Using your TRICARE benefit with OHI

By law, TRICARE pays after all OHI, except for:

• Medicaid
  
• TRICARE supplements
• State victims of crime compensation programs
• Other federal government programs identified by the Defense Health Agency (DHA)

This means your OHI processes your claim first. Then, you or your provider files your claim with TRICARE. Your provider MUST be TRICARE-certified for TRICARE to pay up to the TRICARE Maximum Allowable Charge (TMAC) on covered services. If TRICARE receives your claim before your OHI processes it, TRICARE will deny it. If TRICARE pays first and later discovers you had OHI, TRICARE will take back any payments made and will reprocess the claim after your OHI has processed it.

OHI with prescription drug coverage

When you have OHI with pharmacy benefits, your OHI pays first and TRICARE pays second. You can avoid higher costs by getting your prescriptions filled at a TRICARE network pharmacy that is also in your other plan's network.

To avoid delays or problems when processing your prescriptions claims, tell Express Scripts you have OHI. Likewise, if you no longer have OHI with pharmacy benefits, you must tell Express Scripts.

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Keep your OHI information up-to-date 

If you are adding, removing or changing OHI, you will need to notify TRICARE and all assigned providers to prevent future claims issues. If you only contact TRICARE to remove your OHI and don’t notify your provider, your provider will submit a claim with OHI which will cause your OHI information to automatically be added back to your account when the claim processes and the claim will deny for OHI.

Notifying both TRICARE and your provider of any OHI updates prior to any scheduled appointment should prevent claim delay or denial due to OHI. 

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