FALLS CHURCH, Va. –
When you use the
TRICARE Pharmacy Program benefit, you may wonder if you must file claims for reimbursement for prescription drugs. Here’s an overview of when and how to successfully file pharmacy claims.
“The TRICARE Pharmacy Program is a comprehensive pharmacy benefit, which offers a number of efficient and cost-effective ways to fill your prescription drugs,” said U.S. Public Health Service Cmdr. Teisha Robertson, a pharmacist with the Defense Health Agency’s Pharmacy Operations Division. “In most cases, you won’t have to file pharmacy claims. However, some pharmacy options will require you to submit a claim, so it’s important to understand the process.”
When you don’t need to file a claim
If you’re like most beneficiaries who get your prescription drugs filled at a
military pharmacy, through
TRICARE Pharmacy Home Delivery, or at a
TRICARE retail network pharmacy, you don’t need to file a claim.
When you need to file a claim
Under the TRICARE Pharmacy Program, which
Express Scripts administers, you’ll need to file a claim for prescription drugs if:
- You filled your prescription at a TRICARE non-network pharmacy in the U.S. or U.S. territories (American Samoa, Guam, the Northern Mariana Islands, Puerto Rico, and the U.S. Virgin Islands). You’ll pay the full amount of the prescription upfront and file a claim for reimbursement. Remember, reimbursements are subject to deductibles, out-of-network cost-shares, TRICARE formulary status, and applicable copayments.
- You have other health insurance (OHI). OHI may be through your employer or a private plan you’ve purchased. According to the TRICARE Pharmacy Program Handbook, you may need to file a claim if you have OHI that offers pharmacy coverage.
There are two exceptions, however. You won’t have to pay out of pocket or file a claim if the pharmacy is in network for both your OHI and TRICARE. You must also provide your pharmacist with both your OHI and TRICARE information. The other exception is if the OHI also allows Express Scripts home delivery. In this case, Express Scripts will coordinate with the OHI and TRICARE.
Reimbursement with OHI requires coordination of benefits to decide how much each company will pay on a claim. Generally, when you have OHI pharmacy benefits, your OHI pays first, and TRICARE pays second.
- There’s the unlikely event of a Defense Enrollment Eligibility Reporting System (DEERS) outage. When an outage occurs, your pharmacist can’t verify your benefits. If this happens, you may need to pay in full for prescriptions filled at a network pharmacy and then file a claim for reimbursement.
In all cases, though, you must
file your claim with TRICARE within one year from the date you filled your prescription.
How to file a claim if you live in the U.S. or U.S. territories
You have two options: submit a claim online or file a paper claim.
Online
It’s easy to
submit a claim electronically:
- First, log in to your online Express Scripts account
- Once you’ve logged in, navigate to the “Benefits” menu option and select “Forms”
You’ll need to upload and include images of your:
- Prescriber information, including name, address, and phone number
- Pharmacy receipt with phone number
- OHI payment on the claim, if any
Keep in mind, you can submit an online claim if you’re coordinating benefits or if the prescription drug:
By mail
If you prefer to submit your claim through the mail, follow these steps:
- Complete DD Form 2642
- Mail DD Form 2642, along with the required paperwork—a copy of your OHI explanation of benefits and your pharmacy receipt—to Express Scripts
How to file a claim if you’re overseas
If you fill a prescription overseas, file your claim with your TRICARE Overseas Program claims processor to be reimbursed on covered prescription drugs. You can do this either online through the
secure claims portal or by mail. Be sure to submit
proof of payment with your
overseas pharmacy claims. If you’re in the
Philippines, you must get your prescription filled at a TRICARE-certified pharmacy to ensure your claims are reimbursed.
Download the
TRICARE Pharmacy Program Handbook for everything you need to know about your pharmacy benefit and claims filing. For a quick overview,
watch this video on claims filing. You can also reach out to
Express Scripts 24/7.
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