Pharmacy Claims

If you have other health insurance (OHI), you will need to submit pharmacy claims to Express Scripts, Inc. (ESI) for payment. For TRICARE Standard/Extra, before reimbursement is granted for non-network pharmacy claims, you must meet an annual TRICARE deductible.
Pharmacy claims must be filed within one year of the date of service. To file a pharmacy claim, obtain and fill out a DD Form 2642 Patient’s Request for Medical Payment. Prescription claims require the following information for each drug:
  • Name of the patient
  • Name, strength, date filled, days' supply, quantity dispensed, and price of each drug
  • National Drug Code, if available
  • Prescription number of each drug
  • Name and address of the pharmacy
  • Name and address of the prescribing physician
Mail the claim to:
Express Scripts, Inc.
P.O. Box 66518
St. Louis, MO 63166-6518
Call 1-877-363-1303 with questions about filing a pharmacy claim.
Last Update: February 12, 2014