How TRICARE and VA health care treat weight treatment
TRICARE and VA are two federal programs with two formularies, and the regulation behind each one is what decides a weight treatment question. The TRICARE regulation lists obesity and weight reduction among the services it does not cover, names its own exception for surgery, and sets the clock on every rung of the appeal.
By the Covered Weight editorial team · Updated Aug 9, 2026. Research and sourcing by Evan Reid.
The answer starts in the benefit regulation, not in the formulary
The TRICARE basic program regulation lists obesity and weight reduction among the services and supplies it does not cover, and it names its own exception for surgical treatment of morbid obesity in the same sentence.
No state law reaches any of this. Both programs are federal, so a reader who moves takes the same rule with them, and an employer has no part in it either.
32 C.F.R. 199.4(g)(28), the TRICARE obesity and weight reduction exclusion
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-32 issue date 2026-07-24 · Read Aug 9, 2026
Service and supplies related “solely” to obesity or weight reduction or weight control whether surgical or nonsurgical
Excerpt ends before the sentence continues about jaw wiring and the cross-reference to paragraph (e)(15), which is the separate written path for bariatric surgery. The curly quotation marks around "solely" are the characters the source prints. Same document and same key as the entry in _national/payer-archetypes.json, deliberately: one key never means two documents, and one document keeps one key.
One word in that sentence is doing the work
The word the regulation prints is "solely", so what the list reaches is a USE rather than a molecule. A prescription written for a different condition the program covers is not reached by this paragraph, which makes the useful question one about the condition on the prescription rather than about the brand on the box.
Nothing here is a suggestion about what a prescription should say. It is a statement about how the rule is written, and it matters because a reader who hears that the program bans a drug outright has heard something the paragraph does not say.
The exclusion names its own exception
The exclusion ends with a cross-reference, and the paragraph it points at is a benefit rather than a second exclusion. That paragraph limits the morbid obesity benefit to bariatric surgical procedures whose safety and efficacy has been proven comparable or superior to conventional therapies.
Why this page does not print the selection criteria in that paragraph
That paragraph also sets patient selection criteria, and this record does not publish them. A criteria threshold is its own class of fact with its own record type and its own gate, and lifting numbers out of a regulation into a page about drug coverage is how a threshold ends up quoted without the conditions around it. Read the section itself, which is linked beside this note.
32 C.F.R. 199.4(e)(15), the TRICARE morbid obesity benefit
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-32 issue date 2026-07-24 · Read Aug 9, 2026
The TRICARE morbid obesity benefit is limited to those bariatric surgical procedures for which the safety and efficacy has been proven comparable or superior to conventional therapies
Excerpt ends before the sentence continues with the reference to generally accepted norms for medical practice and the cross-reference to the definition of reliable evidence in § 199.2. The patient selection criteria sit in paragraph (e)(15)(i) below this sentence and are deliberately not quoted or published in this record.
Inside the benefit, one national list decides the drug question
Inside the benefit, a uniform formulary decides which pharmaceutical agents are available and at what tier. It is one national list rather than a per-state or per-contractor one, which is why nothing about it changes when a reader moves.
The pharmacy regulation adds a stop that has no Medicare counterpart. An agent used exclusively in a treatment the regulation expressly excludes is not considered for the formulary at all, and the same paragraph says such an agent is not available on the non-formulary tier either. So for an agent in that position the non-formulary route described below is not a route.
32 C.F.R. 199.21(a)(3)(iii), excluded agents and the uniform formulary
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-32 issue date 2026-07-24 · Read Aug 9, 2026
Excluded pharmaceutical agents shall not be available as non-formulary agents, nor will they be cost-shared under the TRICARE pharmacy benefits program.
The second sentence of the paragraph. The first sentence supplies the antecedent for "excluded": agents used exclusively in medical treatments or procedures that are expressly excluded from the TRICARE benefit by statute or regulation, which will not be considered for inclusion on the uniform formulary. Both sentences were read; the excerpt is the half carrying the consequence.
