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TRICAREBeneficiary Handbook

Your guide to program benefits

TriWest Healthcare Alliance: 1-888-TRIWEST (1-888-874-9378)

TriWest Web Address: www.triwest.com

TRICARE Information Service: 1-888-DoD-CARE (1-888-363-2273)

TRICARE National Web Address: www.tricare.osd.mil

TRICARE Mail Order Pharmacy (Express-Scripts): 1-866-DoD-TMOP (1-866-363-8667)

TRICARE Retail Pharmacy (Express-Scripts): 1-866-DoD-TRRx (1-866-363-8779)

Your Primary Care Manager:

Other Providers:

Name:

Name:

Name:

Behavioral Health Care Provider:

An Important Note About TRICARE Program ChangesThis “TRICARE Beneficiary Handbook” will help you learn about your TRICARE benefits and services.At the time of printing, the information in this booklet is current. It is important to remember that TRICARE policies andbenefits are governed by public law. Changes to TRICARE programs are continuous, and new benefits are added regularly as we continue to make TRICARE a better program for you. For the most recent information, contact your regional contractor,TriWest Healthcare Alliance at 1-888-TRIWEST (1-888-874-9378) or visit them online at www.triwest.com. More information regarding TRICARE, including the Health Insurance Portability andAccountability Act (HIPAA) Notice of Privacy Practices, can also be found online at www.tricare.osd.mil.

Important Information

TRICARE is the Department of Defense (DoD)health care program for active duty and retiredmembers of the uniformed services, theirfamilies, and survivors. TRICARE’s primaryobjectives are to optimize the delivery of healthcare services in military treatment facilities(MTFs) and attain the highest level of beneficiarysatisfaction through the delivery of a world-classhealth care benefit. TRICARE brings together thehealth care resources of the Army, Navy, and AirForce and enhances their services with networksof civilian health care professionals.

TRICARE’s vision is to provide a world-classhealth system that meets all wartime andpeacetime health care needs for the active dutyand retired military and their families.TRICARE is available worldwide to all eligiblebeneficiaries. The TRICARE program continuesto evolve with the ever-changing needs of theuniformed services, both active and reservecomponents. Each year, improvements are madethat make this strong program even better.

1www.triwest.com 1-888-TRIWEST

West Region

1-888-TRIWEST (1-888-874-9378)www.triwest.com

North Region

1-877-TRICARE (1-877-874-2273)www.healthnetfederalservices.com

South Region

1-800-444-5445www.humana-military.com

West North

South

TRICARE:Making a Strong Program Even Better

The DoD has partnered with TriWest HealthcareAlliance to assist in operating the TRICAREprogram for more than 2.6 million beneficiariesin the TRICARE West Region. The West Regionincludes Alaska, Arizona, California, Colorado,Hawaii, Idaho, Iowa (except the Rock IslandArsenal area), Kansas, Minnesota, Missouri(except the St. Louis area), Montana, Nebraska,Nevada, New Mexico, North Dakota, Oregon,South Dakota, Texas (the southwestern cornerincluding El Paso only), Utah, Washington, andWyoming.

TriWest was founded in 1996 with the goal ofproviding access to locally based, cost-effectivehealth care to TRICARE beneficiaries. TriWest isowned by 15 Blue Cross and Blue Shield plansand two university hospital systems. These sameorganizations also serve as TriWest’s providernetwork subcontractors. Thus, TriWest has theexperience needed to provide outstandingcustomer service and access to high-qualityhealth care in the areas it serves.

For the past seven years, TriWest has built astrong foundation on providing TRICAREbeneficiaries like you with unparalleled customerservice, valuable health care programs andservices, dependability, and dedication. TriWestis committed to serving you in this manner andto making the transition into the West Region assmooth as possible.

As the TRICARE health service and supportcontractor for the West Region, TriWest isdedicated to using its time, expertise, and energyto help ensure that you and your family receivethe quality of care you deserve in a timely andcost-effective manner. It is TriWest’s mission toserve you with the same dedication with whichyou or your family members serve, or haveserved, your country. Making good on thepromise of TRICARE is our only focus; you cancount on TriWest to fulfill that mission.


TriWest Proudly Serves Its Beneficiaries One at a Time


Eligibility for TRICARETRICARE Choices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4Updating DEERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5Uniformed Services or Military ID Cards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

TRICARE Program Options TRICARE Prime . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6TRICARE Extra and TRICARE Standard . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7TRICARE Prime Remote and TRICARE Prime Remote for Active Duty Family Members . . . .8TRICARE For Life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9TRICARE Plus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9TRICARE Choices for the Reserve Component . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9TRICARE Dental Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10Uniformed Services Family Health Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11TRICARE Overseas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12Program for Persons with Disabilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12Transitional Health Care Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

What TRICARE Covers Emergency and Urgent Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14Medical and Surgical Covered Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14Clinical Preventive Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18Maternity Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21Behavioral Health Care Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22TRICARE Pharmacy Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23

Limitations and ExclusionsServices or Procedures with Significant Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25Exclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26

Understanding TRICARE Costs and FeesTRICARE Annual Deductible . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27TRICARE Prime Point-of-Service Option . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27Catastrophic Cap Benefit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27Other Health Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27Third Party Liability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28TRICARE Explanation of Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28

Your TRICARE ClaimsWhere to Send Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29Claims for Dual-Eligible Beneficiaries (Medicare and TRICARE) . . . . . . . . . . . . . . . . . . . . . . .30Submitting Claims While Transitioning to the TRICARE West Region . . . . . . . . . . . . . . . . . . .30

Ensuring Customer SatisfactionAppealing a Decision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32Grievances . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32Assistance with Collection Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33Fraud and Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33

For Information and AssistanceRegional Information Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34National Information Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35

Beneficiary ToolsCommon TRICARE Acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36Glossary of Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40

Table of Contents

TRICARE Choices

TRICARE is available to eligible beneficiariesfrom any of the seven uniformed services of theUnited States: the U.S. Army, U.S. Navy, U.S.Air Force, U.S. Marine Corps, U.S. Coast Guard,Commissioned Corps of the U.S. Public Health

Service (USPHS), and the Commissioned Corpsof the National Oceanic and AtmosphericAdministration (NOAA). Several programoptions are available for TRICARE’s uniquebeneficiary population. The chart below lists theoptions available to you. Each of these programsis described in more detail later in this guide.


Eligibility for TRICARE

This chart does not list every eligible beneficiary category. To find out if you’re eligible for TRICARE, call DEERS at 1-800-538-9552 or visit the TRICARE Web site at www.tricare.osd.mil for a complete list of eligible beneficiary categories.

Beneficiary Category Your Options Enrollment Requirements

Active duty service member(ADSM)

TRICARE Prime Enroll with your regional contractor and select a primarycare manager (PCM).

Active duty family member(ADFM)-Spouses andunmarried children up to age21 (23 if enrolled in collegefull time)

TRICARE PrimeTRICARE ExtraTRICARE Standard

If you choose TRICARE Prime, enroll with your regionalcontractor and select a PCM. If you choose to useTRICARE Extra, locate a TRICARE network provider. Touse TRICARE Standard, seek care from any TRICARE-authorized provider.

Uniformed services retireesunder age 65 and eligiblefamily members

ADSM who lives and worksmore than 50 miles or an hourdrive time from an MTF

TRICARE PrimeRemote (TPR)

Enroll with your regional contractor and select a networkPCM (if available).

Family members residingwith ADSM who lives andworks more than 50 miles oran hour drive time from anMTF

TRICARE PrimeRemote for ActiveDuty Family Members(TPRADFM)TRICARE ExtraTRICARE Standard

If you choose TPRADFM, enroll with your regionalcontractor and select a network PCM (if available). If youchoose to use TRICARE Extra, locate a TRICAREnetwork provider. To use TRICARE Standard, seek carefrom any TRICARE-authorized provider.

Member of the ReserveComponent on active dutyorders (activated)

TRICARE Prime(treated as ADSM) orTPR (if you meeteligibility requirements)

Enroll with your regional contractor and select a PCM.

Family of ReserveComponent member activatedfor 30 days or more

TRICARE PrimeTPRADFM TRICARE ExtraTRICARE Standard

If you choose TRICARE Prime or TPRADFM, enrollwith your regional contractor and select a PCM (ifavailable). If you choose to use TRICARE Extra, locate aTRICARE network provider. To use TRICARE Standard,seek care from any TRICARE-authorized provider.

Medicare-eligible beneficiaryunder age 65

TRICARE PrimeTRICARE ExtraTRICARE Standard

Enroll in Medicare Part B (required for all Medicare-eligible beneficiaries except for ADFM under age 65). Ifyou choose TRICARE Prime, enroll with your regionalcontractor and select a PCM. If you choose to useTRICARE Extra, locate a TRICARE network provider. Touse TRICARE Standard, seek care from any TRICARE-authorized provider who accepts Medicare.

Medicare-eligible beneficiaryage 65 and over

TRICARE For Life(TFL)

Enroll in Medicare Part B and seek care from anyTRICARE-authorized provider who accepts Medicare.

Congressional Medal ofHonor recipients and theirimmediate family members

TRICARE PrimeTRICARE ExtraTRICARE StandardTFL (if age 65 and over)

If you choose TRICARE Prime, enroll with your regionalcontractor and select a PCM. If you choose to useTRICARE Extra, locate a TRICARE network provider. Touse TRICARE Standard, seek care from any TRICARE-authorized provider. If age 65 and over, enroll inMedicare Part B and seek care from any TRICARE-authorized provider who accepts Medicare.

Certain former spouses ofactive or retired militaryservice members

Updating DEERS

Eligibility for TRICARE is determined by theDefense Enrollment Eligibility Reporting System(DEERS), a database of uniformed servicesmembers (sponsors), family members, and othersworldwide who are entitled under the law toTRICARE benefits. Active duty and retiredservice members are automatically registered inDEERS, but it’s the sponsor’s responsibility toensure that his or her eligible family membersare registered correctly in DEERS. All sponsorsshould ensure that their family members’ status(marriage, divorce, new child, etc.), residentialaddress, telephone numbers, and e-mail addressare current in DEERS so that TRICARE cansend out information and have claims processedquickly and accurately.

DEERS information may be verified bycontacting TriWest at 1-888-TRIWEST (1-888-874-9378) or the nearest uniformedservices personnel office (where militaryidentification [ID] cards are issued). Sponsors orregistered family members may make addressand contact information changes. However, onlythe sponsor can add or delete a family memberfrom DEERS, and proper documents arerequired, such as a marriage certificate, divorcedecree, and/or birth certificate. Beneficiaries mayupdate their DEERS information in one of thefollowing ways:

• Visit a local uniformed services personneloffice. The nearest uniformed servicespersonnel office can be located online atwww.dmdc.osd.mil/rsl.

• Call 1-800-538-9552.

• Fax address changes to DEERS at 1-831-655-8317.

• Mail the address change to the Defense Manpower Data Center Support OfficeATTN: COA 400 Gigling Road Seaside, CA 93955-6771

• Update addresses electronically atwww.tricare.osd.mil/DEERSAddress.

If you make any changes to your information inDEERS, please contact TriWest so your most up-to-date information will be on file.

Uniformed Services or Military ID Cards

To use TRICARE benefits, you must have a validuniformed services or military ID card issued byyour service branch and you must be listed in theDEERS database. The ID card states on the back,in the “Medical” block, whether you are eligiblefor medical care from military or civiliansources. Children under age 10 can normally usethe ID card of their parent or guardian, but theymust be registered in DEERS. At the age of 10,the child’s sponsor should obtain an ID card forthe child. Children under 10 should also have anID card of their own when in the custody of aparent who is not eligible for benefits.

Newborn Enrollment and DEERS

New parents should register newborns in DEERSas soon as possible after birth to ensurecontinued eligibility for TRICARE. To establishTRICARE eligibility for a newborn in DEERS,parents or legal guardians must submit acertificate of “live birth” from a hospital orTRICARE approved birthing center. They mustalso provide a copy of a verified and approvedDD Form 1172 “Application for UniformedServices Identification and Privilege Card”signed by the sponsor.

A newborn is covered as a TRICARE Primebeneficiary for the first 120 days after birth—aslong as one additional family member is enrolledin TRICARE Prime or TRICARE Prime Remote.After the initial 120 days, any claim submittedfor a newborn will process as TRICAREStandard until the infant is enrolled in DEERSand TRICARE Prime, or the infant’s TRICAREStandard eligibility ends. Eligibility forTRICARE Standard ends 365 days after birth forany newborn who is not properly registered inDEERS.

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TRICARE’s family of programs offerscomprehensive health and dental benefits toevery TRICARE beneficiary category. It’simportant to understand the choices available tochoose the best option for you and your family.

TRICARE Prime

TRICARE Prime offers fewer out-of-pocketcosts than any other TRICARE option.TRICARE Prime beneficiaries receive most oftheir care from a military treatment facility(MTF), supported by the TriWest providernetwork, and are guaranteed access to care. Toenroll in TRICARE Prime, you will complete anenrollment form and select, or will be assigned, aprimary care manager (PCM) who provides andcoordinates your care, maintains your patienthealth records, refers you to specialists, and filesclaims for you. Specialty care must be arrangedand approved by your PCM to be covered underTRICARE Prime. TRICARE Prime also offersenhanced coverage for vision, behavioral health,and clinical preventive services. Specialty carereceived without proper authorization will becovered under the TRICARE Prime point-of-service (POS) option which includes adeductible, higher copayments, and cost-shares.

