved agent - In the retail network: 120 tabs per 30 days, with a days supply limit of 30 days (no multiple fills for multiple copays). In the TMOP: 180 tabs per 45 days, with a days supply limit of 45 days. TRICARE Pharmacy Forms and Criteria page
    Feb 07 Ophthalmic glaucoma agents 2 May 07 Class review Basic Core Formulary class. BCF selections effective 2 May 07.
    NF designations & retail/mail copay changes effective 1 Aug 07.
    MTF implementation period 2 May 07 - 1 Aug 07 (90 days).
    BCF
    UF not BCF
    NF
    MTFs must have on formulary
    MTFs may have on formulary
    MTFs must not have on formulary

    Prostaglandin analogs
    latanoprost (Xalatan)
    Beta blockers
    timolol maleate solution (Timolol or generics) 0.25% and 0.5%& gel-forming solution (Timolol XE or generics) 0.25% and 0.5%
    Alpha 2 adrenergics
    brimonidine (0.2% generics; 0.15% Alphagan P; generics) - excludes the 0.1% strength (Alphagan P)
    Cholinergics (miotics)
    pilocarpine (Pilocar, generics; Pilopine HS gel)

    Prostaglandin analogs
    bimatoprost (Lumigan)
    Beta blockers

    betaxolol (Betoptic, generics; Betoptic S)
    carteolol (Ocupress, generics)
    levobunolol (Betagan, generics)
    metipranolol (Optipranolol)
    Carbonic anhydrase inhibitors/combos
    dorzolamide (Trusopt)
    dorzolamide/timolol (Cosopt)
    Alpha 2 adrenergics
    Apraclonidine (Iopidine, generics)
    Brimonidine 0.1% (Alphagan P)
    Adrenergics
    dipivefrin (Propine, generics)
    Cholinergics (miotics)
    acetylcholine (Miochol-E)
    carbachol (Isopto Carbachol)
    Cholinesterase inhibitors
    echothiophate (Phospholine Iodide)

    Prostaglandin analogs
    travoprost (Travatan, Travatan Z)
    Beta blockers
    timolol hemihydrate (Betimol)
    timolol maleate with potassium sorbate (Istalol)
    Carbonic anhydrase inhibitors/combos
    brinzolamide (Azopt)

    Formulary management sheet

    MN Criteria (TRICARE Pharmacy site)

    MN form (Word version) posted on RxNet for MTF use

    MN form (PDF version) on TRICARE Pharmacy site

    BCF listing

     

    Feb 07 Narcotic analgesics 2 May 07 Class review Basic Core Formulary class. BCF selections effective 2 May 07.
    NF designations & retail/mail copay changes effective 1 Aug 07.
    MTF implementation period 2 May 07 - 1 Aug 07 (90 days).
    BCF
    UF not BCF
    NF
    MTFs must have on formulary
    MTFs may have on formulary*
    MTFs must not have on formulary

    High potency (Schedule II) single analgesic agents
    morphine sulfate 12-hour ER (MS Contin or generics) 15, 30, and 60 mg
    morphine sulfate IR 15 and 30 mg
    High potency (Schedule II) combosoxycodone / APAP 5/325 mg
    Lower potency single analgesic agents
    tramadol IR 50 mg
    Lower potency combos
    hydrocodone / APAP 5/500 mg
    codeine/APAP 30/300 mg
    codeine/APAP elixir 12/120 mg per 5 mL

    High potency (Schedule II) single analgesic agents
    codeine
    fentanyl transdermal, transmuosal, buccal tablets
    hydromorphone
    levorphanol
    meperidine
    methadone
    morphine products (other than BCF selections)
    opium tincture
    opium/belladonna alkaloids (suppositories)
    oxycodone
    oxymorphone
    High potency (Schedule II) combos
    oxycodone/ASA
    oxycodone/APAP other than BCF selections
    Lower potency single analgesic agents
    buprenorphine injection
    butorphanol
    pentazocine/naloxone
    propoxyphene
    nalbuphine
    Lower potency combos
    codeine / APAP (other than BCF selections)
    codeine / ASA
    codeine / ASA / carisoprodoll
    codeine / caffeine / butalbital / APAP or ASA
    dihydrocodeine / caffeine / APAP or ASA
    hydrocodone / APAP (other than BCF selections)
    pentazocine / APAP propoxyphene / APAP
    propoxyphene / ASA / caffeine
    tramadol / APAP

    Lower potency single analgesic agents
    tramadol ER (Ultram ER)

    Notes
    • The narcotic analgesic class did not include narcotic analgesics given primarily by intravenous injection or infusion or requiring professional administration. Formulary status of these products is determined by MTFs.
    • Products in which the narcotic component is primarily used as an antitussive will be reviewed at a later date.

    Formulary management sheet

    MN Criteria (TRICARE Pharmacy site)

    MN form (Word version) posted on RxNet for MTF use

    MN form (PDF version) on TRICARE Pharmacy site

    BCF listing

     

    Feb 07 Monoamine oxidase Inhibitor antidepressants (MAOIs) 2 May 07 Class review Basic Core Formulary class. BCF selections effective 2 May 07.
    NF designations & retail/mail copay changes effective 1 Aug 07.
    MTF implementation period 2 May 07 - 1 Aug 07 (90 days).
    ECF
    UF not ECF
    NF
    MTFs must have on formulary
    MTFs may have on formulary
    MTFs must not have on formulary

    phenelzine (Nardil)

    isocarboxazid (Marplan)
    tranylcypromine (Parnate, generics)

    trandermal selegiline (Emsam patch)

    Formulary management sheet (revised Jun 07)

    MN Criteria (TRICARE Pharmacy site)