When the agent is on the benefit but off the formulary
Where medical necessity has been established, the regulation says eligible beneficiaries receive the non-formulary agent at the formulary cost-share. The effect is on the price rather than on the availability.
Who may file
The beneficiary, or a provider submitting evidence on the beneficiary's behalf.
Evidence after the prescription is filled
60 days, and the rule does not say which kind
From the dispensing date.
The rule prints this figure in words rather than digits. It is the window in which evidence can still arrive after the prescription has been filled, and it is described in the rule as an appeal to reduce the co-payment rather than as a request to change the tier.
32 C.F.R. 199.21(i)(3)(vi), the window for evidence after dispensing
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-32 issue date 2026-07-24 · Read Aug 9, 2026
no later than sixty days from the dispensing date, as an appeal to reduce the non-formulary co-payment to the same co-payment as a formulary drug
Excerpt begins mid-sentence. The clause before it reads that information to establish clinical necessity for use of a non-formulary pharmaceutical agent may also be provided at a later date. The regulation spells the figure as a word rather than in digits, which is the form the quote preserves.
What the regulation means by clinical necessity, and what comes first
The regulation defines clinical necessity as sufficient evidence, submitted by the beneficiary or by a provider for them, that establishes one or more of a listed set of conditions about how the formulary agents in that therapeutic class perform. It is a definition about evidence and about the class, so the request that arrives without the evidence has asked a question the rule cannot answer.
The pharmacy rule sends a reader through the contractor's own internal review first and says every level of it has to be exhausted before the case goes on for a formal review.
32 C.F.R. 199.21(b)(1), the definition of clinical necessity
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-32 issue date 2026-07-24 · Read Aug 9, 2026
Sufficient evidence submitted by a beneficiary or provider on behalf of the beneficiary that establishes that one or more of the following conditions exist
The operative clause of the definition of "Clinically necessary". The listed conditions that follow it in the same paragraph concern contraindication, adverse effects, therapeutic failure, an unacceptable clinical risk in switching, and the absence of any alternative on the formulary. Those conditions are described in the record rather than quoted, because quoting them would put clinical language on the page without the definition around it.
32 C.F.R. 199.21(h)(3)(iv), non-formulary agents at the formulary cost-share
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-32 issue date 2026-07-24 · Read Aug 9, 2026
Eligible beneficiaries will receive non-formulary pharmaceutical agents at the formulary cost-share when medical necessity has been established by the beneficiary and/or his/her provider.
The sentence that states the consequence. The paragraph continues by applying the peer review provisions of § 199.15 to the pre-authorization determination and by allowing TRICARE to require the review to be expedited, without printing a figure for it.
32 C.F.R. 199.21(i)(3)(viii), exhausting the contractor's internal review
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-32 issue date 2026-07-24 · Read Aug 9, 2026
All levels of peer review, appeals, and grievances established by the Contractor for internal review shall be exhausted prior to forwarding to TRICARE Management Activity for a formal review.
The opening sentence of the paragraph. It continues by applying procedures comparable to those established under §§ 199.15 and 199.10, and by allowing the time periods for peer review or for appeal and hearing to be expedited under the pharmacy benefits program without printing a figure for either.
A dollar amount decides how far the appeal can go
For a co-payment dispute the regulation says the relevant amount is the difference between the cost shares of a formulary and a non-formulary drug, which is not the price of the drug and is usually a great deal smaller. The same paragraph allows the amounts for repeated prescriptions of the same drug for the same condition within a twelve month period to be combined.
Below this, the reconsideration is the end
$50
Listed as one of the conditions that make a reconsideration determination final, which is the regulation's way of saying the rungs above it are not available.
32 C.F.R. 199.10(b)(5), when a reconsideration determination is final
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-32 issue date 2026-07-24 · Read Aug 9, 2026
Effect of reconsideration determination. The reconsideration determination is final if either of the following exist:
The lead paragraph of the finality rule. It is cited with the item below it rather than as one string because the two are separate paragraphs on the page and a quote spanning both is not a verbatim match, which the pre-authoring check confirmed.