Eligibility for TRICARE Prime

TRICARE Prime is available to active dutyservice members, family members, and survivorsof active duty personnel; retirees, their familymembers, and survivors under age 65; andmembers of the Reserve Component and theirfamilies if the sponsor is activated for more than30 consecutive days. All eligible beneficiariesmust be registered in the Defense EnrollmentEligibility Reporting System (DEERS) andreside in a service area where TRICARE Primeis offered.

Enrollment

To participate in TRICARE Prime, you mustenroll by completing a TRICARE Primeenrollment form and submitting it to TriWest.

Active duty service members areautomatically covered under the TRICAREPrime benefit but are still required tocomplete an enrollment form. There is noenrollment fee for active duty family members.Retirees and their family members must pay anannual enrollment fee of $230 for an individualor $460 for a family to enroll in TRICAREPrime. Payments can be made in annual,quarterly, or monthly installments.

Enrollment in TRICARE Prime is continuous.You may choose to disenroll, or you may bedisenrolled due to a move to a non-TRICAREPrime service area or for nonpayment ofenrollment fees. If you choose to disenroll fromTRICARE Prime before your annual enrollmentrenewal date, or are disenrolled for nonpayment,you may be subject to a one-year lockout. Thelockout provision does not apply to active dutyfamily members of E-1 through E-4. Please notethat any change in status (e.g., active duty toretired or demobilization) will cause adisenrollment from TRICARE Prime. Whenthere is a status change you MUST re-enroll inTRICARE Prime to maintain your coverage.

TRICARE Prime Access Standards

Another advantage of enrolling in TRICAREPrime is the TRICARE Prime access standards.You are guaranteed an appointment within thefollowing standards:

• The wait time for an urgent care appointmentshall not exceed 24 hours.

• The wait time for a routine appointment shallnot exceed one week.

• The wait time for a specialty care appointmentor wellness visit shall not exceed four weeks.

Additionally, under normal circumstances, yourtravel time may not exceed 30 minutes from yourhome to your PCM’s office for primary care, andyou should not have to travel more than one hourfrom your home for referred specialty care.


TRICARE Program Options

TRICARE Prime Travel Entitlement

If you are referred by your PCM for specialtycare at a location more than 100 miles from yourPCM, you may be eligible to have your“reasonable travel expenses” reimbursed byTRICARE. You must have a valid referral andtravel orders from a TRICARE representative atthe MTF where you are enrolled or from theTRICARE Regional Office if your PCM is aTRICARE network provider.

Reasonable travel expenses are the actual costsincurred when traveling such as meals, gas/oil,tolls, parking, and tickets for public transportation(i.e., airplane, train, bus, etc.). You must submitreceipts for expenses above $75. You are expectedto use the least costly mode of transportation,and government rates will be used to estimate thereasonable cost. The actual cost of lodging(including taxes and tips) and the actual cost ofmeals (including taxes and tips, but excludingalcoholic beverages) may be reimbursed up tothe government rate for the area concerned.

A parent, guardian, or other adult familymember* is authorized to travel with a non-active duty TRICARE Prime-enrolled patient asa non-medical attendant (NMA). If the NMA isnot the parent, he or she must be 21 years of ageor older. The NMA is not required to be enrolledin TRICARE Prime or to be TRICARE-eligible.The patient, however, must be enrolled inTRICARE Prime.

This entitlement does not apply to expensesincurred by active duty service members oractive duty family members residing with theirsponsors overseas, which are reimbursed byother travel entitlements. For additionalinformation about the TRICARE Prime travelentitlement and NMA travel entitlement,visit the TRICARE Web site atwww.tricare.osd.mil/primetravel.

*By statute, the NMA must be a parent, legal guardian, orother adult family member. If the NMA family member isactive duty or a DoD civilian employee authorized by theMTF or TRICARE Regional Office to accompany a non-active duty TRICARE Prime enrollee as an NMA, he or sheis entitled to TDY allowances (per diem and mileage), notactual expenses. If the NMA family member is a civilian notemployed or affiliated with the DoD, they are authorizedreimbursement for actual travel expenses incurred.

Getting Care While Traveling

For emergencies while traveling away fromhome, you should dial 911 or go directly to thenearest hospital emergency department. You (orfamily members on your behalf) should notifyyour PCM or regional contractor within 24 hoursof receiving emergency medical care to allowyour doctor the opportunity to arrange for yourcontinuing treatment.

For treatment of a nonemergency medicalcondition that cannot wait until you return home,you should coordinate with your PCM beforeseeking care. You may also call TriWest at 1-888-TRIWEST (1-888-874-9378) forassistance in coordinating out-of-area care. Ifyou do not receive a referral from your PCM andan authorization from TriWest for nonemergencycare obtained out of area, your care may becovered under the point-of-service (POS) option,which includes a deductible, higher copayments,and cost-shares.

For additional information about enrolling inTRICARE Prime, call TriWest or visit their Website to learn more about TRICARE Prime or torequest a TRICARE Prime Enrollment Package.

TRICARE Extra and TRICARE Standard

TRICARE Extra and TRICARE Standard areavailable for TRICARE-eligible beneficiarieswho are not able to or who choose not to enrollin TRICARE Prime. Active duty servicemembers are not eligible for TRICARE Extra orTRICARE Standard. There is no enrollmentrequired for either option—no annual enrollmentfees and no enrollment forms. Beneficiaries areresponsible for annual deductibles and cost-shares.

TRICARE Extra is a preferred provider option(PPO). This means you choose a doctor, hospital,or other medical provider within the TriWestprovider network to take advantage of lowercosts and less paperwork.

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TRICARE Standard is a fee-for-service option.With TRICARE Standard, you may seek carefrom any TRICARE-authorized provider. Thechart above shows the main differences betweenTRICARE Extra and TRICARE Standard.

To locate a medical provider in the network, visitthe TRICARE provider directory online atwww.tricare.osd.mil/ProviderDirectory.

TRICARE Prime Remote and TRICARE Prime Remote for Active Duty Family Members

TRICARE Prime Remote (TPR) and TRICAREPrime Remote for Active Duty Family Members(TPRADFM) provide active duty servicemembers in the United States and their eligiblefamily members with the TRICARE Primeoption while they are assigned to remote dutystations (typically more than 50 miles or anhour’s drive time away from the nearest MTF).

Eligibility for TRICARE Prime Remote

The following TRICARE beneficiary categoriesare eligible for TPR/TPRADFM:

Active Duty Service Members

Active duty service members (ADSMs) underfull-time orders with a permanent dutyassignment who live and work more than 50miles or one hour’s drive time from an MTF (inTPR-designated ZIP codes) are required to enrollin TPR. In some cases, where geographicboundaries create undue hardship for travel,service members living closer than 50 miles maybe eligible for TPR. Service members may verifytheir eligibility based on location by visiting theTPR Web site at www.tricare.osd.mil/remote.

Active Duty Family MembersActive duty family members (ADFMs) residingwith their TPR-enrolled sponsors are eligible forTPRADFM and must enroll to enjoy the benefit.Family members who are enrolled in TPRADFMmay remain enrolled even if the sponsor receivesunaccompanied permanent change of station(PCS) orders as long they continue to reside inthe same TPR location.

Reserve Component Family Members

Reserve Component (RC) family members areeligible for TPRADFM if their sponsor isactivated for more than 30 consecutive days andthe family members reside with their sponsor(within a TPR-designated ZIP code) uponactivation or effective date of orders. Theactivated reservist (sponsor) is not required to beeligible for or enrolled in TPR for their familymembers to be eligible for TPRADFM.

RC family members must enroll in TPRADFMin order to enjoy the benefit. Once enrolled inTPRADFM, family members who continue toreside in the location where they enrolled mayremain in TPRADFM for the entire period of thesponsor’s activation, regardless of any changes inthe sponsor’s duty location.

Example:

Staff Sergeant (SSG) James Smith of the U.S.Army Reserve lives with his family inSmalltown, Iowa. He receives orders assigninghim to his local Reserve unit for 180 days. Hisfamily decides to enroll in TPRADFM. Twomonths later, SSG Smith receives new ordersdeploying him to an overseas location for sixmonths. There will be no break in hisactivation and he will mobilize from his unit.


Differences between TRICARE Extra and TRICARE Standard

TRICARE Extra TRICARE Standard

Provider Type In network Not in network, but still an authorized provider

Cost-share afterdeductibles

15% for active duty families

20% for retirees and theirfamilies

20% for active duty families; nonparticipating providersmay also “balance bill” up to 15% above the TRICAREallowable charge

25% for retirees and their families; non-participating providers may also “balance bill” upto 15% above the TRICARE allowable charge

His family continues to reside in Smalltown,Iowa, so they may remain enrolled inTPRADFM. If, however, they decide to movewhile SSG Smith is overseas, they will not beable to remain enrolled in TPRADFM, even ifthey move to a different TPR-designated ZIPcode area. They will remain eligible forTRICARE Extra or TRICARE Standard. Ifthey move to a location where TRICAREPrime is available, they can enroll inTRICARE Prime.

Enrolling in TPR/TPRADFM

Eligible ADSMs must enroll in TPR andcomplete an enrollment form. Family membersof eligible active duty service members mayenroll in TPRADFM or continue to receive careunder TRICARE Extra or TRICARE Standardwith applicable cost-shares and deductibles. Toenroll in TPR and TPRADFM, an enrollmentform must be completed and submitted toTriWest.

To see if you reside in a designated TPR servicearea, visit the TPR Web site atwww.tricare.osd.mil/remote. Contact TriWest orvisit them online for an enrollment form and aTRICARE Prime Remote Handbook to learnmore about how TPR/TPRADFM works.

TRICARE For Life

TRICARE For Life (TFL) is TRICARE’sMedicare-wraparound coverage for TRICAREbeneficiaries age 65 and over who becomeentitled to Medicare Part A and purchaseMedicare Part B. TRICARE pays secondary toMedicare beginning on the first day of the monththat you turn 65.

Covered Services

• For services covered by both Medicare andTRICARE, Medicare will pay first andTRICARE pays second.

• For services covered by TRICARE but notMedicare, TRICARE will pay its portion andyou are responsible for applicable TRICAREdeductibles and cost-shares.

• For services covered by Medicare but notTRICARE, Medicare is the only payer, and youare responsible for Medicare cost-shares.

• For services not covered by Medicare orTRICARE, you are responsible for the entirebill.

For services received from a civilian provider,the provider will first file claims with Medicare.Medicare will pay its portion and automaticallyforward the claim to TRICARE for processing.TRICARE will send its payment for theremaining beneficiary liability directly to theprovider. Beneficiaries will receive a Medicaresummary notice and a TRICARE explanation ofbenefits (EOB) indicating the amount paid to theprovider. For more information about TFLclaims, see the description of claims for dual-eligible beneficiaries in the section entitled,“Your TRICARE Claims.”

TRICARE Plus

TRICARE Plus is a primary care enrollmentprogram that is offered at selected MTFs. Allbeneficiaries eligible for care in MTFs (exceptthose enrolled in TRICARE Prime, a civilianHMO, or Medicare HMO) can seek enrollmentfor primary care under TRICARE Plus—where itis available. Non-enrollment in TRICARE Plusdoes not affect TFL benefits or other existingprograms. You should contact your local MTF tofind out if they participate in TRICARE Plus.

TRICARE Choices for theReserve Component

Members of the Reserve Component (RC) whoare called to active duty for more than 30consecutive days are eligible for TRICARE, thesame as any ADSM. Families of theseindividuals become eligible for TRICARE if thesponsor is called to active duty for more than 30consecutive days. To ensure family members areeligible for TRICARE upon activation, sponsorsmust register their family members in DEERS.

Programs Available to the Reserve Component

Family members of the RC become eligible forTRICARE Extra and TRICARE Standard on thefirst day of the military sponsor’s active duty if hisor her orders are for more than 30 consecutivedays or if the orders are for an indefinite period.

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They also become eligible for the TRICAREPharmacy Program and may have prescriptionsfilled at MTF pharmacies, through the TRICAREMail Order Pharmacy (TMOP), and at retailnetwork and non-network pharmacies. TheTRICARE Pharmacy Program has its own costsseparate and apart from all other programs. Seethe section entitled “What TRICARE Covers”for more information about the pharmacybenefit.

Eligible family members may enroll in TRICAREPrime (or TRICARE Prime Remote if distanceeligibility requirements are met) if their sponsoris called to active duty for more than 30consecutive days. There are no enrollment fees orcopayments for family members, but enrollmentforms must be completed, and MTFs or networkproviders must be used if available. Many RCfamilies may have continuing relationships withproviders who are not in the TRICARE Primenetwork. In these cases, enrolling in TRICAREPrime may not be the best choice—instead, usingTRICARE Standard can be the most flexibleoption, even though beneficiaries may be requiredto pay a share of the cost of health care. If familymembers are eligible for the TRICARE ReserveFamily Demonstration Project (see below), theTRICARE Standard annual deductible will bewaived.

