Prescription Claims
TRICARE DoD/CHAMPUS Claim Form-Patient's Request for Medical Payment (DD Form 2642)
CAN'T be Handwritten
on the EOB or Pharmacy Receipt |
CAN be Handwritten
on the EOB or Pharmacy Receipt |
- Date of fill
- Quantity
- Pharmacy name
- What you (the beneficiary) paid
- Drug name and strength
|
- Number of day’s supply
- Prescription number
- Pharmacy address
- Doctor’s name or DEA number
- Pharmacist’s signature (for retail pharmacy claims only)
- Amount paid by the other health plan or the retail price from the pharmacy
|
Claims Addresses
In the U.S. or a U.S. Territory, send your claim with the pharmacy contractor:
Express Scripts
P.O. Box 52132
Phoenix, AZ 85072
In all other overseas areas, send your claim to the claims address for where the prescription is filled.