TRICARE
Your Military Health Plan
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Overview of TRICARE Benefits
for National Guard, Reserve
Component Members and their
families
TRICARE Regions
West Region
TriWest Healthcare Alliance
1-888-TRIWEST
www.triwest.com
North Region
Health Net Federal Services, Inc.
1-877-TRICARE
www.healthnetfederalservices.com
South Region
Humana Military Healthcare Services, Inc.
1-877-249-9179 (TPR/SHCP)
1-800-444-5445 (general)
www.humana-military.com
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Take Action to Ensure Eligibility!
DEERS Registration is Required
• Visit an ID card-issuing facility
– Find one near you at www.dmdc.osd.mil/rsl
• Call 1-800-538-9552
• Mail proof of Medicare-eligibility to:
Defense Manpower Data Center Support Office
Attn: COA
400 Gigling Road
Seaside, CA 93955-6771
Registration in DEERS is
key to TRICARE eligibility
Who is eligible for TRICARE?
• Active duty service members (ADSMs) and retirees of
any of the seven uniformed services
• NG and Reserve Component members on active duty
for more than 30 consecutive days (under Federal
orders), from any of the seven uniformed services
• Spouses of active duty, retired, and eligible NG/
Reserve Component service members
• Unmarried children (including stepchildren) up to age
21 (or 23 if full-time student)
• Past age 21—Mental/Physical incapacity
(Unmarried children remain eligible even if parents divorce or remarry)
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•
Service Member Coverage Varies…
• When on military duty for 30 days or less
– Line of duty coverage
– TRICARE Dental Program
– TRICARE Reserve Select
• When called or ordered to active duty for more than 30
consecutive days
– Active duty health and dental benefits, including pharmacy
– Automatic termination from TRICARE Reserve Select
– Transitional health coverage, including pharmacy
– TRICARE Dental Program
– TRICARE Reserve Select
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• After leaving active service, or demobilizing
Service Member on Military Duty
30 Days or Less
• Health: Line of Duty (LOD) Health Care
– Any injury, illness, or disease incurred or
aggravated in the line of duty
• Includes emergency care
– Covered portal to portal
– Coordinate LOD health care through unit
commander or designated medical
representative
• Dental: TRICARE Dental Program (TDP)
Family members are not eligible for
health coverage when you are on
military duty for 30 days or less
Service Member Activated
More than 30 Days
• Health: TRICARE / Military Treatment Facility
– TRICARE Prime/TRICARE Prime Remote
– TRICARE Overseas Prime/TRICARE Global
Remote Overseas
– Pharmacy coverage
• Dental: Active Duty Dental Coverage
– Military dental treatment facilities
– Tri-Service Remote Dental Program
If activated in support of a
contingency operation, you may also
qualify for pre-activation coverage
Health Care Options for Family Members when
Sponsor is Activated
•
•
•
•
TRICARE Standard and TRICARE Extra (Automatic)
TRICARE pharmacy benefit (Automatic)
TRICARE Prime (Requires enrollment)
TRICARE Prime Remote for Active Duty Family
Members (TPRADFM) (Requires enrollment)
Contact your TAO for information about
health care options if you accompany your
sponsor overseas when they are activated
TRICARE Standard
• Enrollment not required - Automatic
• Care from non-network TRICAREauthorized providers
– Provider may charge up to 15% above
TRICARE allowable charge
– May have to submit your own health care
claims
• Referrals not required for specialty care
– Some services may require prior authorization
• MTF care on a space-available basis only
TRICARE Extra
• Enrollment not required - Automatic
• Care from TRICARE network providers
– Providers agree to accept negotiated rate as
TRICARE allowable charge
– Lower cost-shares than TRICARE Standard
– No claims to file (in most cases)
• Referrals not required for specialty care
– Some services may require prior authorization
• MTF care on a space-available basis only
TRICARE Standard and Extra Costs
TRICARE Option
TRICARE Standard
Deductible
Sponsor rank E1-E4:
(Using non-network/Standard providers)
Amount due each fiscal year
before cost-sharing begins.
$50/single or $100/family
TRICARE Extra
(Using Network/Prime providers)
Same
Sponsor rank E5 & above:
$150/single or $300/family
Outpatient Cost-share
Inpatient Costs
Inpatient Behavioral
Health Care
Catastrophic Cap
20%*
$15.15/day ($25 minimum)
$20/day ($25 minimum)
15%
Same
Same
$1,000 per family per fiscal year
The federal fiscal year is Oct. 1- Sept. 30.
* Non-network providers may charge up to 15% above the TRICARE allowable charge.
Get extra cost-savings with TRICARE Extra!
TRICARE Prime Service Area (PSA)
• Area defined as an approximate 40-mile
radius around an MTF (actual radius can
vary by military installation)
• TRICARE-eligible beneficiaries living within
the Prime service area are eligible for
Prime
• Beneficiaries living outside the Prime
service area may be eligible for TRICARE
Prime Remote for Active Duty Family
Members (TPRADFM)
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Enrolling in TRICARE Prime
• Prime must be available in your area
• Active duty and family members—no
enrollment fee
• Enroll by 20th of month—effective 1st of the
next month
• If you enroll after the 20th of the month,
your enrollment will begin on the 1st day of
the 2nd month after that
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Eligibility for TRICARE Prime Remote / TPRADFM
• National Guard or Reserve sponsor
– Activated more than 30 consecutive days
– Live and work more than 50 miles (or an hour’s
drive time) from an MTF
– Sponsor’s residence address must be in DEERS
– Family must reside with sponsor in a designated
TPR ZIP code at time of activation
To see if you qualify, check your ZIP
code at www.tricare.mil/tpr.