    MN form (Word version) posted on RxNet for MTF use

    MN form (PDF version) on TRICARE Pharmacy site

    ECF listing

    Feb 07 Newer sedative hypnotics (SED-1s) 2 May 07 Class review Basic Core Formulary class. BCF selections effective 2 May 07.
    NF designations & retail/mail copay changes effective 1 Aug 07.
    MTF implementation period 2 May 07 - 1 Aug 07 (90 days).
    PA (step therapy) will apply for all SED-1 agents other than zolpidem IR (Ambien) effective 1 Aug 07.
    BCF
    UF not BCF
    NF
    MTFs must have on formulary
    MTFs may have on formulary
    MTFs must not have on formulary

    zolpidem IR (Ambien)

    eszopiclone (Lunesta)

    ramelteon (Rozerem)
    zaleplon (Sonata)
    zolipidem ER (Ambien CR)

    Formulary management sheet

    MN Criteria (TRICARE Pharmacy site)

    MN form (Word version) posted on RxNet for MTF use

    MN form (PDF version) on TRICARE Pharmacy site

    BCF listing

    Feb 07

    eszopiclone (Lunesta), ramelteon (Rozerem), zaleplon (Sonata), zolpidem ER (Ambien CR)

    2 May 07 PA PA required. Trial of zolpidem IR (Ambien) required for new starts (no SED-1 prescription in last 180 days). Effective date: 1 Aug 07 (90-day implementation period) TRICARE Pharmacy Forms and Criteria page
    Feb 07 omeprazole magnesium (Prilosec OTC) 2 May 07 New Drug Review

    Reviewed as new drug in previously reviewed drug class: PPIs
    Designated as formulary on UF for purposes of the OTC Demonstration Project.

     
    Feb 07 fentanyl buccal tablets (Fentora) 2 May 07 Quantity Limit QL for newly approved agent - In the retail network:112 tabs per 28 days. In the TMOP: 336 tabs per 84 days. TRICARE Pharmacy Forms and Criteria page
    Nov 06 ADHD / Narcolepsy Agents 17 Jan 07 Class review Basic Core Formulary class. BCF selections effective 17 Jan 07.
    NF designations & retail/mail copay changes effective 18 Apr 07.
    MTF implementation period 17 Jan 07 - 18 Apr 07 (90 days).
    BCF
    UF not BCF
    NF
    MTFs must have on formulary
    MTFs may have on formulary
    MTFs must not have on formulary

    methylphenidate IR (Ritalin, Methylin, generics)
    methylphenidate ER tablets (Concerta)
    mixed amphetamine salts, ER (Adderall XR)

    ADHD agents
    atomoxetine (Strattera)
    methylphenidate ER (Metadate CD, Ritalin LA, Methylin ER)
    mixed amphetamine salts, IR (Adderall, generics)
    dextroamphetamine IR and ER (Dexedrine, Dexedrine spansule, Dextrostat, generics)
    methamphetamine (Desoxyn)

    Narcolepsy agents
    modafinil (Provigil)
    sodium oxybate (Xyrem)

    dexmethylphenidate IR and ER (Focalin, Focalin XR) methylphenidate patch (Daytrana)

    See also: Nov 07 meeting changes. NF medications effective ????:

    lisdexamfetamine dimesylate (Vyvanse)

    Formulary management sheets: ADHD meds, narcolepsy meds

    MN Criteria (TRICARE Pharmacy site)

    MN form (Word version) posted on RxNet for MTF use

    MN form (PDF version) on TRICARE Pharmacy site

    BCF listing

     

    Nov 06 Older sedative hypnotics (SED-2s) 17 Jan 07 Class review Basic Core Formulary class. BCF selections effective 17 Jan 07.
    No medications classified as non-formulary under UF.
    BCF
    UF not BCF
    NF
    MTFs must have on formulary
    MTFs may have on formulary
    MTFs must not have on formulary

    temazepam 15 and 30 mg

    butabarbital
    chloral hydrate
    estazolam
    flurazepam
    quazepam (Doral)
    secobarbital
    temazepam 7.5 and 22.5 mg (Restoril)
    triazolam

    -

    Formulary management sheet

    BCF listing

    Nov 06 Ethinyl estradiol 30/10 mcg; levonorgestrel 0.15 mg for extended cycle use (Seasonique) 17 Jan 07 New Drug Review

    New drug in previously reviewed class: Contraceptives (May 06)
    Designated as non-formulary under UF; MTFs must not have on formulary effective 24 Jan 07 (coincides with effective date for other NF contraceptives).
    NF designation and retail/mail copay changes effective 24 Jan 07

    Contraceptives formulary management sheet (updated Jan 07)
    MN Criteria (TRICARE Pharmacy site)
    MN form (Word version) posted on RxNet for MTF use
    MN form (PDF version) on TRICARE Pharmacy site (also includes Seasonale)
    BCF listing

    Nov 06 Ethinyl estradiol 20 mcg / norethindrone acetate 1 mg - 24 day regimen (Loestrin 24 Fe) 17 Jan 07 New Drug Review New drug in previously reviewed class: Contraceptives (May 06)
    Designated as non-formulary under UF; MTFs must not have on formulary effective 24 Jan 07 (coincides with effective date for other NF contraceptives).
    NF designation and retail/mail copay changes effective 24 Jan 07
    Contraceptives formulary management sheet (updated Jan 07)
    MN Criteria (TRICARE Pharmacy site)
    MN form (Word version) posted on RxNet for MTF use
    MN form (PDF version) on TRICARE Pharmacy site
    BCF listing
    Nov 06 0.25% miconazole; 15% zinc oxide ointment (Vusion) 17 Jan 07 New Drug Review New drug in previously reviewed class: Topical Antifungals (May 05.)
    Designated as non-formulary under UF; MTFs must not have on formulary.
    NF designation and retail/mail copay changes effective 21 Feb 07.
    MTF implementation period: 17 Jan 07 - 21 Feb 07 (30 days)
    Topical antifungals formulary management sheet (updated Jan 07)
    MN Criteria (TRICARE Pharmacy site)
    MN form (Word version) posted on RxNet for MTF use
    MN form (PDF version) on TRICARE Pharmacy site
    BCF listing
    Nov 06 Nabilone (Cesamet) 17 Jan 07 New Drug Review

