[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-283929-105":53,"doc-detail-283929-en":126},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":119,"head_meta":121,"extra_data":123,"updated_unix":125},105,"en","brand-over-generic-prior-authorization-request-form","Brand over Generic Prior Authorization Request Form","","Brand over Generic Prior Authorization Request Form designed for TRICARE pharmacy program (TPHARM) prescriptions that require prior authorization through Express Scripts, the DoD contractor. The form must be completed and signed by the prescriber and includes provider contact details, patient and physician information, and medication selection. It outlines governing criteria related to mandatory generic substitution and A-rated generic bioequivalence, and provides a stepwise justification process covering prior generic use or patient-specific clinical reasons to bypass the generic option.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/brand-over-generic-prior-authorization-request-form/283929/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/brand-over-generic-prior-authorization-request-form/283929.png","ImageObject",442,249,{"name":88,"@type":89},"Emma Mercer","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-23","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":35},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"Who must complete and sign this Brand over Generic prior authorization request form?","Question",{"text":108,"@type":109},"The form is to be completed and signed by the prescriber.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"How can the completed form be submitted to Express Scripts for processing?",{"text":113,"@type":109},"It can be called in by the provider, faxed to the listed secure fax number, mailed by attaching it to the prescription, or emailed to the provided TpharmPA address.",{"name":115,"@type":106,"acceptedAnswer":116},"What justification information does the form require when prescribing a brand instead of an A-rated generic?",{"text":117,"@type":109},"The form asks whether the patient tried the generic (then proceeds accordingly). If the patient did not try it, an explanation is requested; if the generic cannot be used, patient-specific clinical justification is required.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},283929,1790238380,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":35,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":4},962084925502,"https://ap-avatar.wpscdn.com/davatar_6f874abed73319feea01a86fa6f0fab8","Brand over Generic Prior Authorization Request Form  \nTo 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.  \n\n| MA IL ORDER | and\u003Cbr>RETA IL | • The provider may call: 1-866-684-4488\u003Cbr>or the completed form may be faxed to:\u003Cbr>1-866-684-4477\u003Cbr>• The patient may attach the completed form\u003Cbr>to the prescription and mail it to: Express Scripts, P.O. Box 52150, Phoenix, AZ 85072-9954\u003Cbr>or email the form only to:\u003Cbr>[TpharmPA@express-scripts.com](TpharmPA@express-scripts.com) |\n| --- | --- | --- |\n\nPrior authorization criteria and a copy of this form are available at [http://pec.ha.osd.mil/forms_criteria.php. This](http://pec.ha.osd.mil/forms_criteria.php. This) prior authorization has no expiration date.  \n\n| Step\u003Cbr>1 | Please complete patient and physician information (Please Print)\u003Cbr>Patient Name:\u003Cbr>\u003Cbr>Address:  \u003Cbr>\u003Cbr>Sponsor ID \\#  \u003Cbr>Date of Birth: | Physician Name:  \u003Cbr>Address:  \u003Cbr>\u003Cbr>Phone \\#:  \u003Cbr>Secure Fax \\#: |\n| --- | --- | --- |\n| Please indicate which medication is being prescribed:   |  |  |\n\nStep  \n2  \nPlease consider the following:  \n• 32 CFR 199.21 (j)(2) Use of generic drugs under the pharmacy benefits program. The pharmacy benefits program generally requires 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.  \n• 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.”  \n\n| 1. Has the patient tried the generic product? | 􀂆 Yes Proceed to Question 2 | 􀂆 No Proceed to Question 3 |\n| --- | --- | --- |\n| 2. Please provide an explanation of the patient’s experience with the generic, then proceed to Step 3: |  |  |\n| 3. Please provide patient-specific clinical justification as to why the A-rated generic product cannot be used, then proceed to Step 3: |  |  |\n\n\n| Step I certify that the above is correct and accurate to the\u003Cbr>3\u003Cbr>_______________________________________________________\u003Cbr>Prescriber Signature | best of my knowledge. Please sign and date:\u003Cbr>Date |\n| --- | --- |\n\nLatest revision: 10 August 2011  \nMade fillable by eForms","cbCaiamSRAWju6PH","https://ap.wps.com/l/cbCaiamSRAWju6PH","pdf",157318,"English","# Prior authorization request details\n## Submission and contact information\n## Step 1: Patient and physician information\n## Step 2: Generic substitution criteria and questions\n## Signature and certification","[{\"question\":\"Who must complete and sign this Brand over Generic prior authorization request form?\",\"answer\":\"The form is to be completed and signed by the prescriber.\"},{\"question\":\"How can the completed form be submitted to Express Scripts for processing?\",\"answer\":\"It can be called in by the provider, faxed to the listed secure fax number, mailed by attaching it to the prescription, or emailed to the provided TpharmPA address.\"},{\"question\":\"What justification information does the form require when prescribing a brand instead of an A-rated generic?\",\"answer\":\"The form asks whether the patient tried the generic (then proceeds accordingly). If the patient did not try it, an explanation is requested; if the generic cannot be used, patient-specific clinical justification is required.\"}]","Brand over Generic Prior Authorization Request Form | PDF",1789622634]