TRICARE For Life - Other Health Insurance Questionnaire

Use this form to let us know if you have or no longer have other health insurance.

Download OHI Questionnaire (PDF) 

Other Health Insurance (OHI) Instructions

U.S. law requires that all Other Health Insurance, including Medicare, process health insurance claims before TRICARE For Life, with the exception of Medicaid. In order for us to process your claim we must have evidence that your other insurance has processed the claim. 

To ensure we have up-to-date and accurate information regarding your Other Health Insurance, please complete the form and mail it to the address at the bottom of the form. 

Login or Create an Account to update your Other Health Insurance under the Family Profile section of TRICARE4u.com. You must be a registered user and logged in to make the update online.

Form Instructions

1. Fill in either the Sponsor number OR the DoD Benefits Number.
   The DoD Benefits number can be found on the back of the newer uniformed service ID card.
2. Other Health Insurance Name of Carrier
   The name of the insurance company. Examples: Medicare, Aetna, Blue Cross/Blue Shield, etc.
   • Do NOT include TRICARE For Life.
   • Carrier Address and Phone #: Usually found on your insurance card. For Medicare, this is only needed if you have a Medicare Advantage/Replacement/Cost plan.
   • Is your policy a Medicare Advantage/Replacement/Cost plan? These plans typically include extra benefits and may involve extra monthly premiums.
   • Does this coverage include pharmacy benefits?
   • Does this coverage have exclusions or limitations? If yes, indicate which services are excluded (e.g., cancer-only coverage, no heart disease coverage).
   • Name of Covered Memeber
   • Date of Birth
   • Policy Number as shown on your insurance card.
   • Effective Date of the policy.
   • Expiration Date: If no longer active, enter expiration date. If still active, write “current”.
3. Additional Other Health Insurance
   If you have more than one policy:
   • Follow the same steps as in section 2 for each additional plan.
   • Use an additional sheet if needed and attach it to the form.
   • Do NOT include TRICARE For Life.
4. Consent and Signature Section
    
   • Your Signature
   • Relationship to Sponsor: (the person who served)
   • Date of signing