    New drug in previously reviewed drug class: Antiemetics (May 06)
    Designated as formulary on UF; MTFs may have on formulary

    Nov 06 Modafinil (Provigil) 17 Jan 07 PA PA required. Effective date: 18 Apr 07 (90-day implementation period) TRICARE Pharmacy Forms and Criteria page
    Nov 06 Fentanyl patches (Duragesic, generics) 17 Jan 07 PA PA required. Effective date: not yet announced TRICARE Pharmacy Forms and Criteria page
    Aug 06 Antilipidemics I 23 Oct 06 Class review Basic Core Formulary class. BCF selections effective 23 Oct 06.
    NF designations & retail/mail copay changes effective 1 Feb 07.
    MTF implementation period 23 Oct 06 - 1 Feb 07 (90 days).
    BCF
    UF not BCF
    NF
    MTFs must have on formulary
    MTFs may have on formulary
    MTFs must not have on formulary

    simvastatin*
    pravastatin
    niacin ER (Niaspan)
    ezetimibe/
    simvastatin
    (Vytorin)

    lovastatin IR
    ezetimibe (Zetia)
    niacin immediate release
    atorvastatin (Lipitor)**
    lovastatin ER (Altoprev)**
    niacin ER/lovastatin (Advicor)**
    fluvastatin IR & ER (Lescol, Lescol XL)**

    **MTFs may, but are strongly advised NOT to, have these agents on formulary

    rosuvastatin
    (Crestor)
    atorvastatin/
    amlodipine (Caduet)

    Formulary management sheet

    MN Criteria (TRICARE Pharmacy site)

    MN form (Word version) posted on RxNet for MTF use

    MN form (PDF version) on TRICARE Pharmacy site. Two forms: Crestor and Caduet

    BCF listing

    Aug 06 H2 Antagonists & GI Protectants 23 Oct 06 Class review Basic Core Formulary class. BCF selections effective 23 Oct 06.
    BCF
    UF not BCF
    NF
    MTFs must have on formulary
    MTFs may have on formulary
    MTFs must not have on formulary
    ranitidine (excludes effeverscent tab and gel-filled cap formulations)

    cimetidine
    famotidine
    nizatidine
    misoprostol
    sucralfate

    -

    Formulary management sheet

    BCF listing

    Aug 06 TZDs 23 Oct 06 Class review Basic Core Formulary class. BCF selections effective 23 Oct 06.
    BCF
    UF not BCF
    NF
    MTFs must have on formulary
    MTFs may have on formulary
    MTFs must not have on formulary
    rosiglitazone (Avandia)
    rosiglitazone/metformin (Avandamet)

    pioglitazone (Actos)
    pioglitazone/metformin (Actoplus Met)
    rosiglitazone/glimepiride (Avandaryl)

    -

    Formulary management sheet

    BCF listing

    Aug 06 Exenatide (Byetta) 23 Oct 06 PA PA required. Effective date: 31 Jan 07. TRICARE Pharmacy Forms and Criteria page
    Aug 06 Dasatinib (Sprycel) 23 Oct 06 Quantity limit QL for newly approved agent - In the retail network: 60 tablets per 30 days for the 70 mg strength, 120 tablets per 30 days for the 50 mg strength, and 120 tablets per 30 days for the 20 mg strength. In the TMOP: 90 tablets per 45 days for the 70 mg strength, 180 tablets per 45 days for the 50 mg strength, and 180 tablets per 45 days for the 20 mg strength.
    Admin change carbinoxamine 1 mg / pseudoephedrine 15 mg per ml oral drops 16 Aug 06 BCF change Administrative change - carbinoxamine 1 mg / pseudoephedrine 15 mg per ml oral drops removed from BCF For more information please click here
    Admin change Tramadol extended release 5 Sep 06 Quantity limit

    QL for new formulation added due to existing QL requirement for tramadol-containing products. In the retail network: 100 mg tablets, 30 per 30 days; 200 & 300 mg tablets (collective), 30 per 30 days. In the TMOP: 100 mg tablets, 90 per 90 days; 200 & 300 mg tablets (collective), 90 per 90 days.

    Admin change Adalimumab (Humira) injection 29 Aug 06 PA Change to criteria due to new FDA approved indication for reducing signs and symptoms of active arthritis in paients with psoriatic arthritis and change in RA indication. TRICARE Pharmacy Forms and Criteria page
    May 06 Antiemetics 26 Jul 06 Class review Basic Core Formulary class. BCF selections effective 26 Jul 06.
    NF designations & retail/mail copay changes effective 27 Sep 06.
    MTF implementation period 26 Jul 06 - 27 Sep 06 (60 days).
    BCF
    UF not BCF
    NF
    MTFs must have on formulary
    MTFs may have on formulary
    MTFs must not have on formulary
    promethazine (oral and rectal)

    granisetron
    ondansetron
    dronabinol
    meclizine
    prochlorperazine
    scopolamine
    thiethylperazine
    trimethobenzamide

    dolasetron (oral)

     

     

    Formulary management sheet

    MN Criteria (TRICARE Pharmacy site)

    MN form (Word version) posted on RxNet for MTF use

    MN form (PDF version) on TRICARE Pharmacy site.

