Get Tricare Other Health Insurance Form - Express Scripts

Completing the TRICARE Other Health Insurance Form is essential for ensuring your healthcare benefits remain uninterrupted. This guide provides straightforward instructions for users to fill out the form effectively online.

Follow the steps to complete the form accurately.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin with Section I, where you will input your personal information. Fill in your DoD ID, date of birth, and contact details, such as your last name, first name, mailing address, home phone, work phone, and email address.
3. Complete the sponsor's details in the same section, entering their DoD ID, date of birth, name, and contact information.
4. Proceed to Section II to provide details about other health insurance (OHI). Indicate if anyone in your family has OHI and specify the source — for instance, your sponsor’s employer or another option.
5. Answer whether the OHI includes pharmacy benefits and provide the policyholder’s full name along with their relationship to the sponsor. Fill in the name of the insurance company, its address, and phone number.
6. Input the information from your prescription ID card, including ID number, RxBIN, RxPCN, Rx group number, issuer, claim type, and effective date.
7. If there is more than one OHI, indicate this and document additional OHI information on a separate piece of paper.
8. In Section III, you will need to sign the form and provide your relationship to the sponsor and the date.
9. Review all information for accuracy, then save your changes, download the completed form, print it out, or share it as needed.

Complete the TRICARE Other Health Insurance Form online to ensure your benefits are properly managed.