32 C.F.R. 199.10(b)(5)(i), the amount below which a reconsideration is final
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-32 issue date 2026-07-24 · Read Aug 9, 2026
The amount in dispute is less than $50.
Item (i) under the lead paragraph quoted in the companion entry, which supplies what "final" attaches to. Read together they are the rule; read alone this item is a figure with no verb, which is why both are cited on the fact.
Below this, there is no hearing
$300
Listed as one of the conditions that make a formal review determination final. The hearing paragraph is written the other way round and lets a party request a hearing only where the formal review determination is not final under that rule.
32 C.F.R. 199.10(c)(5), when a formal review determination is final
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-32 issue date 2026-07-24 · Read Aug 9, 2026
Effect of formal review determination. The formal review determination is final if one or more of the following exist:
The lead paragraph of the finality rule, cited with the item below it for the same reason as its reconsideration counterpart: the two are separate paragraphs and a quote spanning both is not a verbatim match.
32 C.F.R. 199.10(c)(5)(ii), the amount below which a formal review is final
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-32 issue date 2026-07-24 · Read Aug 9, 2026
The amount in dispute is less than $300. (See paragraph (a)(7) of this section.)
Item (ii) under the lead paragraph quoted in the companion entry. The parenthetical cross-reference is printed by the source and is kept because it is what points a reader at how the amount is calculated.
32 C.F.R. 199.10(d), when a hearing may be requested
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-32 issue date 2026-07-24 · Read Aug 9, 2026
Any party to the initial determination may request a hearing if the party is dissatisfied with the formal review determination
Excerpt ends before the sentence continues with the condition that the formal review determination is not final under paragraph (c)(5), and with the separate provider sanction route. That continuation is the link between the dollar threshold and the availability of this rung, and it is why this entry is cited on the threshold as well as on the rung.
This is the part of the TRICARE route with no Medicare counterpart, and it is why the combining rule in the paragraph above it exists at all.
32 C.F.R. 199.10(a)(7), the amount in dispute requirement
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-32 issue date 2026-07-24 · Read Aug 9, 2026
An amount in dispute is required for an adverse determination to be appealed under the provisions of this section, except as set forth below.
The opening sentence of the paragraph. The exceptions it points at concern provider authorisation and sanction matters rather than a beneficiary's drug claim.
32 C.F.R. 199.21(i)(3)(viii), what the amount in dispute is for a drug co-payment
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-32 issue date 2026-07-24 · Read Aug 9, 2026
the relevant amount is the difference between the cost shares of a formulary versus non-formulary drug
Excerpt begins mid-sentence. The clause before it names the amount in dispute requirement of § 199.10(a)(7) as the thing being met. The sentence after it in the same paragraph allows the amounts for multiple prescriptions of the same drug treating the same medical condition and filled within a twelve month period to be combined. A separate key from the exhaustion quote above because a source key names a document and a quote, and these are two facts.
32 C.F.R. 199.21(i)(3)(viii), combining prescriptions to meet the amount in dispute
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-32 issue date 2026-07-24 · Read Aug 9, 2026
The amount for each of multiple prescriptions involving the same drug to treat the same medical condition and filled within a 12-month period may be combined to meet the required amount in dispute.
The closing sentence of the paragraph, following the sentence that defines the amount as the cost-share difference. A THIRD key on the same paragraph, added because audit:data-prose-claims refused the twelve month figure in authored prose while the two existing quotes carried the difference rule and not the combining rule. The gate was right: the figure had no evidence behind it until this sentence was read and stored.
The route after a denial, and what each step is allowed to take
These windows are set by federal regulation, so they are the same in every state. Each figure prints in the unit the rule uses, and the section it was read from sits beside it.