TRICARE Reserve FamilyDemonstration Project

TRICARE Reserve Family DemonstrationProject participants are limited to families ofReserve and National Guard members called toactive duty for periods of more than 30consecutive days in support of operations thatresult from the terrorist attacks of September 11,2001, under Executive Order 13223, 10 U.S.C.12302, 10 U.S.C. 12301(d), or 32 U.S.C. 502(f).Such operations include, for example,OPERATIONS ENDURING FREEDOM,NOBLE EAGLE, and IRAQI FREEDOM.TRICARE Reserve Family DemonstrationProject components include:

• Waiver of TRICARE Standard annualdeductibles

• Waiver of the TRICARE allowable chargeunder TRICARE Standard

• Waiver of requirement to obtain nonavailabilitystatements for nonemergency inpatient care

Temporary Reserve Health CareBenefits for 2004

The recently enacted Emergency SupplementalAppropriations Act and the National DefenseAuthorization Act for Fiscal Year 2004authorized temporary health care benefits forTRICARE eligibility for eligible ReserveComponent sponsors and their family members.The TRICARE Management Activity (TMA) isworking closely with Reserve Affairs and theuniformed services to implement thesetemporary benefits for the Reserve Componentand their families. Please visit the TRICAREWeb site at www.tricare.osd.mil for newinformation about these temporary benefits asthe details are made available. Additionally,information about the new benefits will behighlighted in newsletters, bulletins, and othereducational materials in the future.

For additional information about TRICAREbenefits available to the Reserve Component,visit the TRICARE Web site atwww.tricare.osd.mil.

TRICARE Dental Programs

TRICARE currently offers two dental programs:the TRICARE Dental Program and theTRICARE Retiree Dental Program. Theseprograms are separate from the TRICAREmedical program and have their own eligibilitycriteria and fees.

TRICARE Dental Program

The TRICARE Dental Program (TDP) is avoluntary dental insurance program administeredby United Concordia Companies, Inc. (UCCI).TDP is available to eligible active duty familymembers, Selected Reserve and IndividualReady Reserve (IRR) members, and their eligiblefamily members. Active duty personnel (andReservists called to active duty for a period ofmore than 30 consecutive days) are not eligiblefor TDP. They receive dental care from militarydental treatment facilities. Former spouses,parents, parents-in-law, disabled veterans,


foreign military personnel, and uniformedservices retirees and their families are noteligible for TDP. Other details of TDP benefits,requirements, and restrictions can be found at theUCCI Web site atwww.ucci.com/was/ucciweb/home.jsp.

TRICARE Retiree Dental Program

The TRICARE Retiree Dental Program (TRDP)is a voluntary dental insurance programadministered by the Federal Services division ofDelta Dental Plan (DDP) of California. TRDPoffers comprehensive, cost-effective dentalcoverage for uniformed services retirees andtheir eligible family members, certain survivingfamily members of deceased active dutysponsors, and Medal of Honor recipients andtheir immediate family members and survivors.Other details of TRDP benefits, requirements,and restrictions can be found at the DDP Website at www.trdp.org.

Uniformed Services FamilyHealth Plan

The Uniformed Services Family Health Plan(USFHP) is an extra TRICARE Prime optionavailable to families of active duty military,retirees, and their eligible family members,including those age 65 and over, throughnetworks of community-based hospitals andphysicians in six areas of the country.

With roots as Uniformed Services TreatmentFacilities (USTFs), the USFHP has been a partof the Military Health System for 22 years. Sincethe DoD reorganized the USTFs in 1993, theUSFHP has remained a managed care planoffering all of the health care coverage andbenefits, plus some additional enhancements, atthe same costs as TRICARE Prime.

When enrolled in the USFHP, members do notaccess Medicare or MTFs, but instead receivetheir care from a primary care physician selectedby the beneficiary from a network of privatephysicians affiliated with one of the not-for-profit health care systems offering the plan. Thatprimary care physician assists the member ingetting appointments for specialists in the areaand coordinates care. Members are covered for

worldwide emergency care and many preventivecare services. They can access on-site patientadvocates for assistance, and they enjoyenhancements in some areas, including discountsfor eyeglasses, hearing aids, and dental care.

Enrollment in the USFHP

To enroll in the USFHP, you must submit acompleted application to the USFHP program ofchoice. Enrollees must reside in one of theservice areas listed below. All eligiblebeneficiaries may enroll at anytime throughoutthe year, however, beneficiaries make a one yearcommitment to receive their care from the plan,unless they move out of the area where the planis offered. Enrollment fees, if applicable, areportable to another TRICARE Prime program.

USFHP enrollment is offered through:

Johns Hopkins Community Physicians 1-800-808-7347Serving central Maryland and parts ofPennsylvania, Virginia, and West Virginia

Martin’s Point Health Care 1-888-241-4556Serving Maine and New Hampshire

Brighton Marine Health Center 1-800-818-8589Serving central and eastern Massachusetts,including Cape Cod, and Rhode Island

Saint Vincent Catholic Medical Centers 1-800-241-4848Serving parts of New York, all of New Jersey,eastern Pennsylvania, and southern Connecticut

Christus Health 1-800-678-7347Serving southeast Texas and southwest Louisiana

Pacific Medical Centers (PacMed Clinics) 1-888-958-7347Serving the Puget Sound area of Washington State

For more information, visit the US FamilyHealth Plan Web site atwww.usfamilyhealthplan.org.

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TRICARE Overseas

The TRICARE Overseas Program (TOP) is theDoD’s managed health care program for allgeographic areas and territorial waters outsidethe 50 United States. TOP blends many of thefeatures of the stateside TRICARE programswhile also allowing for the significant culturaldifferences unique to foreign countries and theirhealth care practices.

The TOP consists of three overseas regions:TRICARE Europe, TRICARE Pacific, andTRICARE Latin America and Canada, whichincludes the Caribbean Basin. Unlike the threeregions in the United States—TRICARE North,TRICARE South, and TRICARE West—theoverseas regions are managed by overseasregional directors.

Although TRICARE beneficiaries residingoverseas are entitled to the same benefits asthose living stateside, several differences in theavailability of options exist because of thegeographical differences. The benefit packageslisted below are available overseas:

TOP Prime—Offers TRICARE Prime benefitsto active duty service members and their eligiblefamily members residing with their sponsoroverseas. There are no enrollment fees, cost-shares, or deductibles for TOP Prime enrollees.

TOP Standard—Identical to the statesideprogram, including cost-shares and deductibles.Active duty family members living overseas maychoose between TOP Prime and TOP Standard.Retirees and their families who live overseascannot enroll in TOP Prime but are coveredunder TOP Standard.

TOP TRICARE For Life (TFL)—Available toall beneficiaries who are entitled to MedicarePart A and enrolled in Medicare Part B. BecauseMedicare does not provide benefits for medicalcare received overseas, TFL coverage is similarto TRICARE Standard overseas.

TRICARE Global Remote Overseas—Provides access to the TRICARE Prime benefitto active duty service members and family

members who are assigned to designated dutystations in remote overseas locations whereMTFs are not available. Active duty servicemembers and their families must enroll to adesignated remote overseas location.

Overseas Pharmacy Services—You may haveprescriptions filled at MTF pharmacies in alloverseas locations, if the medication is availableon the MTF’s formulary. TRICARE Mail OrderPharmacy (TMOP) may be used if you have anAPO or FPO address or a state department mailpouch for pharmacy. The prescription must bewritten by a U.S. licensed provider. Drugspurchased by TOP eligible beneficiaries atoverseas embassies may not be covered underTRICARE. The TRICARE retail networkpharmacy benefit is available overseas only inPuerto Rico, the Virgin Islands, and Guam.

The TRICARE Dental Program (TDP) is alsoavailable overseas. For more information aboutTRICARE benefits available overseas, call 1-888-777-8343. All overseas regions may bereached via this telephone number. You may alsovisit the TRICARE Web site atwww.tricare.osd.mil/overseas for moreinformation.

Program for Persons with Disabilities

The Program for Persons with Disabilities(PFPWD) will be replaced by the Extended CareHealth Option (ECHO) in regional phases overthe course of the year 2004. The followinginformation regarding PFPWD pertains to areaswhere ECHO has not yet become effective.

PFPWD is designed to provide financialassistance to family members of active dutyservice members in order to treat and/or reducethe effects of mental retardation or seriousphysical disability. PFPWD is not a stand-aloneprogram and has no enrollment; subject tocertain restrictions, it may be used concurrentlywith other TRICARE medical programs. ThePFPWD serves persons with two types of seriousdisabilities: moderate or severe mentalretardation and/or significant physical disability.


The monthly cost-share amount for the PFPWDvaries from $25 to $250, depending on the activeduty sponsor’s rank. PFPWD allowable amountsare not subject to a deductible. The maximummonthly program payment for PFPWD benefitsis $1,000. The sponsor is responsible for theappropriate cost-share amount plus any amountin excess of the maximum monthly coverage.

To find out if you or a family member qualifiesfor PFPWD, contact TriWest at 1-888-TRIWEST(1-888-874-9378).

Transitional HealthCare Benefits

TRICARE offers options for those beneficiarieswho are separating from active duty. Theseoptions are described below.

Transitional Assistance Management Program

Through the Transitional AssistanceManagement Program (TAMP), certainuniformed services members and their familymembers may be eligible for transitional healthcare benefits when the sponsor separates fromactive duty service. Service member categoriesinclude:

• A member who is involuntarily separated fromactive duty if under honorable conditions

• A Reserve Component member who isseparated from active duty and who was calledup or ordered in support of a contingencyoperation for an active duty period of more than30 consecutive days

• A member who is separated from active dutyand is involuntarily retained in support of acontingency operation

• A member who is separated from active dutyfollowing a voluntary agreement to stay onactive duty for a period of less than one year insupport of a contingency mission

Continued Health Care Benefit Program

The Continued Health Care Benefit Program(CHCBP) is intended to provide transitionalbenefits for a specified period of time (18–36

months) to former service members and theirfamilies, some un-remarried former spouses, andemancipated children (living on their own) whoenroll and pay quarterly premiums. The benefitsavailable under CHCBP are similar to TRICAREStandard, and although it is not part ofTRICARE Standard, it operates under most ofthe same rules. The quarterly premiums for thecoverage are $933 for one person and $1,996 fora family. To receive coverage under CHCBP,eligible persons must enroll by completing aCHCBP application within 60 days afterseparating from active duty or losing theireligibility for TRICARE. The DoD hascontracted with Humana Military HealthcareServices, Inc. (HMHS) to administer CHCBP.Beneficiaries may contact HMHS in writing orby phone for any information regarding CHCBPat the following address or phone number:

Humana Military Healthcare Services, Inc.Attn: CHCBPP.O. Box 740072Louisville, KY 402021-800-444-5445

Voluntary Separation Benefits

Service members voluntarily separated under theSpecial Separation Benefit (SSB) or theVoluntary Separation Incentive (VSI) are entitledto all benefits provided to involuntarily separatedmembers. Members who choose SSB or VSI(and their families) may receive health benefitsby enrolling in CHCBP.

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TRICARE covers most inpatient and outpatientcare that is medically necessary and consideredproven. However, there are special rules or limitson certain types of care, while other types of careare not covered at all. Some military treatmentfacilities (MTFs) may offer services, procedures,or benefits that are not necessarily covered underTRICARE. You should contact your local MTFfor more information. To find an MTF near you,visit the MTF Locator on the TRICARE Website at www.tricare.osd.mil/mtf or visit theTriWest MTF directory at www.triwest.com.

A prior authorization is a process of reviewingmedical, surgical, and behavioral health servicesto ensure medical or psychological necessity andappropriateness of care prior to services beingrendered. You or your provider must notifyTriWest to obtain a prior authorization. For acomplete list of services and/or proceduresrequiring prior authorization, contact TriWest at1-888-TRIWEST (1-888-874-9378).

To find additional information about servicescovered by TRICARE, contact TriWest, visittheir Web site, or visit the TRICARE Web site atwww.tricare.osd.mil.

Emergency and Urgent Care

Urgent Care

Urgent care services are medically necessaryservices which are required for an illness or injurythat would not result in further disability or deathif not treated immediately, but require professionalattention and have the potential to develop such athreat if treatment is delayed longer than 24 hours.An urgent care condition could be a sprain, sorethroat or rising temperature.

Emergency Services

TRICARE defines an emergency as a medical,maternity, or psychiatric emergency that wouldlead a “prudent layperson” (someone withaverage knowledge of health and medicine) tobelieve that a serious medical condition existed,or the absence of medical attention would resultin a threat to his/her life, limb, or sight, and

requires immediate medical treatment, or whichhas painful symptoms requiring immediateattention to relieve suffering. This includessituations where a beneficiary presents withsevere pain.

In the event of a life-, limb-, or eyesight-threatening emergency, you should go, or be takento, the nearest emergency department for care. Inall emergency situations, you must notify yourprimary care manager (PCM) or regionalcontractor within 24 hours of any emergencyadmission so that ongoing care can be coordinated(if enrolled in TRICARE Prime).

