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Coordinating Pharmacy Benefits with Other Health Insurance

In addition to TRICARE®, many people also have additional insurance coverage, often through your employer, Medicare Part D, or another private insurance program. This is called other health insurance (OHI). It is important to understand how your TRICARE Pharmacy Benefit can work with your other insurance – and can even save you money!

Other Health Insurance and TRICARE Retail Network Pharmacies

If you have OHI with pharmacy coverage, you’re required to use it for your prescriptions filled using TRICARE. By law, your OHI will be the primary payer for your prescriptions with TRICARE becoming the secondary payer.

Fortunately, using your OHI at a retail network pharmacy along with TRICARE is easy. Tell your pharmacist about both your TRICARE and OHI coverage and give them your insurance information, such as your plan identification card. If your pharmacy is in network for both TRICARE and your OHI, your pharmacist will electronically submit your prescription to both insurance plans at the same time. Letting your pharmacist know you have two prescription plans means:

  • Minimal out-of-pocket expenses for you – using your OHI will often reduce or even eliminate your copay
  • Whatever your OHI’s copay, you’ll never pay more than the TRICARE copayment for your prescription – even if your OHI has a deductible
  • No need to submit paper claims – your prescription claim is processed by both insurance plans before you even leave the pharmacy

While TRICARE is usually second payer to OHI, it becomes the first payer when:

  • The drug is not covered by your OHI, but is covered by TRICARE, or
  • You’ve exhausted your OHI coverage for the benefit year

Keep in mind that supplemental and discount prescription drug programs, such as Senior Friends and AARP, do not count as OHI pharmacy coverage.

Medicare Parts A and B are not considered pharmacy OHI because there is limited drug coverage which is only for specific disease states. It is expected that if Medicare recognizes you have one of those covered disease states then Medicare should cover those specific drugs.

OHI and TRICARE Pharmacy Home Delivery

You are not eligible to use TRICARE Pharmacy Home Delivery if you have OHI with a prescription plan, including Medicare Part D prescription program, unless you meet one of the following requirements:

  • Your OHI does not include pharmacy benefits
  • The medication you need is not covered by your OHI
  • You have met your OHI’s benefit cap (i.e., you have met your benefit’s maximum coverage limit)

If you meet one of these three requirements, you may submit your prescription to TRICARE Pharmacy Home Delivery. Ask your doctor or provider to write a prescription for up to a 90-day supply of medication. For details on how to get started with Home Delivery visit: Express-Scripts.com/TRICARE/benefits/homedelivery.shtml.

Important: If your medication is not covered by your OHI or if you have met your benefit maximum, you will need to include documentation —such as a copy of an explanation of benefits (EOB) that shows your OHI did not pay. This information must be sent with your prescription or it will be returned.

Keep your Receipts to Submit for Reimbursement!

Once you’ve exceeded the dollar limit for your OHI or if the drug isn’t covered by your OHI, you can file a claim with TRICARE for reimbursement for prescriptions filled at non-network pharmacies or your OHI mail order pharmacy. You have one year from the date your prescription was filled to file your claim. Fill out the Patient’s Request for Medical Payment (DD 2642) found at http://www.tricare.mil/Resources/Claims/PharmacyClaims.

Submit this form along with your OHI explanation of benefits, and your receipt to:

Express Scripts, Inc.
P.O. Box 52132
Phoenix, AZ 85072

While submitting both receipts and your OHI explanation of benefits may seem excessive, both documents are necessary to process reimbursement.

Note: Pharmacy reimbursement for National Guard and Reserve members with line-of-duty care should contact the Defense Health Agency–Great Lakes (formerly known as the Military Medical Support Office) at 1-888-647-6676.

For help or more information, call Express Scripts at 1-877-363-1303 or visit www.tricare.mil/pharmacy/claims.




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