How to Use TRICARE and Other Health Insurance at the Pharmacy

SFL Logo September 26, 2022

by TRICARE Communications 

FALLS CHURCH, Va. – Do you have other pharmacy coverage in addition to the TRICARE Pharmacy Program? Maybe you have coverage through your employer or a private plan that you’ve purchased. TRICARE calls this other health insurance (OHI). Some OHI includes a prescription drug benefit that can be used with TRICARE. Learning more about OHI and TRICARE pharmacy benefits can save you time and money. 
 
“If your OHI includes a prescription plan, there are several important things to know about how the two plans work together,” said U.S. Public Health Service Cmdr. Teisha Robertson, a pharmacist with the Defense Health Agency’s Pharmacy Operations Division. “Making the right choices with OHI and your TRICARE pharmacy benefit can help you pay lower costs, both up front and in total.” 
 
How to report your OHI
It’s important that you share other health insurance you carry in addition to TRICARE with the pharmacy contractor, Express Scripts. If you don’t disclose this information, you may experience delays or problems when processing your prescription claims. To avoid these issues, tell Express Scripts you have OHI with pharmacy benefits. Complete a TRICARE Other Health Insurance (OHI) Form and mail it to Express Scripts. You may need to reach out to your other insurance company to get some required information to fill out the form.
 
Do you have a supplemental or discount prescription drug program? These don’t count as OHI pharmacy coverage. If you don’t know if you have OHI, you can review examples of types of coverage on the Express Scripts website.
 
How to lower your costs when you have OHI
If you have OHI, it doesn’t prevent you from using your TRICARE pharmacy benefit. When you have OHI with pharmacy benefits, your OHI pays first and TRICARE pays second. You can avoid higher costs by getting your prescriptions filled at a pharmacy located in both your OHI network and the TRICARE retail network.
 
When you fill a prescription at a network pharmacy, tell your pharmacist you have TRICARE coverage in addition to your OHI. Your pharmacist can electronically submit your prescription to both plans at the same time. Letting your pharmacist know you have two prescription plans means:

  • Minimal out-of-pocket expenses for you
  • Never paying more than the TRICARE copayment
  • No need to submit paper claims
  • Reduced or eliminated up-front costs

 
How to get reimbursement for prescriptions
You can file a claim with TRICARE for reimbursement if you meet one of the following requirements:

  • The pharmacy in your OHI network isn’t a TRICARE retail network pharmacy
  • You’ve exceeded the dollar limit for your OHI
  • The drug isn’t covered by your OHI

 
To file a claim, fill out the Patient’s Request for Medical Payment form (DD Form 2642). And mail the form, along with your OHI explanation of benefits and your pharmacy receipt to Express Scripts. You must file your claim with TRICARE within one year from the date your prescription was filled. Remember to keep your receipts. You must also print your OHI explanation of benefits. An explanation of benefits is an itemized statement that shows what action your insurance provider has taken on your claims. Submit your receipts and your OHI explanation of benefits together for reimbursement.
 
How to use TRICARE Pharmacy Home Delivery with OHI
As outlined in the TRICARE Pharmacy Program Handbook, you aren’t eligible to use TRICARE Pharmacy Home Delivery if you have OHI with a prescription plan. This includes the Medicare Part D prescription program. There are some exceptions, however.
 
You can use home delivery if you meet one of the following requirements:

  • You have a supplemental pharmacy benefit, which is managed by Express Scripts
  • Your OHI doesn’t include pharmacy benefits
  • The drug you need isn’t covered by your OHI
  • You’ve met your OHI’s benefit cap (for example, you’ve met your benefit’s maximum coverage limit)

 
Once you’ve met one of these requirements, you may submit your prescription to TRICARE Pharmacy Home Delivery. If your drug isn’t covered or if you’ve met the OHI benefit cap, you must also include your OHI explanation of benefits. If you have a supplemental pharmacy benefit managed by Express Scripts, your benefits are automatically coordinated using both your OHI and TRICARE. This means you don’t have to file a paper claim to coordinate your OHI and TRICARE pharmacy coverage. Review details on how to get started with home delivery.
 
Download the TRICARE Pharmacy Program Handbook for more information about OHI and your pharmacy benefits. You can also reach out to Express Scripts. Representatives are available 24/7 to answer your questions.

Article Source: https://newsroom.tricare.mil/Articles/Article/3050887/how-to-use-tricare-and-other-health-insurance-at-the-pharmacy