Medical and Surgical Covered Services

The following charts summarize TRICARE-covered services. Any covered services obtained atan MTF are at no cost to you. Please note thatTRICARE Prime Remote (TPR) and TRICAREPrime Remote for Active Duty Family Members(TPRADFM) offer coverage similar to TRICAREPrime, and if enrolled, you are not responsible fordeductibles, cost-shares, or copayments. However,for active duty family members (ADFMs), thewaiver of copayments, cost-shares, and deductiblesdoes not apply to pharmacy copayments, Programfor Persons with Disabilities (PFPWD) cost-shares,or TRICARE Prime point-of-service (POS) cost-shares and deductibles. See the section entitled“Costs and Fees” for information about theTRICARE Prime POS option. For moreinformation about pharmacy copayments, see thedescription of the TRICARE Pharmacy Programlater in this section.

For the services listed in these charts, TRICAREhas established catastrophic caps (cat caps). Catcaps act as built-in safety nets to limitbeneficiaries’ out-of-pocket expenses onTRICARE-covered medical bills. In order to getmedical costs credited towards cat caps, thebeneficiary may be required to provide proof ofmedical care, such as an explanation of benefits(EOB). Please see the section entitled“Understanding TRICARE Costs and Fees” forinformation about catastrophic caps.

What TRICARE Covers


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Outpatient Services Outside of an MTF

Outpatient services received in an MTF are at no cost to the beneficiary. For the chartson the following pages, “ADFM” is the active duty family member responsibility.

Services Covered TRICARE Prime** TRICARE Extra* TRICARE Standard*

Ancillary Services Certain diagnostic radiology and ultrasound(70000-76999); diagnostic nuclear medicine(78000-78999); pathology and laboratoryservices (80000-89399); and cardiovascularstudies (93000-93350)

Per visit:ADFM: Nocopayment

Retirees and others:No copayment

ADFM: 15% of contractedreimbursement

Retirees and others:20% of contractedreimbursement

ADFM: 20% of themaximum allowablecharge

Retirees and others:25% of the maximumallowable charge

Ambulance Services When medically necessary and when neededfor a medical condition that is covered byTRICARE

Per occurrence:ADFM: Nocopayment

Retirees and others:$20 copayment

Same as above Same as above

Ambulatory Surgery (Same Day)(1)

When surgery is conducted at a hospital-based or freestanding ambulatory surgicalcenter that is TRICARE-certified

TRICARE Prime Retirees and others—copayment is applied to the ambulatorysurgical facility only.

Per occurrence:ADFM: Nocopayment


ADFM:$25 copayment

Retirees and others:Professional—20% of contractedreimbursement

Facility—20% of contractedreimbursement

ADFM:$25 copayment

Retirees and others:Professional—25% of the maximumallowable charge

Facility—25% of the group rate or25% of billedcharges; whichever isless

Durable Medical Equipment (DME),Prosthetic Devices and Medical Supplies(Prescribed by a Physician)(1)(3)

For DME, prosthetic devices, and medicalsupplies, care is subject to TRICARE policyafter an office or home health visit whenmedically necessary and a covered benefit.

ADFM: Nocopayment


ADFM: 15% ofcontractedreimbursement




Emergency Services(1)

Emergency care obtained on an outpatientbasis, both network and non-network, in orout of the region.

Per visit:ADFM: Nocopayment



*Cost-share is applied after deductible has been satisfied.**Benefits under TRICARE Prime Remote (TPR) and TRICARE Prime Remote for Active Duty Family Members (TPRADFM)

are similar to TRICARE Prime.1. TRICARE Standard beneficiaries may pay up to 15 percent above the maximum allowable charge when the provider does not

accept assignment (balance billing). See the Glossary for a description of balance billing.2. If provided as part of an office visit and a copayment is collected for the visit under TRICARE Prime, no additional

copayment will be collected for these services.3. Requires prior authorization for TRICARE Prime, TPR, and TPRADFM.


Outpatient Services Outside of an MTF (continued)

*Cost-share is applied after deductible has been satisfied.**Benefits under TRICARE Prime Remote (TPR) and TRICARE Prime Remote for Active Duty Family Members (TPRADFM)

are similar to TRICARE Prime.1. TRICARE Standard beneficiaries may pay up to 15 percent above the maximum allowable charge when the provider does not

accept assignment (balance billing). See the Glossary for a description of balance billing.2. If provided as part of an office visit and a copayment is collected for the visit under TRICARE Prime, no additional

copayment will be collected for these services.3. Requires prior authorization for TRICARE Prime, TPR, and TPRADFM.

Services Covered TRICARE Prime** TRICARE Extra* TRICARE Standard*

Eye Examinations One routine examination per year for activeduty family members. For additionalcoverage, see “Eye Examinations” underClinical Preventive Services Benefits.

ADFM:No copayment

Retirees and others:Not covered





Home Health Care(3)

Same as the Medicare home health carebenefit, providing a maximum of 28 hoursper week part time, or 35 hours per weekintermittent, skilled nursing care andphysical, speech, and occupational therapy.All care must be provided by a participatinghome health care agency.

Per visit:ADFM:No copayment




Does not apply

Individual Provider Services(1)

Office visits; outpatient office-based medicaland surgical care; consultation, diagnosis, andtreatment by a specialist; allergy tests andtreatment; osteopathic manipulation;rehabilitation services, e.g., physical therapy,speech pathology services, and occupationaltherapy; medical supplies used within theoffice, including casts, dressings, and splints.



Same as above ADFM: 20% of themaximum allowablecharge


Immunizations for Required Overseas Travel Immunizations required for ADFMs whosesponsors have permanent change-of-stationorders to overseas locations.

Per Visit:ADFM: Nocopayment


ADFM: 15% of contractedreimbursement




Laboratory and X-Ray Services (providedas part of an office visit) (1)(2)

TRICARE Prime Retirees and others do nothave an additional copayment if theseservices are provided as part of an officevisit.








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*Benefits under TPR and TPRADFM are similar to TRICARE Prime.1. Cost-share and daily inpatient charges are subject to change at the beginning of each fiscal year (October 1–September 30).2. TRICARE Standard beneficiaries may pay up to 15 percent above the maximum allowable charge when the provider does not

accept assignment (balance billing). See the Glossary for a description of balance billing.3. TRICARE Standard cost-share for retirees may vary depending on type of treatment or type of hospital.4. Requires prior authorization for TRICARE Prime, TPR, and TPRADFM.

Inpatient Services (Both MTF and Civilian Facility)

Hospice Care

Hospice care is available, in lieu of otherTRICARE benefits, to provide palliative care toindividuals with prognoses of less than sixmonths to live if the terminal illness runs itsnormal course. Hospice care must be providedby a Medicare-approved program and mayinclude: physician services, nursing care,counseling, inpatient respite care, medical

supplies, medications, medical social services,home health aide services, physical andoccupational services, speech and languagepathology, and short-term acute patient carerelated to terminal diagnosis.

Note: The individual hospice may charge a cost-share for medications, biologicals, and/orinpatient respite care.

Services Covered TRICARE Prime* TRICARE Extra TRICARE Standard

Hospitalization(1)(2)(3)(4)

Semiprivate room (and when medicallynecessary, special care units), generalnursing, and hospital service. Includesinpatient physician and surgical services;meals (including special diets); drugs andmedications while an inpatient; operating andrecovery room; anesthesia; laboratory tests;X-rays and other radiology services;necessary medical supplies and appliances;and blood and blood products. Unlimitedservices, as medically necessary.

ADFM:MTF: No copayment Civilian: Nocopayment

Retirees and others:MTF: $13.32 per day Civilian: $11 per dayor $25 minimumcharge peradmission, whicheveris greater.

(No separatecopayment forseparately billedprofessional charges.Catastrophic Capprotection limits doapply.)

ADFM:MTF: $13.32 per day Civilian: $13.32 perday or $25 minimumcharge per admission,whichever is greater.

Retirees and others:MTF: $13.32 per day Civilian: $250 perday or 25% cost-share of the totalcontractedreimbursement forinstitutional services,whichever is less,plus 20% cost-shareof separately billedprofessional chargesbased on thecontractedreimbursement.

ADFM:MTF: $13.32 per day Civilian care: $13.32per day or $25minimum charge peradmission, whicheveris greater.

Retirees and others:MTF: $13.32 per day Civilian: $441 perday or 25% cost-share of billedcharges, whichever isless, plus 25% cost-share of themaximum allowablecharge for separatelybilled professionalcharges.

Maternity(1)(2)(4)

Hospital and professional services (prenatal,postnatal). Unlimited services, as medicallynecessary.

Same as above Same as above Same as above

Skilled Nursing Facility (SNF) Care(1)(4)

Semiprivate room; regular nursing services;meals including special diets; physical,occupational, and speech therapy; drugsfurnished by the facility; and necessarymedical supplies and appliances. Unlimitedservices, as medically necessary.


Except 20% cost-share of the totalcontractedreimbursement

ADFM: $25 peradmission or $13.32per day, whichever isgreater.

Retirees and others:25% cost-share ofbilled charges, plus25% cost-share of themaximum allowablecharge for separatelybilled professionalcharges.



Clinical Preventive Examinations Comprehensive-health-promotion anddisease-prevention exams for ages 24months and older.

Examinations can include: blood pressuretests; clinical breast exams (high-riskwomen age 39 and under; annually for allwomen over 40); pelvic exams (sameguideline as Pap smears and should beadministered during same visit); clinicaltesticular exams (annually for high-risk men13-39); digital rectal exams (annually forhigh-risk men 40-49; and all men over 50);Prostate Specific Antigen (annually forhigh-risk men 40-49; men with history ofvasectomy at least 20 years previous or atage 40 and over; and all men over 50); oralcavity exams; thyroid palpations; schoolenrollment physicals ages 5-11 years.

Note: Annual sports physicals are not acovered benefit under TRICARE.

No copayment

Clinical preventiveservices are anenhanced benefitunder TRICAREPrime.

Applicable cost-shareand deductible applywhen service isincluded as part of acancer screening visit.

Applicable cost-shareand deductible applywhen service isincluded as part of acancer screeningvisit.

Eye ExaminationsClinical preventive service eye exams varyby TRICARE program option (see columnsfor details of coverage for children andadults).

Note: In addition to the clinical preventiveservice eye exams, ADFMs can receiveannual eye exams under normal TRICAREoutpatient benefits.

Except for active duty service members(ADSMs), lenses or eyeglasses are onlycost-shared for treatment of infantileglaucoma, keratoconus, dry eyes, andirregularities in the shape of the eye.

For Infants:No copayment • One eye and vision

screening by thebeneficiary’s PCMduring routine examat birth and 6 monthsof age. Exam toinclude screening forvisual acuity, ocularalignment, and redreflex along withexternal examinationfor ocularabnormalities.

For Adults andChildren Age 3 andover:No copayment • One comprehensive

eye exam by aspecialist(ophthalmologist oroptometrist) includingscreening for visualacuity and glaucomaevery two years.

• Diabetic patients atany age are coveredfor one compre-hensive eye examyearly.

For Children:Covered under Well-Child Care benefit. Applicable cost-shareand deductible apply.• One eye and vision

screening by aTRICARE networkprovider duringroutine exam atbirth and 6 monthsof age.

• Two comprehensiveeye exams byspecialist(ophthalmologist oroptometrist) foramblyopia (visionloss) and strabismus(cross eye) between3-6 years of age.

For Adults:Not covered

For Children:Covered under Well-Child Care benefit. Applicable cost-shareand deductible apply.• One eye and vision

screening by aTRICARE networkprovider duringroutine exam atbirth and 6 monthsof age.

• Two comprehensiveeye exams byspecialist(ophthalmologist oroptometrist) foramblyopia (visionloss) and strabismus(cross eye) between3-6 years of age.

For Adults:Not covered

Clinical Preventive Services

*TRICARE Prime beneficiaries may receive clinical preventive services from any network provider without a referral orpre-authorization.


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Immunizations Age appropriate doses of vaccinesrecommended and adopted by the Centerfor Disease Control (CDC) AdvisoryCommittee on Immunization Practices(ACIP). Refer to CDC’s homepage(www.cdc.gov) for a current schedule ofrecommended vaccines.

Immunizations for Overseas Travel: Seeinformation listed in the Outpatient ServicesOutside of the MTF section of these charts.

No copayment Applicable cost-shareand deductible apply.

Applicable cost-shareand deductible apply.

Patient and Parent Education or Counseling Services The following education or counselingservices are covered when included as partof an office visit: dietary assessment andnutrition; physical activity and exercise;cancer surveillance; safe sexual practices;tobacco, alcohol, and substance abuse;accident and injury prevention; promotingdental health; stress, bereavement, andsuicide risk assessment.



Periodic Screening ExaminationsBeneficiaries will be offered age- andgender-appropriate screening tests for theearly detection of disease and/or diseaserisk factors, including:

Cancer Screening: Annual screeningmammograms for women over the age of39, (for high-risk baseline at 35 years, thenannually); Pap smears (see below);proctosigmoidoscopy or sigmoidoscopy(once every 3-5 years beginning at age 50);colonoscopy (every 2 years beginning atage 25 or 5 years younger than the earliestage of diagnosis for colon rectal cancer,whichever is earlier, and then annually afterage 40 for individuals with hereditary non-polyposis colon rectal cancer syndrome.Individuals with familial risk of sporadiccolon rectal cancer (i.e. individuals withfirst degree relatives with sporadic colonrectal cancer or adenomas before the age of60 or multiple first degree relatives withcolon rectal cancer or adenomas) mayreceive a colonoscopy every 3 to 5 yearsbeginning at age 10 years earlier than theyoungest affected relative), and fecal occultblood testing (annually age 50 and above);skin cancer exams (for high-risk individualswith family history or increased exposure tosunlight)



Clinical Preventive Services (continued)




Routine Pap Smears: Annually starting atage 18 (or younger if sexually active) untilthree consecutive satisfactorily normalannual examinations. Frequency may beless often at the discretion of the patient andthe clinician, but not less than every threeyears.

