TRICARE Uniform Formulary. Pre-Authorization Requirements
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1 TRICARE Uniform Formulary Pre-Authorization Requirements The Department of Defense (DoD) requires pre-authorization on select medications. These medications are on the DoD s pre-authorization list because of high cost or because the drugs are conditionally eligible. This list is not all-inclusive and is subject to change. Refer to the DoD Pharmacoeconomic Center ( for the most current listing of prescription drugs that are subject to pre-authorization requirements. Maxor Plus Pharmacy is also able to assist with TRICARE Uniform Formulary questions. Contact Maxor Plus Pharmacy at (phone) or (fax). Comments Classification Name Generic Name Aciphex Rabeprrazole Actoplus Met/Actoplus Met XR Pioglitazone Hydrocloride Actos Pioglitazone Hydrochloride Adcirca Tadalfil Advicor Lovastatin; Niacin Altoprev Lovastatin Ambien CR Zolpidem extended release Amevive Amturnide Atacand Avalide Alefacept Amolodipine Besylate; Hydrochlorothiazide Candesartan Cilexetil Hydroclorothiazide: Irbesartan
2 Avandamet Avandaryl Avandia Avapro Avinza Azor Benicar/Benicar HCT Bravelle Byetta Rosiglitazone Maleate Glimepiride: Rosiglitazone Maleate Rosiglitazone Irbesartan Morphine Sulfate Hydrochlorothiazide; Urofollitropin Exenatide High potency opioid Caduet Atorvastatin Calcium Cialis Tadalafil ; gender and age restrictions Cimzia Certolizumab Pegol Crestor Rosuvastatin Calcium Dexilant Dexlansoprazole Duetact Glimepiride; Pioglitazone Hydrochloride Duragesic Fentanyl High potency opioid Edarbi Azilsartan Medoxomil Edlur Zolpidem Tartrate Enbrel Etanercept Exalgo Hydromorphone High potency opioid
3 Hydrochloride Fentanyl Fentanyl High potency opioid Follistim AQ Follitropin Beta Genotropin Somatropin Gilenya Fingolimod Hydrochloride Gonal-F/Gonal RFF Follitropin Alfa Humatrope Somatropin Humira Adalimumab Increlex Mecasermin Jalyn Janumet Dutasteride; Tamsulosin Hydrochloride Sitagliptin Phosphate Januvia Sitagliptin Phosphate Kadian Morphine Sulfate High potency opioid Kineret Anakinra Kombiglyze XR Lansoprazole/Lansoprazole ODT Saxagliptin Hydrochloride Lansoprazole Lescol/Lescol XL Fluvastatin Sodium Levitra Vardenafil ; age and gender restrictions Livalo Pitavastatin Calcium Lunesta Eszopiclone Menopur Menotripins Morphine Sulfate ER Morphine Sulfate High potency opioid MS Contin Morphine sulfate High potency opioid
4 Norditropin Flexpro Somatropin Nutropin/Nutropin AQ/Nutropin AQ Nuspin Somatropin Nuvigil Armodafinil Omeprazole/Sodium Bicarbonate Omeprazole; Sodium Bicarbonate Omnitrope Somatropin Onglyza Saxagliptin Hydrochloride Onsolis Fentanyl Citrate High potency opioid Oramorph SR Morphine Sulfate High potency opioid Oxycontin Oxycodone Hydrochloride High potency opioid Pantoprazole Sodium Prevacid/Prevacid 24 hours/prevacid Solutab Pantoprazole Sodium Sesquihydrate Lansoprazole Protonix Pantoprazole Provigil Modanfinil Qualaquin Quinine Sulfate Rapaflo Silodosin Repronex Menotropins Revatio Sildenafil Rozerem Ramelteon Saizen/Saizen Click.Easy Somatropin (Serono) Serostim Somatropin (Serono) Silenor Doxepin Hydrochloride Simcor Niacin; Simvastatin
5 Simponi Golimumab Sonata Zaleplon Symlin Pramlintide Acetate Tekamlo Amlodipine Besylate Tekturna/Tekturna HCT Aliskiren Fumarate Teveten/Teveten HCT Eprosartan Mesylate Tev-Tropin Somatropin Tribenzor Valturna Hydrochlorothiazide; Valsartan Viagra Sildenafil ; age and gender restrictions Victoza Liraglutide Vytorin Ezetimibe; Simvastatin Zaleplon Zaleplon Zegerid Omeprazole/sodium bicardonate Zolpidem Tartrate ER Zolpidem Tartrate Zolphimist Zolpidem Tartrate Zorbtive Somatropin
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