TRICARE Choices. Your guide to selecting the TRICARE program option that s best for you

Transcription

1 TRICARE Choices Your guide to selecting the TRICARE program option that s best for you

2 Important Information TRICARE National Web site: TRICARE Mail Order Pharmacy (Express Scripts, Inc.): DoD-TMOP ( ) TRICARE Retail Pharmacy (Express Scripts, Inc.): DoD-TRRX ( ) TRICARE North Region Contractor Health Net Federal Services, Inc. (Health Net): TRICARE ( ) Health Net Web site: TRICARE South Region Contractor Humana Military Healthcare Services, Inc. (Humana Military): Humana Military Web site: TRICARE West Region Contractor TriWest Healthcare Alliance (TriWest): TRIWEST ( ) TriWest Web site: TRICARE Overseas (TRICARE Europe,TRICARE Latin America and Canada, and TRICARE Pacific) Overseas Toll-Free Number: Overseas Web site: An Important Note About TRICARE Program Changes At the time of printing, the information in this guide is current. It is important to remember that TRICARE policies and benefits are governed by public law. Changes to TRICARE programs are continually made as public law is amended. For the most recent information, contact your regional contractor or local TRICARE Service Center. More information regarding TRICARE, including the Health Insurance Portability and Accountability Act (HIPAA) Notice of Privacy Practices, can be found online at

3 TRICARE Choices TRICARE, the worldwide health care program of the Department of Defense (DoD), is available to eligible beneficiaries from any of the seven uniformed services the Army, Navy, Air Force, Marine Corps, Coast Guard, Commissioned Corps of the U.S. Public Health Service, and the Commissioned Corps of the National Oceanic and Atmospheric Administration. TRICARE Choices is designed to walk you through the steps to choosing the best TRICARE program option for you and your family. This guide identifies available program options, gives you details about each plan, and compares the different benefits so that you can make a more informed decision. This book also gives you information about how to enroll in TRICARE s premier programs: TRICARE Prime, TRICARE Prime Remote, and TRICARE Prime Remote for Active Duty Family Members, which offer the most affordable and comprehensive coverage. After reading the important information in the Eligibility for TRICARE section, proceed to Step 1. The text in each section will guide you through to the next step. TRICARE Choices is best used in conjunction with the TRICARE: Summary of Beneficiary Costs flyer, and with assistance from beneficiary counseling and assistance coordinators, who are located at military treatment facilities and at the TRICARE Regional Offices. The DoD has partnered with regional contractors Health Net Federal Services, Inc.; Humana Military Healthcare Services, Inc.; and TriWest Healthcare Alliance to help administer TRICARE in the three U.S. regions North, South, and West. Throughout this guide, we refer to your regional contractor. The regional contractor in your region handles TRICARE enrollment, billing, and administration of your health care. See the Information and Assistance section to learn more about your regional contractor. Note: Because TRICARE costs are subject to change (for all except active duty service members, who have no costs) every fiscal year (October 1 September 30), this guide does not include specific costs. For updated cost information, refer to the TRICARE: Summary of Beneficiary Costs flyer or visit 1

4 Table of Contents 1. Eligibility for TRICARE Registering in DEERS Medicare Eligibility National Guard and Reserve Eligibility Step 1: Identify Your Program Options Step 2: Explore Your Options TRICARE Prime Options US Family Health Plan TRICARE Standard and TRICARE Extra TRICARE For Life Step 3: Make a Decision Step 4: Enroll or Begin Using TRICARE Coverage TRICARE Prime Options US Family Health Plan TRICARE Standard and TRICARE Extra TRICARE For Life Step 5: Understand Your Benefit Catastrophic Cap Pharmacy Services Dental Programs Offered by TRICARE Extended Care Health Option Transitional Health Care Benefits TRICARE Reserve Select Step 6: Get to Know Your Regional Contractor Acronyms Glossary

5 Eligibility for TRICARE Understanding the rules and administrative details about TRICARE eligibility will help you determine which program option best meets your needs. The Defense Enrollment Eligibility Reporting System (DEERS) is the computerized database of the DoD that is used to determine TRICARE eligibility. DEERS holds information about military sponsors (i.e., active duty or retired service members), their eligible family members, and others worldwide who are entitled under the law to military benefits, including TRICARE. All eligible beneficiaries must be registered properly in DEERS and have a valid uniformed services identification (ID) card showing TRICARE eligibility. The following section explains how to register in DEERS, as well as how and when to update your information in the database. Registering in DEERS The sponsor is automatically registered in DEERS. However, you are responsible for registering your family members, and you should ensure that their information is always kept up to date, including address, telephone number, and . Registered family members can make address and contact information changes. However, only the sponsor can add or delete a family member from DEERS. This means that you will have to update DEERS when your personal information changes; for example, when you have a change in military career status or when your family status changes (i.e., marriage, divorce, birth, adoption, or Medicare entitlement). Mistakes in DEERS can cause problems with accessing care and processing your TRICARE claims. Be sure to keep your DEERS records up to date. Once you are registered in DEERS, you will receive a uniformed services ID card that you will present when you seek care. Children under age 10 generally can use a parent s or guardian s ID card, but they must be registered in DEERS. At age 10, children must have their own ID card. Children under age 10 should have ID cards of their own when in custody of a parent or guardian who is not eligible for TRICARE benefits or who is not the custodial parent after a divorce. To register in or update DEERS: Visit a uniformed services personnel office. Find one near you at Call Fax address changes to DEERS at Mail address changes to: Defense Manpower Data Center Support Office Attn: COA 400 Gigling Road Seaside, CA Update addresses online at Medicare Eligibility The following are important rules about Medicare eligibility. Be sure that you follow these guidelines to ensure that you remain eligible for TRICARE. Active Duty Family Members When you are entitled to Medicare Part A, you are not required to have Medicare Part B coverage to remain eligible for TRICARE. However, when your active duty sponsor retires, you must have Medicare Part B coverage to retain TRICARE eligibility. SECTION 1 ELIGIBILITY FOR TRICARE 3

