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Coordinating Your Pharmacy Benefits When You Have TRICARE and Other Health Insurance

If you have health insurance in addition to TRICARE, such as through your employer or a private program, it is called "other health insurance" or OHI. With OHI, it’s important to understand how your TRICARE pharmacy benefit works with your other insurance should it also have a pharmacy benefit.

Federal law requires that if your OHI has a pharmacy benefit that it is the primary payer for your prescriptions and TRICARE is the secondary payer. This means medication cost not covered by your primary insurance may be covered by your TRICARE pharmacy benefit. That’s why it is important to understand your coordination of benefits.

TRICARE only becomes the primary payer when:

  • Your medication is not covered by your OHI, but is covered by TRICARE, or
  • Coverage under your OHI is exhausted for the benefit year

The electronic coordination of benefits helps you to make the most of your TRICARE pharmacy benefit by:

  • Reducing upfront out-of-pocket expenses
  • Eliminating the need to submit a paper claim
  • Never paying more than your TRICARE copayment

How do I coordinate my benefits online?

  1. Contact your primary insurer to identify pharmacies near you that are covered by your plan. Then choose a pharmacy that is also included in the TRICARE network. You can find a TRICARE network pharmacy by visiting our Find a Pharmacy page or using the pharmacy locator through our free Express Scripts mobile app.
  2. Tell your local pharmacist you have TRICARE coverage in addition to your OHI and confirm that your pharmacy accepts TRICARE claims. The pharmacist will submit your prescription to both insurance plans at the same time and charge the proper copayment for your drug.
  3. Ask your pharmacy to coordinate your primary insurance claims for secondary payment through TRICARE online and to call Express Scripts at 1-866-684-4466 for assistance.

Note: If you use a non-network pharmacy, the pharmacist cannot coordinate your benefits and you will pay up to the full price for your drug(s), and then you’ll need to file a paper claim for the TRICARE reimbursement.

Submitting a paper claim with OHI

If you have OHI and have to submit a paper claim for reimbursement, the claim must be post marked by one year from the original fill date and the following documentation is required:

  • Explanation of Benefits (EOB) from your OHI provider
  • Prescription receipts
  • TRICARE DoD/CHAMPUS Claim Form – Patient’s Request for Medical Payment (DD Form 2642)
    - You can print the form on the TRICARE Forms & Claims page at tricare.mil

Note: If you have OHI and submit a claim for reimbursement without an EOB, your claim may be returned for missing information or explanation regarding your other coverage.

To learn more about using TRICARE with OHI, visit express-scripts.com/TRICARE or call Express Scripts at 1.877.363.1303.




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