Drug & Vaccine Coverage
Explore your plan's prescription drug benefits—including copays, coverage limits, and vaccines.
Martin's Point US Family Health Plan members have Prescription Drug coverage built right into the plan. Below you will find your plan's coverage information including drug costs and copays, drug tiers, and more.
In addition to prescription drug coverage, plan members also have vaccine coverage. This benefit gives members access to many routine vaccines with little or no out-of-pocket costs.
The information below applies to USFHP members who are Active Duty, Retirees, Survivors, Family Members, or those who are enrolled in the TRICARE® Young Adult Prime (TYA) plan.
Table of Contents:
Prescription Drug Tiers & Copays
Your prescription drug coverage is an essential part of your health care services and we want to ensure you are fully informed about your cost shares and the available tiers.
Understanding Prescription Tiers
The US Family Health Plan organizes prescription drug coverage into four tiers. The tier of a certain drug will determine the price members pay for their prescription. The four tiers include:
Generic | Tier 1 |
Formulary | Tier 2 |
Non-Formulary | Tier 3 |
Non-Covered | Tier 4 |
|
|---|---|---|---|---|
| Chemically equivalent versions of brand-name drugs. | Preferred therapy drugs without generic equivalents. | Drugs with the same clinical effects as formulary equivalents but no clinical advantage. | Drugs not covered by TRICARE®. Alternatives are available on the formulary. | |
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 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).
NOTE: 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
Prescription Copays
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
Prescription drug copay amounts as well as drug supply allowances vary depending on where the prescription is filled.
Local Pharmacies | Retail Stores
To find detailed coverage information for a specific prescription drug, use the Formulary Search Tool.
Drug Tiers & Copays |
|
Retail pharmacy prescriptions can be filled up to a 30-day supply Generic (Tier 1): $16 copay Brand-Name (Tier 2): $43 copay Non-Formulary (Tier 3): $76 copay Non-Covered Drugs (Tier 4): 100% cost of the drug |
Martin's Point Pharmacy | Mail-Order
To find detailed coverage information for a specific prescription drug, use the Formulary Search Tool.
Drug Tiers & Copays |
|
Mail-order prescriptions can be filled up to a 90-day supply Generic (Tier 1): $13 copay Brand-Name (Tier 2): $38 copay Non-Formulary (Tier 3): $76 copay Non-Covered Drugs (Tier 4): 100% cost of the drug |
For more on prescription drug pricing and availability, visit:
For more on retail/mail-order pharmacy requirements, visit:
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 using the TRICARE 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 responsible for refunding the difference.
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.
Important Note on OTC Coverage
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.
Have questions? We're here to help.
Call US Family Health Plan Member Services to speak with one of our health plan specialists today. We're here for you!