6 Retirees and Their Eligible Family Members When you are entitled to Medicare Part A, due to age, disability, or end-stage renal disease, you must have Medicare Part B coverage to remain eligible for TRICARE, unless you enroll in the US Family Health Plan. Note: If you are eligible for both Medicare and TRICARE Prime, Prime enrollment fees are waived. Note: If you are not eligible for premium-free Medicare Part A at age 65, based on your work record or that of a family member, you retain your eligibility for TRICARE and are not required to have Medicare Part B coverage. If you become entitled to Medicare Part A on a spouse s work record following your 65th birthday, you should consider enrolling in Medicare Part B when first eligible to avoid paying a surcharge for late enrollment. Call Medicare at or visit for information about premium surcharges. National Guard and Reserve Member Eligibility The National Guard and Reserves includes the Army National Guard, the Army Reserve, the Navy Reserve, the Marine Corps Reserve, the Air National Guard, the Air Force Reserve, and the U.S. Coast Guard Reserve. When called to active duty for more than 30 consecutive days (under federal orders), you and your family members become eligible for TRICARE. You are considered an active duty service member and family members are considered active duty family members when you are on active duty orders. Throughout this guide, when we refer to active duty service members or active duty family members, we are also referring to you and your family. Note: Active duty service members are eligible for TRICARE coverage starting from day one of his or her orders. The 30 day limitation only affects family members. To ensure that family members are eligible for TRICARE, sponsors must register eligible family members in DEERS and keep the information up to date. You will need proper documentation, such as a marriage certificate, birth certificate, or divorce decree, to update your family's status. Visit or for more information about benefits for the National Guard and Reserve. Members (and their family members) of the National Guard and Reserve who are not on active duty are eligible for the TRICARE Dental Program. 4

7 Step 1: Identify Your Program Options Use the table below to determine the program options available to you based on your beneficiary category. The third column will tell you which step to take next. SECTION 1 ELIGIBILITY FOR TRICARE TRICARE Program Options Figure 2.1 Your Beneficiary Category Your Program Options Your Next Step Active Duty Service Member (ADSM) TRICARE Prime TRICARE Prime enrollment is mandatory. (includes National Guard and Reserve members activated for more than 30 consecutive days) ADSM who lives and works more than 50 miles or an hour s drive from a military treatment facility (MTF) (includes National Guard and Reserve members activated for more than 30 consecutive days) Active Duty Family Member (ADFM) (includes family members of National Guard and Reserve members activated for more than 30 consecutive days) TRICARE Prime Remote TRICARE Prime TRICARE Standard TRICARE Extra US Family Health Plan (if available in your area) Proceed to Step 4 to learn how to enroll. TRICARE Prime Remote enrollment is mandatory. Proceed to Step 4 to learn how to enroll. Proceed to Step 2 to learn more about your program options. SECTION 2 STEP 1: IDENTIFY YOUR PROGRAM OPTIONS ADFM who resides with an ADSM who lives and works more than 50 miles or an hour s drive from an MTF (includes National Guard and Reserve members activated for more than 30 consecutive days) TRICARE Prime Remote for Active Duty Family Members TRICARE Standard TRICARE Extra US Family Health Plan (if available in your area) Proceed to Step 2 to learn more about your program options. Retiree and eligible family members (regardless of age) who are not eligible for Medicare TRICARE Prime TRICARE Standard TRICARE Extra US Family Health Plan (if available in your area) Proceed to Step 2 to learn more about your program options. Medicare-eligible beneficiary under age 65 TRICARE Prime TRICARE For Life Proceed to Step 2 to learn more about your program options. US Family Health Plan (if available in your area) Medicare-eligible beneficiary age 65 and over TRICARE For Life US Family Health Plan (if available in your area) Proceed to Step 2 to learn more about your program options. Congressional Medal of Honor recipients and their family members, and certain former spouses of active or retired service members TRICARE Prime TRICARE Standard TRICARE Extra TRICARE For Life Proceed to Step 2 to learn more about your program options. US Family Health Plan (if available in your area) 5

8 Once you have identified which TRICARE program options are available to you based on your beneficiary category, you can proceed to the next step. In some cases, you will be eligible for only one program. For example, if you re an ADSM or a National Guard and Reserve member called to active duty for more than 30 consecutive days, you must enroll in TRICARE Prime or TRICARE Prime Remote. In this case, you can skip to Step 4 for information on how to enroll. 6

