tricare benefits for activated reserve – guard and their

TRICARE BENEFITS FOR

ACTIVATED RESERVE – GUARD AND

THEIR FAMILY MEMBERS

TRICARE Southwest Health Plans

TRICARE Southwest Health Plans 02 October 2001

OVERVIEW

TRICARE

Regions

Eligibility

Improved Benefit (Prime)

Prime – Standard – Extra

Pharmacy

TRICARE Prime Remote (AD & Family Members)

Eligibility, Enrollment, Benefits, Timeline, and Areas

AD and Reserve/Family Member Dental Program

Important Web Sites and Phone Numbers


TRICARE REGIONS

TRICARE Southwest Health Plans

Region 6

Texas (less El Paso area) Louisiana (western half) Oklahoma Arkansas (less West Memphis area)


Duration of Active Duty (AD) Orders

30 days or less 31 to 178 days179 days or more (or combination of orders*)

and “Indefinite” orders

Family is not eligible for TRICARE benefits.

R-G member’s family is eligible for TRICARE Standard and Extra effective first day of sponsor being on active duty.

R-G member’s family has option to enroll in Prime or receive waived charges if eligible for TRICARE Prime Remote for Family Member (TPRFM). *Effective with date of orders taking member over 179 days.

Activated Reserve/Guard (R-G) members are eligible for TRICARE Prime (or Remote, if eligible) for any injury, illness or disease incurred or aggravated in the line of duty.

TRICARE ELIGIBILITY RESERVE – GUARD (R-G)

Eligible R-G members enroll in TRICARE Prime at initial staging/processing location and then use “Portability” to transfer enrollment once at deployed location (Prime or TPR (if eligible)).

Family maintains TRICARE coverage for 30 days after R-G member is deactivated.

Uniformed Services Employment and Re-employment Rights Act of 1994

Allows mobilized reservists to keep health coverage for up to 18 months (Employer may charge full premium plus 2% admn fee… http://esgr.org/)


IMPROVED BENEFIT TRICARE PRIME

TPRFM Waived Charges Effective 30 Oct 00


TPRFM Waived Charges Effective 30 Oct 00

IMPROVED BENEFIT TRICARE PRIME

(POS Deductibles Only Apply to Outpatient Claims)


Active Duty Family

Members (ADFM)

TRICARE Prime

E-1 thru E-4

TRICARE Prime

E-5 and Above

TRICARE Standard/Extra

E-1 thru E-4

TRICARE Standard/Extra E-5 and Above

Deductible Annual

(Individual/Family)None None $50/$100 $150/$300

Outpatient Civilian Visit

$0 $0Extra: 15%

Standard: 20%

Extra: 15%

Standard: 20%

Inpatient Civilian Admission

$0 $0$11.00 per day or $25.00 minimum,

which ever is greater

$11.00 per day or $25.00 minimum,

which ever is greater

Mental Health Civilian Inpatient

$0 $0 $20.00 per day $20.00 per day

PRIME - STANDARD – EXTRA FAMILY MEMBER TRICARE BENEFIT


Place of Service Generic Drug Brand Name Drug

Military Treatment Facility (MTF) $0 $0

Mail Order Pharmacy (90 Day Prescription) $3 $9

TRICARE Network Pharmacy (30 Day

Prescription)$3 $9

Non Network Pharmacy$9 or 20% of total cost (whichever is greater) co-pay applies

TRICARE PHARMACY BENEFIT


TPR – TPRFM Eligibility

TPR – TPRFM Eligibility Criteria

ADSM must reside AND work greater than 50 miles from primary care Military Treatment Facility (MTF)

R-G (activated for 31 or more days) and family members of R-G activated for 179 or more days

All ADSMs must enroll in Prime or Prime Remote (if eligible)

TPR Family Members (TPRFM) must reside with TPR ADSMs

Interim Period TPRFM Waived Charges (reimbursement) started

Sep 01…“TPRFM” enrollment begins April 2002

Address Changes: UPDATE DEERS (1-800-538-9552) For activations of 31 days or more, complete DD Form 1172,

