[HEALTH.MIL] How TRICARE Works with Other Health Insurance

  • From: HEALTH.MIL Mailing List
  • To: <HEALTH.MIL@xxxxxxxxxxxxx>, <TFL@xxxxxxxxxxxxx>
  • Date: Fri, 29 Jul 2011 19:53:51 -0500

How TRICARE Works with Other Health Insurance
By  Sharon Foster
TRICARE Management Activity
July 25, 2011

The coordination of benefits between TRICARE and other health insurance (OHI)
can be confusing. If a beneficiary has health care coverage through an employer,
public or private insurance program, including government programs such as
Medicare, he or she is considered to have OHI.             

If a beneficiary has OHI, he or she should tell his or her provider and regional
health care contractor. Beneficiaries should also fill out the OHI form located
on their regional health care contractor's website
(http://www.tricare.mil/contactus). Keeping the regional health care contractor
informed about the OHI will allow TRICARE to better coordinate benefits and will
help ensure that there is no delay in payment of claims.
TRICARE is the secondary payer when a beneficiary has OHI. Before TRICARE
considers the claim, the beneficiary's OHI must pay first. The exceptions are
Medicaid and TRICARE supplemental plans. Please go to TRICARE's website to learn
more http://www.tricare.mil/mybenefit/home/Medical/OHI.
After the other insurer pays, TRICARE will pay what is left up to the TRICARE
allowable charge, which is the maximum amount TRICARE will authorize for medical
and other services furnished in an inpatient or outpatient setting. There is no
change in benefit limits when TRICARE is the secondary payer.
Beneficiaries need to be sure to submit all claims to TRICARE because
deductibles may be applied to their annual catastrophic cap. The beneficiary's
provider may submit secondary claims as well.
To reduce pharmacy costs, a beneficiary's best option is to use a TRICARE retail
network pharmacy that is also covered by their OHI. After the OHI pays, TRICARE
may reimburse the beneficiary for part or all of their out-of-pocket costs,
including copayments. Beneficiaries are not eligible to fill prescriptions via
home delivery if they have OHI with a prescription plan, including a Medicare
Part D prescription program, unless they meet one of the following requirements:
. The medication they need is not covered by their OHI. 
. They have met their OHI's benefit cap. 
If the OHI provides only medical coverage, not pharmacy coverage, he or she
still may be eligible to use home delivery (http://www.tricare.mil/homedelivery)
as their prescription benefit. Beneficiaries can go to
http://www.tricare.mil/mybenefit/home/Prescriptions/OHI for pharmacy questions
or contact Express Scripts, Inc. at (877) 363-1303.
Finally, active duty service members, including activated National Guard and
Reserve members, cannot use OHI. TRICARE is their primary payer.

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