9 Step 2: Explore Your Options This step will help you decide whether to enroll in a TRICARE Prime option or to use TRICARE Standard and TRICARE Extra. TRICARE For Life (TFL), TRICARE s wraparound coverage for Medicare-eligible beneficiaries, is also described in this section. TRICARE Prime vs. TRICARE Standard and TRICARE Extra Figure 3.1 TRICARE Prime TRICARE Standard TRICARE Extra Type of Program Enrollment Providers Costs of Care Claims Program Availability Additional Details Managed care Fee-for-service Preferred provider Enrollment is required. Active duty service members (ADSMs) and active duty family members (ADFMs) do not pay enrollment fees. All other eligible beneficiaries pay enrollment fees. Receive most of their care from a primary care manager (PCM) at military treatment facilities (MTFs) or from TRICARE network providers. Priority access to care at MTFs. Offers fewer out-of-pocket costs than TRICARE Standard and TRICARE Extra. Pay nothing for care at MTF (in most cases). Providers will file claims for you (in most cases). In most cases, available in TRICARE Prime service areas (PSAs). ADSMs and their family members who do not live in a TRICARE PSA may be eligible for TRICARE Prime Remote (TPR) or TRICARE Prime Remote for Active Duty Family Members (TPRADFM). Beneficiaries (except ADSMs) may seek nonemergency care without a referral through the point of service (POS) option, but will pay higher out-ofpocket costs when using this option. Enrollment is not required. Receive care from TRICAREauthorized non-network providers. MTF care on a space-available basis only. Pay annual deductibles and cost-shares. Higher costs than TRICARE Prime or TRICARE Extra. Providers may choose to file claims for you or you will have to file your own claims. Available worldwide. The program is available for beneficiaries (except ADSMs) who choose not to enroll in TRICARE Prime. The provider or the beneficiary must file a medical claim before TRICARE Standard will pay its portion of the bill. If the beneficiary files the claim, the payment is then mailed to the beneficiary who must reimburse the provider. If the provider files the claim, he or she will be reimbursed by TRICARE. Enrollment is not required. Receive care from TRICARE network providers. MTF care on a space available basis only. Pay annual deductibles and discounted cost-shares. Higher costs than TRICARE Prime, but lower than TRICARE Standard. Providers will file claims for you (in most cases). Available within the Continental United States; not available overseas. The program is available for beneficiaries (except ADSMs) who choose not to enroll in TRICARE Prime. SECTION 2 STEP 1: IDENTIFY YOUR PROGRAM OPTIONS SECTION 3 STEP 2: EXPLORE YOUR OPTIONS 7

10 TRICARE Prime Options Active duty service members (ADSMs), including National Guard and Reserve members called to active duty for more than 30 consecutive days, must enroll in TRICARE Prime or TRICARE Prime Remote (described below) proceed to Step 4 for information about how to enroll. Here are some general features of the TRICARE Prime options: Enrollment required Enhanced benefits and services Priority access for care at MTFs Most care received from an assigned PCM (or approved TRICARE-authorized provider if enrolled in TPR/TPRADFM and network providers are not available) PCM referrals required for specialty care No claims to file (in most cases) Figure 3.2 and the following information are some additional features of the TRICARE Prime options that you should take into consideration. Enrollment in Non-Prime Service Areas If enrolled in TPR or TPRADFM (available only to ADSMs and ADFMs), you will choose a network PCM in a non-prime service area, when available. If a network provider is not available, you may choose any approved TRICAREauthorized, non-network provider as your PCM. All other beneficiaries (retirees, their families, or others) residing in a non-prime service area who want to enroll in TRICARE Prime must choose a PCM within a PSA, even if a network provider is available outside of the PSA. When you select a PCM outside of the PSA, you are agreeing to waive your TRICARE Prime access standards and travel longer distances to receive care from a network provider. All other beneficiaries cannot enroll in Prime outside of a PSA. Note: If you live within 100 miles of an MTF, you may be able to waive your access standards to enroll in TRICARE Prime at the MTF. TRICARE Prime Split Enrollment Feature Split enrollment allows families living in separate TRICARE regions to enroll in TRICARE Prime together. To use split enrollment, you must notify each family member s regional contractor of the split enrollment status. The region where the enrollment fee payment is made is determined by the sponsor s TRICARE Prime enrollment location. If the sponsor is not enrolled, the region TRICARE Prime Options Figure 3.2 TRICARE Prime TRICARE Prime Remote (TPR) TRICARE Prime Remote for Active Duty Family Members (TPRADFM) TRICARE Prime is a managed care option offering the most affordable and comprehensive coverage. TRICARE Prime is available in TRICARE Prime service areas (PSAs) areas near an MTF and where regional contractors have established TRICARE Prime networks. While ADSMs must enroll in TRICARE Prime where available, ADFMs, retired service members and their family members, survivors, certain former spouses, and other eligible beneficiaries may choose to enroll in TRICARE Prime or remain covered by TRICARE Standard and TRICARE Extra. TPR offers a TRICARE Prime benefit for ADSMs who live and work more than 50 miles or an hour s drive from an MTF. Visit the TPR Web site at and type in your residential and work ZIP codes or call your regional contractor to determine your eligibility. If you live or work within 50 miles of an MTF, you will generally not be eligible for TPR. However, you may submit a TPR Determination of Eligibility Enrollment Request form if you believe geographic boundaries cause you to drive more than one hour to an MTF. The request must be directed through your unit commander to the TRICARE Regional Office (TRO) in your area. Visit to submit your request online. TPRADFM is available to eligible ADFMs residing with their TPR-enrolled sponsors. Your DEERS address information is used to determine residency, and accurate address information in DEERS is essential to determine your eligibility for TPRADFM. In most cases, you can remain enrolled in TPRADFM if your sponsor received unaccompanied orders to another location, if you don t move from the TPR ZIP code location where you are enrolled. 8