Application for Uniformed Services Identification Card – DEERS Enrollment, for each family member and legal dependent to replace your red ID cards with tan ID cards


TPR – TPRFM Web SITEhttp://www.tricare.osd.mil/remote 1-800-406-2832 (Option 3)

1- (888 or 877) DOD-CARE(ADFMs)

ADSM Enrollment/Claims FormsCheck TPR Eligibility


TPR – TPRFM BENEFITS

Local Provider: Primary Care Manager (PCM) Prime Network: Choose PCM in Provider Directory

Only Standard/Extra Areas (No Prime Network): Choose any authorized local primary care provider

When are preauthorizations (HCF authorized) not required for enrolled TPR ADSMs and TPRFMs? Primary care visits (including lab tests or x-rays) to Network

PCM or authorized primary care provider for non-Network areas

Preventive care (Immunizations, hearing tests, routine eye exams, breast exams, mammography, and pap smears)

Emergency Care

TPR ADSMs and TPRFM must contact a Health Care Finder (HCF) for all other care at 1-800-406-2832 (Option 3 for TPR)


TPR/TPRFM BENEFITS

When must TPR – TPRFM call a Health Care Finder (HCF) for preauthorization? Specialty care referrals (28 day access standard)

Network PCM cannot meet access standards

24 hours for urgent care

7 days for routine care

If in doubt, always call HCF before getting non emergency care

No Co-pays, Cost Shares, or Deductibles For authorized medical care

Waived and or reimbursed for TPRFM


HEALTH NET FEDERAL SERVICES

Provider Directory - Prime Network/TPR

AD TPR and Prime Enrollment Forms

TRICARE Assistance and Information

Provider Directory Enrollment Forms

1-800-406-2832 (Option 3 for TPR) http://www.healthnetfederalservices.com


TPRFM PROGRAM TIMELINE

Interim Rule (31Oct00 to Apr02)…No TPRFM Enrollment

Automatic reimbursement (Sep 01)…TPRFM claims matched to TPR enrolled ADSMs

Contact your Regional contractor to get reimbursed for out of pocket expenses not automatically reimbursed

TPRFM claims with TPR eligible but unenrolled sponsors

Keep receipts of medical payments

Authorized providers are being notified to waive TPRFM co-pays, cost shares, and deductibles

TPRFM Program (April 2002) Enrollment begins but still keep and submit receipts of any

unreimbursed medical payments


Community & MTF Location

A – San Antonio

Randolph AFB

Ft Sam Houston - BAMC

Lackland AFB – Wilford Hall

Brooks AFB

B – Killeen - Ft Hood

C – Texhoma

Ft Sill

Sheppard AFB

Altus AFB

D – Oklahoma City - Tinker AFB

E – Little Rock - Little Rock AFB

F – Shreveport - Barksdale AFB

G – Corpus Christi - Corpus Christi NAS

H – Vernon - Ft Polk

I – Abilene - Dyess AFB

J – San Angelo - Goodfellow AFB

K – Garfield - Vance AFB

L – Del Rio - Laughlin AFB

AL

G

JI

KD

C

B HF

E

MTF Prime Catchment Area

Prime NonCatchment Area – Interim Rule AreaExtra – Interim Rule Area

Standard – Interim Rule Area

Interim Rule Waives TPRFM Co-pays, Cost Shares and Deductibles

MTF Prime Catchment Area

Prime NonCatchment Area

Extra – TPRFM Area

Standard – TPRFM Area

TPRFM Enrollment Effective April 2002

30 Oct 00 to Apr 2002

AREAS WITH TPRFM BENEFITS


TRICARE DENTAL BENEFITS TPR and FAMILY MEMBERS OF ACTIVE DUTY/RESERVE

TPR Dental is only for TPR Enrolled ADSMs

TPR Dental Benefits

Choose any licensed dentist in local area because there is no civilian dental network for ADSMs

