With TRICARE, there are three options to choose from so that you have a choice in selecting the one that will best meet your and your family’s needs. Eligible TRICARE beneficiaries are entitled to use TRICARE Standard. However, they may enjoy enhanced benefits when they use Extra and maximum benefits when they enroll in Prime.
Active duty service members who live and work more than a one-hour drive from a military treatment facility and their family members who live with them are also eligible for TRICARE Prime Remote and TRICARE Prime Remote for Active Duty Family Members.
Once you’ve familiarized yourself with the differences in these plans, you’ll be able to choose the one that’s right for you.
TRICARE Prime, an HMO-style plan that offers quality care at the lowest out-of-pocket cost when your care is coordinated by your primary care manager (PCM)
TRICARE Extra, a plan that offers cost-saving features when you use our network of credentialed providers
TRICARE Standard, which offers the freedom to see any TRICARE-certified provider at a higher out-of-pocket cost.
TRICARE provides a generous prescription benefit for eligible TRICARE and TRICARE For Life beneficiaries. Under TRICARE, beneficiary copayments for prescriptions vary depending on where the medications are purchased and whether the prescriptions are for generic or brand name drugs. Additional information about TRICARE prescription coverage can be found on the ExpressScripts website, www.express-scripts.com/TRICARE/.
NOTE: Active duty service members who obtain their prescriptions from the MTF, TRICARE Mail Order Pharmacy (TMOP) or retail network pharmacies have no copayments.
Although TRICARE is a comprehensive program of health care benefits, there are certain services and supplies that are excluded from coverage. These are shown in the TRICARE Prime Handbook and can be seen by clicking on the link below. You can also contact your Health Benefits Advisor (HBA) or TRICARE Service Center (TSC) if you have questions about TRICARE-covered services.
The TRICARE Dental Program combines the Family Member and the Selected Reserve Dental Plans.
The TDP covers a wide range of diagnostic, preventive and restorative services. If you are interested in enrolling in the TDP, you can obtain an enrollment application by contacting MetLife at (855) 638-8371.
The TRICARE Retiree Dental Program provides enhanced dental benefits for retirees and their families. The enhanced benefits allow for additional services. Additional information about the TRDP program is available at the Delta Dental Plan Web site.
A catastrophic cap
is the annual limit you will have to pay out-of-pocket for your medical expenses. Once you reach your annual catastrophic cap, TRICARE will pay 100 percent of your medical expenses for the rest of that year, with the exception of Point of Service charges.
Under TRICARE Prime the maximum family liability (catastrophic cap) for active duty family members is $1,000 per fiscal year. For all other Prime enrollees (retirees and retiree family members, survivors, etc.) the maximum liability is $3,000 per enrollment year and $3,000 per fiscal year.
Under TRICARE Extra and Standard the maximum family liability for active duty family members is $1,000 per fiscal year. For all other TRICARE beneficiaries the maximum family liability is $3,000 per fiscal year.
Eyeglasses and contacts are not covered by TRICARE at this time with certain exceptions under very limited circumstances, such as corneal lens removal.
If you have health care coverage under a plan other than TRICARE, you have other health insurance (OHI).
Many TRICARE beneficiaries are enrolled in other health plans through non-military employers or their spouse’s employer. When you are covered by another plan, the other plan, by law, must be considered your primary source of health care coverage, with the following exceptions:
VA coverage (in which beneficiaries who are eligible for both TRICARE and VA benefits select either TRICARE or VA for coverage of each episode of care).
Other plans that are supplemental to TRICARE:
Medicaid
Maternal and Child Health Program and Indian Health Services plans
State Victims of Crime Compensation programs
That means that each claim must be filed with the OHI before it can be filed with TRICARE.
TRICARE beneficiaries may consult with another provider for a second medical opinion when they are uncertain about a contemplated course of action. A second opinion may be requested by the beneficiary, the provider, or even by HMHS. TRICARE Prime members who wish to seek a second opinion must first obtain an authorization from their primary care manager, which will then be reviewed by a Humana Military HCF.
