TRICARE For Life - Other Health Insurance Questionnaire

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 to the address at the bottom of the form. Login or Create an Account to update your other health insurance information under the Family Profile section of TRICARE4u.com. You must be a registered user and logged in to your account 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: Primary 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 #: The address and phone number of your insurance company. This is usually given somewhere on your insurance card. For Medicare, this is only needed if you have a Medicare Advantage/Replacement/Cost plan. Check either the YES or NO box for the following:
• Is your policy a Medicare Advantage/Replacement/Cost plan? Medicare Advantage/Replacement plans are plans that Medicare has approved to administer the same traditional Medicare benefits but members typically also pay a monthly premium in addition to the Medicare Part B premium to cover items not covered by traditional Medicare such as prescription drugs, dental care, vision care, etc.
•  Does this coverage include pharmacy benefits? Does this plan cover prescription medications?
•  Does this coverage have exclusions or limitations? Does your policy limit the types of services provided? Some examples would be cancer coverage only, or no heart disease coverage, etc. If you check the YES box, indicate what services are excluded or limited.
• Name of Covered Member: Enter the first and last name of the person(s) covered by this plan.
• Date of Birth: Enter the date of birth of the person(s) covered by this plan.
• Policy Number: Enter the policy number of the plan. This can usually be found on your insurance card.
• Effective Date: Enter the date the policy became effective for this person. For Medicare this is usually the first of the month of your birthday month.
• Expiration Date: If you no longer have this coverage enter the date the policy expired. If the coverage is still in effect, write “current”.

3: Additional Other Health Insurance

• If you have more than one Other Health Insurance Policy, enter the information in this section. You would follow the same instructions as given in 2. If you have more than two Other Health Insurances, include an additional sheet with the additional insurance information and attach to this form. Provide the same information as given in 2.
• Do NOT include TRICARE For Life.

4: Read the consent information and if you agree fill in the following information.

• Your Signature: Sign your name.
• Relationship to Sponsor: Fill in your relationship to the sponsor. The sponsor is the person who served.
• Date: Fill in the date you signed the form.