The facts
Weight loss
Covered*
Type 2 diabetes
Not indicated
Prior auth
Required
Typical cost
Standard TRICARE pharmacy copay
Who actually decides this
Not the logo on your card, most of the time. Three parties sit between you and the answer, and knowing which one is saying no tells you who to ask.
- 1
The pharmacy benefit manager · Express Scripts
TRICARE hands its formulary to Express Scripts, so what is preferred, excluded or subject to step therapy is Express Scripts’s decision rather than TRICARE’s. When you read that a formulary changed, this is the company that changed it. It also means the answer here largely applies to other plans running Express Scripts.
- 2
Your employer, if the plan comes through work
Weight-loss drugs are usually a category an employer buys or declines, not something the insurer includes by default. That is why two people holding identical cards get opposite answers, and why the useful question for member services is whether your plan includes the weight-loss medication benefit at all, before anything about criteria.
Also on Express Scripts: Cigna.
Get your real answer
Confirm which TRICARE plan you hold, because that decides the answer before any clinical criteria do. If you are on Prime or Select, get the prescription from a TRICARE network provider and have them submit the prior authorization form. If you are on TRICARE For Life, this route is closed to you and Medicare Part D is the one to ask about instead.
Coverage is plan-specific: this page reports what TRICARE publishes, not a promise about your plan. Not medical or insurance advice.
