TRICARE Health Care Programs
TRICARE Prime is a "managed care" type of health care program. When you sign up for TRICARE Prime, you will be expected to receive health care services using a Primary Care Manager, known as a PCM, who will manage your care and refer you to specialists as needed. This is the lowest cost TRICARE option if you follow the rules about going through your PCM for care. TRICARE also guarantees Prime patients access to care within certain time and distance standards. You can choose to receive care using military clinics or hospitals, called military treatment facilities (MTFs). Or, you may choose to receive your care from TRICARE network civilian clinics, hospitals, and providers. TRICARE Prime enrollees have priority for care in military hospitals, but there are some locations where there may not be space in the military hospital for everyone who wants to enroll there. Your local hospital or clinic will tell you whether you must enroll in Prime with them or whether you may find a civilian PCM. Your local TRICARE Service Center or TRICARE contractor can provide you with a list of civilian providers in the network. For additional information, go to http://www.tricare.mil/mybenefit/home/overview/Plans and click "TRICARE Prime" on the left menu.
TRICARE Prime Remote (TPR) and TRICARE Prime Remote for Active Duty Family Members (TPRADFM)
TRICARE Prime Remote (TPR) is only for active duty service members, who live and work more than 50 miles or one hour's drive from a military hospital or clinic. TPR works like TRICARE Prime. You are expected to receive health care services using a TRICARE network provider or an approved TRICARE authorized provider if there isn't a network provider available in your area. For additional information, go to http://www.tricare.mil/mybenefit/home/overview/Plans and click "TRICARE Prime Remote" on the left menu.
Active duty family members living in remote areas with their TPR-enrolled service members may choose to enroll in TRICARE Prime Remote for Active Duty Family Members (TPRADFM). Because TPRADFM works like TRICARE Prime, you will have lower costs than if you choose to be in TRICARE Extra or Standard. But you must seek your care through your Primary Care Manager, who will refer you to specialists if necessary. Once enrolled in TPRADFM, you may remain in the program if your active duty sponsor receives a subsequent unaccompanied permanent change of assignment as long you continue to reside in the same TPR location.
Family members of activated National Guard or Reserve members may choose to enroll in TPRADFM if their service member is called to active duty for more than 30 days and they reside within a designated remote location where their sponsor resided when activated. For more information, go to http://www.tricare.mil/mybenefit/home/overview/Plans and click on "TRICARE Prime Remote" on the left menu.
TRICARE Standard and Extra
TRICARE Standard and Extra are called fee-for-service options. Unlike TRICARE Prime, where you must seek care through your Primary Care manager first, TRICARE Standard and Extra allow you more flexibility in whom you see for care. This TRICARE option may be desirable if you prefer the freedom to manage your own health care or if you have other health insurance.
TRICARE Standard is an option for all beneficiaries except active duty service members, who must be enrolled in TRICARE Prime. There is no enrollment fee in Standard or Extra. You may choose to receive your care from any TRICARE authorized hospital, clinic, and health care provider, but will have to pay a portion of the charge each time you receive care. If you see a TRICARE network provider, you'll be using the TRICARE Extra option and will pay less than if you see a non-network provider. Your local TRICARE Service Center or TRICARE contractor can help you in finding a civilian provider in the network.
While you are still eligible to use military hospitals and clinics, you may do so only on a space available basis, at a lower priority level than if you were enrolled in TRICARE Prime. For additional information, go to http://www.tricare.mil/mybenefit/home/overview/Plans and click "TRICARE Standard and Extra" on the left menu.
TRICARE Reserve Select
TRICARE Reserve Select (TRS) is a fee-for-service type of health care program, similar to TRICARE Standard and Extra. To be eligible for this program, the service member needs to be a member of the Selected Reserve – a drilling National Guardsman or Reservist. TRS requires a monthly premium and offers service member and family coverage if the service member enrolls. You are expected to receive your health care from TRICARE-authorized civilian clinics, hospitals, and providers. You are still eligible to receive care in military clinics and hospitals, but only on a space available basis. For more information, go to http://www.tricare.mil/mybenefit/home/overview/Plans and click on "TRICARE Reserve Select" on the left menu.
TRICARE for Life (TFL) is a "wraparound" type of health care program for TRICARE beneficiaries who are eligible for Medicare Part A and have purchased Medicare Part B coverage (active duty family members are not required to have Part B). With TFL, TRICARE usually becomes the secondary payer to Medicare, in most cases covering all costs above what Medicare would pay. You do not have to file separate claims with Medicare and TRICARE for Life. Medicare will pay the claim submitted by your doctor and then automatically forward the claim to TRICARE which will pay the remainder.
You do not enroll in TFL, but become eligible for it automatically when you become covered by Medicare. Age is NOT a fact in determining eligibility for this TRICARE program. You qualify for TFL based on disability through Social Security Administration or by reaching the age of 65. Medicare is a separate program from TRICARE and is overseen by the Centers of Medicare and Medicaid Services. TRICARE is managed by the Department of Defense. You can receive health care from any health care provider, who is authorized to treat Medicare patients.