Under provisions of the 2001 National Defense Authorization Act (NDAA), TRICARE Prime beneficiaries referred by their primary care manager (PCM) for services at a location more than 100 from their PCM may be eligible to have their "reasonable travel expenses" reimbursed by TRICARE. The travel reimbursement entitlement is retroactive to Oct. 30, 2000.
The TRICARE Prime travel entitlement is available to non-active duty TRICARE Prime enrollees and TRICARE Prime Remote family members (when implemented) when they are referred for specialty care more than 100 miles from the PCM location. Beneficiaries must have a valid referral and travel orders from a TRICARE representative at the military treatment facility (MTF) where they are enrolled or from the TRICARE Regional Office if their PCM is a TRICARE network provider.
When you separate from active duty or lose eligibility for TRICARE, you’ll automatically receive a certificate of creditable coverage. The certificate is needed to show you previously had healthcare coverage for when you apply for new healthcare coverage: it will reduce the amount of time the new healthcare plan can exclude a person from coverage for a pre-existing health condition.
The certificates are issued by the Defense Manpower Data Center Support Office (DSO) – automatically for active duty service and family members and upon a written request from eligible retirees and those who may have lost their certificate, it will be delivered through the mail free of charge. Certificates can’t be requested by phone from the DSO. For more information, contact the DSO at 1-800-538-9552 (TTY/TDD call 1-866-363-2883).
If the school is located where TRICARE Prime is offered, the student may take advantage of TRICARE Prime benefits. If your student’s school is located in a different region from where the rest of the family resides, the TRICARE Prime split enrollment feature provides you with the opportunity of keeping all family members enrolled. You must notify the regional contractors involved of the split enrollment status, complete a TRICARE Prime Enrollment and PCM Change Form (DD Form 2876) and send it to the regional contractor for your student’s new region. The contractor will then coordinate applicable enrollment fees.
TRICARE covers annual school physicals required for school enrollment for TRICARE eligible beneficiaries ages five to eleven. The benefit does not include physical exams that may be required by a school for the child to participate in a school sport.
Physical therapy to improve, restore or maintain function or to minimize or prevent deterioration of function of a patient is covered if prescribed by a physician. Services can be inpatient or outpatient - as determined by medical necessity. In addition to the services being prescribed by a physician, they also must be professionally administered as an aid in the patient’s recovery from a covered injury or procedure. General exercise programs not covered are maintenance programs that don’t require the presence of a skilled administrator for them to be effective.
If you’re an active duty family member enrolled in TRICARE Prime, you are entitled to a routine eye examination every year (at no cost) and a comprehensive eye examination every two years (with no co-payment). If you are a retired service member enrolled in Prime, you are entitled to a comprehensive eye examination every two years (with no co-payments) - with the benefit beginning two years after your last eye exam before retirement. If you’re an ADFM using TRICARE Extra or Standard, you are covered for one routine eye exam every year - with TRICARE Extra/Standard cost shares applying after the annual deductible has been met. Retired service members using TRICARE Extra/Standard are not covered for vision services. For additional information about TRICARE’s vision coverage, call Humana Military at 1-800-444-5445.
Generic, brand name or non-formulary prescriptions obtained at the MTF have no co-payments. Non-formulary medications generally won't be found at MTF pharmacies Prescriptions obtained through the TRICARE Pharmacy Home Delivery program have three co-payment levels for a 90-day supply of your medication: $3 for generics, $9 for brand name medications and $22 for non-formulary medications. In the TRICARE Retail Pharmacy program (TRRx), the co-pays are the same as for the TRICARE Pharmacy Home Delivery program - but for only a 30-day supply.
TRICARE defines an emergency as a medical, maternity or psychiatric condition that a "prudent layperson" (someone with an average knowledge of health and medicine) believes could threaten life, limb or eyesight without immediate treatment. Urgent care is considered an illness or injury that won’t cause further disability or death if it’s not treated immediately but requires professional attention to prevent it from developing into a greater threat. Urgent care for Prime beneficiaries does require a referral from their PCM.
Examples of emergencies include severe bleeding, chest pains, no pulse, spinal cord or back injuries, severe eye injuries or severely broken bones.
Examples of urgent care situations include ear aches, migraine headaches, sinus infections, urinary tract infections, sprains or rising fever.
