What to Expect if You Need to File a TRICARE Pharmacy Claim > TRICARE Newsroom > Articles
When using the TRICARE Pharmacy Program benefit, you may be wondering if you need to file prescription drug claims. Here’s an overview of when and how to successfully file pharmaceutical claims.
“The TRICARE Pharmacy Program is a comprehensive pharmacy benefit, which offers a number of efficient and cost-effective ways to fill your prescription medications,” said U.S. Public Health Service Cmdr. Teisha Robertson, a pharmacist in the Pharmaceutical Operations Division of the Defense Health Agency. “In most cases, you won’t have to file claims at the pharmacy. 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 recipients who get your prescription drugs from a military pharmacy, through TRICARE Pharmacy Home Delivery, or from a pharmacy in the TRICARE retail network, you don’t need to file a claim.
When you should file a complaint
Under the TRICARE Pharmacy Program, administered by Express Scripts, you will need to file a prescription drug claim if:
- You filled your prescription at an out-of-network TRICARE pharmacy in the United States or US Territories (American Samoa, Guam, Northern Mariana Islands, Puerto Rico, and US Virgin Islands). You will prepay the full amount of the prescription and file a claim. Remember that refunds are subject to deductibles, out-of-network cost shares, TRICARE form status, and applicable copayments.
- You have other health insurance (AHO). OHI can be through your employer or through a private plan you have purchased. According to TRICARE Pharmacy Program Manualyou may need to file a claim if you have OHI that offers pharmaceutical coverage.
There are, however, two exceptions. You won’t have to pay out of pocket or file a claim if the pharmacy is in-network for your IHO and TRICARE. You should also provide your pharmacist with your OHI and TRICARE information. The other exception is if the IHO also allows home delivery of Express Scripts. In this case, Express Scripts will coordinate with the IHO and TRICARE.
Reimbursement with OHI requires coordination of benefits to decide how much each company will pay for a claim. Generally, when you have OHI drug benefits, your OHI pays first and TRICARE pays second.
- There is the unlikely event of a Defense Enrollment Eligibility Reporting System (DEERS) failure. When a breakdown occurs, your pharmacist cannot verify your benefits. If this happens, you may need to pay in full for prescriptions filled at an in-network pharmacy and then file a claim.
In all cases, however, you must file your claim with TRICARE within one year of the date you filled your prescription.
How to file a claim if you live in the United States or US territories
You have two options: submit a claim online or file a claim on paper.
Submitting a claim electronically is easy:
- First, log in to your Express Scripts account online
- Once logged in, navigate to the “Benefits” menu option and select “Forms”.
You will need to upload and include images of your:
- Prescriber information including name, address and phone number
- Pharmacy receipt with phone number
- IHO payment on claim, if applicable
Remember that you can submit a claim online if you are coordinating benefits or if the prescription drug:
If you prefer to submit your claim by mail, follow these steps:
- Complete the DD 2642 form
- Submit the DD Form 2642, along with the required documents (a copy of your IHO Explanation of Benefits and your pharmacy receipt) to Express Scripts
How to file a complaint if you are abroad
If you are filling 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 complaints portal or by mail. Be sure to submit proof of payment with your overseas pharmacy claims. If you are in the Philippines, you must have your prescription filled at a TRICARE-certified pharmacy to ensure your claims are reimbursed.
Download the TRICARE Pharmacy Program Manual for everything you need to know about your drug benefits and claims. For a quick overview, watch this video on filing complaints. You can also contact Express Scripts 24/7.
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