Tricare pharmacy program medical necessity form for glaucoma agents
US Family Health Plan Prior Authorization Request Form for Viagra (sildenafil) Page 1 of 2 To be completed and signed by the prescriber. To be used only for prescriptions which are to be fil ed through the Department of Defense (DoD) US Family Health Plan pharmacy program (USFHP). • The provider may call : or the completed form may be faxed