    BCF listing

    May 06 Contraceptives 26 Jul 06 Class review Basic Core Formulary class. BCF selections effective 26 Jul 06.
    NF designations & retail/mail copay changes effective 24 Jan 07.
    MTF implementation period 26 Jul 06 - 24 Jan 07 (180 days).
    EE = ethinyl estadiol
    BCF
    UF not BCF
    NF
    MTFs must have on formulary
    MTFs may have on formulary
    MTFs must not have on formulary
    EE 20 mcg; 3 mg drospirenone (Yaz)
    EE 20 mcg; 0.1 mg levonorgestrel (Alesse, Levlite or equivt)
    EE 30 mcg; 3 mg drospirenone (Yasmin)
    EE 30 mcg; 0.15 mg levonorgestrel (Nordette or equiv; excludes Seasonale)
    EE 35 mcg; 1.0 mg norethindrone (Ortho-Novum 1/35 or equiv)
    EE 35 mcg; 0.25 mg norgestimate (Ortho-Cyclen or equiv)
    EE 25 mcg; 0.18/0.215/0.25 mg norgestimate (Ortho Tri-Cyclen Lo)
    EE 35 mcg; 0.18/0.215/0.25 mg norgestimate (Ortho Tri-Cyclen or equiv)
    0.35 mg norethindrone (Nor-QD, Micronor or equiv)

    EE 20 mcg; 1.0 mg norethindrone
    EE 20 mcg; 1.0 mg norethindrone; ferrous fumarate
    EE 30 mcg; 0.3 mg norgestrel
    EE 30 mcg; 0.15 mg desogestrel
    EE 30 mcg; 1.5 mg norethindrone
    EE 30 mcg; 1.5 mg norethindrone; ferrous fumarate
    EE 35 mcg; 0.5 mg norethindrone
    EE 35 mcg; 1.0 mg ethynodiol diacetate
    Mestranol 50 mcg; 1 mg norethindrone
    EE 50 mcg; 1 mg ethynodiol diacetate
    EE 50 mcg; 0.5 mg norgestrel
    EE 35 mcg; 0.5/1.0 mg norethindrone
    EE 20/10 mcg; 0.15 mg desogestrel
    EE 30/40/30 mcg; 0.05/0.075/0.125 mg levonorgestrel
    EE 35 mcg; 0.5/1/0.5 mg norethindrone
    EE 35 mcg; 0.5/0.75/1 mg norethindrone
    EE 25 mcg; 0.1/0.125/0.15 mg desogestrel
    EE; norelgestromin transdermal (Ortho-Evra)
    EE; etonorgestrel vaginal ring (Nuvaring)
    104 mg/ 0.65mL depot medroxyprogesterone acetate injection (Depo-subq Provera 104)
    150 mg/mL depot medroxyprogesterone acetate injection
    0.75 mg levonorgestrel (Plan B)

    EE 30 mcg; levonorgestrel 0.15 mg in special packaging for extended cycle use (Seasonale & equivalents, e.g., Jolessa, Quasense)
    EE 35 mcg; 0.4 mg norethindrone (Ovcon 35)
    EE 50 mcg; 1 mg norethindrone (Ovcon 50)
    EE 20/30/35 mcg; norethindrone 1 mg (Estrostep Fe)

    See also: Nov 06 meeting changes. NF medications effective 24 Jan 07:

    EE 30/10 mcg; 0.15 mg levonorgestrel for extended cycle use (Seasonique)
    EE 20 mcg; 1 mg norethindrone - 24 day regimen (Loestrin 24 Fe)

     

    Formulary management sheet (updated Jan 07)

    MN Criteria (TRICARE Pharmacy site)

    MN form (Word version) posted on RxNet for MTF use

    MN forms (PDF version) on TRICARE Pharmacy site: Estrostep Fe, Ovcon 35, Ovcon 50; Seasonale / Seasonique, Loestrin 24 Fe

    BCF listing

    May 06 Rizatriptan tablets and orallly disintegrating tablets (Maxalt, Maxalt MLT) 26 Jul 06 Quantity limit QL changed to 18 tablets per 30 days or 36 tablets per 90 days.
    May 06 Fentanyl oral transmucosal lozenges (Actiq ) 26 Jul 06 Quantity limit New QL - 120 units per 30 days, 360 units per 90 days
    May 06 Sunitinib (Sutent) 26 Jul 06 Quantity limit QL for newly approved agent - In the retail network: 30 capsules per 30 days for the 50 mg strength, 60 capsules per 30 days for the 25 mg strength, and 120 capsules per 30 days for the 12.5 mg strength. In the TMOP: 60 capsules per 84 days for the 50 mg strength, 120 capsules per 84 days for the 25 mg strength, and 180 capsules per 84 days for the 12.5 strength.
    Admin change Budesonide AQ (Rhinocort Aqua) nasal spray 26 Jul 06 Quantity limit QL changed to 18 gm per 30 days (2 inhalers); 54 gm per 90 days (6 inhalers)
    Admin change Mecasermin injection 28 Jun 06 PA New formulation (mecasermin rifabate; Iplex) added to existing PA for mecasermin TRICARE Pharmacy Forms and Criteria page
    Feb 06 GABA Analogs 26 Apr 06 Class review
    Basic Core Formulary class. BCF selections effective 26 Apr 06.
    NF designations & retail/mail copay changes effective 28 Jun 06.
    MTF implementation period 16 Apr 06 - 28 Jun 06 (60 days).
    BCF
    UF not BCF
    NF
    MTFs must have on formulary
    MTFs may have on formulary
    MTFs must not have on formulary
    gabapentin

    tiagabine (Gabitril)

    pregabalin (Lyrica)

    Formulary management sheet

    MN Criteria (TRICARE Pharmacy site)

    MN form (Word version) posted on RxNet for MTF use

    MN form (PDF version) on TRICARE Pharmacy site.

