TRICARE Prime

TRICARE health insurance options are available to service members, their spouses, and dependents. There are a variety of health insurance plans under TRICARE to choose from depending on the status of the current duty station, and the best options for dependents:

• TRICARE Prime
• TRICARE Prime Remote
• TRICARE Prime Overseas
• TRICARE Prime Remote Overseas
• TRICARE Select
• TRICARE Select Overseas
• TRICARE For Life
• TRICARE Reserve Select
• TRICARE Retired Reserve
• TRICARE Young Adult
• US Family Health Plan

Family members of active-duty personnel have the option of signing up for Prime or TRICARE Select. TRICARE recommends family members use TRICARE Prime because it has fewer out-of-pocket costs than TRICARE Select, but less freedom of choice for selecting care providers.

Eligibility For TRICARE Health Care Plans

All active-duty personnel must register for TRICARE Prime. Those eligible include:

• Members of the “uniformed services” and their family members
• Army National Guard
• Army Reserve
• Navy Reserve
• Marine Corps Reserve
• Air National Guard
• Air Force Reserve
• S. Coast Guard Reserve
• Survivors
• Former spouses
• Medal of Honor recipients and families
• Those registered in the Defense Enrollment Eligibility Reporting System (DEERS)

There are different versions of Prime offered depending on where the military member is stationed:

• TRICARE Prime– When seeking care under TRICARE Prime, you may be referred to either a military facility or an in-network caregiver. Those who use a military clinic or hospital as the primary care source may have the option to book appointments online.
• TRICARE Prime Remote– Military members may not always have a Primary Care Manager depending on availability in remote assignment locations. Those who do not have a PCM can use any TRICARE-authorized caregiver.
• TRICARE Prime Overseas– Military members will have an assigned PCM at the nearest military hospital/clinic/etc. Those who need a referral or an appointment with a non-military facility at an overseas location will need to contact the TRICARE Overseas office for assistance.
• TRICARE Prime Remote Overseas– Those who need care under TRICARE Remote Prime Overseas, contact the appropriate Regional Call Center to schedule appointments.

Signing Up For TRICARE

Sign-up procedures and requirements vary depending on the duty location (stateside, remote assignments, overseas assignments).

For general registration, begin the process online. Keep in mind, you will be required to call your nearest regional office and mail paperwork to either the East or West Region (some paperwork is region-specific) office.

TRICARE Primary Care Managers

Each TRICARE Prime account is assigned a Primary Care Manager (PCM) who may be a military medical care or in-network provider. These care managers offer referrals to specialists as needed, work with a regional contractor for referral authorizations and accept co-payment.

You do have the option of changing PCMs if needed. TRICARE advises beneficiaries to search their region’s directory to find a new PCM. To change PCMS, call your Regional Contractor or simply log in to the official site to change PCM preferences online.

Rules for TRICARE Prime Members

The rules of TRICARE Prime vary depending on whether you are an active duty service member or a family member.

TRICARE Prime Rules For Active-Duty Service Members

Active-duty personnel are required to obtain a referral from the primary care manager (PCM) for any type of medical care or options not offered by the PCM, including urgent care and specialty care.

The PCM works with the appropriate regional contractor to get insurance authorization for the referral services. In these cases, an attempt will be made to refer the service member to a military-operated facility first, or an authorized network provider in cases where military-provided care is not an option. Military members who choose to get care without consulting the PCM may be held responsible for the costs of that care.

TRICARE Prime Rules For Family Members

Families have slightly different rules. The PCM is still required to provide a referral for most services that are not offered by the Primary Care Manager. When a military care facility is not available, an in-network referral is the next step.

Family members who want to see a specialist without a PCM referral can opt for a “Point Of Service,” which allows military family members to visit any TRICARE-authorized provider but requires extra out-of-pocket costs.

The point-of-service option is not available to active-duty military members, those who are enrolled in a non-TRICARE Prime health plan or have a referral. The Point-of-Service option is also unavailable to those who have a newborn or who have adopted a child unless the child is enrolled in Prime.

Using Point-of-Service care means paying associated fees and any other fees charged by non-network care providers. These fees are charged instead of the usual TRICARE copay. Outpatient fees and hospitalization fees in these cases may be up to 50% of the charge allowed by TRICARE.

TRICARE Network Care Versus Non-Network Care

TRICARE recommends beneficiaries seek in-network care wherever possible. When that is not possible, patients covered under PRIME should keep the following in mind:

• In-network providers cannot ask you to sign paperwork “to make you pay for authorized services”
• In-network providers cannot ask patients to sign a document “to make you pay for any part of the service not covered by TRICARE”
• In-network care providers cannot refuse to treat a patient because they will not sign the type of documents listed above

TRICARE Prime Coverage and Exclusions

TRICARE Prime is billed as a comprehensive health care insurance plan covering “services that are medically necessary,” defined by TRICARE regulations as a service that is “appropriate, reasonable, and adequate for your condition, and considered proven.”

Depending on the type of medical service or care required, there may be rules or limits on certain options and others may be excluded.

What TRICARE Won’t Cover

The TRICARE official site has a list of options, services, and care excluded from reimbursement or insurance coverage:

• Acupuncture
• Alterations to Living Space
• Alternative Treatments
• Assisted Living Facility Care
• Augmentation Mammoplasty
• Autopsy Services
• Aversion Therapy
• Blood Pressure Monitoring Devices
• Camps
• Charges for Missed Appointments
• Computerized Dynamic Posturography (CDP)
• Cosmetic Drugs
• Domiciliary Care
• Dynamic Posturography
• Dyslexia Treatment
• Elective Psychotherapy and Mind Expansion Psychotherapy
• Elective Services or Supplies
• Electrolysis
• Elevators or Chair Lifts
• Exercise Equipment
• Exercise Programs
• Experimental Procedures
• Fluoride Preparations
• Gym Membership
• Hair Removal
• Homeopathic and Herbal Drugs
• Hospitalization for Medical or Surgical Error
• LASIK Surgery
• Learning Disorders
• Long Term Care
• Magnetic Resonance Neurography
• Massage
• Medical Care from a Family Member
• Mental Health Exclusions
• Multivitamins and Megavitamins
• Naturopathic Care
• Neurofeedback
• Nursing Homes
• Orthoptics
• Paternity Test
• Personal Items
• Postpartum Stay without a Medical Reason
• Private Hospital Rooms
• Psychiatric Treatment for Sexual Dysfunction
• Psychogenic Surgery
• Retirement Homes
• Safety Medical Supplies
• Sensory Integration Therapy
• Sexual Dysfunction or Inadequacy Treatment
• Therapeutic Absences from Inpatient Facility
• Uncovered Services and Supplies
• Unnecessary Diagnostic Tests
• Unnecessary Inpatient Stays
• Unproven Procedures
• Vestibular Rehabilitation
• Vision Therapy
• Weight Loss Products

Visit the TRICARE official site to sign up or learn more about specific coverage options.

Joe Wallace is a 13-year veteran of the United States Air Force and a former reporter for Air Force Television News