TRICARE Prime

In this option, most health care will
come from a military treatment facility (MTF), augmented by
the TRICARE contractor?s Preferred Provider Network (PPN).
All active duty personnel are enrolled in TRICARE Prime. Find
out the benefits here.

Note: All active duty servicemembers are automatically
enrolled in TRICARE Prime and receive most of their care from
military medical personnel. For active duty families, there
is no enrollment fee for TRICARE Prime, however they
must complete an enrollment form to select Prime as their
coverage plan.

With TRICARE Prime, most health care will come from a military
treatment facility (MTF), along with the TRICARE contracted
Civilian Medical Providers called Preferred Provider Network
(PPN).

Primary Care Manager

Your Primary Care Manager (or team of providers) will see
you first for your health care needs. The Primary Care Manager:

• Provides and/or coordinates your care
• Maintains your health records
• Refers you to specialists, if necessary (To be covered,
  specialty care must be arranged and approved by your Primary
  Care Manager)

Care is usually provided in a military treatment facility,
but civilian clinics may be used in some cases.

Point of Service (POS) Option

The POS Option under TRICARE Prime allows enrollees the freedom
to seek and receive non-emergency health care services from
any TRICARE authorized civilian provider, in or out of the
TRICARE network, without requesting a referral from their
Primary Care Manager (PCM) or the Health Care Finder (HCF).
When Prime enrollees choose to use the POS option, all requirements
applicable to TRICARE
Standard apply except the requirement for a Nonavailability
Statement (NAS).

However POS claims are subject to outpatient deductibles ($300
individual and $600 family), 50% cost-shares for outpatient
and inpatient claims, and excess charges up 15% over the allowed
amount. The 50% cost-share continues to be applied even after
the Enrollment Year catastrophic cap has been met.

TRICARE Prime – Advantages

• No enrollment fee for active
  duty and families
• Small fee per visit to civilian
  providers, and no fee for active duty members

• No balance billing
• Guaranteed appointments (access
  standards)

• Primary care manager supervises
  and coordinates care

• Away-from-home emergency coverage
• Point-of-Service option
• Reduced catastrophic cap for
  retirees ($7,500 now decreased to $3,000)

TRICARE Prime – Disadvantages

• Enrollment fee for retirees and
  their families

• Provider choice limited
• Specialty care by referral only
• Not universally available

TRICARE Cost Comparison at a Glance

The following tables provide examples of cost-shares or copayments
for families who use civilian providers and facilities under
each of the three TRICARE options. The listed fees are subject
to change.

Active Duty Family Members

Retirees (under 65), Their Family
Members, and Others

Summary — Tricare Prime
Guaranteed access to timely medical care

• Priority for care at military hospitals and clinics
• Primary Care Manager provides and guides health care delivery
• Lowest cost for treatment among three options
• Requires enrollment for one year
• Retirees pay enrollment fee
• Very expensive to receive care outside Tricare Prime (Point-of-Service
  Option)

• Not available everywhere

Additional Resources:

• Sponsors should ensure their family members have up-to-date
  uniformed services identification cards, and that they are
  properly enrolled in the Defense Enrollment Eligibility
  Reporting System (DEERS).*

• Beneficiaries may find that the closest MTF is outside
  their area. In that case they will be enrolled in TRICARE
  Prime Remote.

• Beneficiaries may be required to file their own claims
  when using TRICARE
  Standard. Beneficiaries may find more information about
  filing claims and download claims forms on the TRICARE Web
  site at www.tricare.osd.mil/claims/default.htm.

• Although TRICARE Standard beneficiaries have a lower priority
  for access to care in MTFs than TRICARE Prime enrollees,
  Standard beneficiaries may attempt to receive their care
  from an MTF. This will save money and paperwork.

*See also:
TRICARE
Regional Managed Care Support Contractor Fact Sheet
Defense Enrollment Eligibility and Reporting System Fact Sheet.

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