11 where payment is made is determined by the next eldest TRICARE Prime family member enrolled. The regional contractors will coordinate enrollment fees and send the statements to the designated payer. An enrollment fee left unpaid causes the entire family to be disenrolled. Key points to remember with split enrollment: Families with college students, children living with a custodial parent or guardian, or families otherwise separated can enroll together in separate regions. Active duty families are not required to pay enrollment fees, but they can still enroll in separate regions. Retiree families have only one enrollment fee. There is no limit to the number of family members that can enroll. Note: While split enrollment is not available with TPR and TPRADFM, family members residing in separate locations may enroll in TRICARE Prime, if it is available where they reside. TRICARE Prime Access Standards The TRICARE Prime access standards are another advantage to enrolling in TRICARE Prime. The following access standards apply: The wait time for an urgent care appointment will not exceed 24 hours (one day). The wait time for a routine appointment will not exceed one week (seven days). The wait time for a specialty care appointment or wellness visit will not exceed four weeks (28 days). Additionally, you should have access to a PCM whose office is within 30 minutes of your home. Specialty care travel time should not exceed one hour under normal circumstances, unless a longer time is necessary because of the absence of providers in the area. TRICARE Prime Travel Entitlement If you are referred by your PCM for specialty care at a location more than 100 miles (one way) from your PCM, you may be eligible to have your reasonable travel expenses reimbursed by TRICARE. You must have a valid referral and travel orders from a TRICARE representative at the MTF where you are enrolled or from the TRICARE regional office (TRO) if your PCM is a TRICARE network provider. Note: The above only applies to enrollees in Continental United States locations. TRICARE Prime Point of Service Option You are required to obtain all care from your PCM or through referrals from your PCM to specialists within the TRICARE provider network, when available. However, the point of service (POS) option allows you to receive nonemergency health care services from any TRICARE-authorized provider without requesting a referral from your PCM. Using the POS option results in higher out-of-pocket costs. The POS option does not apply to the following: Active duty service members Newborns or adopted children in their first 60 days Emergency care Preventive care services from a network provider First eight behavioral health outpatient visits from a network provider If you have other health insurance TRICARE Prime Enrollment Portability Enrollment portability allows you to easily transfer your TRICARE Prime coverage to another TRICARE region, if TRICARE Prime is offered at your new location. We recommend that you transfer your enrollment if you will be staying at your new location for at least 30 days (even if the relocation is only temporary). Retirees, their family members, survivors, and former spouses may transfer enrollment twice during an enrollment year, as long as the second transfer is back to the original region of enrollment. There are no limitations on the number of transfers for ADSMs and ADFMs. If you move within the same region, you are not affected by enrollment portability (if the move is to an area that offers TRICARE Prime) and are only required to fill out a TRICARE Prime SECTION 2 STEP 1: IDENTIFY YOUR PROGRAM OPTIONS SECTION 3 STEP 2: EXPLORE YOUR OPTIONS 9

12 Enrollment Application and PCM Change Form to update your address and designate your new PCM. Note: ADSMs and ADFMs moving to or from a designated TPR ZIP code area can transfer between TRICARE Prime and TPR/TPRADFM. US Family Health Plan The US Family Health Plan (USFHP) is an additional TRICARE Prime-like option available to ADFMs, retirees, and their eligible family members (including those age 65 and over), through networks of community-based hospitals and physicians in six areas of the country. If you enroll in USFHP, you may not access care at an MTF or use MTF pharmacies. Furthermore, you are not eligible to use the other program options listed in this section. If you move or disenroll from USFHP, you may choose any TRICARE program that you are eligible for and that is available in your area. See Figure 3.3 for a list of USFHP enrollment areas. USFHP Enrollment Areas Figure 3.3 Johns Hopkins Community Physicians Serving central Maryland and parts of Pennsylvania, Virginia, and West Virginia Martin s Point Health Care Serving Maine and New Hampshire Brighton Marine Health Center Serving central and eastern Massachusetts, including Cape Cod and Rhode Island Saint Vincent Catholic Medical Centers Serving parts of New York, all of New Jersey, eastern Pennsylvania, and southern Connecticut CHRISTUS Health Serving southeast Texas and southwest Louisiana Pacific Medical Centers (PacMed Clinics) Serving the Puget Sound area of Washington State Call USFHP ( ) or visit for more information or to enroll. TRICARE Standard and TRICARE Extra If you do not enroll in one of the TRICARE Prime options, you are covered by TRICARE Standard and TRICARE Extra as long as you remain eligible in DEERS. TRICARE Standard and TRICARE Extra have higher out-of-pocket costs than TRICARE Prime. But, there is no enrollment process for TRICARE Standard and TRICARE Extra, which means there are no forms to fill out and no annual enrollment fees for retirees, their families, and others. TRICARE Standard and TRICARE Extra give you the freedom to manage your own health care you don t have an assigned PCM and you don t need referrals for care. Prior authorization is required for certain services, such as adjunctive dental care and inpatient behavioral health care, so you ll need to check with your regional contractor to learn about each region s prior authorization requirements. Because you have the freedom to seek care from any TRICARE-authorized provider in or out of the TRICARE network, you can only seek care from MTFs on a space-available basis. While the options can be used interchangeably together, it s important to understand the key differences between TRICARE Standard and TRICARE Extra. If you seek care from a non-network, TRICARE-authorized provider, you re using the TRICARE Standard option. Because you re using a non-network provider, you ll have higher costs than with TRICARE Extra and you may be required to file your own claims. If you seek care from a TRICARE network provider, you re using the TRICARE Extra option. Because you re using a network provider, you ll pay less than with TRICARE Standard and your provider will file claims for you. TRICARE Standard is available worldwide, while TRICARE Extra is not available overseas. Note: ADSMs are not able to use TRICARE Standard and TRICARE Extra. 10

