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Updated June 11, 2003
TRICARE: The Basics
TRICARE is the Department of Defense’s
worldwide health care program for active duty and retired uniformed services members and their families. TRICARE
consists of TRICARE Prime, a managed care option; TRICARE Extra, a preferred provider option; and TRICARE Standard, a
fee-for-service option. TRICARE For Life is also available for Medicare-eligible beneficiaries age 65 and over
(effective Oct. 1, 2001).*
TRICARE Prime
TRICARE Prime is a managed care option
similar to a civilian health maintenance organization (HMO). This option requires enrollment. Active duty
service members are required to enroll in Prime. Active duty family members, retirees and their family members are
encouraged, but not required, to enroll in Prime. However, to receive the TRICARE Prime benefit, they must reside
where TRICARE Prime is offered. Ask your local TRICARE service center (TSC) about the TRICARE Prime availability in
your area. If you are stationed in a remote area, TPR/TRICARE Prime Remote for Active Duty Family Members (TPRADFM)
may be the option available to you and your family members.* This option also requires enrollment. If
enrollment for TRICARE Prime and TPR/TPRADFM is received by the 20th of the month, it is effective the first day of the
next month. For instance, if an enrollment is received by March 20, coverage will begin April 1. If a family
enrolls March 25, they will be covered under the TRICARE Prime benefit starting May 1. If an individual
disenrolls from TRICARE Prime, he or she is locked out for 12 months.
TRICARE Prime
offers less out-of-pocket costs than any other TRICARE option. Active duty members and their families do not
pay enrollment fees, annual deductibles or co-payments for care in the TRICARE network. Retired service members pay
an annual enrollment fee of $230 for an individual or $460 for a family, and minimal co-pays apply for care in the TRICARE
network. TRICARE Prime offers a “point-of-service” option for care received outside of the TRICARE Prime network,
but point-of-service care requires payment of significant out of pocket costs.*
TRICARE Prime enrollees receive most of their
care from military providers or from civilian providers who belong to the TRICARE Prime network. Enrollees are
assigned a primary care manager (PCM) who manages their care and provides referrals for specialty care. All
referrals for specialty care must be arranged by the PCM to avoid point-of-service* charges.
TRICARE Prime
enrollees are guaranteed certain access standards for care. The chart below describes the access standards for Prime
enrollees.
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Urgent
Care
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Routine
Care
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Referred/Specialty
Care
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Wellness/ Preventive
Care
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Appointment wait
time
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Not to exceed 24
hours
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Not to exceed seven
days
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Not to
exceed
four weeks
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Not to
exceed
four weeks
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Drive
time
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Within 30 minutes from
home
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Within 60 minutes from
home
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Wait time in
office
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Not to exceed 30 minutes for
nonemergency situations.
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TRICARE Extra
& TRICARE Standard
TRICARE Extra and TRICARE Standard are
available for all TRICARE-eligible beneficiaries who elect or are not able to enroll in TRICARE Prime. Active duty
service members are not eligible for Extra or Standard. There is no enrollment required for TRICARE Extra or
Standard—no annual enrollment fees, no enrollment forms. Beneficiaries are responsible for annual deductibles and
cost-shares. Beneficiaries may see any TRICARE authorized provider they choose, and the government will share the
cost with the beneficiaries after deductibles.
TRICARE Extra is a preferred provider option (PPO) in which beneficiaries choose a doctor,
hospital, or other medical provider within the TRICARE provider network. Network providers can be located by calling
your local TRICARE service center or visiting our Web page.
TRICARE Standard is a fee-for-service option. You can see an authorized TRICARE
provider of your choice. Having this flexibility means that care generally costs more. See the chart below for
the differences between Extra and Standard.
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TRICARE
Extra
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TRICARE
Standard
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Physician/Provider
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In network
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Not in network, but still an
authorized provider
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Cost share after
deductibles
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15% active duty
families
20% retirees
and their families
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20%
active duty families; non-participating providers may also “balance bill” up to 15% above the TRICARE
allowable charge
25%
retirees and their families; non-participating providers may also “balance bill” up to 15% above
the TRICARE allowable charge
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TRICARE For
Life and TRICARE Plus
When beneficiaries age
65 and over become eligible for Medicare Part A, they can use TRICARE For Life (TFL)* if they purchase Medicare Part
B. These beneficiaries are not eligible for TRICARE Prime but are eligible to use Medicare, network and non-network
providers. Under TFL, TRICARE acts as a second payer to Medicare for benefits payable by both Medicare and TRICARE.
Beneficiaries can use an authorized Medicare provider and claims will be automatically sent to TRICARE after Medicare pays
its portion. There are no enrollment fees for TFL—beneficiaries are only required to pay the Medicare Part B
premium. TRICARE is first payer for TRICARE benefits not covered by Medicare, such as pharmacy, which is available
only under TRICARE.
Some military treatment
facilities will have capacity to offer a primary care affiliation program called TRICARE Plus.* Enrolled beneficiaries
have priority access to care at military treatment facilities; however, beneficiaries who choose to use TRICARE Extra,
TRICARE Standard or TRICARE For Life may also continue to receive care in a military treatment facility on a
space-available basis.
FAQs: http://tricare.osd.mil/faqs/
Contact: http://www.tricare.osd.mil/contactus/
Handbook: http://tricare.osd.mil/TricareHandbook/
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