Brand over Generic Prior Authorization Request Form
To be completed and signed by the prescriber. To be used only for prescriptions which are to be filled through the Department of Defense (DoD)
TRICARE pharmacy program (TPHARM). Express Scripts is the TPHARM contractor for DoD.
• The provider may call: 1-866-684-4488
or the completed form may be faxed to:
1-866-684-4477
• The patient may attach the completed form
to the prescription and mail it to: Express Scripts, P.O. Box 52150, Phoenix, AZ 85072-9954
or email the form only to:
Prior authorization criteria and a copy of this form are available at This prior authorization has no expiration
date.
Step
Please complete patient and physician information (Please Print)
Patient Name:
Physician Name:
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Address:
Address:
Sponsor ID #
Phone #:
Date of Birth:
Secure Fax #:
Please indicate which medication is being prescribed: ________________________________________________
Step
Please consider the following:
•
32 CFR 199.21 (j)(2) Use of generic drugs under the pharmacy benefits program. The pharmacy benefits program generally requires
2
mandatory substitution of generic drugs listed with an “A” rating in the current Approved Drug Products with Therapeutic Equivalence
Evaluations (Orange Book) published by the FDA and generic equivalents of grandfather or Drug Efficacy Study Implementation (DESI)
category drugs for brand name drugs. In cases in which there is a clinical justification for a brand name drug in lieu of a generic equivalent,
under the standards and procedures of paragraph (h)(3) of this section, the generic substitution policy is waived.
•
The generic products are A-rated by the Food and Drug Administration for bioequivalence and therapeutic equivalence to the brand name
product. An A-rated product will produce comparable absorption and blood levels to the brand name product. It is the judgment of the FDA
that based on its determination of therapeutic equivalence between generic and innovator drug products, “products evaluated as
therapeutically equivalent can be expected to have equivalent clinical effect whether the product is brand name or generic drug product.”
Yes
No
1. Has the patient tried the generic product?
Proceed to Question 2
Proceed to Question 3
2. Please provide an explanation of the patient’s experience with the generic, then proceed to Step 3:
3. Please provide patient-specific clinical justification as to why the A-rated generic product cannot be used,
then proceed to Step 3:
Step
I certify that the above is correct and accurate to the best of my knowledge.
Please sign and date:
3
_______________________________________________________
____________________________________________________
Prescriber Signature
Date
Latest revision: 10 August 2011
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