When a spouse has other insurance
March 19th, 2010 | TriCare Help | Posted by Military Times
Q. I’m a retired reservist with Tricare For Life. My wife has her own civilian health insurance, as well as Tricare Standard, since I am her sponsor. How does coordination of benefits work for medical care and prescriptions? For example, her drug plan has a higher copay for some drugs than Tricare has. Can she use Tricare to get the lower co-pay, or does she pay the higher co-pay and file a claim with tricare to get the difference? And can my wife and I use the Tricare mail order drug plan?
As required by federal law, Tricare is always last payer to all other health insurance, medical plans such as an HMO, or medical payments such as one might receive for medical bills resulting from an auto accident, slip-and-fall injury, or the like. The beneficiary must file first with all other plans. When the other health insurance (OHI) has paid its maximum and issued the beneficiary an Explanation of Benefits, a Tricare claim may be filed.
The only exceptions to the rule making Tricare last payer are if the OHI is a bona fide, specially written Tricare supplement, or if the OHI is a welfare-related plan such as Medicaid (not Medicare), Indian Health Service, and the like.
Your wife must use her OHI first for all medical and pharmacy services. For medical care, to file with Tricare as second payer, she must do the following:
1. Complete an official Tricare Claim Form DD2642.
2. Attach copies of exactly the same bills (the same sheets of paper) that were sent to the OHI.
3. Attach a copy of the OHI’s Explanation of Benefits that reports details of its processing of each of those charges.
4. Make copies of all the documents for your records.
5. Send Tricare’s copy of the package to the proper Tricare claims processing contractor for your Tricare Region.
Your wife must use her commercial plan’s pharmacy benefit first.
To be reimbursed a portion of the OHI’s pharmacy deductibles and copayments, contact Express Scripts, toll-free, at 1-877-363-1303, for instructions.
Please note that because of the way federal law requires pharmacy benefits to be coordinated, Tricare beneficiaries who have OHI are not eligible to use the Tricare Mail Order Pharmacy Plan.
Tags: claims, other health insurance, pharmacy
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