Your TRICARE Standard benefit is flexible and easy-to-use when it comes to making decisions regarding your family’s health care. However, if you or members of your family are also covered by other health insurance (OHI), you should be aware of several things when filing claims.
The first thing to remember when filing claims if you have OHI coverage is that TRICARE Standard is the secondary payer in most instances. If the OHI is Medicaid, the Indian Health Service, a TRICARE supplement or another secondary-payer program or plan identified by the TRICARE Management Activity, then TRICARE pays first.
Note: When an active duty sponsor retires, his or her OHI, which had been secondary to TRICARE, now becomes primary to TRICARE. The same applies to a National Guard or Reserve member transitioning out of active duty. To avoid problems in processing claims, be sure to keep Humana Military informed of your OHI status.
To file a TRICARE Standard claim, you or your provider must first file a claim with your OHI plan. After your OHI makes a payment determination, you may file a claim with TRICARE.
Keep the EOB Statements
You must submit a copy of the OHI plan’s explanation of benefits (EOB) statement and a copy of the itemized charges from the provider’s bill along with a DD Form 2642 Patient’s Request for Medical Payment to TRICARE. Your EOB is a statement sent to you showing how the claim was processed and the amount paid to providers.
If the claim is denied, an explanation of denial will be provided. If your OHI plan denies your claim for not following its rules, such as receiving care without authorization, TRICARE may also deny the claim.
Your Prescriptions and OHI
If your OHI offers a pharmacy benefit, the OHI is the first payer and TRICARE is the second payer for claims involving prescription drug coverage. Your TRICARE Standard benefit supplements your OHI pharmacy benefit.
You are encouraged to use a retail pharmacy under your private insurer that is also in the TRICARE retail network, because the retail pharmacist can immediately submit electronic claims to TRICARE when you purchase medications. In many instances, you’ll pay less and not have to file a claim when you visit a TRICARE retail network pharmacy.
If your retail pharmacy is unable to electronically process your claim or your OHI requires you to use their mail order pharmacy services, you may submit paper claims for full or partial reimbursement from TRICARE for your out-of-pocket cost, including copayments.
If you use a non-network pharmacy, you will be required to file a paper claim and pay the TRICARE non-network deductible and applicable copayment before reimbursement is calculated.
Claims should be submitted to Express Scripts, Inc. (ESI) using the DD Form 2642. Go to the
claims section of the TRICARE Web site or the
prescription claims section of the TRICARE Web site to get forms and instructions.
You may not use the TRICARE Mail Order Pharmacy if you have prescription drug coverage from OHI, unless the medication is not covered under the plan, or unless you exceed the dollar limit of coverage under the plan. You will save time and money by using a TRICARE network pharmacy. If you have questions about pharmacy claims, please call 1-866-DoD-TRRX (1-866-363-8779).
How TRICARE Works with