While TFL will cover most costs above what Medicare would pay, there are some exceptions. For example, some services may be covered by TRICARE that are not covered by Medicare. Then TRICARE becomes the primary payer and pays as it would if you were under TRICARE Standard. Some services are covered by Medicare but not by TRICARE. Then TRICARE would not cover any of the remaining costs. For additional information, go to http://www.tricare.mil/mybenefit/home/overview/Plans and click on "TRICARE For Life" on the left menu or contact Wisconsin Physician Services (WPS), the contractor that handles TFL claims at 1.866.773.0404 or www.tricare4u.com.
US Family Health Plan
The US Family Health Plan (USFHP) is a "managed care" type of health care program, similar to TRICARE Prime. It is open to active duty service members, active duty family members, retirees and their family members, and survivors. Unlike TRICARE Prime, it is even open to Medicare-eligible TRICARE beneficiaries. The USFHP provides its enrollees with health care services through a network of community-based hospitals, clinics, and providers. Choosing the USFHP as your TRICARE option requires you to agree not to access care through a military hospital or clinic. This program may work for you if you live in the areas in which this program is offered. For additional information, go to: http://www.usfhp.com.
There are several TRICARE options when stationed or living overseas. For additional information, go to: http://www.tricare.mil/mybenefit/home/overview/Regions/RegionsNonUS.
Most active duty service members and their families are enrolled in TRICARE Prime overseas and obtain their care through military hospitals and clinics and a network of doctors from the host country. Retirees and their families living overseas usually rely on TRICARE Standard.
TRICARE Global Remote Overseas is a "managed care" type of health care program similar to TRICARE Prime, offered to active duty service members and their family members, who are assigned to designated duty stations in remote overseas locations with no available military hospitals or clinics.
TRICARE Standard Overseas gives you more choices for providers, but costs you more in out-of-pocket costs. You will also be using host nation providers and not military hospitals and clinics.
TRICARE for Life (TFL) overseas runs differently than stateside because Medicare cannot be used overseas. TRICARE becomes the primary source of health care services and works like TRICARE Standard Overseas, a "fee-for-service" type health care program. You may receive health care services from any host nation provider.
Medicare is available in U.S. territories, which will make TFL become a secondary payer as in the U.S. You must receive health care services from a Medicare-authorized provider for the care to be covered by TFL. For additional information, go to: www.tricare4u.com.
TRICARE Dental Insurance Programs
TRICARE also offers a variety of dental insurance programs for eligible beneficiaries. The coverage is fairly robust, contains some cost-shares depending on the type of dental care received, and has a monthly premium for family members, retirees, and non-activated National Guard and Reserve members and their families. The dental program premiums are based on your beneficiary category and, in some cases, where you live. The TRICARE dental care programs are:
- TRICARE Active Duty Dental Program—for active duty service members, including activated National Guard and Reserve members
- TRICARE Dental Program (TDP)—for active duty family members, non-activated National Guard and Reserve members and their families
- TRICARE Retiree Dental Program (TRDP)—for military retirees and their family members
For more information on your dental coverage options, go to: http://tricare.mil/mybenefit/ProfileFilter.do?puri=%2Fhome%2FDental.
TRICARE Pharmacy Program
The TRICARE Pharmacy program provides eligible beneficiaries the ability to get prescriptions drugs as part of their robust TRICARE benefit. There are several ways in which you can get your prescriptions filled. You can use:
- the pharmacy at a military hospital or clinic;
- the TRICARE mail order pharmacy (TMOP);
- a network retail pharmacy; or
- a non-network retail pharmacy.
Each option has its pluses and minuses depending on your circumstances. Your out-of-pocket cost will depend on where you pick up your medicine. The cheapest option will be your military hospital or clinic, where you pay no co-payment or fee. Not all military pharmacies carry the full range of prescription medicines. If you receive care from a civilian provider, you may find your closest military pharmacy, especially if it serves a small clinic, does not carry the drug your doctor prescribed.
If you cannot obtain your medications through a military pharmacy, consider having your medication delivered directly to your home through TMOP. You can obtain a 90-day supply of your medication for the same co-payment as a 30-day supply through your civilian network retail pharmacy. TMOP is a great benefit, especially for medications you take on a daily basis for chronic conditions.
When you need a medication immediately, look for a retail network pharmacy. To find a network pharmacy, go to: http://member.express-scripts.com/web/pharmacyLocator/openPharmacyLocator.do?portal=dodCustom&net=1991.
For more information on each TRICARE pharmacy option, go to: http://www.tricare.mil/mybenefit/home/Prescriptions/FillingPrescriptions.
Enrolled in the US Family Health Plan?
If you are enrolled at one of the US Family Health Benefit Plan (USFHP) facilities, you are NOT covered by the TRICARE pharmacy program and may not obtain medications at military pharmacies or use the TRICARE Mail Order Pharmacy. Each USFHP facility has its own on-site, mail order, or retail network that you must use. For additional information, go to: http://www.usfhp.com.