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TRICARE Your Military Health Plan

Overview of TRICARE Benefits for National Guard,

Reserve Component Members and their families

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TRICARE Regions

North RegionHealth Net Federal Services, Inc.

1-877-TRICARE www.healthnetfederalservices.com

South RegionHumana Military Healthcare Services, Inc.

1-877-249-9179 (TPR/SHCP)1-800-444-5445 (general)www.humana-military.com

West RegionTriWest Healthcare Alliance

1-888-TRIWEST www.triwest.com

Take Action to Ensure Eligibility! DEERS Registration is Required

• Visit an ID card-issuing facility– Find one near you at www.dmdc.osd.mil/rsl

• Call 1-800-538-9552• Mail proof of Medicare-eligibility to:Defense Manpower Data Center Support OfficeAttn: COA400 Gigling RoadSeaside, CA 93955-6771

Registration in DEERS is key to TRICARE eligibility

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• Active duty service members (ADSMs) and retirees of any of the seven uniformed services

• NG and Reserve Component members on active duty for more than 30 consecutive days (under Federal orders), from any of the seven uniformed services

• Spouses of active duty, retired, and eligible NG/ Reserve Component service members

• Unmarried children (including stepchildren) up to age 21 (or 23 if full-time student)

• Past age 21—Mental/Physical incapacity• (Unmarried children remain eligible even if parents divorce or

remarry)

Who is eligible for TRICARE?

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Service Member Coverage Varies…

• When on military duty for 30 days or less– Line of duty coverage – TRICARE Dental Program– TRICARE Reserve Select

• When called or ordered to active duty for more than 30 consecutive days– Active duty health and dental benefits, including pharmacy

– Automatic termination from TRICARE Reserve Select

• After leaving active service, or demobilizing– Transitional health coverage, including pharmacy– TRICARE Dental Program – TRICARE Reserve Select

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Service Member on Military Duty 30 Days or Less

• Health: Line of Duty (LOD) Health Care– Any injury, illness, or disease incurred or aggravated in the line of duty • Includes emergency care

– Covered portal to portal– Coordinate LOD health care through unit commander or designated medical representative

• Dental: TRICARE Dental Program (TDP) Family members are not

eligible for health coverage when you are on military duty for 30 days or less

Service Member Activated More than 30 Days

• Health: TRICARE / Military Treatment Facility– TRICARE Prime/TRICARE Prime Remote– TRICARE Overseas Prime/TRICARE Global Remote Overseas

– Pharmacy coverage

• Dental: Active Duty Dental Coverage– Military dental treatment facilities – Tri-Service Remote Dental Program

If activated in support of a contingency operation, you may also qualify for pre-activation coverage

Health Care Options for Family Members when Sponsor is Activated

• TRICARE Standard and TRICARE Extra (Automatic)

• TRICARE pharmacy benefit (Automatic)• TRICARE Prime (Requires enrollment)• TRICARE Prime Remote for Active Duty Family Members (TPRADFM) (Requires enrollment)

Contact your TAO for information about health care options if you accompany your sponsor overseas when they are activated

TRICARE Standard

• Enrollment not required - Automatic• Care from non-network TRICARE-authorized providers– Provider may charge up to 15% above TRICARE allowable charge

– May have to submit your own health care claims

• Referrals not required for specialty care – Some services may require prior authorization

• MTF care on a space-available basis only

TRICARE Extra

• Enrollment not required - Automatic• Care from TRICARE network providers

– Providers agree to accept negotiated rate as TRICARE allowable charge

– Lower cost-shares than TRICARE Standard– No claims to file (in most cases)

• Referrals not required for specialty care – Some services may require prior authorization

• MTF care on a space-available basis only

TRICARE Standard and Extra CostsTRICARE Extra(Using Network/Prime

providers)

TRICARE Standard(Using non-network/Standard

providers)TRICARE Option

$1,000 per family per fiscal year

$20/day ($25 minimum)

$15.15/day ($25 minimum)

20%*

Sponsor rank E1-E4: $50/single or $100/familySponsor rank E5 & above: $150/single or $300/family

SameInpatient Behavioral Health CareCatastrophic Cap

SameInpatient Costs

15% Outpatient Cost-share

SameDeductibleAmount due each fiscal year before cost-sharing begins.

Get extra cost-savings with TRICARE Extra!

The federal fiscal year is Oct. 1- Sept. 30.* Non-network providers may charge up to 15% above the TRICARE allowable charge.

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TRICARE Prime Service Area (PSA)

• Area defined as an approximate 40-mile radius around an MTF (actual radius can vary by military installation)

• TRICARE-eligible beneficiaries living within the Prime service area are eligible for Prime

• Beneficiaries living outside the Prime service area may be eligible for TRICARE Prime Remote for Active Duty Family Members (TPRADFM)

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• Prime must be available in your area

• Active duty and family members—no enrollment fee

• Enroll by 20th of month—effective 1st of the next month

• If you enroll after the 20th of the month, your enrollment will begin on the 1st day of the 2nd month after that

Enrolling in TRICARE Prime

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Eligibility for TRICARE Prime Remote / TPRADFM

• National Guard or Reserve sponsor– Activated more than 30 consecutive days

– Live and work more than 50 miles (or an hour’s drive time) from an MTF

– Sponsor’s residence address must be in DEERS

– Family must reside with sponsor in a designated TPR ZIP code at time of activation

To see if you qualify, check your ZIP code at

www.tricare.mil/tpr.

