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 insuranceHealth insurance you have in addition to TRICARE, such as Medicare or an employer-sponsored health insurance. TRICARE supplements don’t qualify as "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 85072

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