Annual exams, cleanings and fillings

Must obtain preauthorization for any other care or any care exceeding $500/visit or $1500/year by contacting MMSO/SPOC at 1-888-647-6676

TRICARE Dental Program (TDP)

Dental program for Family members of AD and R-G


ACTIVE DUTY TPR DENTALhttp://navymedicine.med.navy.mil/mmso/

(1-888-647-6676)


http://www.tricare.osd.mil/tricare/beneficiary/supprog.html

1-800-332-0366http://www.ucci.com/tdp/tdp.html

Active Duty Family Members and Selected Reserve/(IRR) and Their Family Members


http://www.tricare.osd.mil/tricare/beneficiary/supprog.html

TRICARE Dental Program (TDP) Rates

R-G Family Rate

R-G Individual Family Member

Rate

Individual R-G Rate

Non Activated Selected Reserve and Individual Ready Reserve (IRR) (Orders for 30 or less days)

$47.69/month (Includes Sponsor)

$19.08/month (Excludes Sponsor)

$7.63/month (Sponsor Only)

Activated (31 days or more) Selected Reserve and Individual Ready Reserve (IRR)



United Concordia (UC) administers the TRICARE Dental Program (TDP).

R-G member is automatically removed from UC dental when activated for 31 days or more via DEERS update to UC. The military covers active duty service member (ADSM) dental care. These activated R-G family members remain in UC with lower rate.

R-G member (sponsor) is advised to phone UC 888-622-2256 when orders of 31 days or more are received and upon deactivation.


Annual maximum for general dentistry is $1,200 per year

Lifetime orthodontic maximum is $1,500 for each enrollee

Premiums (separate premiums for sponsor and family)

Enrollment is for at least twelve (12) months

Twelve month Service commitment from sponsor (active duty, reserve or combination of the two) then enrollment is month-to-month basis

EXCEPTION to 12 month enrollment: Waived for family members of sponsor who is on active duty for a contingency operation but must remain enrolled for duration of orders


RESERVE-GUARDhttp://www.tricare.osd.mil/reserve/


WEB SITE RESOURCES

Reserve/Guard: http://www.tricare.osd.mil/reserve/

Reserve Affairs: http:www.defenselink.mil/ra/

TPR – TPRFM: http://www.tricare.osd.mil/remote/

TRICARE Management Activity (TMA) http://www.TRICARE.osd.mil

Health Net Federal Services (formerly Foundation) http://www.healthnetfederalservices.com

TRICARE Southwest Health Plans (Region 6) http://www.tricaresw.af.mil

National Committee for Employer Support (R-G) http://www.esgr.org/


AD Dental (MMSO): http://navymedicine.med.navy.mil/mmso/

DOD Pharmacy Center: http://www.pec.ha.osd.mil

TRICARE Dental Program for Selected Reserve (SR), Individual Ready Reserve (IRR) and SR/IRR/Active Duty Family Members

http://www.ucci.com/tdp/tdp.html http://www.tricare.osd.mil/tricare/beneficiary/supprog.html

DEERS (Address Changes) https://www.tricare.osd.mil/DEERSAddress

WEB SITE RESOURCES


IMPORTANT PHONE NUMBERS

National Phone Numbers: AD Dental Claims/Questions (MMSO): 1-888-647-6676

AD Service Point of Contact (SPOC): 1-800-368-2777 (Option 2)

TRICARE Dental Program 1-800-332-0366 or 1-800-866-8499

TPR-TPRFM Questions: 1-(888 or 877)-DOD-CARE

National Mail Order Pharmacy: 1-800-903-4680

DEERS Address Changes: 1-800-538-9552

Region 6 Phone Numbers: PCM Changes, Medical Claims, Health Care Finder

(Medical/Pharmacy): 1-800-406-2832 (Option 3 for TPR)

Health Care Information: 1-800-611-2875


If deployed to different TRICARE Region, phone new Region to transfer enrollment via “Portability”

http://www.tricare.osd.mil/regionalinfo/

tricare benefits for activated reserve – guard and their

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