13 TRICARE For Life TRICARE For Life (TFL) offers Medicarewraparound coverage to TRICARE beneficiaries regardless of age, provided they are entitled to Medicare Part A and also have Medicare Part B coverage.* Under the TFL program, your provider will file the claims with Medicare. Medicare will pay its portion and automatically forward the claim electronically to TRICARE for processing. Here are some features of TFL: Must have Medicare Part B coverage* May receive care from any Medicare provider Claims processed as follows: For services covered by both Medicare and TRICARE, Medicare pays first and TRICARE pays second. You pay nothing out of pocket. For services covered by TRICARE, but not by Medicare, TRICARE will pay its portion and you are responsible for applicable TRICARE deductibles and cost-shares. For services covered by Medicare, but not by TRICARE, Medicare will pay its portion and you are responsible for applicable Medicare deductibles and cost-shares. For services not covered by Medicare or TRICARE, you are responsible for the entire bill. For all Medicare-eligible ADFMs, claims for inpatient services will be processed as described above. For outpatient services, if an ADFM is not enrolled in Medicare Part B, TRICARE will pay its portion and you are responsible for any applicable TRICARE deductibles and cost-shares (like any ADFM not entitled to Medicare). TFL is administered by Wisconsin Physicians Service (WPS). If you are eligible for TFL, visit or contact WPS at Additional steps may be required to coordinate benefits if you have other health insurance in addition to TRICARE and Medicare. *With the exception of ADFMs and USFHP enrollees, all beneficiaries entitled to Medicare Part A must have Medicare Part B coverage to maintain their TRICARE eligibility. SECTION 2 STEP 1: IDENTIFY YOUR PROGRAM OPTIONS SECTION 3 STEP 2: EXPLORE YOUR OPTIONS 11

14 Step 3: Make a Decision Now that you ve learned about the programs that are available to you, it s time to make your decision. The following are some scenarios that may help you. If you still have questions after reading this section, contact a beneficiary counseling and assistance coordinator (BCAC) at any military treatment facility (MTF), or contact your regional contractor. Scenario 1: I am an active duty family member with young children. I m new to the area and don t know much about the doctors or hospitals here. I want affordable health care that will cover office visits when my children are sick or when they need their immunizations. Enrolling in TRICARE Prime or TRICARE Prime Remote for Active Duty Family Members (TPRADFM) is probably the best option for you. When you enroll, you ll select or be assigned a primary care manager (PCM) at an MTF or a network PCM if you are not near an MTF. Your PCM will guide and manage your health care and the health care for your children. When you or your children need specialty care, your PCM will refer you to an appropriate specialist. Note: You can select a different provider as a PCM for each individual family member if you wish. Your office visits at the MTF will cost you nothing, you ll have priority access for appointments, and you won t have to worry about claims or costly deductibles. Under TRICARE Prime, immunizations are covered under clinical preventive services. As part of TRICARE Prime s enhanced benefit, you can go to any network provider without a referral for clinical preventive services and pay nothing out of pocket. Scenario 2: I am a new active duty family member and I have several doctors that I ve been going to for years. I want to continue seeing these doctors. Your doctors may be part of the TRICARE network. Visit your regional contractor s online provider directory and search for your doctors by name. If they are in the TRICARE network, you ll be able to use the TRICARE Prime or TRICARE Extra option and pay less than you would if you were using TRICARE Standard. If your doctors are not in the TRICARE Prime network, the TRICARE Prime option may not be the best option for you. Although you ll pay more in annual deductibles and copayments, TRICARE Standard and TRICARE Extra will allow you the flexibility to see the doctors you want. Scenario 3: I m retiring from the military and my daughter is beginning her first year of college in another state. As a retiree living in a TRICARE Prime service area (PSA), you have the option of re-enrolling yourself and your family members in TRICARE Prime. You will have coverage similar to that which you did as an active duty service member, but you will have to pay an annual enrollment fee and minimal copayments. For example, if your daughter is attending school in a TRICARE PSA, she can enjoy the benefits of TRICARE Prime while attending school through TRICARE Prime s split enrollment feature. To use split enrollment, you must notify each family member s regional contractor of the split enrollment status. The region where enrollment fee payment is made is determined by the sponsor s TRICARE Prime enrollment location. If the sponsor is not enrolled, the region where payment is made is determined by the next eldest TRICARE Prime family member enrolled. The regional contractors will coordinate enrollment fees and send the statements to the designated payer. 12

