arrangements for specialized care. This option effectively places you in a health care network with no annual deductibles. You are responsible for any excess costs. TRICARE Prime offers a Point of Service (POS) option which allows enrollees to receive non-emergency health care services from any TRICARE authorized provider in or out- of-network without requesting a referral from their PCM or Health Care Finder. POS does not apply to active duty service members. POS claims are subject to outpatient deductibles ($300 per person and $600 per family) and 50% cost-shares of the allowable TRICARE charge for patient claims. The 50% cost share continues to be applied even after the catastrophic cap has been met. Depending on your situation, you may also enroll in TRICARE Prime Remote (TPR) if both your home and work addresses are more than 50 miles (or one hour’s drive time) from a military hospital or clinic; TRICARE Prime Overseas; or TRICARE Prime Remote Overseas. TRICARE Select. This program is available to the same population as Prime except for those on active duty and activated Guard/Reserve. Select allows you to manage your own health care and gives you the freedom to seek care from any TRICARE-authorized provider you choose. Enrollment fees are only applicable for beneficiaries whose sponsor’s initial enlistment or appointment occurs on or after January 1, 2018. Additionally, participants in the Select program will have an annual deductible for outpatient services and cost- shares for most services. A deductible is the total amount you pay each year before TRICARE pays anything. A cost- share is the percentage or portion of costs that you pay for inpatient or outpatient care once your deductible is met. Which Plan Is Right For You? If you are an active duty service member or an activated Guard or Reserve member, you must enroll in TRICARE Prime. All other eligible beneficiaries have the option to enroll in either the Prime or Select options. TRICARE Prime offers fewer out-of-pocket costs than TRICARE Select but less freedom of choice for providers since you must select a provider from the network. The Prime option places you into an HMO network. Therefore, it allows you to more accurately predict your health care costs, which is a real advantage if your family situation requires frequent use of health care facilities. Also the system reduces paperwork and is prepared to support your requirements on a 24–hour, seven days a week basis.
On the other hand, if you have other health care insurance that serves as your primary coverage, Prime may not be your best choice because Prime will only pay after your other insurance has made its payment for your civilian care. Retirees and their dependents who are enrolled in Prime pay enrollment fees and may transfer their Prime enrollment from one region to another without paying additional enrollment fees. However, the annual fee is nonrefundable. Consequently, retirees who are relocating to a new area should consider quarterly payments if the relocation will be to an area that does not provide TRICARE Prime. Also, since Prime is a managed–care, regionally administered program, it may not be the best option for retirees who travel frequently. However, it should be noted that Prime will pay for emergency services provided outside of the retiree’s normal TRICARE service area. If you are concerned about selecting your own physician, you may not want to be restricted to using only those providers who are members of the Prime network — in this case, the Prime POS or TRICARE Select option may be a better choice. Enrollment. You must enroll in one of the TRICARE programs to participate. TRICARE Open Season is the annual period when you can enroll in or change your health care coverage for the next year. The next TRICARE Open Season will be in Fall 2022. Open season applies to anyone enrolled in or eligible for a TRICARE Prime option or TRICARE Select. During Open Season you can choose to a) keep your plan; b) enroll in TRICARE, or; c) change your plan. Outside of TRICARE Open Season, you can enroll in or change enrollment to TRICARE Prime or TRICARE Select following a Qualifying Life Event (QLE). A QLE is a certain change in your life, such as marriage, birth of a child, or retirement from active duty. What is Covered? The TRICARE program is designed to provide both inpatient and outpatient support for health care that is considered medically necessary and non– experimental. However, there are a number of special rules and limits, so if you have any doubt concerning specific coverage, it is best to contact your Health Benefits Advisor at the nearest Military Treatment Facility or your TRICARE contractor (see “TRICARE Regions and Contacts”). You can also go to www.tricare.mil to get a list of what is covered. What is Not Covered? In general, TRICARE excludes services and supplies that are not medically or psychologically necessary for the diagnosis or treatment of a covered illness (including mental disorder), injury, or for the diagnosis and
CHAPTER 3: TRICARE
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