TRICARE

Department of the Navy
Bureau of Medicine and Surgery

TRICARE is the Department of Defense's regionally managed health care program. Beneficiaries include the following:

• Active duty members and their family members.

• Retirees and their family members.

• Survivors of all uniformed service members who are not eligible for Medicare.

TRICARE is designed to expand access to care, ensure high quality care, control health care costs for patients and taxpayers alike, and improve medical readiness. TRICARE offers families three choices:

• Enrollment in TRICARE Prime, a health maintenance organization (HMO) option which has very low costs.

• TRICARE Extra, a preferred provider organization option that offers reduced cost sharing and doesn't require enrollment.

• TRICARE Standard, a fee for service option (formerly known as CHAMPUS), that doesn’t require enrollment and is the most costly of the TRICARE choices.

Brief Description of each option.

TRICARE Prime

This is a voluntary enrollment option that's much like a civilian health maintenance organization (HMO). If you live in an area where TRICARE Prime is offered, you'll normally receive your care from within the Prime network of civilian and military providers. Active duty service members will be enrolled in Prime, and will choose, or be assigned to, a primary care manager. Their families, and all others, who are eligible, must enroll in TRICARE Prime.

Active duty family members don’t have to pay an annual enrollment fee. All others will, but there'll be no annual deductibles, and the patient's share of the costs for services under Prime will be reduced. You won't have to file claims when using TRICARE Prime network providers.

You'll choose, or will be assigned, a "primary care manager" (PCM), from whom you'll get most of your routine health care. Your PCM will manage all aspects of your care, including referrals to specialists, with the help of the local Health Care Finder (HCF). Remember your PCM and HCF must arrange for a referral when required, before you get specialized care.

As a TRICARE Prime enrollee, you also have what's called a "point-of-service" (POS) option. This means that you can choose to get non-emergency services without a referral from your primary care physician. However, if you decide to get care under the POS option, there's an annual deductible of $300 for an individual or $600 for a family. After the deductible is satisfied, your cost-share for POS care will be 50 percent of the TRICARE allowable charge. You may also have to pay any additional charges by non-network providers, up to 15 percent above the allowable charge. You may even be required to pay the entire bill when you receive the services, file the claim, and then wait for reimbursement of the Government's share of the costs.

TRICARE Standard

This option is formerly known as CHAMPUS. The name change doesn't change the benefits or how you use them. TRICARE Standard pays a share of the cost of covered health services that you obtain from a non-network civilian health care provider. There's no enrollment in TRICARE Standard. You will have to meet the normal annual outpatient deductible ($50 for one person or $100 for a family, for active duty pay grades E-4 and below; or $150 for one person, and $300 for a family, for all other eligible persons). Under this option, you have the most freedom to choose your provider of care, but your costs will be higher than with the other two TRICARE options. Also, you may have to file your own claim forms and perhaps pay a little more for the care (up to 15 percent more than the allowable charge), if the provider you choose isn’t a participating TRICARE provider. If the provider does participate, he or she agrees to accept the TRICARE maximum allowable charge as the full fee for the care you receive.

To use TRICARE Standard, just pick a physician or other provider of care. Ask the provider if he or she is an authorized CHAMPUS or TRICARE provider. Of course, you can still use your nearby military hospital or clinic, if they have the capacity to provide services for you, or use a TRICARE Extra provider for a lower cost share.

TRICARE Extra

Under this option, you don't have to enroll, or pay an annual fee. You can seek care from a provider who's part of the TRICARE network. You will get a discount on services, and pay reduced cost-shares (five percent below those of TRICARE Standard) in most cases. You won't have to file any claims when using network providers. However, you will have to meet the normal annual outpatient deductible ($50 for one person or $100 for a family, for active duty pay grades E-4 and below; or $150 for one person, and $300 for a family, for all other eligible persons), as you would under TRICARE Standard. Call your region’s local Health Care Finder for help in locating a provider who's part of the TRICARE Extra network. You can also visit your nearest military treatment facility or TRICARE Service Center. You can still use a military medical facility when space is available, or use TRICARE Standard if your provider is not a member of the TRICARE Extra Network.

No matter which of the three TRICARE options you decide to use, be sure you understand the rules under which they operate. Get copies of any brochures, fact sheets or handbooks that pertain to the option you select. If you have questions about your military health care benefits under TRICARE, there are many places to get answers. Ask your nearest medical facility to help you locate a Health Benefits Advisor, Managed Care Office or TRICARE Service Center. This should be your first contact for information. You can also obtain TRICARE information from their website http://www.tricare.osd.mil .