    BCF listing

    Feb 06 Miscellaneous Antihypertensives 26 Apr 06 Class review
    Basic Core Formulary class. BCF selections effective 26 Apr 06.
    NF designations & retail/mail copay changes effective 26 Jul 06.
    MTF implementation period 16 Apr 06 - 26 Jul 06 (90 days).
    BCF
    UF not BCF
    NF
    MTFs must have on formulary
    MTFs may have on formulary
    MTFs must not have on formulary
    benazepril/amlodipine combination (Lotrel)
    clonidine tablets
    hydralazine

    clonidine patch
    guanfacine
    guanabenz
    hydralazine
    mecamylamine
    methyldopa
    minoxidil
    prazosin
    reserpine

    combinations of the above products with thiazide diuretics, such as hydrochlorothiazide or chlorthalidone

    felodipine/enalapril combination (Lexxel)
    verapamil/trandolapril combination (Tarka)

    Formulary management sheet

    MN Criteria (TRICARE Pharmacy site)

    MN form (Word version) posted on RxNet for MTF use

    MN form (PDF version) on TRICARE Pharmacy site

    BCF listing

    Feb 06 Overactive Bladder (OAB) Medications 26 Apr 06 Class review
    Basic Core Formulary class. BCF selections effective 26 Apr 06.
    NF designations & retail/mail copay changes effective 26 Jul 06.
    MTF implementation period 16 Apr 06 - 26 Jul 06 (90 days).
    BCF
    UF not BCF
    NF
    MTFs must have on formulary
    MTFs may have on formulary
    MTFs must not have on formulary
    oxybutynin IR tolterodine SR (Detrol LA)

    oxybutynin SR (Ditropan XL)
    solifenacin (Vesicare)
    darifenacin (Enablex)

    tolterodine IR (Detrol)
    oxybutynin patch (Oxytrol)
    trospium (Sanctura)

    Formulary management sheet

    MN Criteria (TRICARE Pharmacy site)

    MN form (Word version) posted on RxNet for MTF use

    MN form (PDF version) on TRICARE Pharmacy site

    BCF listing

    Feb 06 Sorafenib (Nexavar) 26 Apr 06 Quantity limit QL for newly approved agent - 120 tablets per 30 days. No more than 30 days supply will be dispensed in the retail network at any one time. This product is not currently available from the TMOP due to restricted distribution requirements. If it becomes available from TMOP, a quantity limit of 180 tablets per 45 days and a days supply limit of 45 days will apply.
    Admin change Fluoroquinolones 16 Mar 06 BCF Change Administrative change - levofloxacin added to BCF. For more information please click here.
    Admin change Fluoroquinolones 16 Mar 06 BCF Change Administrative change - gatifloxacin removed from BCF. For more information please click here.
    Nov 05 Antidepressants I 19 Jan 06 Class review
    Basic Core Formulary class. BCF selections effective 19 Jan 06.
    NF designations & retail/mail copay changes effective 19 Jul 06.
    MTF implementation period 19 Jan 06 - 19 Jul 06 (180 days).
    BCF
    UF not BCF
    NF
    MTFs must have on formulary
    MTFs may have on formulary
    MTFs must not have on formulary
    bupropion SR
    citalopram
    fluoxetine (generic)
    sertraline (Zoloft)
    trazodone

    fluvoxamine
    mirtazapine
    nefazodone
    paroxetine IR
    venlafaxine IR/ER (Effexor, Effexor XR)

    bupropion ER (Wellbutrin XL)
    duloxetine (Cymbalta)
    escitalopram (Lexapro)
    fluoxetine 90-mg capsules (Prozac Weekly)
    fluoxetine (Sarafem)
    paroxetine CR (Paxil CR)

    Formulary management sheet

    MN Criteria (TRICARE Pharmacy site)

    MN forms (Word version) posted on RxNet for MTF use

    MN forms (PDF version) posted on TRICARE Pharmacy site. Three versions: Cymbalta; Lexapro; and the other four NF products (Paxil CR, Prozac Weekly, Sarafem, Wellbutrin XL)

    BCF listing

    Nov 05 Alzheimers Meds 19 Jan 06 Class review
    Extended Core Formulary class. ECF selections effective 19 Jan 06. NF designations & retail/mail copay changes effective 19 Apr 06.
    MTF implementation period 19 Jan 06 - 19 Apr 06 (90 days).
    ECF
    UF not ECF
    NF
    MTFs must have on formulary
    MTFs may have on formulary
    MTFs must not have on formulary
    donepezil (Aricept) galantamine (Razadyne)
    rivastigmine (Exelon)
    memantine (Namenda)
    tacrine (Cognex)

    Formulary management sheet

    MN Criteria (TRICARE Pharmacy site)

    MN Form (Word version) posted on RxNet for MTF use

    MN form (PDF version) on TRICARE Pharmacy site

    BCF listing

    Nov 05 Nasal Corticosteroids 19 Jan 06 Class review Basic Core Formulary class. BCF selections effective 19 Jan 06.
    NF designations & retail/mail copay changes effective 19 Apr 06.
    MTF implementation period 19 Jan 06 - 19 Apr 06 (90 days).
    BCF
    UF not BCF
    NF
    MTFs must have on formulary
    MTFs may have on formulary
    MTFs must not have on formulary
    fluticasone propionate (Flonase) flunisolide (Nasarel or generic equiv)
    mometasone (Nasonex)

    beclomethasone (Beconase AQ)
    budesonide (Rhinocort Aqua)
    triamcinolone (Nasacort AQ)

    See also: Aug 07 meeting changes.
    NF medication effective 19 Dec 2007: fluticasone furoate (Veramyst)

    Formulary management sheet

    MN Criteria (TRICARE Pharmacy site)

    MN Form (Word version) posted on RxNet for MTF use

    MN form (PDF version) on TRICARE Pharmacy site

    BCF listing

    Nov 05 Macrolides/Ketolides
    19 Jan 06 Class review Basic Core Formulary class. BCF selections effective 19 Jan 06.
    NF designations & retail/mail copay changes effective 22 Mar 06.
    MTF implementation period 19 Jan 06 - 22 Mar 06 (60 days).
    BCF
    UF not BCF
    NF
    MTFs must have on formulary
    MTFs may have on formulary
    MTFs must not have on formulary
    azithromycin 250 mg tab
    erythromycin*
    azithromycin (all other forms, except Zmax)
    clarithromycin IR/ER (generic / Biaxin XL) tab/susp
    azithromycin 2 gm SR suspension (Zmax)
    telithromycin 400 mg tabs
    *MTFs must have at least one form of oral erythromycin base or salt on formulary.