Infectious Disease Screening: Screeningfor Hepatitis B, Rubella antibodies, andHIV and screening and/or prophylaxis fortetanus, rabies, Rh immune globulin,Hepatitis A&B, meningococcal meningitis,and tuberculosis

Cardiovascular: Cholesterol (once every 5years beginning at age 18) and bloodpressure (children: annually between ages3-6 and every 2 years thereafter; adults:minimum every 2 years)

Hearing: Preventive hearing screenings forall high risk neonates as defined by theJoint Committee on Infant Hearing. Anewborn audiology screening should beperformed on high-risk newborns prior tohospital discharge or within the first threemonths. Evaluative hearing tests may beperformed at other ages during routineexams.

Other: Assessment of risk for leadexposure by structured questionnaire(during each Well-Child Care visit from 6months to 6 years); blood lead test for allchildren determined to be high-risk

No copayment Applicable cost-shareand deductible applywhen service isincluded as part of acancer screening visit.

Applicable cost-shareand deductible applywhen service isincluded as part of acancer screeningvisit.

Well-Child Care Well-Child Care (birth to 6 years) includesroutine newborn care; comprehensive healthpromotion and disease prevention exams;vision and hearing screenings; height,weight, and head circumference; routineimmunizations; and developmental andbehavioral appraisal in accordance with theAmerican Academy of Pediatrics (AAP)and CDC guidelines.



Clinical Preventive Services (continued)


Hepatitis B Screening and Vaccines

For Hepatitis B Surface Antigen (HBsAg):

• Screenings for pregnant women during prenatalperiod

• Infants born to HBsAg-negative mothersreceive Hepatitis B vaccine as recommended bythe American Academy of Pediatrics (AAP)

• Infants born to HBsAg-positive mothers receiveHepatitis B Immune Globulin (HBIG) asrecommended by the AAP

High-risk adults and children receive Hepatitis Bvaccine as recommended by the Center forDisease Control Advisory Committee onImmunization Practices. There is no copaymentfor TRICARE Prime. Applicable cost-share anddeductible apply for TRICARE Extra andTRICARE Standard when the service is includedas part of a cancer screening visit.

Maternity Care

TRICARE helps pay for maternity care duringpregnancy, delivery of the baby, and up to sixweeks after the baby is born. Prenatal care isimportant, and TRICARE strongly recommendsthat those who are pregnant, or who anticipatebecoming pregnant, seek appropriate medicalcare. If TRICARE eligibility ends during thepregnancy (for example, due to discharge ofsponsor), TRICARE does not cover anyremaining maternity care unless the familyqualifies for the Transitional AssistanceManagement Program (TAMP) or has enrolled inthe Continued Health Care Benefits Program(CHCBP).

Family-centered Care

The new family-centered care program offersfamilies services starting with the first obstetric(OB) visit and continuing after the birth of thechild. In creating the family-centered careprogram, the military services combine theirexpertise to offer patients a world-class OBbenefit while upholding the military’s uniqueability to assist family members whose sponsorsare deployed. Family-centered care gives you:

• Respect for your emotional well-being, privacy,and personal preferences

• Empowerment through honoring your family’spersonal and cultural beliefs

• Choices in treatment, including painmanagement, drugs, and tests used before,during, and after childbirth and newborn care

• Flexibility to welcome fathers, significantothers, and siblings to be a part of yourchildbirth experience

Your local MTFs are committed to beingresponsive to your needs and have implementedseveral initiatives that include:

• Improved continuity of providers for prenatalcare

• Careful, seamless coordination betweenfacilities if you need to relocate during yourpregnancy

• Personalized pain management

• Individualized birth plans

• Improved access to first trimester appointments

• Individualized prenatal education

• Private postpartum rooms

• Lactation education and support

Some facilities have even instituted “storkparking” and allow you to schedule follow upappointments before you leave the clinic. Beforechecking into the civilian network for maternitycare and delivery options, we encourage you tovisit your local MTF. Military facilities offer anextended “family” who understand theuniqueness of military life.


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1. Requires prior authorization.2. TRICARE Standard beneficiaries may have to pay up to 15 percent over the maximum allowable charge when the provider

does not accept assignment (balance billing). Treatment must be provided by TRICARE-authorized institutional providers.3. Cost-share and daily inpatient charges are subject to change at the beginning of each fiscal year (October 1–September 30).4. NAS Note: A nonavailability statement (NAS) is required for all nonemergency inpatient admissions with TRICARE Extra and

TRICARE Standard. This does not apply to admissions to RTC, PHP, and SUDRF facilities.5. All services provided by Pastoral Counselors or Licensed Professional Counselors (LPCs) must be referred and supervised by

a physician (M.D. or D.O.).

Behavioral Health Care Services

Services Covered TRICARE Prime TRICARE Extra TRICARE Standard

Outpatient Behavioral Health(1)(5)

Outpatient psychotherapy is limited toa maximum of two psychotherapysessions per week in any combinationof individual, family, collateral, orgroup sessions.

Individual & FamilyTherapy:ADFM: No copayment


Group Therapy:ADFM: No copayment


Cost-share afterdeductible has beensatisfied:



Cost-share afterdeductible has beensatisfied:

ADFM: 20% of theTRICARE allowedamount

Retirees and others:25% of the TRICAREallowed amount

Medication Management No prior authorization is required. (CPT code 90862)

ADFM: No copayment



Hospitalization for MentalIllness(1)(2)(3)(4)

Up to 30 days per fiscal year (October 1–September 30) for age 19and over; up to 45 days per fiscal yearfor age 18 and under. The ResidentialTreatment Center benefit is up to 150days per fiscal year for children andadolescents (as medically orpsychologically necessary).

ADFM: No copayment

Retirees and others:$40 per day (Nocopayment forseparately billedprofessional charges.)

ADFM: $20 per day($25 minimum charge)

Retirees and others:20% cost-share ofcontractedreimbursement forinstitutional services,plus 20% cost-share ofseparately billedprofessional charges,based on contractedreimbursement.

ADFM: $20 per day($25 minimum charge)

Retirees and others:25% cost-share ofallowable charges forseparately billedprofessional charges,plus, one of thefollowing:Inpatient High VolumeHospital: 25% hospitalspecific per diem Inpatient Low VolumeHospital: Lower of fixeddaily amount or 25%hospital billed charges RTC: 25% of theTRICARE allowed amount Partial Hospitalization:25% of the TRICAREallowed amount

Substance Use Treatment (InpatientPartial Hospital Program)(1)(2)(3)(4)

Up to seven days for detoxification andup to 21 days for rehabilitation per 365days. Maximum of one rehabilitationprogram per year and three per lifetime.Detoxification and rehabilitation dayscount toward inpatient day limit.


Partial Hospitalization – Mental Illness(1)(2)(3)

Up to 60 days per fiscal year (October1–September 30). Minimum of threehours per day, five days per week oftherapeutic services.


ADFM represents the active duty family member responsibility.

Getting Behavioral Health Care

You are encouraged to receive behavioral healthcare from an MTF. However, access may belimited due to space-availability issues or theMTF’s ability to render the care needed. When aservice is not available at an MTF, you may seekbehavioral health care from a network provider.Before you do, please check with your primarycare manager or TriWest to make sure you have allrequired referrals and authorizations. This willensure you receive the correct benefit payment.

TRICARE Pharmacy Program

TRICARE provides a world-class pharmacybenefit. TRICARE beneficiaries, includingMedicare-eligible beneficiaries age 65 and over,are eligible for the TRICARE PharmacyProgram, and can fill prescription medications atMTF pharmacies, through the TRICARE MailOrder Pharmacy (TMOP), and at retail networkand non-network pharmacies. To have aprescription filled, you will need a writtenprescription and a valid uniformed services IDcard. If you are Medicare-eligible and turned age65 on April 1, 2001, or later, you must beenrolled in Medicare Part B.

Generic Drug Use Policy

It is DoD’s policy to substitute genericmedications for brand-name medications whenavailable. Brand-name drugs that have a genericequivalent may be dispensed only if theprescribing physician is able to justify medicalnecessity for use of the brand-name drug in placeof the generic equivalent. If a generic equivalentdrug does not exist, the brand-name drug will bedispensed at the brand-name copayment.

Drug/Medication Coverage

The DoD Pharmacy and Therapeutics Committeehas established quantity limits on certainmedications, which means that DoD will payonly for up to a specified quantity per 30-, 60-,or 90-day supply. Quantity limits are applied toaddress the problem of overuse of medicationsthat can be unsafe for you and costly to thegovernment. Exceptions to established quantitylimits can be made if the prescribing physician isable to justify medical necessity. Additionally,

some drugs require prior authorization. For ageneral list of prescription drugs that are coveredunder TRICARE and for drugs requiring priorauthorization or quantity limits at TRICAREretail network pharmacies, visit www.express-scripts.com/TRICARE or call toll-free 1-866-DoD-TRRx (1-866-363-8779).

TRICARE Pharmacy Options

MTF Pharmacies

Prescriptions may be filled (up to a 90-day supplyfor most medications) at an MTF pharmacy free ofcharge. Each facility is required to make availablethe medications listed in the DoD basic coreformulary. The MTF may add additionalmedications to its local formulary based on thescope of care at that MTF. Beneficiaries shouldcontact their local MTF for specific details aboutfilling and refilling prescriptions at its pharmacy.MTF pharmacies will accept written prescriptionsfrom any TRICARE-authorized provider.

TRICARE Mail Order Pharmacy

The TRICARE Mail Order Pharmacy (TMOP) isavailable for prescriptions that you take on aregular basis. You may receive up to a 90-daysupply for most medications. TMOP isadministered by Express Scripts, Inc. TMOPallows you to mail your written prescription, alongwith the appropriate copay to TMOP, and themedications will be sent directly to you.Prescriptions may be refilled by mail, phone, oronline. For more information about how to useTMOP, visit the TRICARE Web site atwww.tricare.osd.mil/pharmacy/tmop.cfm orcontact TMOP member services toll-free at 1-866-DoD-TMOP (1-866-363-8667) within the U.S., or1-866-ASK-4PEC (1-866-275-4732) outside theU.S. You may also visit the Express Scripts Website at www.express-scripts.com/TRICARE.

TRICARE Retail Pharmacy Network

You may have prescriptions filled at any civilianretail network pharmacy for a small copayment.The TRICARE Retail Pharmacy Network isadministered by Express Scripts, Inc. For moreinformation, or to locate a TRICARE networkpharmacy near you, contact Express Scripts atwww.express-scripts.com/TRICARE or 1-866-DoD-TRRx (1-866-363-8779).


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Non-network Pharmacies

Filling prescriptions at a non-network pharmacyis the most expensive option and is notrecommended. You may have to pay for the totalamount first and file a claim to receive a partialreimbursement.

Pharmacy Copayments

Pharmacy Data Transaction Service

The Pharmacy Data Transaction Service (PDTS)creates a global centralized data repository thatrecords information about prescriptions filled forTRICARE beneficiaries at MTFs, the TRICAREretail pharmacy network, and through TMOP.PDTS improves the quality of prescription servicesand enhances patient safety by conducting anonline clinical screening against your completemedication history for each new or refilledprescription in real-time before it is dispensed.

*Please see the description of point-of-service (POS) in thesection entitled, “Understanding TRICARE Costs and Fees.”

Place of Service Generic Brand Name

MTF Pharmacy $0 $0

TMOP (up to a90-day supply)

$3 $9

Retail NetworkPharmacy (up to a 30-day supply)

$3 $9

Non-networkPharmacy

1. $9 or 20% of total cost(whichever is greater)

2. Existing deductibles andpoint-of-service* (POS)penalty apply: E-4 andbelow, TRICARE Standard,$50 per person/$100 perfamily; E-5 and above,TRICARE Standard, $150per person/$300 per family;TRICARE Prime, $300 perperson/$600 per family, POSpenalty–50%.


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Below you will find a list of medical, surgical,and behavioral health care services generally notcovered under TRICARE. The items here are notintended to be all-inclusive. To contact TriWest,visit their Web site at www.triwest.com, or visitthe TRICARE Web site at www.tricare.osd.milfor more information.

Services or Procedures withSignificant Limitations

Abortions—Abortions are only covered whenthe mother’s life is in danger. The attendingphysician must certify in writing that theabortion was performed because a life-threatening condition existed. Medicaldocumentation must be provided.

Cardiac and Pulmonary Rehabilitation—Bothare only covered for non-hospital based cardiacrehabilitation programs and phase III cardiacrehabilitation for lifetime maintenance performedat home or in medically supervised settings.

Chiropractic Care—Coverage is limited toactive duty service members and is onlyavailable at specific military treatment facilitiesunder the Chiropractic Care Program. Visit theTRICARE Web site atwww.tricare.osd.mil/chiropractic for moreinformation.

Cosmetic, Plastic, or ReconstructiveSurgery—Only covered when used to restorefunction, correct a serious birth defect, restorebody form after a serious injury, improveappearance of a severe disfigurement, or after amedically necessary mastectomy.