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TPR/TPRADFM
• TRICARE Prime option for active duty
families in remote locations
– Available in designated TPR ZIP code areas
• Enrollment required
• TRICARE-authorized providers
– Network providers when available
– Same rules as TRICARE Prime for getting care
• No claims to file (in most cases)
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Enrolling in TRICARE Prime/TPRADFM
• Submit completed enrollment application to
your regional contractor
– If received by 20th of month, coverage begins
1st of next month
– If received after 20th of month, coverage begins
1st of following month
• Select a PCM
– From military treatment facility (MTF) or TRICARE
network
– For TPRADFM, select any TRICARE-authorized
provider if a network PCM is not available
Primary Care Manager
• Any TRICARE-authorized provider
– Network provider, if available
– Non-network, if network provider not available
• Provides most care—routine, urgent, and
some clinical preventive services
• Provides referrals for necessary specialty
care
– Coordinates referral request
– Obtains necessary prior authorization
Contact your regional contractor for
assistance finding a PCM.
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TRICARE Prime/TPRADFM Costs
(TRICARE Prime Remote Active Duty Family Member)
Enrollment Fees
$0
Deductible*
$0
Outpatient Costs* $0
Inpatient Costs*
$0
Emergency Care
$0
Catastrophic Cap
$1,000 per family per fiscal year
The federal fiscal year is Oct. 1- Sept. 30.
*You’ll pay higher out-of-pocket costs if
you use the point of service option (POS).
Emergency Care
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• Call 911
• Visit nearest emergency room
• Notify your PCM or Regional Contractor
within 24 hours of any emergency admission
so that your follow-up care can be
coordinated (if enrolled in TRICARE Prime)
• A family member can call on your behalf
Urgent Care
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• Medically necessary treatment that is
required for illness or injury
• TRICARE Prime beneficiary must coordinate
urgent care with PCM or Regional Contractor
before receiving care
• A TRICARE Prime beneficiary who seeks
urgent care services without coordinating
with his or her PCM will be utilizing the
TRICARE Point-of-Service (POS) option
Nonemergency Health Care
While Traveling
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• All routine medical care should be taken care
of before you depart or delayed until you
return and can see your PCM
• For out-of-area urgent/acute care, you must
coordinate with your PCM or Regional
Contractor for an authorization before
seeking care if enrolled in TRICARE Prime
• For out-of-area emergency care, call 911 or
go to the nearest emergency room (civilian
or military)
Point of Service Option
• Seek nonemergency/specialty care without
a referral or prior authorization
• Higher out-of-pocket costs
– Annual Deductible: $300/individual or
$600/family
– Cost-Shares: 50% after POS deductible is met
• POS fees not reimbursed by TRICARE
• POS fees do not apply to the annual
catastrophic cap
Avoid POS fees!
Follow TRICARE Prime/
TPRADFM referral and
authorization guidelines
TRICARE and Other Health Insurance
• TRICARE pays after all other health insurance plans
except for:
–
–
–
–
Medicaid
TRICARE supplements
The Indian Health Service
Other programs/plans as identified by TMA
• Not required to obtain TRICARE referrals or prior
authorization for covered services, except for
adjunctive dental care and behavioral health care
services
• However, you must follow the OHI referral and
authorization requirements if applicable
• TRICARE is NOT a supplement to other insurance.
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TRICARE Pharmacy Coverage
Generic
Brand Name Non-Formulary
MTF
$0
$0
TMOP
$3
$9
$22
Network Retail
$3
$9
$22
(up to a 90-day supply)
(up to a 90-day supply)
(up to a 30-day supply)
Non-network
Retail Pharmacy
(up to a 30-day supply)
$0*
†Non-TRICARE
†Non-TRICARE
†Non-TRICARE
†TRICARE
†TRICARE
†TRICARE
Prime: $9 or 20%
Prime:
50% cost-share
Prime: $9 or 20%
Prime:
50% cost-share
Prime: $22 or 20%
Prime:
50% cost-share
*Not available in the MTF unless medical necessity is established.
†Deductibles apply.
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Type
of Pharmacy
TRICARE Dental Options
Military dental treatment
facilities
Contact your local military dental
treatment facility.
Tri-Service Remote Dental
Program
Military Medical Support Office
http://mmso.med.navy.mil
TRICARE
Dental
Program
• Active duty family
members
• National Guard and
Reserve members (not
activated) and family
members
United Concordia Companies,
Inc.
1-800-866-8499
www.TRICAREdentalprogram.co
m
TRICARE
Retiree
Dental
Program
• Retired service members
and family members
• Medal of Honor
recipients and family
members
Delta Dental Plan of California
1-888-838-8737
www.trdp.org
Active Duty
Dental
Options
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Questions?
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