    Formulary management sheet

    MN Criteria (TRICARE Pharmacy site)

    MN Form (Word version) posted on RxNet for MTF use

    MN form (PDF version) on TRICARE Pharmacy site

    BCF listing

    Nov 05 Mecasermin injection (Increlex) 19 Jan 06 New drug review

    PA required. Effective date: 22 Feb 06 (30-day implementation period).

    TRICARE Pharmacy Forms and Criteria page
    Nov 05 Etanercept injection (Enbrel) 19 Jan 06 Quantity limit QL changed to a 4-week supply in retail, an 8-week supply at mail order, and up to an 8-week supply at MTFs, based on instructions for use on the prescription. TRICARE Pharmacy Forms and Criteria page
    Nov 05 Zolmitriptan (Zomig, Zomig-ZMT) 19 Jan 06 Quantity limit QL changed to 12 tablets per 30 days or 36 tablets per 90 days. TRICARE Pharmacy Forms and Criteria page
    Nov 05 Mometasone furoate oral inhaler (Asmanex) 19 Jan 06 Quantity limit QL for newly approved agent - 120 inhalations per 30 days or 360 inhalations per 90 days (available in multiple package sizes
    Admin change Adalimumab (Humira) injection 3 Nov 05 PA Change to criteria due to new FDA approved indication for reducing signs and symptoms of active arthritis in paients with psoriatic arthritis and change in RA indication. TRICARE Pharmacy Forms and Criteria page
    Aug 05
    Alpha Blockers for BPH 13 Oct 05 Class review

    Note: below listing for historical purposes only;
    class re-reviewed Nov 07; see current listing

    Basic Core Formulary class. BCF selections effective 13 Oct 05.
    NF designations & retail/mail copay changes effective 15 Feb 06.
    MTF implementation period 13 Oct 05 - 15 Feb 06 (120 days).

    BCF
    UF not BCF
    NF
    MTFs must have on formulary
    MTFs may have on formulary
    MTFs must not have on formulary
    alfuzosin (Uroxatral)
    terazosin
    doxazosin tamsulosin (Flomax)
    Formulary management sheet

    MN Criteria

    MN Form (Word version) on RxNet

    MN form (PDF version) on TRICARE Pharmacy site

    BCF listing
    Aug 05 CCBs 13 Oct 05 Class review Basic Core Formulary class. BCF selections effective 13 Oct 05.
    NF designations & retail/mail copay changes effective 15 Mar 06.
    MTF implementation period 13 Oct 05 - 15 Mar 06 (150 days).
    BCF
    UF not BCF
    NF
    MTFs must have on formulary
    MTFs may have on formulary
    MTFs must not have on formulary

    diltiazem ER (Tiazac)
    nifedipine ER (Adalat CC)
    verapamil SR

    Note: amlodipine placed on BCF Nov 07

    diltiazem IR/SR felodipine
    nisoldipine (Sular)
    diltiazem SR

    amlodipine NOTE: historical reference; status of amlodipine changed to UF and amlodipine placed on BCF Nov 07).
    The following CCBs remain NF:diltiazem ER (Cardizem LA)
    isradipine
    nicardipine
    verapamil ER (Verelan, Verelan PM, Covera HS)

    Formulary management sheets (two versions: DHPs & non-DHPs)

    MN Criteria

    MN Form (Word version) on RxNet

    MN form (PDF version) on TRICARE Pharmacy site (two versions, DHPs and non-DHPs)

    BCF listing

    Aug 05 ACEIs & ACEI/HCTZ Combos 13 Oct 05 Class review Basic Core Formulary class. BCF selections effective 13 Oct 05.
    NF designations & retail/mail copay changes effective 15 Feb 06.
    MTF implementation period 13 Oct 05 - 15 Feb 06 (120 days).
    BCF
    UF not BCF
    NF
    MTFs must have on formulary
    MTFs may have on formulary
    MTFs must not have on formulary
    captopril
    lisinopril
    lisinopril/HCTZ
    benazepril +/HCTZ
    captopril/HCTZ
    enalapril +/HCTZ
    fosinopril +/HCTZ
    trandolapril (Mavik)
    moexipril +/HCTZ (Univasc, Uriretic)
    perindopril (Aceon)
    quinapril +/HCTZ (Accupril, Accuretic)
    ramipril (Altace)
    Formulary management sheet (updated Feb 06)
    MN criteria (two versions; ACEI only and ACEI/HCTZ combos)

    MN Form (Word version) on RxNet

    MN form (PDF version) on TRICARE Pharmacy site

    BCF listing
    Aug 05 Sildenafil (Revatio) 13 Oct 05 New drug review

    New drug in previously reviewed class (PDE-5 inhibitors). New sildenafil product for treatment of pulmonary arterial hypertension (also known as primary pulmonary hypertension); not approved for erectile dysfunction. Added to UF. PA required (added to PDE-5 inhibitor PA).

    PDE-5 inhibitor PA criteria and PA form available on the TRICARE Pharmacy Forms and Criteria page (listed under brand names (Cialis, Levitra, Viagra))
    Aug 05 Pramlintide injection (Symlin) 13 Oct 05 New drug review

    PA required.