Cranial Orthotic Device or Molding Helmet—Cranial orthotic devices are excluded fortreatment of nonsynostic positionalplagiocephaly.

Dental Care and Dental X-Rays—Both arecovered only for adjunctive dental care.

Limitations and Exclusions

Dental Anesthesia and Facility Charges—Covered only to safeguard a patient’s life.

Education and Training—Education andtraining may be covered under the PFPWD.Outpatient diabetic self-management and trainingprograms are covered when the services areprovided by a TRICARE authorized individualprovider who also meets national standards fordiabetes self-management education programsrecognized by the American DiabetesAssociation (ADA). The provider’s “Certificateof Recognition” from the ADA must accompanythe claim for reimbursement.

Eyeglasses or Contact Lenses—Both arecovered under limited circumstances such ascorneal lens removal.

Food, Food Substitutes or Supplements, orVitamins—Not covered outside of a hospitalsetting.

Gastric Bypass—To be covered, you must be100 pounds over ideal body weight and have aco-morbidity or 200 percent of ideal body weightwith no co-morbidity.

Genetic Testing—Genetic testing is onlycovered under certain conditions.

Hearing Aids—Hearing aids are covered underthe PFPWD.

Intelligence Testing—Only covered whenmedically necessary for the diagnosis ortreatment planning of covered psychiatricdisorders.

Marital Therapy and/or CouplesCounseling—Beneficiaries for whom thistreatment modality is authorized must have acovered DSM-IV primary diagnosis, and themarital or couples therapy must be medicallynecessary.

Private Hospital Rooms—Not covered unlessordered for medical reasons, or a semi-privateroom is not available. Hospitals that are subjectto the TRICARE diagnosis-related group (DRG)payment system may provide the patient with aprivate room, but will only receive the standardDRG amount. The hospital may bill the patientfor the extra charges if the patient requests aprivate room.

Smoking Cessation—Not a covered serviceexcept for certain TRICARE Prime Remoteactive duty service members who meet specificcriteria.

Weight Reduction—Only covered whenpsychiatric or psychological evaluations areconducted to assess appropriateness for coveredsurgical gastric procedures.

Exclusions

The following services are excluded under anycircumstance:

• Acupuncture

• Artificial insemination

• Autopsy services or post-mortem examinations

• Care that is not medically or psychologicallynecessary

• Birth control (non-prescription)

• Camps (such as those for diabetics or obesepersons)

• Care or supplies furnished or prescribed by animmediate family member

• Diagnostic admissions

• Experimental or unproven procedures

• Foot care (routine)

• Laser/LASIK/Refractive corneal surgery

• Learning disabilities

• Megavitamins and orthomolecular psychiatrictherapy

• Mind expansion and elective psychotherapy

• Naturopaths

• Psychiatric treatment for sexual dysfunction

• Sex changes or sexual inadequacy treatment

• Telephone counseling consultation


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Review the benefits and coverage charts in thesection entitled “What TRICARE Covers” formore information about specific cost-shares andcopayments for TRICARE-covered services.

TRICARE Annual Deductible

There is no annual deductible for TRICAREPrime or TRICARE Prime Remote (TPR) andTRICARE Prime Remote for Active DutyFamily Members (TPRADFM). (However, thereis a deductible if a TRICARE Prime orTPRADFM beneficiary exercises the point-of-service [POS] option.)

TRICARE Extra and TRICARE Standardbeneficiaries are required to meet an annualdeductible for outpatient services. Thedeductibles are as follows:

• Active duty family members (ADFMs) E-4 andbelow: $50/person or $100/family per fiscal year

• All retirees and active duty family members E-5 and above: $150/person or $300/family per fiscal year

TRICARE Prime Point-of-Service Option

The TRICARE Prime POS option applies to allnon-referred, nonemergency services received byTRICARE Prime and TPRADFM beneficiaries.The POS deductible applies only to outpatientservices, and the cost-share applies to bothinpatient and outpatient services. TRICAREreimbursement is limited to 50 percent of theTRICARE allowable charge. The POS optionalso applies to prescription drugs. If you takeyour prescription into a non-network pharmacy,you will pay more. POS cost-sharing anddeductible amounts do not apply if you haveother health insurance (OHI). The POSdeductibles and cost-shares are as follows (for allbeneficiary categories):

Deductibles: $300 per individual/$600 per family

Cost-share: 50 percent of the TRICARE allowable charge

Catastrophic Cap Benefit

The catastrophic cap limits your out-of-pocketliability on copayments, cost-shares, anddeductibles. The catastrophic cap by beneficiarycategory is as follows:

• ADFMs using TRICARE Standard—$1,000 perfiscal year

• All other beneficiaries using TRICAREStandard (retirees, family members of retirees,survivors, former spouses)—$3,000 per fiscalyear

• ADFMs using TRICARE Prime—$1,000 perfiscal year

• All other beneficiaries using TRICARE Prime(retirees, family members of retirees, survivors,former spouses)—$3,000 per fiscal year

TRICARE Prime POS option and theCatastrophic Cap

For unauthorized care, the TRICARE Prime POSdeductible is $300 per person and $600 perfamily. The beneficiary cost-share is 50 percentof the allowable charges after the deductible.

The TRICARE Prime beneficiary’s out-of-pocketcost while utilizing POS is accrued against thecatastrophic cap. However, there is no cap onPOS out-of-pocket expenses. The beneficiarycost-share will remain at 50 percent of theTRICARE allowable charge even after thecatastrophic cap has been reached.

Other Health Insurance

TRICARE is the secondary payer to all healthbenefits and insurance plans, except forMedicaid, TRICARE supplements, the IndianHealth Service, and other programs or plans asidentified by the TRICARE ManagementActivity (TMA). If you have other healthinsurance (OHI), you are not required to obtainreferrals or prior authorizations for coveredservices, except for adjunctive dental care, thePFPWD, stem cell and organ transplants, and

Understanding TRICARE Costs and Fees


behavioral health care services. A former spousecovered by an employer-sponsored OHI plan isnot eligible for TRICARE.

After OHI has covered its portion of the bill,TRICARE will review your claims to determineif any additional payment should be made. TheOHI payment methodology for all primarycoverage EXCEPT Medicare is that once yourprovider has received the full TRICAREallowable charge from any source (includingyour OHI and our payment), they have receivedall the money available. Watch your TRICAREexplanation of benefits for “BeneficiaryResponsibility.” Always submit all claims toTRICARE because deductibles may be appliedto your annual catastrophic cap. Your provider

may submit secondary claims for you. If you aresubmitting a secondary claim, you must includeDD Claim Form 2642 (available online atwww.triwest.com). Send your itemized bill and acopy of the OHI’s explanation of benefits to:

West Region ClaimsP.O. Box 77028Madison, WI 53707-7028

Please inform your provider and TriWest if youhave OHI so that your benefits can becoordinated and so there is no delay in paymentof claims.

Third Party Liability

The Federal Medical Recovery Act allowsTRICARE to be reimbursed for its costs oftreating you if you are injured in an accident thatwas caused by someone else. The DD Form2527 Statement of Personal Injury Third PartyLiability Form will be sent to you if a claim isreceived that appears to have third party liabilityinvolvement. Within 35 calendar days, you mustcomplete and sign this form and follow thedirections for returning the form to theappropriate claims processor. The DD Form2527 is available through the TriWest Web site atwww.triwest.com.

TRICARE Explanation of Benefits

A TRICARE explanation of benefits (EOB) is astatement sent to you showing what action hasbeen taken on your TRICARE claims. An EOBis sent to you for your information and files. AnEOB is not a bill. After reviewing the EOB, youhave the right to appeal certain decisionsregarding your claims and must do so in writingwithin 90 days of the date of the EOB notice.You should keep EOBs with your healthinsurance records for reference.

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Payment of health care-related claims in a timelymanner is important. One of the benefits of beingenrolled in TRICARE Prime is that there arevirtually no claims for you to file. Your networkprimary care manager (PCM) will file claims onyour behalf, and all TRICARE network providersare required to file claims for beneficiaries usingTRICARE Extra. However, beneficiarieschoosing TRICARE Standard using non-networkproviders may be required to file their own claims.

By using the following checklist, you can help tomake sure your claims are paid in a timelymanner:

• Update DEERS for yourself and/or your familyregularly.

• Call your PCM first for all health care needs. Inthe case of an emergency, go immediately tothe emergency room or dial 911 and notify yourPCM within 24 hours for potential follow-upcare.

• Ensure authorizations and/or referrals havebeen obtained before receiving care.

• When receiving care, show both your militaryand TRICARE Prime identification cards.

• If you have other health insurance (OHI), youmust follow the OHI rules when receivingservices outside of the military treatmentfacility (MTF), or TRICARE coverage may berestricted or denied.

• Be sure to follow the OHI rules forauthorization.

• Before seeking care you must contactyour OHI plan to obtain any requiredauthorization for non-MTF services, andto help ensure those services are receivedfrom an OHI company network provider.

• Claims for services must be submitted tothe OHI plan by you or your provider.

• After the OHI plan makes payment onthe claim, you or your provider maysubmit a secondary claim to TRICARE,which will determine if an additionalpayment may be made based on itscoverage.

• For assistance in contacting the OHI planor filing a secondary claim, call 1-888-TRIWEST (1-888-874-9378).

• See detailed information about OHI inthe section entitled “UnderstandingTRICARE Costs and Fees.”

TRICARE Prime enrollees will receive mostmedical care from an MTF or network provider. Onoccasion, you may be referred to a non-networkprovider if the needed medical care is not availablein the network, or you may receive services from anon-network practitioner at a hospital. Some non-network providers are allowed to bill a TRICAREPrime enrollee for amounts over what TRICAREpays (not to exceed the TRICARE allowable chargeby 15 percent). This is called “balance billing.” Aprovider who accepts assignment will file the claimfor the enrollee and receive payment directly fromTRICARE. They will not balance bill.

In the event you receive a bill or pay forauthorized services from a non-network provider,submit a copy of the bill and the followinginformation on the DD Claim Form 2642 orCMS Form 1500. These forms are available onwww.triwest.com:

• The sponsor’s name, address, Social Securitynumber, date of birth, and the name of thepatient

• The name and address of the provider of serviceand date(s) of services (if not on the bill)

• A brief explanation of why you needed care,including the diagnosis, if you know it

Where to Send Claims

All claims, including claims for active dutyservice members, should be sent to the followingaddress:


The reimbursement you receive, if any, will beconsistent with TRICARE coverage provisions.If you need assistance with a claim or havequestions, please call TriWest at 1-888-TRIWEST (1-888-874-9378).

Your TRICARE Claims

Claims for Dual-EligibleBeneficiaries (Medicare and TRICARE)

Wisconsin Physicians Service (WPS) is theclaims processor for all claims for beneficiarieswho are eligible for both TRICARE andMedicare. Claims are submitted on your behalfby your provider and you will receive anexplanation of benefits (EOB) from WPS afterthe claims processing has been completed. Thechart below contains important contactinformation for you regarding dual-eligibleclaims.

Submitting Claims WhileTransitioning to the TRICAREWest Region

As the current TRICARE regions transition tothe new TRICARE West Region, it is importantthat you and/or your provider pay carefulattention to the dates of service, the currentregion in which you are receiving care, and thetransition dates in order to file with the correctclaims processor. Network providers currently inthe Health Net provider network should followHealth Net instructions for service dates prior toJune 1, 2004. The regions and transition datesare described below.

Washington, Oregon, and Northern Idaho

All non-network claims with dates of serviceprior to June 1, 2004, should continue to be sent to WPS at the current address until August 31, 2004. On and after September 1, 2004, all claims with dates ofservice of June 1, 2004, or after should be sent to:


California, Alaska, and Hawaii

All non-network claims with dates of serviceprior to July 1, 2004, should continue to be sentto Palmetto Government Benefits Administrators,LLC (PGBA) at the current address untilSeptember 30, 2004. On and after October 1, 2004, all claims with dates of serviceof July 1, 2004, or after should be sent to:



Claims Submission WPS TRICARE For LifeP.O. Box 7890 Madison, WI 53707-7890

Appeals WPS TRICARE For LifeAttn: Appeals P.O. Box 7490 Madison, WI 53707-7490

Program Integrity WPS TRICARE For LifeAttn: Program Integrity P.O. Box 7516 Madison, WI 53707-7516

Third PartyLiability

WPS TRICARE For LifeAttn: Third Party LiabilityP.O. Box 7897 Madison, WI 53707-7897

Refunds WPS TRICARE For LifeAttn: Refunds P.O. Box 7928 Madison, WI 53707-7928

Customer Service WPS TRICARE For LifeP.O. Box 7889 Madison, WI 53707-7889

Toll-free 1-866-773-0404

Toll-free TDDTelephone

1-866-773-0405

Online www.tricare4u.com

Central Region

All non-network claims with dates of serviceprior to October 1, 2004, should continue to besent to PGBA at the current address untilDecember 31, 2004. On and after January 1, 2005, all claims with dates of serviceof October 1, 2004, and after should be sent to:


Network providers currently in the TriWestprovider network should send all claims with

service dates prior to October 1, 2004, to PGBAat the current address until April 1, 2005.Beginning April 1, 2005, all claims with servicedates prior to October 1, 2004, should be sent to:


The reimbursement you receive, if any, will beconsistent with TRICARE coverage provisions.If you need assistance with a claim or havequestions, please call TriWest at 1-888-TRIWEST (1-888-874-9378).