Step 1
Reconsideration
Time to file
90 days, and the rule does not say which kind
From the date of the notice of initial determination.
The regulation dates the filing from the postmark rather than from arrival, so a request that is mailed inside the window is filed inside it.
32 C.F.R. 199.10(b)(1)(iii), the window to request a reconsideration
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-32 issue date 2026-07-24 · Read Aug 9, 2026
Allowed time to file. The request must be mailed within 90 days after the date of the notice of initial determination.
The whole paragraph, with its own heading. Paragraph (b)(1)(iv) immediately below it deems the request filed on the date it is mailed and postmarked, which is why the record describes the postmark rather than arrival.
Time to decide
60 days, and the rule does not say which kind
From receipt of the request for reconsideration.
The regulation words this as what the office normally shall do, so it is the published expectation rather than a guarantee a reader can hold anyone to.
32 C.F.R. 199.10(b)(3), the window for a reconsideration determination
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-32 issue date 2026-07-24 · Read Aug 9, 2026
normally shall issue its reconsideration determination no later than 60 days from the date of receipt of the request for reconsideration
Excerpt begins mid-sentence. The subjects before it are the office, the contractor and the peer review organisation that may have made the initial determination. The word "normally" is the regulation's own and is why the record calls this a published expectation.
What this step is, who files it, and who reviews it
The first appeal after a denial. It goes back to the contractor or the peer review organisation that issued the determination and asks whether the determination was made in accordance with law, regulation and policy.
Filed by: Any party to the initial determination, in writing, with the office that made it.
The office that made the determination being appealed is the office that reconsiders it, so the first rung is not an outside look.
Step 2
Formal review
Time to file
60 days, and the rule does not say which kind
From the date of the notice of the reconsideration determination.
The regulation runs this window from the notice of the reconsideration determination, and it runs from the initial determination instead where that determination was the one being appealed.
32 C.F.R. 199.10(c)(1)(iii), the window to request a formal review
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-32 issue date 2026-07-24 · Read Aug 9, 2026
The request shall be mailed within 60 days after the date of the notice of the reconsideration determination or OCHAMPUS initial determination being appealed.
The operative sentence of the paragraph, which carries the heading "Allowed time to file". The alternative trigger in the same sentence is why the record says the window runs from the initial determination where that is the determination under appeal.
Time to decide
90 days, and the rule does not say which kind
From receipt of the request for formal review.
Worded as what the Chief of the Office of Appeals and Hearings or a designee normally shall do.
32 C.F.R. 199.10(c)(3), the window for a formal review determination
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-32 issue date 2026-07-24 · Read Aug 9, 2026
normally shall issue the formal review determination no later than 90 days from the date of receipt of the request for formal review
Excerpt begins mid-sentence. The subject before it is the Chief of the Office of Appeals and Hearings or a designee, which is the reviewer the record names.
What this step is, who files it, and who reviews it
The first look from outside the office that decided the case. It asks whether the earlier determinations were made in accordance with law, regulation and policy, on the record as it then stands.
Filed by: Any party to the determination, in writing, with the Office of Appeals and Hearings named in the reconsideration notice.
The Chief of the Office of Appeals and Hearings, or a designee, rather than the contractor that issued the denial.
Step 3
Hearing before a hearing officer
Time to file
60 days, and the rule does not say which kind
From the date of the notice of the formal review determination.
The window runs from the formal review determination, and from the initial determination instead where that is the determination being appealed.
32 C.F.R. 199.10(d)(1)(iii), the window to request a hearing
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-32 issue date 2026-07-24 · Read Aug 9, 2026
The request shall be mailed within 60 days after the date of the notice of the initial determination or formal review determination being appealed.
The operative sentence of the paragraph, which carries the heading "Allowed time to file". Paragraph (d)(1)(iv) below it deems the request filed on the date it is mailed and postmarked.
Time to decide
60 days, and the rule does not say which kind
From the date of written notice of the hearing officer's assignment.