    Pramlintide (Symlin) PA criteria and PA form available on the TRICARE Pharmacy Forms and Criteria page
    May 05

    PDE-5 Inhibitors
    (requires PA, has QL)

    14 Jul 05 Class review Extended Core Formulary class. ECF selections effective 14 Jul 05.
    NF designations & retail/mail copay changes effective 12 Oct 05.
    MTF implementation period 14 Jul 05 - 12 Oct 05 (90 days).
    ECF
    UF not ECF
    NF
    MTFs must have on formulary
    MTFs may have on formulary
    MTFs must not have on formulary
    vardenafil (Levitra)
    -
    Sildenafil (Viagra)
    Tadalafil (Cialis)
    May 05

    Topical Antifungals*

    14 Jul 05 Class review Basic Core Formulary class. BCF selections effective 14 Jul 05.
    NF designations & retail/mail copay changes effective 17 Aug 05.
    MTF implementation period 14 Jul 05 - 17 Aug 05 (30 days).
    BCF
    UF not BCF
    NF
    MTFs must have on formulary
    MTFs may have on formulary
    MTFs must not have on formulary
    clotrimazole
    nystatin
    butenafine (Mentax)
    ketoconazole
    miconazole
    naftifine (Naftin)

    ciclopirox* (Loprox, generic cream, lotion)
    econazole
    oxiconazole (Oxistat)
    sertaconazole (Ertaczo)
    sulconazole (Exelderm)

    See also: Nov 06 meeting changes.
    NF medication effective 21 Feb 07: 0.25% miconazole; 15% zinc oxide ointment (Vusion)

    *The topical antifungal drug class excludes vaginal products and products for onychomycosis (e.g., ciclopirox topical solution [Penlac])
    Formulary management sheet (updated Jan 07)

    MN Criteria

    MN Form (Word version) on RxNet - revised form not yet posted

    MN form (PDF version) on TRICARE Pharmacy site- revised form not yet posted

    BCF listing
    May 05 MS-DMDs 14 Jul 05 Class review Extended Core Formulary class. ECF selections effective 14 Jul 05.
    None of the MS-DMDs are designated as NF under the UF.
    ECF
    UF not ECF
    NF
    MTFs must have on formulary
    MTFs may have on formulary
    MTFs must not have on formulary
    interferon beta-1a IM (Avonex) glatiramer (Copaxone)
    interferon beta-1a SQ (Rebif)
    interferon beta-1b (Betaseron)
    -
    May 05 Alendronate 70 mg / cholecalciferol (vit D) 14 Jul 05 BCF change

    Added to BCF

    BCF listing
    May 05 lnsulin glargine 14 Jul 05 BCF clarification

    BCF listing excludes 100 u/mL 3 mL cartridges

    Feb 05
    ARBs 18 Apr 05 Class review

    Note: below listing for historical purposes only;
    class re-reviewed May 07; see current listing

    Basic Core Formulary class. BCF selections effective 18 Apr 05.
    NF designations & retail/mail copay changes effective 17 Jul 05.
    MTF implementation period 18 Apr 05 - 17 Jul 05 (90 days).

    BCF
    UF not BCF
    NF
    MTFs must have on formulary
    MTFs may have on formulary
    MTFs must not have on formulary
    telmisartan +/HCTZ (Micardis, Micardis HCT) candesartan +/HCTZ (Atacand, Atacand HCT)
    irbesartan +/HCTZ (Avapro, Avalide)
    losartan +/HCTZ
    (Cozaar, Hyzaar)
    olmesartan +/HCTZ (Benicar, Benicar HCT)
    valsartan +/HCTZ (Diovan, Diovan HCT)
    Eprosartan +/HCTZ (Teveten, Teveten HCT)
    See current listing for formulary management sheets and MN forms

    BCF listing
    Feb 05 PPIs 18 Apr 05 Class review

    Note: below listing for historical purposes only;
    class re-reviewed May 07; see current listing

    Basic Core Formulary class. BCF selections effective 18 Apr 05.
    NF designations & retail/mail copay changes effective 17 Jul 05.
    MTF implementation period 18 Apr 05 - 17 Jul 05 (90 days).

    BCF
    UF not BCF
    NF
    MTFs must have on formulary
    MTFs may have on formulary
    MTFs must not have on formulary
    omeprazole
    (10 & 20 mg)
    rabeprazole (Aciphex)
    lansoprazole (Prevacid)
    pantoprazole (Protonix)
    omeprazole (Prilosec 40 mg & Zegerid oral susp)
    esomeprazole (Nexium)
    See current listing for formulary management sheets and MN forms

    BCF listing
    Feb 05 Azelastine nasal spray 18 Apr 05 Quantity limit QL for newly approved agent - 1 bottle per 30 days or 3 bottles per 90 days TRICARE Pharmacy Forms and Criteria page
    Feb 05 Tazarotene cream 18 Apr 05 Quantity limit QL for newly approved agent - 60 gm (1 large tube) per 30 days, 180 gm per 90 days TRICARE Pharmacy Forms and Criteria page
    Feb 05 Dihydroergotamine nasal spray 18 Apr 05 Quantity limit QL changed to 16 amps per 30 days, 18 amps per 90 days TRICARE Pharmacy Forms and Criteria page
    Feb 05 Azithromycin 250- and 600 mg tabs 18 Apr 05 Quantity limit QL deleted
    Feb 05 Dornase alpha inhalation solution 18 Apr 05 Quantity limit QL deleted
    Feb 05 Fluconazole 150 mg tabs 18 Apr 05 Quantity limit QL deleted
    Feb 05 Imiquimod cream 18 Apr 05 Quantity limit QL deleted
    Feb 05 Testosterone buccal system 18 Apr 05 Quantity limit QL deleted
    Feb 05 Timolol maleate opthalmic solution 18 Apr 05 BCF clarification BCF listing for timolol maleate ophthalmic does not include the Istalol brand BCF listing
    Jul 04 Estrogen patches 5 Oct 04 BCF change Esclim removed from BCF; BCF listing changed to estradiol patches (no specific product listed) BCF listing
    Jul 04 Ciprofloxacin 5 Oct 04 BCF change Ciprofloxacin oral added to BCF BCF listing
    Jul 04 Erythromycin ethylsuccinate/
    sulfisoxazole
    5 Oct 04 BCF change Removed from BCF
    Jul 04 Ramipril 5 Oct 04 BCF change Removed from BCF
    Jul 04 Etanercept 5 Oct 04 PA criteria change Change to criteria due to new FDA approved indication for chronic moderate to severe plaque psoriasis TRICARE Pharmacy Forms and Criteria page
    Jul 04 PDE-5 Inhibitors 5 Oct 04 PA criteria change Change to criteria to allow male patients 50 years of age or older to receive PDE-5 inhibitors without going through the PA process TRICARE Pharmacy Forms and Criteria page