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Appealing a Decision

An appeal is a dispute with certain paymentand/or coverage decisions made by TRICARE.There are two types of appeals: a factual denial(i.e. non-covered service) and an appeal of adenial of services based upon medical necessity.You have the right to appeal the decisionsTRICARE makes regarding the payment ofclaims. Additionally, there is a separatemechanism for appealing the denial forauthorization of services based upon a medicalnecessity review.

Appeal of a Claim

This appeal is based on the denial of benefitsduring claims processing. To appeal a claimsdecision, submit your appeal in writing to:

TriWest Healthcare AllianceClaims AppealsP.O. Box 86036Phoenix, AZ 85080

You must file your appeal within 90 days of thedate on the explanation of benefits (EOB). Besure to include a copy of the EOB along withany materials you feel will explain your reasonsfor the appeal.

You may appeal the payment of a claim underthe point-of-service (POS) option if you believethe care was an emergency. In this case, markyour appeal “POS Claims Appeals” and send to:

TriWest Healthcare AllianceAttn.: POS Claims AppealsP.O. Box 42049Phoenix, AZ 85080

Appeal of a Medical Decision

When a service request is denied for lack ofmedical necessity, you will receive writtennotification of the decision, including yourappeal rights. These services may include areferral, a procedure or continued stay in a

medical facility. This type of appeal is basedupon medical necessity and follows a differentprocess from a claims appeal. There are twolevels of appeal: a reconsideration of a denial ofan authorization and an appeal of areconsideration. When TriWest denies servicesbased on a medical necessity review, the providerand beneficiary are automatically notified inwriting. The notification includes an explanationof what was denied and the reasoning behindthat decision. You can request an appeal of thedenial of a care approval or reconsideration bysending your request in writing to:

TriWest Healthcare AllianceAttn.: Reconsideration UnitP.O. Box 42049Phoenix, AZ 85080

Grievances

A grievance is a written formal complaint aboutservice or care. You may file a grievance aboutsuch items as quality of care, quality andavailability of service, timeliness of services,appropriateness of care, and inappropriatebehavior on the part of a health care provider.

It is best to resolve your complaint with yourhealth care provider. If the provider is unable tohelp you, you may submit your grievance inwriting to TriWest for resolution. All grievancesshould be addressed to:

TriWest Healthcare AllianceAttn.: Customer Relations Dept.P.O. Box 42049Phoenix, AZ 85080

You will receive an interim written responsewithin 30 days if the grievance is not resolved,and a final written notification of the resultswithin 60 days.

Ensuring Customer Satisfaction


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Assistance with Collection Activities

Debt Collection Assistance Officers (DCAOs)are located at the TRICARE Regional Office–West and each military treatment facility (MTF)to assist you in resolving health care collection-related issues. Questions about billing should beaddressed to TriWest.

You must bring or submit documentationassociated with a collection action or adversecredit rating to the DCAO for assistance. Thisincludes debt collection letters, explanations ofbenefits statements, and medical/dental billsfrom providers. The more information you canprovide, the faster it will be to determine thecause of the problem. The DCAO will researchyour claim, provide you with a written resolutionof your collection problem, and inform thecollection agency that action is being taken toresolve the issue.

DCAOs cannot provide legal advice or fix yourcredit rating, but they can help you through thedebt collection process by providing

documentation for the collection or credit-reporting agency in explaining the circumstancesrelating to the debt. To find a DCAO near you,visit the DCAO directory online atwww.tricare.osd.mil/DCAO.

Fraud and Abuse

Anyone can identify potential fraud and abuse.Please be alert to anything that “doesn’t lookright.” Call 1-888-584-9378 or fax 1-602-564-2458 to anonymously report suspected fraudand/or abuse and give as much information aspossible. Types of activities that should bereported include:

• A provider billing for services when serviceswere not rendered

• Services billed do not match the servicesrendered

• A provider waiving copayments or deductibles

• Someone you know is not TRICARE eligiblebut is receiving benefits


Regional Information Resources

Through the enhanced interactive customerservice features of TriWest’s Web site,www.triwest.com, and TriWest’s InteractiveVoice Response (IVR) system, you will be ableto conduct most of your business with TriWestfrom your personal computer or telephone.

TriWest Web Sitewww.triwest.com

All TRICARE beneficiaries have access to themost current TRICARE information throughTriWest’s Web site. You will be able to conductmost of your business with TriWest withoutleaving home. You will be able to:

• Determine the status of a claim, receiveinformation about the payment of a previouslyprocessed claim, and obtain a duplicateexplanation of benefits (EOB) for claims thathave been processed

• Verify your eligibility or eligibility for a familymember by checking the Defense EnrollmentEligibility Reporting System (DEERS)

• Check the current dollar amounts appliedtoward your out-of-pocket expense limits

• Learn about your TRICARE benefits byreviewing a list of frequently asked questions,utilizing a search engine, or by submitting aquestion electronically to TriWest

• Locate a network provider

• Visit your local military treatment facility(MTF) online (if the MTF has a Web page)

• Receive the latest regional updates from theTRICARE West Regional Office staff

You will also find a monthly feature of specialtopics: weekly TRICARE program updates;provider directory updates; the latest TRICAREand TriWest news; a new Healthy Living section;review the rules of Other Health Insurance(OHI), and keep your records up-to-date; findcontact information for your local militarytreatment facility; receive the latest regionalupdates from the TRICARE Regional Office–West staff.

Interactive Voice Response System1-888-TRIWEST (1-888-874-9378)

When you dial 1-888-TRIWEST (1-888-874-9378), TriWest’s Interactive VoiceResponse (IVR) System will quickly route yourrequests and inquiries to the most appropriatecustomer service representative and will offer anautomated self-service option for accessingrecorded routine information. You will speakyour menu requests rather than using thetelephone keypad. The convenient, voice-activated IVR system will be available aroundthe clock, 24 hours a day, seven days a week.You will be able to access personalizedinformation regarding eligibility; benefits andhealth care plan guidelines; claim status; and feepayments, cost-shares, and deductibles. If youprefer, you will also be able to speak with acustomer service representative.

TriWest’s customer service representatives areavailable Monday–Friday 8 a.m. to 6 p.m. in allWest Region time zones to assist you.

For Information and Assistance


National Information Resources

TRICARE Web Sitewww.tricare.osd.mil

You can consult TRICARE’s trusted onlineresource for the most up-to-date informationabout TRICARE. Learn about TRICAREprogram options, policies and guidance, and thelatest news and events.

TRICARE Onlinewww.tricareonline.com

The Department of Defense’s (DoD’s) Internetportal to TRICARE and health care information,TRICARE Online is available to all TRICAREbeneficiaries. Registered users can even bookappointments online.

TRICARE Information Service1-888-363-CARE (1-888-363-2273)

Customer service representatives are availableMonday–Friday (except federal holidays) from 8 a.m. to 8 p.m. Eastern Time to answer yourquestions. An interactive voice response (IVR)feature, available 24 hours a day, seven days aweek, works with the TRICARE InformationService and offers you access to commonlyrequested TRICARE eligibility information. Italso offers assistance finding the appropriatepartner call center for specific issues. With theTRICARE IVR, callers may request TRICAREinformation by saying the number of the optionthey wish to hear about or by using a touch-tonetelephone keypad.

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Common TRICARE Acronyms

ADFM Active Duty Family MemberADSM Active Duty Service MemberBCAC Beneficiary Counseling and

Assistance CoordinatorCHCBP Continued Health Care Benefit

ProgramDCAO Debt Collections Assistance

OfficerDEERS Defense Enrollment Eligibility

Reporting SystemDMDC Defense Manpower Data CenterDoD Department of DefenseDSO Defense Manpower Data Center

(DMDC) Support Office EOB Explanation of BenefitsHCF Health Care FinderHMHS Humana Military Healthcare

ServicesMHS Military Health SystemMTF Military Treatment FacilityNOAA National Oceanic and

Atmospheric AdministrationOHI Other Health InsurancePCM Primary Care ManagerPDTS Pharmacy Data Transaction

ServicePGBA PGBA, LLCPHS Public Health ServicePOS Point-of-ServiceRC Reserve ComponentSPOC Service Point of ContactTAMP Transitional Assistance

Management ProgramTDP TRICARE Dental ProgramTFL TRICARE For LifeTMA TRICARE Management ActivityTMOP TRICARE Mail Order PharmacyTPR TRICARE Prime RemoteTPRADFM TRICARE Prime Remote for

Active Duty Family MembersTRDP TRICARE Retiree Dental

ProgramTRO TRICARE Regional Office

TRRx TRICARE Retail Pharmacy Program

TSC TRICARE Service CenterUCCI United Concordia

Companies, Inc.USFHP Uniformed Services Family

Health PlanUSPHS United States Public Health

ServiceWPS Wisconsin Physicians Service

Beneficiary Tools


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Glossary of Terms

Allowable Charge, also TRICARE Allowable ChargeThe term “allowable charge” is themaximum amount TRICARE will authorizefor medical and other services furnished inan inpatient or outpatient setting. Theallowable charge is normally the lowest ofthe actual billed charge or the allowablecharge. For example, if the allowable chargefor a service is $90 and the billed charge is$50, TRICARE will pay $50 (actual billedcharge); if the billed charge is $100,TRICARE will pay $90 (the allowablecharge). In the case of inpatient hospitalpayments, the diagnosis-related group(DRG) is the TRICARE allowable charge ofthe billed amount regardless.

Authorized ProviderAn authorized provider is a hospital orinstitutional provider, a physician or otherindividual professional provider, or otherprovider of services meeting specificeducational, licensing, and otherrequirements. Authorized providers are notnecessarily network providers. TRICAREwill share costs if a beneficiary sees aprovider of this type.

Balance BillingA term used to describe when a providerbills a beneficiary for the rest of the charges.A beneficiary cannot be billed for theremainder or “balance” of the providercharges, after TRICARE (and other healthinsurance) has paid everything it’s going topay. A beneficiary is not legally responsiblefor amounts above 15 percent of theTRICARE allowable charge, even if theprovider is not network and does not acceptassignment of benefits. Network providersare prohibited from balance billing.

BeneficiaryA person who is eligible for TRICAREbenefits. Beneficiaries include active dutyservice members, active duty familymembers (ADFMs), retired service membersand their families. Family members include

spouses and unmarried natural orstepchildren up to the age of 21 (or 23 iffull-time students at accredited institutions oflearning). Other beneficiary categories arelisted in the section entitled “Eligibility forTRICARE.”

Beneficiary Counseling and AssistanceCoordinators (BCACs)Persons at military treatment facilities(MTFs) who are available to answerquestions, help solve health care-relatedproblems, and assist beneficiaries inobtaining medical care through TRICARE.BCACs were previously known as HealthBenefits Advisors or HBAs.

Catastrophic CapThe maximum out-of-pocket expenses forwhich TRICARE beneficiaries areresponsible in a given fiscal year (October1–September 30). The catastrophic cap foractive duty families is $1,000, and thecatastrophic cap for all other TRICAREeligible families is $3,000.

Certified ProviderA certified provider is one that meets all therequirements to be a TRICARE-authorizedprovider and has been “certified” to provideservices to TRICARE beneficiaries.“Authorized” and “certified” areinterchangeable terms.

CopaymentThe fixed amount a TRICARE Prime*enrollee will pay for care in the civilianprovider network. Active duty servicemembers and active duty family membersare not required to pay copayments forservices received from a network providerunder TRICARE Prime.

Cost-ShareThe percentage of the allowable charges abeneficiary will pay under TRICARE Extraand TRICARE Standard. The cost-sharedepends on the sponsor’s status—active dutyor retired.

*Includes TRICARE Prime Remote and TRICAREPrime Remote for Active Duty Family Members.


DeductibleThe annual amount a TRICARE Extra orTRICARE Standard beneficiary must pay forcovered outpatient benefits before TRICAREbegins to share costs. TRICARE Prime andTRICARE Prime Remote for Active DutyFamily Members (TPRADFM) beneficiariesdo not have an annual deductible, unless theyare utilizing their point-of-service (POS) option.

EnrolleeA TRICARE-eligible beneficiary who haselected to enroll in TRICARE Prime,TRICARE Prime Remote (TPR), orTRICARE Prime Remote for Active DutyFamily Members.

Explanation of Benefits (EOB)A statement sent to beneficiaries showingthat claims were processed and the amountpaid to providers. If denied, an explanationof denial is provided.

Health Care Finder (HCF)Representatives who help locate TRICAREproviders and applicable community, state,and federal health care resources forbeneficiaries who require benefits andservices beyond TRICARE.

Military Treatment Facility (MTF)A medical facility operated by the militarythat may provide inpatient and/or ambulatorycare to eligible TRICARE beneficiaries.MTF capabilities vary from limited acutecare clinics to teaching and tertiary caremedical centers.

Network ProviderA network provider is one who servesTRICARE beneficiaries by agreement withyour region’s contractor as a member of theTRICARE Prime network or any otherpreferred provider network or by any othercontractual agreement. A network provideraccepts the negotiated rate as payment in fullfor services rendered.

