Pharmacy Program

TRICARE Pharmacy Home Delivery Form

TRICARE Pharmacy Home Delivery Order Form

Use this form to sign up for TRICARE Pharmacy Home Delivery services. Contact your doctor to write a new prescription for up to a three-month supply with authorized refills for up to one year.

• Complete the form.
• Attach your prescriptions to the order form. Clearly write your name, sponsorThe term sponsor specifically refers to the active duty, retired or deceased service member whose military status entitles their dependents (spouse, children, etc.) to receive TRICARE health benefits. ID number, and date of birth on the back of the prescription.
• Mail the form and your prescriptions to:

Express Scripts, Inc.
P.O. Box 52150
Phoenix, AZ 85072-2150

Your doctor can fax this form to Express Scripts at:

• 877-895-1900
• 602-586-3911 (overseas)

You can also complete your registration by phone. Call 877-363-1303 and have your prescription bottle handy. A patient care advocate will work with your doctor to transfer your maintenance medications to home delivery. 

Or, you can activate your account online.

Prior Authorization for Brand-Name Drugs

Brand Name Over Generic Prior Authorization Request

Your provider will use this form to request prior authorization to use a brand name drug instead of a generic alternative.

• Complete the form.
• Attach the completed form to the prescription.

Your provider can email, fax, or send it in the mail:

Email: TpharmPA@express-scripts.com

Fax: 866-684-4477

Mail:

Express Scripts, Inc.
P.O. Box 52150
Phoenix, AZ 85072-2150

Medical Necessity Forms

• Search for your drug on the TRICARE Formulary Search Tool
• Download and print the form for your drug.
• Give the form to your provider to complete and send back to Express Scripts.
  • Instructions are on the form.
  • You don’t need to send multiple forms.
• Your medical necessity approval will apply at network pharmacies and home delivery.

Prior Authorization Forms

• Search for your drug on the TRICARE Formulary Search Tool.
• Download and print the form for your drug.
• Give the form to your provider to complete and send back to Express Scripts.
  • Instructions are on the form.
  • You don’t need to send multiple forms.
• Your authorization approval will apply to network pharmacies and home delivery.