TRICARE Coverage After Gaining or Losing Other Health Insurance

8/15/2019

If you have any health insurance other than TRICARE, it’s called “other health insurance” or simply “OHI.” An example of OHI is having employer-sponsored coverage in addition to TRICARE. If you’re on active duty, you can’t use OHI. TRICARE is your only coverage. And TRICARE supplemental insurance isn’t OHI.

If you recently gained or lost OHI, you’ve experienced a TRICARE Qualifying Life Event (QLE). This means that you have 90 days after you gain or lose other health insuranceHealth insurance you have in addition to TRICARE, such as Medicare or an employer-sponsored health insurance. TRICARE supplements don’t qualify as "other health insurance." to change your TRICARE health plan. You need to take action and understand how your plans will work together in the future. Here are some tips regarding what comes next.

Tell TRICARE When You Gain Other Health Insurance

Tell your TRICARE contractors, doctors, and pharmacies if you have other health insurance. This includes medical insurance, prescription drug insurance, dental insurance, and vision insurance. This will help them coordinate your benefits for payment by both the OHI and TRICARE, as well as prevent claim delays or denials.

You can report your OHI through the following:

Coordinating Your Benefits

Once obtained, OHI becomes your primary insurance. Therefore, if you have health coverage through an employer, association, private insurer, or school (for students), your OHI is always your primary insurance and pays any claims before TRICARE does. OHI must process the claim before TRICARE can consider the charges. A TRICARE-authorized network or TRICARE-authorized non-network provider must provide the TRICARE-covered health care services.

Most providers and pharmacies will file your claim with TRICARE. If they don’t, you can submit the amount remaining to your TRICARE contractor. Be sure you follow the rules of your OHI. If your OHI doesn’t pay on your claim because you didn’t follow their rules, TRICARE may not pay on your claim. If TRICARE receives your claim before your OHI processes it, TRICARE will deny it.

Medicare and TRICARE

TRICARE pays after Medicare and your OHI for TRICARE-covered health care services. As outlined in the TRICARE For Life Handbook, how Medicare coordinates with OHI “depends on whether or not the OHI is based on current employment.” But in either case, TFL pays last. You can also learn about how Medicare works with OHI on the Medicare website.

Using Other Health Insurance with Prescription Drug Coverage

When you have OHI with pharmacy benefits, your OHI pays first and TRICARE pays second. The TRICARE Pharmacy Overview states that you “can save money by using a pharmacy that is also in-network with your other health insurance, if you have it.” Tell Express Scripts, Inc. you have OHI by completing the TRICARE Other Health Insurance Form.

If you have OHI prescription coverage, you can’t use TRICARE Pharmacy Home Delivery unless the TRICARE pharmacy contractor can coordinate benefits with your OHI plan and either: 1) the drug isn’t covered by your OHI, or 2) you have met the OHI benefit cap. Visit Using Other Insurance and check out the TRICARE Pharmacy Handbook for more information on how to coordinate OHI with pharmacy benefits and file claims.

Losing Other Health Insurance

If you lose other health insurance, TRICARE becomes your primary payer. Inform the applicable TRICARE contractors and your health care provider and pharmacy of loss of OHI. If you don’t share the loss of OHI, then you risk the chance of TRICARE denying your claim. 

Whether you lose or gain OHI, don’t wait to report it to your TRICARE contractor.

Visit Qualifying Life Events to learn more about this QLE and other QLEs that you may experience in the future. Doing this will help you make the most of your benefit and take command of your health care.

Last Updated 6/23/2020