Bread Crumbs

Prescription Claims

TRICARE DoD/CHAMPUS Claim Form-Patient's Request for Medical Payment (DD Form 2642)

  • Send your pharmacy claims within one year of the date of service.
  • Send the claim form and the following information for each drug.
  • If you have other health insurance, include a copy of your explanation of benefits (EOB)
CAN'T be Handwritten 
on the EOB or Pharmacy Receipt
CAN be Handwritten
on the EOB or Pharmacy Receipt
  • Date of fill
  • Quantity
  • Pharmacy name
  • What you (the beneficiary) paid
  • Drug name and strength
  • Number of day’s supply
  • Prescription number
  • Pharmacy address
  • Doctor’s name or DEA number
  • Pharmacist’s signature (for retail pharmacy claims only)
  • Amount paid by the other health plan or the retail price from the pharmacy

Claims Addresses

In the U.S. or a U.S. Territory, send your claim with the pharmacy contractor:

Express Scripts
P.O. Box 52132
Phoenix, AZ 85082

In all other overseas areas, send your claim to the claims address for where the prescription is filled.

Active Duty
All Overseas Areas
TRICARE Active Duty Claims
P.O. Box 7968
Madison, WI 53707-7968
www.tricare-overseas.com 
Eurasia-Africa
Non-active duty 
TRICARE Overseas Program
P.O. Box 8976
Madison, WI 53708-8976
www.tricare-overseas.com
Latin America & Canada
Non-active duty
TRICARE Overseas Program
P.O. Box 7985
Madison, WI 53707-7985
www.tricare-overseas.com 
Pacific
Non-active duty
TRICARE Overseas Program
P.O. Box 7985
Madison, WI 53707-7985
www.tricare-overseas.com 

Last Updated 12/3/2014