Prescription Plan Rules & Coverage
I have other health insurance (OHI), I couldn’t use my uniformed services ID card to buy a prescription at a local network pharmacy, or I had to get medication at a pharmacy that’s not in my network. How do I get reimbursed?
To get reimbursed, you must submit a paper claim. It must be postmarked within one year from the date you filled the medication.
You must submit these forms with your claim:
- Explanation of Benefits (EOB) form from your OHI provider
- Prescription receipts
- TRICARE DoD/CHAMPUS Claim Form – Patient’s Request for Medical Payment (DD Form 2462)
To find the claim form:
- Go to TRICARE forms.
- Download the TRICARE Claim Form (DD Form 2462).
- Mail your completed form to the Express Scripts address on the website.
What is the TRICARE Formulary Search Tool?
The Formulary Search Tool is fast and easy to use. It can help you determine where to fill your prescription (e.g. at the military pharmacy, Home Delivery, or a retail pharmacy) and for what cost. In addition, the tool allows you or your doctor to:
- Download required forms (prior authorization (PA) and medical necessity (MN);
- Understand copayments; and
- Look for alternatives if your medication has a generic equivalent or is not covered.
How do I get reimbursed if I am a National Guard or Reserve member?
National Guard and Reserve members with line-of-duty care should contact the Military Medical Support Office at (888)647-6676.
To find the claim form:
- Go to TRICARE forms.
- Follow their instructions to submit the reimbursement claim form.
What forms might by doctor need to fill out?
Prior Authorization Form: Your prescription may need prior authorization to assure appropriate use for high-risk or high-cost drugs. Prior Authorization criteria are used to make sure your medication is safe, cost effective, and medically necessary.
Your doctor may need to fill out a prior authorization if your drug is generally used for a certain health condition, has the potential to be misused, or has an age or quantity limit.
Medical Necessity Form: Your doctor can complete a medical necessity form if you take non-formulary drugs, which are often a higher cost. If your doctor can establish medical necessity for these drugs, you can get the drug at the formulary (brand) copayment.
Brand Name Request Form: A generic drug contains the same chemical as the brand-name drug but has a lower copayment. If your doctor determines it is medically necessary for you to take the brand-name drug over the generic version, your doctor can request through the Brand Name Request Form. You may pay additional costs for the brand-name drug.
What is a Network Pharmacy and how does it affect my prescriptions?
A network pharmacy is a pharmacy that accepts TRICARE copayment. TRICARE will pay for part or all of your medication’s cost from a network pharmacy. Military Treatment Facilities and Express Scripts Pharmacy® are network pharmacies. But, not all retail pharmacies are network pharmacies. Watch this short video to learn the difference between network and non-network pharmacies.
You can go to a non-network pharmacy two or three times before you’re charged the full price of your medication. We call these “courtesy fills.”
Are there any differences in my benefits if I choose delivery or a local pharmacy?
You can choose how to get your maintenance medications. Most plans allow you to choose to get your medications from a Military Treatment Facility, a retail network pharmacy, or through TRICARE Home Delivery Pharmacy Program. But, some plans require you to use delivery for certain medications. We’ll alert you if your medication has restrictions on your pharmacy location.
Express Scripts Pharmacy® offers delivery of up to a 90-day supply of your medication to any location. You can track your order online or through the Express Scripts mobile app. We also offer an optional 3-month payment plan. And, you have access to an Express Scripts pharmacist at any time, 24/7.
How do I find local pharmacies covered by my plan?
- Go to Prescriptions and select Find a Pharmacy.
- Enter a ZIP code or city and state. Be sure to include a comma between the city name and the state abbreviation.
You can use the Express Scripts app on your mobile device for turn-by-turn directions to the pharmacy you choose.
Do supplemental and discount prescription drug programs, such as Senior Friends and AARP, count as OHI pharmacy coverage?
No. These do not count as Other Health Insurance (OHI). But, Medicare Part D programs do count as OHI.
I have met my catastrophic cap requirement for the year. Will I still be charged a copay for a medication that isn't on the formulary?
No. After your cap is met, no copayments will be charged for your medications until the following fiscal year (beginning January 1).
Do I have to notify Express Scripts if I have other health insurance (OHI)?
Yes. This is required under your TRICARE plan. Please follow these steps to submit information about your OHI:
- Complete the TRICARE OHI form.
- Mail the form to the address shown on page 1.
If you have questions about the form, please call Express Scripts at (877)363-1303.
Where can I find a summary of my prescription plan coverage?
How does my TRICARE pharmacy benefit work with my other health insurance?
By law, your other health insurance (OHI) must be the primary payer for your prescriptions and TRICARE is the secondary payer. TRICARE becomes the primary payer only when:
- A drug is not covered by your OHI, but is covered by TRICARE
- Your OHI coverage is exhausted for the benefit year
How do I know if a specific medication is covered?
To view your coverage information, log in:
- Go to Prescriptions and select Price a Medication.
- Enter the name of the medication you want to price and click Search.
- Select the medication you’re looking for and enter your dosage amount. Price a Medication will show you if your medication is covered by your plan and how much it costs.
Can I get my medications by home delivery if I have other health insurance?
In general, no. You can use TRICARE home delivery only if:
- Your other health insurance (OHI) does not include pharmacy benefits
- The medication you need is not covered by your OHI
- You have met your catastrophic cap.
If you meet one of these three conditions, here’s how to submit your prescription to for home delivery:
- Ask your doctor or provider to write a prescription for up to a 90-day supply of medication.
- Include a copy of an explanation of benefits (EOB) showing your OHI did not pay for the medication.
- Send this information, along with your prescription, to:
P.O. Box 52150
Phoenix, AZ 85072-9954
How do I find out if the medication I need has any restrictions, is on the Uniformed Services Formulary, or requires a Prior Authorization (PA)?
Use the Formulary Search Tool to find out about the medication you need:
- Go to the Benefits menu and select Covered Medications.
- Follow the instructions in the Formulary Search Tool to look up a medication.
The results will give you details about the medications covered, strength, form, whether there’s a generic option, and whether there are any restrictions or extra requirements.
If I have other health insurance (OHI), can I use TRICARE retail network pharmacies?
Yes. When you fill a prescription at an in-network retail pharmacy, tell the pharmacist if you have TRICARE coverage in addition to your OHI. Your pharmacist will submit your prescription to both insurance 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
To get reimbursed by TRICARE:
- Keep the receipt for your medication. You will need to file a claim with TRICARE for reimbursement within one year from the date your prescription was filled.
- Fill out the Patient's Request for Medical Payment (DD 2642) form.
- Submit this form along with your OHI explanation of benefits and your receipt to:
Express Scripts Inc.
P.O. Box 52132
Phoenix, AZ 85082
What should I do if my medication is not on the Uniformed Services Formulary?
If your medication is not on the Uniformed Services Formulary, you will be charged the non-formulary price unless your doctor’s medical necessity waiver is approved. Download the form for your medication and your doctor can complete and submit it to us.
What is the TRICARE Formulary?
The TRICARE Formulary is a list of brand-name and generic drugs available through the TRICARE pharmacy benefit. Some drugs are covered but not preferred, and are categorized as Non-Formulary. These drugs have a higher copayment and generally are only available via home delivery.
You can use the TRICARE Formulary Search Tool to search for specific drugs and to see whether they are available through the TRICARE pharmacy benefit and if they are, what you will pay. The TRICARE Formulary Search Tool will also advise as to any quantity or day supply limitations associated with the drug in question.
If you can’t find the answer to your question, please contact us.