TRICARE and Other Health Insurance Pharmacy Claims Guide

*Note: TRICARE.com is an independent reference site and is not affiliated with the Department of Defense. For official policy and the most current government data, visit TRICARE.mil.*

## Quick answer Yes, you can submit claims to TRICARE for prescription costs partially covered by Other Health Insurance (OHI). By law, TRICARE acts as the secondary payer; you must first use your private insurance, and TRICARE may then cover some or all of your remaining out-of-pocket costs, provided the drug is on the TRICARE formulary.

## In detail When you have private health insurance through an employer or a spouse, that insurance is considered your **Primary Payer**. TRICARE becomes the **Secondary Payer**. This process is known as Coordination of Benefits (COB).

### How the process works 1. **Fill the prescription:** Present both your OHI card and your Military ID/TRICARE info at the pharmacy. 2. **Primary Payment:** The pharmacy bills your private insurance first. They pay their portion. 3. **TRICARE Payment:** If the pharmacy has your TRICARE information on file and is "in-network," they can often coordinate the claim electronically. TRICARE will evaluate the remaining balance (your OHI copay). 4. **The "Lesser Of" Rule:** TRICARE generally pays the lesser of: * The amount TRICARE would have paid if it were primary. * The actual out-of-pocket cost remaining after your OHI paid.

### Using Network vs. Non-Network Pharmacies The ease of submitting these "partially paid" bills depends on where you go:

### 2026 Pharmacy Rates and Rules For 2026, the pharmacy benefit managed by **Express Scripts** requires that if your OHI pays for a drug, TRICARE will only chip in if the drug is also covered by the TRICARE formulary. If your OHI has a deductible, TRICARE may apply its payment toward that deductible amount, depending on the specific plan (Prime vs. Select).

### Key Restrictions * **Excluded Drugs:** If TRICARE does not cover a specific medication (e.g., cosmetic or weight loss drugs not on the formulary), they will not pay the "remainder" left by your OHI. * **Mail Order:** You generally cannot use the TRICARE Pharmacy Home Delivery (Express Scripts) if you have OHI with a pharmacy benefit, unless your OHI does not cover the drug or you have reached your OHI's benefit limit.

## Who this applies to * **Active Duty Family Members (ADFMs):** Frequently have OHI through a civilian employer; TRICARE Select or Prime ADFMs use this to reduce OHI copays to $0 in many cases. * **Retirees and their Families:** TRICARE For Life (TFL) users often have OHI that acts alongside TRICARE and Medicare. * **National Guard and Reserve:** Members using TRICARE Reserve Select (TRS) who also have employer-sponsored coverage.

Common scenarios

### Scenario A: The Generic Drug Jane is an ADFM with private insurance through her job at a bank. Her OHI copay for a generic drug is $15. She goes to a TRICARE network pharmacy (CVS or Walgreens). The pharmacy bills her OHI first. TRICARE then pays the $15 balance. Jane walks out paying **$0**.

### Scenario B: The High-Cost Brand Drug Mark is a retiree with OHI. He buys a brand-name drug that costs $300. His OHI pays $200, leaving a $100 copay. In 2026, TRICARE's standard retail network copay for brand drugs might be higher than in previous years (varies by plan year—check TRICARE.mil for current rates). If the TRICARE copay for that drug is $68, TRICARE will pay the difference so that Mark's final out-of-pocket cost matches the TRICARE copay, rather than the higher OHI copay.

## Related terms * **COB (Coordination of Benefits):** The process of determining which insurance pays first when a beneficiary has multiple plans. * **Explanation of Benefits (EOB):** The statement from your OHI showing what they paid and what you owe; required for manual TRICARE claims. * **Primary Payer:** The insurance plan that pays claims first (for TRICARE users, this is almost always the OHI). * **TRICARE Formulary:** The list of brand-name and generic drugs covered by the TRICARE pharmacy program. * **DD Form 2640:** The official TRICARE Pharmacy Claim Form used for manual reimbursement requests.

## Sources * **TRICARE.mil - Using Other Health Insurance:** https://www.tricare.mil/ohi * **Express Scripts TRICARE Pharmacy Program:** https://militaryrx.express-scripts.com/ * **Defense Health Agency (DHA) - Coordination of Benefits:** https://health.mil/Military-Health-Topics/Business-Support/Partnering-with-the-DHA/Pharmacy-Operations/Coordination-of-Benefits