15 If TRICARE Prime is not offered in your daughter s area, you may want to disenroll her from TRICARE Prime and have her use TRICARE Standard and TRICARE Extra. If she stays in TRICARE Prime, she ll be using the Prime point of service (POS) option for routine care, which can become very costly. Scenario 4: My husband is an active duty service member, but I have health insurance through my employer. Look carefully at your employer-sponsored health plan. If the health plan is a health maintenance organization (HMO), in which you have to use doctors in the plan's network, enrolling in TRICARE Prime may not be your best option. Because TRICARE Prime and your other health insurance both require you to use doctors in a specific network, they may require you to use different providers. If you use TRICARE Standard and/or TRICARE Extra as a secondary insurance to your employer-sponsored health plan, you can see TRICARE-authorized network or non-network providers and TRICARE will pay its portion for covered services after your employer-sponsored health plan has paid its portion. Scenario 5: I am 65 and not entitled to premium-free Medicare Part A based on my own work record (Social Security number). Am I eligible for TRICARE? If applicable, you must file for benefits under your spouse s (or former spouse s) Social Security number if he or she is 62 years of age or older. If your spouse or former spouse is not yet 62, you are eligible for TRICARE benefits. Because you aren t entitled to premium-free Part A, you aren t required to purchase Part B to remain eligible for TRICARE. However, if you expect to become eligible for premium free Medicare Part A on your spouse s record at a date following your 65th birthday, you may want to enroll in Medicare Part B when first eligible to avoid paying a higher Part B premium. Medicare Part B premiums increase 10 percent for each 12- month period that you could have enrolled, but chose not to. SECTION 3 STEP 3: MAKE A DECISION SECTION 4 STEP 3: MAKE A DECISION 13

16 Step 4: Enroll or Begin Using TRICARE Coverage Now that you ve chosen a TRICARE program option, use this section to learn what you need to do to begin using TRICARE coverage. Read the information regarding your specific TRICARE program. If you need to enroll in the program you chose, this section will give you details on how to go about enrolling. TRICARE Prime Options Enrolling in TRICARE Prime, TRICARE Prime Remote (TPR), or TRICARE Prime Remote for Active Duty Family Members (TPRADFM), is easy and you have several options for completing the enrollment process. 1.Via the Mail Download a copy of the TRICARE Prime Enrollment Application and PCM Change Form from your regional contractor s Web site or request one by calling their toll-free number. Complete the application and then follow the directions for returning the application to your regional contractor through the mail. The enrollment application provides instructions to help you complete the form. See Tips for Completing Your Enrollment Application later in this section for information about the enrollment application. 2. Visit a TRICARE Service Center You can visit any TRICARE Service Center (TSC), pick up a copy of the TRICARE Prime Enrollment Application and PCM Change Form, complete it, and submit the form to TSC representatives. To locate a TSC near you, visit visit your regional contractor s Web site, or call your regional contractor. See Tips for Completing Your Enrollment Application later in this section for information about the enrollment application. Enrollment Deadlines For ADSMs enrolling in TRICARE Prime or TPR, coverage begins when your regional contractor receives the completed enrollment application. For ADFMs enrolling in TRICARE Prime or TPRADFM, and for retired service members, their families, and all others enrolling in TRICARE Prime, the 20th-of-the-month rule applies. With the 20th-of-the-month rule, as long as your regional contractor receives your completed enrollment application by the 20th of the month, your coverage will begin on the first day of the next month. The application must be received by the 20th of the month, not postmarked by the 20th of the month. If the form is received after the 20th of the month, then coverage begins on the first day of the second month following receipt of your application. See Figure 5.1 to determine when your coverage will begin. Enrollment Deadlines Application Received Enrollment Start January 1-20 February 1 January March 1 February 1-20 March 1 February April 1 March 1-20 April 1 March May 1 April 1-20 May 1 April June 1 May 1-20 June 1 May July 1 June 1-20 July 1 June August 1 July 1-20 August 1 July September 1 August 1-20 September 1 August October 1 September 1-20 October 1 September November 1 October 1-20 November 1 October December 1 November 1-20 December 1 November January 1 December 1-20 January 1 December February 1 Figure

17 Be sure to include all beneficiary information requested (Social Security number, birth dates, home addresses, telephone numbers, etc.). If information is incomplete or missing on your enrollment application, it may delay processing as well as the effective date of your TRICARE coverage. Remember to sign and date your application, and include both your home and daytime telephone numbers where you can be reached, if necessary. TRICARE Prime Enrollment Fees Retired service members, their families, survivors, eligible former spouses, and others (e.g. Medal of Honor recipients) enrolled in TRICARE Prime are required to pay an annual enrollment fee. In most cases, the TRICARE Prime enrollment fees are not refundable. There are no enrollment fees for ADSMs and ADFMs (or for survivors during the transitional survivor period following the ADSM s death) enrolled in TRICARE Prime, TPR, or TPRADFM. Refer to the TRICARE: Summary of Beneficiary Costs flyer for TRICARE Prime enrollment fee amounts and payment options. US Family Health Plan If you choose to enroll in the US Family Health Plan (USFHP), you must submit a completed application to the USFHP program near you. The TRICARE Prime Enrollment Application and PCM Change Form serves as the enrollment application for USFHP and has the USFHP address indicating where to send your enrollment form. Refer to TRICARE Prime Options in this section to learn more about completing this form. You may enroll at any time throughout the year; however, you make a one-year commitment to receive your care from the plan, unless you move out of the plan service area. Enrollment fees, if applicable, are transferrable to another TRICARE Prime region. SECTION 5 STEP 4: ENROLL OR BEGIN USING TRICARE Tips for Completing the Enrollment Application Figure 5.2 Enrollment Application Selecting a PCM Medicare Eligibility There is a single, 8-page enrollment application for TRICARE Prime, TPR, and TPRADFM the TRICARE Prime Enrollment Application and PCM Change Form. The only thing that varies on the form in each region is the address to return your completed form. Your regional contractor s name and address are found in the mailing instructions on page 4 of the enrollment application. Remember, you only need one enrollment application for your entire family (unless utilizing the split enrollment option for TRICARE Prime). You may need a second form if you have more than three family members or at least copies of the family member information page (Section II). If you live in a TRICARE Prime service area, contact your regional contractor to verify any MTF guidelines for PCM assignment. If you are choosing a network PCM, contact the PCM s office to make sure the provider is accepting new patients. If you do not indicate a PCM on the enrollment form or if your choice is not available, one will be assigned to you. Remember to choose a PCM for each person enrolling. If enrolling in TPR or TPRADFM, you may not have an assigned PCM. Contact your regional contractor for assistance. If any family member is entitled to Medicare Part A, regardless of age, fill out Section III of the form and include copies of each Medicare card. ADFMs and beneficiaries enrolling in the USFHP are not required to have Medicare Part B coverage to remain eligible to enroll in TRICARE Prime or USFHP, however, all others (e.g., retired service members, their families, and others) must have Medicare Part B coverage to remain eligible for TRICARE. TRICARE Prime enrollment fees will be waived if entitlement to Medicare Part A is based on disability or end-stage renal disease. 15 SECTION 3 COVERED SERVICES, LIMITATIONS, & EXCLUSIONS SECTION 4 STEP 4: ENROLL OR BEGIN USING TRICARE

