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Prescription Claim Forms

TRICARE DoD/CHAMPUS Claim Form-Patient's Request for Medical Payment (DD Form 2642)

Prescription claims must be filed within one year of the date of service.  To file a pharmacy claim, obtain and fill out a Patient's Request for Medical Payment (DD Form 2642). Prescription claims require the following information for each drug:

  • Name of the patient
  • Name, strength, date filled, days supply, quantity dispensed and price of each drug
  • National Drug Code, if available
  • Prescription number of each drug
  • Name and address of the pharmacy
  • Name and address of the prescribing physician

In the U.S. or a U.S. Territory, file your claim with the pharmacy contractor:

Express Scripts
P.O. Box 52132
Phoenix, AZ 85082

In an overseas area (other than a U.S. Territory), file your claims with the overseas claims processor, at the appropriate address.

Active Duty
All Overseas Areas
TRICARE Active Duty Claims
P.O. Box 7968
Madison, WI 53707-7968
www.tricare-overseas.com 
Eurasia-Africa
Non-active duty 
TRICARE Overseas Program
P.O. Box 8976
Madison, WI 53708-8976
www.tricare-overseas.com
Latin America & Canada
Non-active duty
TRICARE Overseas Program
P.O. Box 7985
Madison, WI 53707-7985
www.tricare-overseas.com 
Pacific
Non-active duty
TRICARE Overseas Program
P.O. Box 7985
Madison, WI 53707-7985
www.tricare-overseas.com 

Last Updated 12/9/2013