The window covers reviewing the file, scheduling and holding the hearing and issuing a recommended decision. It is not the end of the case, and the block below this table is the rest of it.
32 C.F.R. 199.10(d)(3)(ii), the hearing officer's window
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-32 issue date 2026-07-24 · Read Aug 9, 2026
The hearing officer, except as otherwise provided in this Section, normally shall have 60 days from the date of written notice of assignment to review the file, schedule and hold the hearing
Excerpt ends before the sentence continues with issuing a recommended decision to the Director, which is the step the record's separate final decision block covers. The capitalised "Section" is the character case the source prints.
What this step is, who files it, and who reviews it
An administrative proceeding in front of a hearing officer, at which the facts relevant to the appealable issue are presented and evaluated. It is available only where the formal review determination is not already final under the finality rule.
Filed by: Any party to the initial determination who is dissatisfied with the formal review determination, in writing.
A hearing officer appointed for the case, who writes a recommended decision rather than the decision itself.
This reads the TRICARE appeal clocks for all 51 jurisdictions. These rules reach TRICARE. VA health care runs its own process, which is covered further down this page and is not described by these figures.
After the hearing
The hearing officer's decision is a recommendation. It goes to the Director or a designee, who adopts it, rejects it, or refers it onward, so a reader who has had a hearing is still waiting on somebody else.
90 days, and the rule does not say which kind
From receipt of the recommended decision.
Worded as what the Director or a designee normally will do. Where the case has been sent back to the hearing officer, the window runs from the revised recommended decision instead.
32 C.F.R. 199.10(e)(1), the window for the final decision
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-32 issue date 2026-07-24 · Read Aug 9, 2026
The Director, OCHAMPUS, or designee, normally will take action with regard to the recommended decision within 90 days of receipt of the recommended decision
Excerpt ends before the sentence continues with the alternative trigger, receipt of a revised recommended decision following a remand order to the hearing officer. The sentence before it in the same paragraph is the one that makes the hearing officer's decision a recommendation rather than a decision.
The pharmacy rule allows these periods to be expedited and prints no figure for it, so there is no expedited clock on this page. That is a limit of what the regulation publishes rather than a statement that urgency changes nothing.
This record reads three rungs of one regulation and stops at both ends of them. Below the first rung, the pharmacy rule sends a reader through the contractor's own internal review, whose levels are set by the contractor rather than by this section, and nothing here describes them. Above the last, what follows a final agency decision is not described in the paragraphs read for this record, so nothing here says whether anything follows or what it would be. The absence of a fourth row in the table is a limit of what was read, not a statement that the road ends.
VA health care is a different program, and this page reads less of it
The VA medical benefits package includes prescription drugs, and the regulation ties them to the VA national formulary system rather than to any state list or employer document.
So the VA question is a formulary question first, and the facility and the treatment team are who apply it.
What a VA non-formulary request has to contain, who decides it, and on what clock, are set in Veterans Health Administration directives rather than in the regulation, and this repo has not read them. Nothing on this page describes the VA request or appeal process, and the TRICARE detail above must not be read across to it: they are separate programs with separate formularies. A reader eligible for both asks each one separately.
38 C.F.R. 17.38(a)(1)(iii), prescription drugs in the VA medical benefits package
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-38 issue date 2026-07-28 · Read Aug 9, 2026
Prescription drugs, including over-the-counter drugs and medical and surgical supplies available under the VA national formulary system.
Item (iii) under "(1) Basic care". Nothing inside the excerpt was altered. Same document and same key as the entry in _national/payer-archetypes.json, deliberately: one key never means two documents, and one document keeps one key.
What this page does not answer
This record describes the federal rules. It does not describe what the TRICARE uniform formulary or a VA facility formulary lists on any given day, and it does not reach a service billed outside the pharmacy benefit. TRICARE and VA are two programs and a person eligible for both has to ask each one separately.
