Pharmacy Claims

Reading Your Pharmacy Explanation of Benefits

A TRICARE explanation of benefits isn’t a bill. It’s a summary of the services and items you received. It tells you how much your provider billed, the approved amount TRICARE paid, and how much you may have to pay to the provider.

You’ll get all your pharmacy EOBs online if you have an email on file or if you have an account with the TRICARE Pharmacy Program contractor, Express Scripts. You’ll be notified as soon as your EOB is available to view online. You’ll get monthly emails or texts linking to your online EOBs. If you don’t have an account or submit a request, you’ll get a paper EOB every three months.

You can change your preference at any time by calling the contractor or logging in to the portal.

When should I file a claim?

You’ll need to file a claim for reimbursement if:

• You get your prescription filled at a non-network pharmacy. Reimbursements are subject to applicable deductibles, cost-shares, and copayments.
• You have other health insurance with pharmacy benefits.

You must file your claim within one year of the date of service.

How can I file a claim?

You may be able to file a claim online or by mail.

To file your claim file a claim online, you’ll need:

• An Express Scripts account
• Your prescriber’s information
• A photocopy of your pharmacy receipt
• Your pharmacy’s phone number

Here are some tips for filing a claim:

• Fill out a Patient’s Request for Medical Payment form (DD Form 2642).
• You must send the form and the information below with your claim.
• If you have other health insurance, you should send an explanation of benefits.

U.S. and U.S. Territories

In the U.S. or a U.S. territory, file your claim with the pharmacy contractor:

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

Other Overseas Locations

In an overseas area (other than a U.S. territory), you’ll file your claim with the overseas claims processor. File a claim through the overseas secure claims portal or at the appropriate address.

Do you have other health insurance with pharmacy benefits? Your other health insurance is the first payer and TRICARE pays second. You can avoid higher costs by filling your prescriptions at a TRICARE network pharmacy that is also in your other plan’s network.

You can’t use TRICARE Pharmacy Home Delivery when you have OHI, unless:

• Your health insurance doesn’t include pharmacy benefits,
• The drug you need isn’t covered by your other plan, or
• You’ve met the other plan’s benefit cap

If you’ve met any of these requirements, you can fill your prescription through home delivery. You’ll need to send proof from your other plan that your prescription isn’t covered or you’ve met the benefit cap.

OHI doesn’t prevent you from using a TRICARE retail network pharmacy. Your other plan pays first and TRICARE pays second.

Online coordination of benefits

When you get your prescriptions at a network pharmacy, tell your pharmacist you also have TRICARE. Your pharmacist will submit your prescription online to both plans at the same time.

When you process your pharmacy claims online, you:

• Pay minimal out-of-pocket expenses
• Never pay more than the TRICARE copayment
• Don’t need to submit paper claims

TRICARE becomes the first payer when:

• The drug isn’t covered by your other plan but is covered by TRICARE or
• You’ve met the other plan’s benefit cap

If you’re using a mail­-order program through your other plan, online coordination of benefits isn’t possible. You must file a prescription claim to get reimbursement for the eligible portion of your out-of-pocket expenses.

Filing claims with OHI

You must file a prescription claim to get reimbursed for the eligible portion of your out-of-pocket expenses.

Avoid processing delays or problems with your claims by telling Express Scripts you have OHI. Complete the TRICARE Other Health Insurance Form and mail it to:

Express Scripts
P.O. Box 60903
Phoenix, AZ 85082-0903

Once you’ve met the other plan’s benefit cap, or if your OHI doesn’t cover your drug, you can file a claim with TRICARE for reimbursement.

To file a claim:

1. Fill out the TRICARE Claim Form-Patient’s Request for Medical Payment (DD 2642).
2. Mail the form, your OHI explanation of benefits, and receipts, to:

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

Ending OHI

Are you no longer covered by other health insurance with pharmacy benefits? You must update your status with the TRICARE pharmacy contractor. Contact Express Scripts