18 TRICARE Standard and TRICARE Extra There is no enrollment process for TRICARE Standard or TRICARE Extra. However, your personal information in DEERS must be up to date, and you must have a valid military identification (ID) card. Visit the online provider directory at to find a list of TRICARE-authorized providers. Remember, you can save yourself money by using the TRICARE Extra option and seeing a TRICARE network provider. TRICARE For Life TRICARE For Life (TFL) is administered by Wisconsin Physicians Service (WPS). If you are eligible, visit or contact WPS at While there is no enrollment process for TFL, you must have Medicare Part B coverage (see exceptions listed in the Eligibility for TRICARE section of this book). 16

19 Step 5: Understand Your Benefit TRICARE strives to offer a world-class health care benefit that meets all the needs of our beneficiaries. TRICARE covers most inpatient and outpatient care that is medically necessary and considered proven. TRICARE also offers supplemental programs for health care needs that go beyond the basic TRICARE program options. This section highlights some of the features of TRICARE coverage, including some supplemental programs that may be available to you, such as the TRICARE Dental Program and the Extended Care Health Option. Catastrophic Cap The TRICARE catastrophic cap limits your outof-pocket expenses on annual deductibles, costshares, and other costs (such as those for pharmacy) for TRICARE-covered medical services and supplies. As a TRICARE beneficiary, you will not be responsible for any cost-shares over the catastrophic cap total in a given fiscal year (October 1 September 30). Refer to the TRICARE: Summary of Beneficiary Costs flyer for the catastrophic cap by beneficiary category. Note: The catastrophic cap does not apply to services that are not covered or to the additional 15 percent that nonparticipating providers may charge above the TRICARE allowable charge or POS charges. Pharmacy Services TRICARE offers comprehensive prescription drug coverage and several options for filling your prescriptions. To have a prescription filled, you ll need a written prescription and a valid uniformed services ID card. Refer to the TRICARE: Summary of Beneficiary Costs flyer or for pharmacy cost information. Military Treatment Facility Pharmacy Prescriptions may be filled (up to a 90-day supply for most medications) at no cost at an MTF pharmacy, as long as the medication is on the MTF formulary. You should contact the MTF to find out what is on the formulary and for specific details about filling prescriptions at the MTF pharmacy. If you do not live near an MTF, this may not be your best option for filling prescriptions. TRICARE Mail Order Pharmacy The mail-order pharmacy is your least expensive option when not using an MTF. You may receive up to a 90-day supply for most medications, which will be delivered to your home for a small copayment. Refills may be requested by mail, phone, or online. For faster processing of your mail-order prescription, you can register before placing your first order. Once you are registered, your provider can fax or call in your prescriptions. Medications will be sent directly to your home in about 14 days after receiving your prescription. If you have prescription drug coverage from another health insurance plan, you can only use the mail-order pharmacy if the medication is not covered under the other plan or if you have exceeded the dollar limit of coverage under the other plan. For more information regarding the mail-order pharmacy, please contact your regional contractor or visit TRICARE Retail Pharmacy Network You can have prescriptions filled (up to a 30-day supply) at any pharmacy in the TRICARE retail pharmacy network for a small copayment. For more information on locating a TRICARE retail network pharmacy, please contact your regional contractor or visit Non-network Pharmacies Filling prescriptions at a non-network pharmacy is the most expensive option. You may have to pay for the total cost of the prescription first and then file a claim to receive a partial reimbursement after your deductible is met. SECTION 5 STEP 4: ENROLL OR BEGIN USING TRICARE SECTION 6 STEP 5: UNDERSTAND YOUR BENEFIT SECTION 3 COVERED SERVICES, LIMITATIONS, & EXCLUSIONS 17