If the coverage you are asking about is not one of these two, work out which of the eight kinds of plan is yours first, because the document that governs your case changes with the answer. If a request has already been denied on some other kind of plan, the appeal route for each plan type names the body that hears it. The other federal program with its own drug rule is Medicare Part D, whose exclusion is written a different way.
Start by finding out which document governs your plan
Everything else follows from it. A state program publishes its own rules. A marketplace plan is measured against a state benchmark. An employer plan that pays claims out of the employer's own funds sets its own rules, and no state rule reaches it.
No. They are two federal programs with two formularies and two request processes, and being eligible for one says nothing about the other. A person enrolled in both asks each one separately, because the answer can differ and the document that governs it is different.
What does the TRICARE regulation actually say about obesity?
It lists services and supplies related solely to obesity or weight reduction among the things the program does not cover, and it ends that sentence with a cross-reference to its own morbid obesity benefit for surgery. The word doing the work is solely, so what the paragraph reaches is a use rather than a molecule.
If a drug is not on the uniform formulary, can it still be dispensed?
The pharmacy regulation has two answers depending on where the agent sits. An agent that is on the benefit but off the formulary can be dispensed, and where clinical necessity has been established the regulation says the beneficiary receives it at the formulary cost-share. An agent used exclusively in a treatment the regulation expressly excludes is a different case: the same rule says it is not available on the non-formulary tier at all.
Why does a dollar amount decide whether an appeal can continue?
Because the appeal regulation requires an amount in dispute before an adverse determination can be appealed, and it makes a determination final below two published figures. For a co-payment dispute the amount is the difference between the formulary and non-formulary cost shares rather than the price of the drug, and the same paragraph allows repeated prescriptions of the same drug for the same condition inside a twelve month period to be added together.
Does this page tell me whether my own request will be approved?
No. Covered Weight publishes what a named, dated, published rule says and nothing about how any particular request will be decided. The notice you receive is the document that governs your case, including where a request has to go and the date it has to get there by.
Documents this page reads
The 21 documents behind every figure on this page, with the section and the quote
32 C.F.R. 199.4(g)(28), the TRICARE obesity and weight reduction exclusion
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-32 issue date 2026-07-24 · Read Aug 9, 2026
Service and supplies related “solely” to obesity or weight reduction or weight control whether surgical or nonsurgical
Excerpt ends before the sentence continues about jaw wiring and the cross-reference to paragraph (e)(15), which is the separate written path for bariatric surgery. The curly quotation marks around "solely" are the characters the source prints. Same document and same key as the entry in _national/payer-archetypes.json, deliberately: one key never means two documents, and one document keeps one key.
32 C.F.R. 199.4(e)(15), the TRICARE morbid obesity benefit
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-32 issue date 2026-07-24 · Read Aug 9, 2026
The TRICARE morbid obesity benefit is limited to those bariatric surgical procedures for which the safety and efficacy has been proven comparable or superior to conventional therapies
Excerpt ends before the sentence continues with the reference to generally accepted norms for medical practice and the cross-reference to the definition of reliable evidence in § 199.2. The patient selection criteria sit in paragraph (e)(15)(i) below this sentence and are deliberately not quoted or published in this record.
32 C.F.R. 199.21(a)(3)(iii), excluded agents and the uniform formulary
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-32 issue date 2026-07-24 · Read Aug 9, 2026
Excluded pharmaceutical agents shall not be available as non-formulary agents, nor will they be cost-shared under the TRICARE pharmacy benefits program.
The second sentence of the paragraph. The first sentence supplies the antecedent for "excluded": agents used exclusively in medical treatments or procedures that are expressly excluded from the TRICARE benefit by statute or regulation, which will not be considered for inclusion on the uniform formulary. Both sentences were read; the excerpt is the half carrying the consequence.