    BCF = Basic Core Formulary, ECF = Extended Core Formulary, UF = Uniform Formulary, NF = non-formulary; CR = controlled release; ER = extended release, IR = immediate release, SR = sustained release; SQ = subcutaneous; ARBs = Angiotensin receptor Blockers, ACEIs = Angiotensin Converting Enzyme Inhibitors, BPH = Benign Prostatic Hypertrophy, CCBs = Calcium Channel Blockers, DHP = dihydropyridine, HCTZ = hydrochlorothiazide, MS-DMDs = Multiple Sclerosis Disease-Modifying Drugs, PDE-5 inhibitors = Phosphodiesterase-5 inhibitors, PPIs = Proton Pump Inhibitors; PA = prior authorization, QL = quantity limit


    Definitions & Timelines
    • The DoD P&T Committee meets quarterly to make recommendations concerning the status of medications on the UF, which affects both MTFs and the purchased care sector, and the BCF or ECF, which affect only MTFs. Minutes of DoD P&T Committee meetings are sent to MTFs and posted on the TRICARE Pharmacy website about 8 weeks after the meeting, after final decisions on the Committee's recommendations are made by the Director, TRICARE Management Activity (TMA).

    • The Beneficiary Advisory Panel - meets about 6 weeks after DoD P&T Committee meetings to comment on recommendations. The agenda and background material for the Beneficiary Advisory Panel (BAP) are posted about a week prior to the BAP meeting. These materials contain a summary of the DoD P&T Committee's UF recommendations, but do not include BCF/ECF recommendations or specific medical necessity criteria.

    • BCF/ECF Changes - A combined listing of medications on the BCF or ECF is available on the PEC website. Changes to the BCF or ECF are posted a few days after final UF decisions are made by the Director, TMA. Definitions of the BCF and ECF are available on the main BCF/ECF page. Listings are provided by therapeutic class and by generic name.

    • Upcoming Meetings - Information about drug classes to be reviewed by the DoD P&T Committee at upcoming meetings is maintained on an ongoing basis on the PEC website. MTF personnel, pharmaceutical manufacturers, and other interested parties can sign up to be notified about changes to the review schedule.

    • Provider Opinion - The PEC starts preparing clinical reviews of drug classes to be reviewed by the DoD P&T Committee 6 or even 9 months prior to the Committee's final review and recommendation. A key part of this process are provider surveys, typically sent to MTF providers through Service specialty leaders (depending on the drug class under review) and posted on RxNet, the PEC's webforum.

    • Formulary Management Sheets - 1-2 page documents containing essential information to assist MTFs in implementing Uniform Formulary decisions. Sent to MTFs and posted on RxNet and this webpage (see table above) about 7-10 days after final UF decisions are made by the Director, TMA.

    • Medical Necessity Criteria - specific criteria for determining medical necessity for medications designated as non-formulary under the Uniform Formulary. These criteria apply to both MTFs and purchased care. Medical necessity criteria are posted on the TRICARE Pharmacy Forms and Criteria page about 7-10 days after final UF decisions are made by the Director, TMA.

    • Medical Necessity Forms - forms submitted by providers to justify medical necessity (MN) for prescriptions for non-formulary medications to be filled at the TRICARE Mail Order Pharmacy (TMOP) or retail network pharmacies under the TRICARE Retail Pharmacy (TRRx) program. These forms may also be used by MTFs for prescriptions to be filled within the MTF.
      • Because MTFs may wish to customize the MN forms, they are posted in Microsoft Word format under the "DoD P&T Library" forum on RxNet (the PEC's webforum), about 7-10 days after final UF decisions are made by the Director, TMA. Membership in RxNet is open to DoD healthcare providers.
      • The MN forms will be posted on the TRICARE Pharmacy Forms and Criteria page in PDF (Adobe Acrobat) format for download by providers and beneficiaries, generally no earlier than 40 days after final UF decisions are made by the Director, TMA. Providers may begin submitting medical necessity requests for prescriptions to be filled at TMOP or TRRx to Express-Scripts, the TMOP and TRRx contractor, when the MN forms are posted on the TRICARE Pharmacy website. In most cases this will be well in advance of the effective date.

    • Implementation Periods for MTFs - For UF decisions, the implementation period technically begins on the date that the Director, TMA, makes final UF decisions in a specific drug class. Practically, MTFs can expect to have MN criteria and Word versions of MN forms available 7-10 days after the decision in order to plan implementation strategies. The effective date marks the date when co-pay and availability changes become effective in mail order and the retail network.

    • The TRICARE Formulary Search Tool provides an easy way for providers and beneficiaries to determine availability and copays for specific medications at retail pharmacies and in mail order and provides links to information about prior authorizations and quantity limits. While the Formulary Search Tool cannot provide information about availability of medications at specific MTFs, it does designate BCF and ECF medications.

    • Pharmacy Policies -Health Affairs Policy (04-032): TRICARE Pharmacy Benefit Program Formulary Management (22 Dec 04) addresses the structure, implementaion, and administration of the DoD Uniform Formulary, the BCF, the ECF, and MTF formularies. It supercedes several earlier policies. A 22 Mar 2005 clarification to HA Policy 04-032 addresses the continued existence of the "you write it, you fill it" policy, and a 19 Dec 2005 guidance document addresses local MTF blanket purchase agreements with pharmaceutical manufacturers (available on the TRICARE policy page under "2005 guidances.")

    • Request for DoD P&T Committee Consideration of Potential Changes to the Uniform Formulary,
      Basic Core Formulary, or Extended Core Formulary
      - The purpose of this form is to establish a process by which MTF providers can request the DoD P&T Committee consider potential revisions to previous UF, BCF, ECF, non-formulary medical necessity criteria, and other coverage decisions (e.g., PAs, quantity limits). Requests must be reviewed by an MTF P&T Committee prior to submission (please see form for requirements).

    PEC Webmaster
    Last updated 8/5/10

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