20 Important Note about Medicare Part D: As a beneficiary eligible for TRICARE and Medicare, and entitled to the TRICARE pharmacy benefit, you need to consider a number of factors when deciding whether or not to enroll in a Medicare drug plan. You should consider monthly premiums, deductibles, copayments, and drug coverage (also known as a formulary) under the different plans offered. The Medicare Part D drug plans vary by state. In most cases, beneficiaries eligible for both TRICARE and Medicare will get no added value by purchasing Medicare prescription drug coverage. The exceptions are those with limited incomes and assets who qualify for Medicare s extra help with prescription drug plan costs. Contact your local State Health Insurance Assistance Program (SHIP) for free health insurance counseling and assistance. Call Medicare at for the number of your local SHIP agency. Dental Programs Offered by TRICARE Active duty service members usually receive all dental care from military dental treatment facilities. If enrolled in TRICARE Prime Remote, you are automatically covered by the Tri-Service Remote Dental Program, administered by the Military Medical Support Office (MMSO). More information about active duty dental benefits is available at or in the TRICARE Prime Handbook or the TRICARE Prime Remote Handbook. For all other beneficiaries, TRICARE offers two dental programs the TRICARE Dental Program (TDP) and the TRICARE Retiree Dental Program (TRDP). Each program is administered by a separate dental contractor and has its own monthly premiums and cost-shares. TRICARE Dental Program The TDP is a voluntary dental insurance program available worldwide to eligible active duty family members and to members of the National Guard and Reserve and/or their families. United Concordia Companies, Inc., (United Concordia) currently administers the program. For TDP information, visit or call United Concordia toll-free at TRICARE Retiree Dental Program The TRDP is a voluntary dental insurance program available to retired service members and their eligible family members living in the United States, Canada, Puerto Rico, Guam, the U.S. Virgin Islands, American Samoa, and the Commonwealth of the Northern Mariana Islands. Delta Dental Plan of California (Delta Dental) currently administers the program. For TRDP information, visit or call Delta Dental toll-free at Extended Care Health Option The TRICARE Extended Care Health Option (ECHO) provides financial assistance to active duty family members who qualify based on specific mental or physical disabilities, and offers an integrated set of services and supplies not available through the basic TRICARE program. TRICARE ECHO supplements the benefits of the TRICARE program option you currently use TRICARE Prime (including TPRADFM), TRICARE Standard, or TRICARE Extra. Qualifying conditions include: Moderate or severe mental retardation Serious physical disability Extraordinary physical or psychological condition of such complexity that the beneficiary is confined to their home A diagnosis of a neuromuscular developmental condition or other condition in an infant or toddler that is expected to precede a diagnosis of moderate or severe mental retardation or a serious physical disability Multiple disabilities, which may qualify if there are two or more disabilities affecting separate body systems 18

21 For those who qualify, TRICARE ECHO provides benefits not available through the basic TRICARE program. These benefits may include: Medical and rehabilitative services Training to use assistive technology devices Special education Institutional care when a residential environment is required Transportation under certain circumstances Assistive services, such as those from a qualified interpreter or translator Durable equipment, including adaptation and maintenance Expanded in-home medical services through TRICARE ECHO Home Health Care In-home respite care services: ECHO Respite care 16 hours per month when receiving other authorized ECHO benefits TRICARE ECHO Home Health Care Respite care up to 40 hours per week (eight hours per day, five days per week) for those who qualify Contact your regional contractor for more information about qualifying for ECHO. Transitional Health Care Benefits When an active duty sponsor separates from the uniformed services, TRICARE coverage may or may not continue, depending on the circumstances of the separation. TRICARE offers two transitional health care options the Transitional Assistance Management Program (TAMP) and the Continued Health Care Benefit Program (CHCBP) that offer temporary coverage until you have a new health plan. Contact your regional contractor or a beneficiary counseling and assistance coordinator (BCAC) to discuss your family s eligibility for either of these programs. You also can visit for details about either program. Transitional Assistance Management Program For those who qualify, TAMP provides 180 days of transitional health benefits after leaving active duty. During this 180-day period you can enroll in TRICARE Prime if you reside in a TRICARE Prime service area, or you will be covered under TRICARE Standard and TRICARE Extra. Rules and processes for these programs will apply. Your costs will be the same as those for active duty family members. Note: TPR and TPRADFM are not available during the TAMP period. Continued Health Care Benefit Program The Continued Health Care Benefit Program (CHCBP) is a premium-based health care program administered by Humana Military Healthcare Services, Inc., (Humana Military). CHCBP offers temporary transitional health coverage (18-36 months) after TRICARE eligibility ends. Service members and certain family members can purchase CHCBP within 60 days of loss of eligibility for either regular TRICARE or TAMP coverage. CHCBP acts as a bridge between military health benefits and your new civilian health plan. CHCBP is comparable to TRICARE Standard with the same benefits, providers, and program rules. The main difference is that you pay premiums to participate. TRICARE Reserve Select TRICARE Reserve Select (TRS) is a premiumbased health plan that National Guard and Reserve members who qualify may purchase. TRS offers coverage similar to TRICARE Standard and TRICARE Extra, and a monthly premium is charged. You will receive comprehensive coverage with access to TRICARE-authorized providers. Annual deductibles and cost-shares apply. Visit for more information about TRS coverage. For additional information about the National Guard and Reserve and the Selected Reserve, visit the Reserve Affairs Web site at or your Service personnel office. SECTION 6 STEP 5: UNDERSTAND YOUR BENEFIT SECTION 3 COVERED SERVICES, LIMITATIONS, & EXCLUSIONS 19