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  • US Family Health Plan

Drug & Vaccine Coverage

Explore your plan's prescription drug benefits—including copays, coverage limits, and vaccines.

The information below applies to US Famly Health Plan members who are Active Duty, Retirees, Survivors, Family Members, or those who are enrolled in the TRICARE Young Adult Prime® (TYA) plan.

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For the most accurate, personalized benefit and coverage information tailored to you, sign in to your member account.

Prescription Drug Tiers Prescription Drug Copays Coverage Limits Vaccine Coverage


Prescription Drug Tiers

Your prescription drug coverage is an essential part of your health care services and we want to ensure you are familiar with the drug tiers.

Some prescription drugs require a Prior Authorization before they can be covered under you plan—learn more about the prior authorization process here: Prior Authorizations & Appeals


Understanding prescription tiers

The tier of a certain drug will determine the price members pay for their prescription.


The US Family Health Plan organizes prescription drug coverage into a four-tiered open formulary that includes:
   Tier 1 | Generic

Chemically equivalent versions of brand-name drugs.

 

   Tier 2 | Formulary

Preferred therapy drugs that do not have any generic equivalents. 

   Tier 3 | Non-Formulary

Drugs with the same clinical effects as formulary equivalents but no clinical advantage.

 

   Tier 4 | Non-Covered

Drugs not covered by TRICARE. See formulary for alternatives.

Tier Exceptions

Tier exceptions can be made in certain situations. Exceptions are only available on Tier 3 medications (reducing to Tier 2).  To request a tier exception, please call either:

Mail-Order Pharmacy Team:  1-800-322-0280 (ext. 3879)   |    Member Services Team: 1-888-674-8734  (TTY: 711)



Prescription Drug Copays

Prescription drug copay amounts as well as drug supply allowances vary depending on where the prescription is filled. US Family Health Plan members have two pharmacy options for filling prescriptions:

  • Retail Pharmacies (CVS, Walgreens, Hannaford Pharmacies, etc.)
  • The Martin's Point Mail-Order Service

pharmacy store icon
Local Pharmacies | Retail Stores

To find detailed coverage information for a specific prescription drug, use the Formulary Search Tool.


Retail Drug Copays

Retail pharmacy prescriptions can be filled up to a 30-day supply

  • Generic (Tier 1): $16
  • Brand-Name (Tier 2): $48
  • Non-Formulary (Tier 3): $85
  • Non-Covered Drugs (Tier 4): 100% cost of drug


For more on prescription drug pricing, visit:

Prescription Drug Formulary
mailbox icon
Martin's Point Pharmacy | Mail-Order

To find detailed coverage information for a specific prescription drug, use the Formulary Search Tool.


Mail-Order Drug Copays

Mail-order prescriptions can be filled up to a 90-day supply

  • Generic (Tier 1): $14
  • Brand-Name (Tier 2): $44
  • Non-Formulary (Tier 3): $85
  • Non-Covered Drugs (Tier 4): 100% cost of drug

For more on retail/mail-order pharmacies, visit:

Pharmacy Network & Mail-Order
Copay amount different than you expected?

If you notice a difference between the copay charged and what you expected, take the following steps:

Verify the correct copay amount.

You can do this by searching for the drug in the TRICARE formulary:

Formulary Search Tool
Check for processing errors.

Contact the Martin’s Point Mail-Order Pharmacy at 1-800-322-0280 (Ext. 3879) or contact Member Services at 1-888-674-8734 (TTY: 711).

Check for pharmacy overcharge.

If a medication was overcharged, the pharmacy is responsible for refunding the difference.

Coverage Limits

There are limits to the items that are eligible for coverage under your over-the-counter benefit.

It is important to note that the US Family Health Plan does not cover most over-the-counter (OTC) products or medications. This coverage is based on federal law and FDA classifications, not state regulations. If a product is OTC according to the FDA, it will not be covered under your plan. For additional questions or assistance, please contact our Member Services team.

More information, including a list of common items that do not qualify for coverage under the benefit, can be found below:

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What Is Not Covered? |  Item List
There are coverage limits on certain drugs or pharmaceutical products.

  • Drugs not requiring a prescription—this includes most over-the-counter (OTC) medications.

There are exceptions—OTC medications including insulin, loratadine (Claritin®), Plan B, Narcan OTC, and omeprazole, all of which are covered with a valid prescription.

  • Retail smoking cessation products—all smoking-cessation products are only covered at the Martin’s Point Mail-Order Pharmacy, with a valid prescription.
  • Drugs used for cosmetic reasons—such as Propecia, Renova, Rogaine, Vaniqa.
  • Medical supplies—such as bandages, wound dressing, and antiseptics.
  • Natural drugs—such as homeopathic and herbal preparations.
  • Food-related items—such as food or dietary supplements or medical foods.
  • Experimental drugs—these are drugs that cannot be lawfully marketed without the approval of the FDA and such approval has not been granted at the time of their use or proposed use.
  • Off-label drug usage—prescription drugs prescribed for an off-label use that is not generally accepted by the medical community.
  • Early refills—any prescriptions refilled before the previous refill is 80% used.
  • Out-of-network refills—prescriptions filled at out-of-network pharmacies, except when part of an emergency treatment.
  • Items/services outside of plan coverage—including prescriptions associated with non-covered TRICARE® benefits or other non-approved services.

You can find more information about Pharmacy appeals here.



Vaccine Coverage

Martin’s Point USFHP covers vaccines following guidelines from the Center for Disease Control and Prevention (CDC). TRICARE Prime plans that include Prescription Drug coverage now cover most common vaccines, including:

Influenza
Diphtheria & Tetanus
Hepatitus A & B
Measles, Mumps, Rubella (MMR)
Covid-19
Shingles & HPV

A full list of covered vaccinations and TRICARE-authorized providers can be found on the TRICARE.mil website:

Learn More at TRICARE.mil




Need help? We're here for you.

Whether you’re exploring plan options or already a US Family Health Plan member, our team is ready to help.

Prospective Members: Call us at 1-877-757-7087
Current Members: Call Member Services at 1-888-674-8734