32 C.F.R. 199.21(b)(1), the definition of clinical necessity
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-32 issue date 2026-07-24 · Read Aug 9, 2026
Sufficient evidence submitted by a beneficiary or provider on behalf of the beneficiary that establishes that one or more of the following conditions exist
The operative clause of the definition of "Clinically necessary". The listed conditions that follow it in the same paragraph concern contraindication, adverse effects, therapeutic failure, an unacceptable clinical risk in switching, and the absence of any alternative on the formulary. Those conditions are described in the record rather than quoted, because quoting them would put clinical language on the page without the definition around it.
32 C.F.R. 199.21(h)(3)(iv), non-formulary agents at the formulary cost-share
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-32 issue date 2026-07-24 · Read Aug 9, 2026
Eligible beneficiaries will receive non-formulary pharmaceutical agents at the formulary cost-share when medical necessity has been established by the beneficiary and/or his/her provider.
The sentence that states the consequence. The paragraph continues by applying the peer review provisions of § 199.15 to the pre-authorization determination and by allowing TRICARE to require the review to be expedited, without printing a figure for it.
32 C.F.R. 199.21(i)(3)(viii), exhausting the contractor's internal review
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-32 issue date 2026-07-24 · Read Aug 9, 2026
All levels of peer review, appeals, and grievances established by the Contractor for internal review shall be exhausted prior to forwarding to TRICARE Management Activity for a formal review.
The opening sentence of the paragraph. It continues by applying procedures comparable to those established under §§ 199.15 and 199.10, and by allowing the time periods for peer review or for appeal and hearing to be expedited under the pharmacy benefits program without printing a figure for either.
32 C.F.R. 199.10(a)(7), the amount in dispute requirement
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-32 issue date 2026-07-24 · Read Aug 9, 2026
An amount in dispute is required for an adverse determination to be appealed under the provisions of this section, except as set forth below.
The opening sentence of the paragraph. The exceptions it points at concern provider authorisation and sanction matters rather than a beneficiary's drug claim.
32 C.F.R. 199.10(e)(1), the window for the final decision
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-32 issue date 2026-07-24 · Read Aug 9, 2026
The Director, OCHAMPUS, or designee, normally will take action with regard to the recommended decision within 90 days of receipt of the recommended decision
Excerpt ends before the sentence continues with the alternative trigger, receipt of a revised recommended decision following a remand order to the hearing officer. The sentence before it in the same paragraph is the one that makes the hearing officer's decision a recommendation rather than a decision.
38 C.F.R. 17.38(a)(1)(iii), prescription drugs in the VA medical benefits package
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-38 issue date 2026-07-28 · Read Aug 9, 2026
Prescription drugs, including over-the-counter drugs and medical and surgical supplies available under the VA national formulary system.
Item (iii) under "(1) Basic care". Nothing inside the excerpt was altered. Same document and same key as the entry in _national/payer-archetypes.json, deliberately: one key never means two documents, and one document keeps one key.
32 C.F.R. 199.21(i)(3)(vi), the window for evidence after dispensing
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-32 issue date 2026-07-24 · Read Aug 9, 2026
no later than sixty days from the dispensing date, as an appeal to reduce the non-formulary co-payment to the same co-payment as a formulary drug
Excerpt begins mid-sentence. The clause before it reads that information to establish clinical necessity for use of a non-formulary pharmaceutical agent may also be provided at a later date. The regulation spells the figure as a word rather than in digits, which is the form the quote preserves.
32 C.F.R. 199.10(b)(5), when a reconsideration determination is final
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-32 issue date 2026-07-24 · Read Aug 9, 2026
Effect of reconsideration determination. The reconsideration determination is final if either of the following exist:
The lead paragraph of the finality rule. It is cited with the item below it rather than as one string because the two are separate paragraphs on the page and a quote spanning both is not a verbatim match, which the pre-authoring check confirmed.
32 C.F.R. 199.10(b)(5)(i), the amount below which a reconsideration is final
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-32 issue date 2026-07-24 · Read Aug 9, 2026
The amount in dispute is less than $50.
Item (i) under the lead paragraph quoted in the companion entry, which supplies what "final" attaches to. Read together they are the rule; read alone this item is a figure with no verb, which is why both are cited on the fact.