Nonavailability Statement (NAS)A certification from an MTF that a specifichealth care service or procedure cannot beprovided.

Non-network ProviderA non-network provider is one who has nocontractual relationship to provide care toTRICARE beneficiaries, but is authorized toprovide care to TRICARE beneficiaries. Anon-network provider must be authorized.There are two types of non-networkproviders—“participating” and “non-participating.”

Nonparticipating ProviderA nonparticipating provider is an authorizedhospital, institutional provider, physician, orother provider that furnishes medicalservices (or supplies) to TRICAREbeneficiaries, but who has not signed acontract with your regional contractor anddoes not agree to “accept assignment.” Anonparticipating provider may balance bill.

Other Health Insurance (OHI)Any non-TRICARE health insurance that isnot considered a supplement. This insuranceis acquired through an employer, entitlementprogram, or other source. Under federal law,TRICARE is the secondary payer to allhealth benefits and insurance plans, exceptfor Medicaid, TRICARE supplements, theIndian Health Service, or other programs orplans as identified by TRICAREManagement Activity (TMA).

Participating ProviderProviders who participate in TRICARE, alsocalled “accepting assignment,” and agree toaccept the TRICARE-determined allowablecost or charge as the total charge forservices—also known as the TRICAREallowable charge as the full fee for care. Inthe case of network providers, the negotiatedrate is considered the full fee for care. Non-network, individual providers mayparticipate on a case-by-case basis. Providersmay seek applicable copayments, cost-shares, and deductibles from the beneficiary.


Hospitals that participate in Medicare must,by law, also participate in TRICARE forinpatient care. For outpatient care, they mayor may not participate.

Point of Service (POS)An option that allows a TRICARE Primebeneficiary to obtain medically necessaryservices—inside or outside the network—from someone other than his or her primarycare manager, without first obtaining areferral or authorization. Utilizing the POSoption results in a deductible and greater out-of-pocket expenses for the beneficiary.

Pre-AuthorizationSee the definition for Prior Authorization.

Primary Care Manager (PCM)A TRICARE civilian network provider ormilitary treatment facility (MTF) providerwho provides primary care services toTRICARE beneficiaries. A PCM is eitherselected by the beneficiary or assigned by anMTF commander or his or her designatedappointee. To the extent consistent withgoverning state rules and regulations, PCMscan include internal medicine physicians,family practitioners, pediatricians, generalpractitioners, obstetricians, gynecologists,physician assistants, nurse practitioners, orcertified nurse midwives.

Note: TRICARE Prime Remote beneficiariesmay choose a TRICARE authorized providerif a network provider is not available.

Prime Service AreaFormerly was called catchment area definedto be within a 40-mile radius (determined byZIP code) of a military treatment facility(MTF). It now also includes areas containinga high concentration of TRICAREbeneficiaries and who are not within thecatchment area of an MTF. TriWest isrequired to offer TRICARE Prime in eachprime service area.

Prior AuthorizationA review determination made by a licensedprofessional nurse or paraprofessional forrequested services, procedures, oradmissions. Prior authorizations must beobtained prior to services being rendered orwithin 24 hours of an admission.

ReferralThe process by which a primary caremanager (PCM) refers a TRICARE Primebeneficiary to another professional orancillary provider for specialized medicalservices, prior to those services beingrendered.

Reserve Component (RC)The RC includes the Army National Guard,the Army Reserve, the Naval Reserve, theMarine Corps Reserve, the Air NationalGuard, the Air Force Reserve, and the U.S.Coast Guard Reserve.

Split EnrollmentRefers to multiple family members enrolledin TRICARE Prime in different TRICAREregions.

SponsorThe active duty service member (ADSM) orretiree through whom family members areeligible for TRICARE.

Supplemental InsuranceHealth benefit plans that are specificallydesigned to supplement TRICARE Standardbenefits. Unlike other health insurance (OHI)plans, TRICARE supplemental plans arealways secondary payers on TRICAREclaims. These plans are frequently availablefrom military associations and other privateorganizations and firms.

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Abortion, 25Abuse, 19, 33Accident, 19, 28Activated, 4, 6, 8Active duty family member, 4, 15, 22, 36Active duty service members, 4, 6-9, 12, 18,

25-26, 29, 36-37, 39Acupuncture, 25-26Adenomas, 19Allergy tests, 16Allowable charge, 8, 10, 15-17, 22, 27-29, 37-38Amblyopia, 18Ambulance services, 15Ambulatory surgical facility, 15Annual enrollment, 6-7Appeals, 28, 30, 32Artificial insemination, 25-26Assignment, 8, 15-17, 22, 29, 37-38Attending physician, 25Authorized provider, 8, 37, 39Authorized reimbursement, 7Autopsy services, 25-26

B

Baby, 21Balance Billing, 15-17, 22, 29, 37Behavioral health care, 6, 14, 22-23, 25, 28Beneficiary Counseling and

Assistance Coordinator, 36Billed charge, 37Birth, 5, 18, 20-21, 25-26, 29Birth control, 25-26Bone marrow transplants, 25Breast pumps, 25Breast reconstruction, 25

C

Camps, 25-26Cancer, 18-21, 25Caps, 14Cardiac rehabilitation, 25Catastrophic cap, 17, 27-28, 37Catchment area, 39CDC, 19-20CHCBP, 13, 21, 36Chiropractic Care Program, 25

Civilian facility, 17Claims, 5-6, 9, 25, 28-32, 34, 38-39Claims processing, 30, 32Clinical preventive services, 6, 16, 18-20Co-morbidity, 25-26Collection agency, 33Collection problem(s), 33Colon rectal cancer, 19Contact lenses, 25-26Copayment, 6-7, 10, 14-24, 27, 33, 37-38Cost-share, 13, 15-22, 27, 37Counseling services, 19Couples therapy, 26Covered services, 9, 14-15, 18, 26-27, 38

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Debt Collections Assistance Officer (DCAO), 33,36

Deductible, 6-7, 10, 13, 15-16, 18-22, 27,38-39

DEERS, 4-6, 9, 29, 34, 36Dental care, 10-11, 25, 27Dental treatment facilities, 11Detoxification, 22Diagnosis-related group, 26, 37Disability, 12, 14Disenrollment, 6Divorce, 5Doctor, 7Dual-eligible, 9, 30Durable Medical Equipment, 15

E

Education, 19, 21, 25-26Elective psychotherapy, 26Eligibility, 4-6, 8, 10-13, 21, 34-38Emergency, 7, 10-11, 14-15, 29, 32Enrollment, 4-7, 9-12, 18, 29, 34, 36-39Enrollment fees, 6-7, 10-12Explanation of benefits, 9, 14, 28, 30, 32, 34, 36,

38Express Scripts, Inc., 23Extended Care Health Option (ECHO), 12Eye examinations, 16, 18Eyeglasses, 11, 18, 25-26Eyesight-threatening emergency, 14


Index

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Family member, 1-16, 19, 21-22, 24-27, 29, 34,36-39

Fecal occult blood testing, 19Federal health care resources, 38Fee-for-service option, 8Fiscal year, 10, 17, 22, 27, 37Food, 25-26Food substitutes, 25-26Foot care, 25-26Former spouses, 4, 11, 13, 27Fraud, 33

G

Gastric bypass, 25-26Genetic testing, 25-26Glaucoma, 18Grievance, 32Gynecologists, 39

H

HBA, 37HBsAg, 21Health Benefits Advisors, 37Health Care Finder, 36, 38Hepatitis, 20-21HIV, 20Home health care, 16Hospice care, 17Hospital, 2, 5, 7, 17, 20, 22, 25-26, 29, 37-38Hospitalization, 17, 22

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ID card, 5, 23Indian Health Service, 27, 38Individual Ready Reserve, 10Infectious disease screening, 20Inpatient care, 10, 39

L

LASIK, 25-26Limited acute care clinics, 38

M

Mammograms, 19Managed care, 11Marriage, 5Mastectomy, 25Maternity care, 21

Medicaid, 27, 38Medical necessity, 23, 32Medicare, 4, 9, 11-12, 16-17, 23, 28, 30, 38Medications, 17, 23Military treatment facility, 6, 29, 33-34, 36,

38-39Mind expansion, 26

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National Defense Authorization Act, 10National Guard, 10, 39National Oceanic and Atmospheric

Administration (NOAA), 4, 36Naturopaths, 25-26Network pharmacies, 10, 23-24 Network provider, 4, 7-8, 18-20, 22-23, 29, 34,

37-39Newborn, 5, 20-21Nonavailability statement (NAS), 22, 38Nonemergency, 6-7, 10, 27Non-network pharmacies, 10, 23-24Non-network provider, 29, 38Nonparticipating provider, 38Nutrition, 19, 25

O

Obstetric, 21Occupational therapy, 16One-year lockout, 6Ophthalmologist, 18Optometrist, 18Orthomolecular psychiatric therapy, 26Other health insurance, 27, 29, 34, 36-39Out-of-pocket, 6, 14, 27, 34, 37, 39Outpatient care, 14-16, 19, 22, 25-27, 37, 39Overseas travel, 16, 19Overseas travel immunizations, 16

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Pap smear, 18-20Parenteral nutrition therapy, 25Partial hospitalization, 22Pastoral counselors, 22Pediatricians, 39Pelvic exams, 18PFPWD, 12-14, 25-27Pharmacy, 10, 12, 14, 23-24, 27, 36Physical therapy, 16Physicians, 11, 36, 39Point-of-service, 6-7, 14, 24, 27, 32, 36, 38-39

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Pregnancy, 21Prenatal, 17, 21Prescriptions, 10, 12, 23-24Preventive services, 6, 16, 18-20Primary care manager, 4, 6-7, 9, 11, 14, 18, 29,

36, 39Primary care services, 39Prime service area, 6, 39Prior authorization, 14-17, 22-23, 39Privacy, 21Prostate Specific Antigen, 18Prosthetic devices, 15Providers, 8, 10, 21-22, 29-31, 33, 37-38Psychiatric treatment, 26Psychological evaluations, 26Pulmonary rehabilitation, 25

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Radiology services, 17Reconsideration of a denial, 32Reconstructive surgery, 25Referral, 7, 18-20, 23, 32, 39Regions, 4, 7, 12, 14, 30, 38-39Rehabilitation, 16, 22, 25Reimbursement, 7, 15-17, 22, 24, 26-27, 29, 31Reserve Component, 4, 6, 8-10, 13, 36, 39Residential Treatment Center, 22Retail network pharmacy, 12, 23-24Retirees, 4-6, 8, 10-12, 15-17, 22, 27, 36-37, 39Routine care, 6, 18, 20, 34

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Screenings, 20-21Self-refer, 22Sexual dysfunction, 26Sexual inadequacy treatment, 26Short-term acute patient care, 17Skilled nursing facility, 17Skin cancer exams, 19Social Security number, 29Specialty care, 6-7, 11, 16, 18Speech therapy, 16-17Sponsor, 5-13, 16, 21, 29, 37, 39Substance abuse, 19, 22Supplements, 25-27, 38Surgical care, 14-17, 25-26Survivors, 1, 6, 11, 27

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Terminal illness, 17Tetanus, 20Third Party Liability, 28, 30Transitional Assistance Management Program,

13, 21, 36Transitional health care benefits, 13TRICARE Allowable Charge, 8, 10, 27-29,

37-38TRICARE authorized provider, 39TRICARE costs, 24, 27, 29TRICARE Dental Program, 10, 12, 36TRICARE Extra, 4, 7-9, 15-22, 27, 29, 37-38TRICARE For Life, 4, 9, 12, 30, 36TRICARE Mail Order Pharmacy (TMOP), 10,

12, 23, 36TRICARE Management Activity, 10, 27, 36, 38TRICARE Overseas, 12TRICARE Pharmacy Program, 10, 14, 23TRICARE Plus, 9TRICARE Prime, 4-12, 14-22, 24, 26-27, 29,

36-39TRICARE Prime Remote (TPR), 4-5, 8-10,

14-17, 26-27, 36-39TRICARE Prime Remote for Active Duty

Family Members (TPRADFM), 4, 8-9,14-17, 27, 36-38

TRICARE Regional Office, 7, 33-34, 36TRICARE Retiree Dental Program, 10-11, 36TRICARE Service Center, 36TRICARE Standard, 4-5, 7-10, 12-13, 15-22, 24,

27, 29, 38-39

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Uniformed services, 1, 4-5, 10-11, 13, 23, 36Uniformed Services Treatment Facilities, 11Un-remarried former spouses, 13Urgent care, 6, 14Uniformed Services Family Health Plan

(USFHP), 11, 36

V

Voluntary Separation Incentive, 13

W

Well-child Care, 18, 20Wisconsin Physicians Service, 30, 36

X

X-rays, 16-17, 25



Notes

Please provide feedback on this handbook at:http://www.tricare.osd.mil/evaluations/handbooks

1-888-TRIWESTwww.triwest.com

TriWest Healthcare Alliance1-888-TRIWEST (1-888-874-9378)

TRICARE Information Service1-888-DoD-CARE (1-888-363-2273)

TRICARE Mail Order Pharmacy (Express-Scripts)1-866-DoD-TMOP (1-866-363-8667)

TRICARE Retail Pharmacy (Express-Scripts)1-866-DoD-TRRx (1-866-363-8779)

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