TRICARE Letter of Medical Necessity Guide
How to write an LMN and overturn a prior authorization denial with TRICARE. Includes denial reasons, turnaround times, appeals address, and clinician tips.
Quick Facts
- Avg Turnaround: 60 days standard
- Appeals Address: TRICARE Appeals (via regional contractor)
- Provider Portal: https://www.tricare.mil/
Why TRICARE Denies Prior Authorizations
- 1. Not on TRICARE Uniform Formulary
- 2. Non-preferred without medical necessity
- 3. Step therapy
Clinician Tips for TRICARE
- ✓ Express Scripts is TRICARE PBM
- ✓ Active duty has different rules than retirees
- ✓ MTF pharmacy first, then retail network
Military health system — separate from civilian Medicare.
TRICARE Prior Authorization FAQ
Why does TRICARE deny prior authorizations?
The most common TRICARE denial reasons are: Not on TRICARE Uniform Formulary; Non-preferred without medical necessity; Step therapy.
How long does TRICARE take to review a prior authorization?
TRICARE typically responds in 60 days standard.
What should a Letter of Medical Necessity for TRICARE include?
An LMN for TRICARE should reference the specific medical policy or coverage bulletin, document failed first-line therapies with dates, include current labs and ICD-10 codes, and cite supporting clinical guidelines. Military health system — separate from civilian Medicare.