32 C.F.R. 199.10(c)(5), when a formal review determination is final
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-32 issue date 2026-07-24 · Read Aug 9, 2026
Effect of formal review determination. The formal review determination is final if one or more of the following exist:
The lead paragraph of the finality rule, cited with the item below it for the same reason as its reconsideration counterpart: the two are separate paragraphs and a quote spanning both is not a verbatim match.
32 C.F.R. 199.10(c)(5)(ii), the amount below which a formal review is final
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-32 issue date 2026-07-24 · Read Aug 9, 2026
The amount in dispute is less than $300. (See paragraph (a)(7) of this section.)
Item (ii) under the lead paragraph quoted in the companion entry. The parenthetical cross-reference is printed by the source and is kept because it is what points a reader at how the amount is calculated.
32 C.F.R. 199.10(d), when a hearing may be requested
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-32 issue date 2026-07-24 · Read Aug 9, 2026
Any party to the initial determination may request a hearing if the party is dissatisfied with the formal review determination
Excerpt ends before the sentence continues with the condition that the formal review determination is not final under paragraph (c)(5), and with the separate provider sanction route. That continuation is the link between the dollar threshold and the availability of this rung, and it is why this entry is cited on the threshold as well as on the rung.
32 C.F.R. 199.10(b)(1)(iii), the window to request a reconsideration
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-32 issue date 2026-07-24 · Read Aug 9, 2026
Allowed time to file. The request must be mailed within 90 days after the date of the notice of initial determination.
The whole paragraph, with its own heading. Paragraph (b)(1)(iv) immediately below it deems the request filed on the date it is mailed and postmarked, which is why the record describes the postmark rather than arrival.
32 C.F.R. 199.10(b)(3), the window for a reconsideration determination
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-32 issue date 2026-07-24 · Read Aug 9, 2026
normally shall issue its reconsideration determination no later than 60 days from the date of receipt of the request for reconsideration
Excerpt begins mid-sentence. The subjects before it are the office, the contractor and the peer review organisation that may have made the initial determination. The word "normally" is the regulation's own and is why the record calls this a published expectation.
32 C.F.R. 199.10(c)(1)(iii), the window to request a formal review
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-32 issue date 2026-07-24 · Read Aug 9, 2026
The request shall be mailed within 60 days after the date of the notice of the reconsideration determination or OCHAMPUS initial determination being appealed.
The operative sentence of the paragraph, which carries the heading "Allowed time to file". The alternative trigger in the same sentence is why the record says the window runs from the initial determination where that is the determination under appeal.
32 C.F.R. 199.10(c)(3), the window for a formal review determination
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-32 issue date 2026-07-24 · Read Aug 9, 2026
normally shall issue the formal review determination no later than 90 days from the date of receipt of the request for formal review
Excerpt begins mid-sentence. The subject before it is the Chief of the Office of Appeals and Hearings or a designee, which is the reviewer the record names.
32 C.F.R. 199.10(d)(1)(iii), the window to request a hearing
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-32 issue date 2026-07-24 · Read Aug 9, 2026
The request shall be mailed within 60 days after the date of the notice of the initial determination or formal review determination being appealed.
The operative sentence of the paragraph, which carries the heading "Allowed time to file". Paragraph (d)(1)(iv) below it deems the request filed on the date it is mailed and postmarked.
32 C.F.R. 199.10(d)(3)(ii), the hearing officer's window
U.S. Government Publishing Office, Electronic Code of Federal Regulations · Federal regulation · eCFR content as of the title-32 issue date 2026-07-24 · Read Aug 9, 2026
The hearing officer, except as otherwise provided in this Section, normally shall have 60 days from the date of written notice of assignment to review the file, schedule and hold the hearing
Excerpt ends before the sentence continues with issuing a recommended decision to the Director, which is the step the record's separate final decision block covers. The capitalised "Section" is the character case the source prints.