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TPR/TPRADFM

• TRICARE Prime option for active duty families in remote locations– Available in designated TPR ZIP code areas

• Enrollment required• TRICARE-authorized providers

– Network providers when available– Same rules as TRICARE Prime for getting care

• No claims to file (in most cases)

Enrolling in TRICARE Prime/TPRADFM

• Submit completed enrollment application to your regional contractor– If received by 20th of month, coverage begins 1st of next month

– If received after 20th of month, coverage begins 1st of following month

• Select a PCM – From military treatment facility (MTF) or TRICARE network

– For TPRADFM, select any TRICARE-authorized provider if a network PCM is not available

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Primary Care Manager

• Any TRICARE-authorized provider– Network provider, if available– Non-network, if network provider not available

• Provides most care—routine, urgent, and some clinical preventive services

• Provides referrals for necessary specialty care– Coordinates referral request – Obtains necessary prior authorization

Contact your regional contractor for assistance finding a PCM.

TRICARE Prime/TPRADFM Costs (TRICARE Prime Remote Active Duty Family Member)

$1,000 per family per fiscal year

Catastrophic Cap

$0Emergency Care

$0Inpatient Costs*

$0Outpatient Costs*

$0Deductible*

$0Enrollment Fees

*You’ll pay higher out-of-pocket costs if you use the point of service option (POS).

The federal fiscal year is Oct. 1- Sept. 30.

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• Call 911 • Visit nearest emergency room• Notify your PCM or Regional Contractor within 24 hours of any emergency admission so that your follow-up care can be coordinated (if enrolled in TRICARE Prime)

• A family member can call on your behalf

Emergency Care

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• Medically necessary treatment that is required for illness or injury

• TRICARE Prime beneficiary must coordinate urgent care with PCM or Regional Contractor before receiving care

• A TRICARE Prime beneficiary who seeks urgent care services without coordinating with his or her PCM will be utilizing the TRICARE Point-of-Service (POS) option

Urgent Care

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• All routine medical care should be taken care of before you depart or delayed until you return and can see your PCM

• For out-of-area urgent/acute care, you must coordinate with your PCM or Regional Contractor for an authorization before seeking care if enrolled in TRICARE Prime

• For out-of-area emergency care, call 911 or go to the nearest emergency room (civilian or military)

Nonemergency Health CareWhile Traveling

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Point of Service Option

• Seek nonemergency/specialty care without a referral or prior authorization

• Higher out-of-pocket costs– Annual Deductible: $300/individual or $600/family

– Cost-Shares: 50% after POS deductible is met

• POS fees not reimbursed by TRICARE• POS fees do not apply to the annual catastrophic capAvoid POS fees!

Follow TRICARE Prime/ TPRADFM referral and authorization guidelines

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• TRICARE pays after all other health insurance plans except for:– Medicaid– TRICARE supplements – The Indian Health Service – Other programs/plans as identified by TMA

• Not required to obtain TRICARE referrals or prior authorization for covered services, except for adjunctive dental care and behavioral health care services

• However, you must follow the OHI referral and authorization requirements if applicable

• TRICARE is NOT a supplement to other insurance.

TRICARE and Other Health Insurance

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TRICARE Pharmacy Coverage

*Not available in the MTF unless medical necessity is established.

†Deductibles apply.

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Typeof Pharmacy Generic Brand Name

Non-Formulary

MTF(up to a 90-day supply)

$0 $0 $0*

TMOP(up to a 90-day supply)

$3 $9 $22

Network Retail(up to a 30-day supply)

$3 $9 $22

Non-network Retail Pharmacy(up to a 30-day supply)

†Non-TRICARE Prime: $9 or 20%

†TRICARE Prime: 50% cost-share

†Non-TRICARE Prime: $9 or 20%

†TRICARE Prime:50% cost-share

†Non-TRICAREPrime: $22 or 20%

†TRICARE Prime:50% cost-share

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TRICARE Dental Options

Active Duty Dental Options

Military dental treatment facilities

Contact your local military dental treatment facility.

Tri-Service Remote Dental Program

Military Medical Support Office http://mmso.med.navy.mil

TRICARE Dental Program

•Active duty family members

•National Guard and Reserve members (not activated) and family members

United Concordia Companies, Inc.1-800-866-8499www.TRICAREdentalprogram.com

TRICARE Retiree Dental Program

•Retired service members and family members

•Medal of Honor recipients and family members

Delta Dental Plan of California1-888-838-8737www.trdp.org

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Questions?