TRICARE

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TRICARE

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Title: TRICARE

1
TRICARE Your Military Health Plan
Transitioning from Active Duty to Retirement -
2008
2
Decision Process

Where will you live?
Will you be employed?
How is your and your familys health?
What health plans are available?
What are the costs of the different plans?
Are you and your family insurable?
Will you need supplemental insurance?

3
TRICARE Regions
Regional Contractors TRICARE North (Health
Net) 1-877-TRICARE (1-877-874-2273) TRICARE
South (Humana) 1-800-444-5445 TRICARE West
(TriWest) 1-888-TRIWEST (1-888-874-9378)
4
TRICARE Eligibility

Must show eligible in DEERS
Active duty retired sponsors
Medal of Honor recipients
Family members (spouse and children)
Unmarried children to age 21 23 if full-time
student
Incapacitated child (if determined physically or
mentally disabled prior to age 21)
Valid ID card required for all beneficiaries age
10 and older
Certain survivors
Certain former spouses

5
Defense Enrollment Eligibility Reporting System
(DEERS)

Defense Enrollment Eligibility Reporting System
Defense Manpower Data Center Support Office (DSO)
Phone 1-800-538-9552
Fax 1-831-655-8317
Mail DSO (Attn COA or TFL), 400 Gigling Road,
Seaside, CA 93955-6771
Web www.tricare.mil/DEERS

6
Making Changes in DEERS

Demographic changes (address, phone)
Can be done in person by phone, fax or mail or
online
To add or remove a family member
Sponsor responsibility
Personnel / ID Card Office
Birth, death, adoption, marriage, divorce
Documentation required
Certificates
Decrees

7
DEERS Unremarried Former Spouses

Unremarried Former Spouses
Former spouses SSN used to verify eligibility
(20/20/20 rule)
Not eligible if covered by an employer-sponsored
health plan
Personnel / ID Card Office
Stepchildren eligibility

8
Accessing Care During Terminal Leave

ADSM is still considered active duty during the
terminal leave period and must access care under
the Prime rules
Access care through the nearest MTF
Go to a civilian hospital-based emergency room
Call back to PCM / Regional contractor to
authorize urgent care through a civilian doctor
or urgent care clinic
Routine care from other than your PCM will not be
authorized while on terminal leave

9
How TRICARE Changes When You Retire
ADSMs are not eligible for TRICARE Extra or
TRICARE Standard for ADFMs only
10
Military Treatment Facilities Access to Care

Upon retirement, your access to services at an
MTF will change to a lower priority
You will have higher priority access to specialty
care in an MTF if you enroll in TRICARE Prime
If you choose to use TRICARE Extra or TRICARE
Standard, you will continue to have access to
care in an MTF on a space-available basis only
Access to most ancillary services will continue
(pharmacy, lab, x-ray, immunizations, emergency
room)

11
Military Treatment Facility Priorities for Care

Active duty service members
Active duty family members enrolled in Prime
Retirees, their family members, and others
enrolled in Prime
Active duty family members NOT enrolled in
TRICARE Prime
Retirees, their family members, and others NOT
enrolled in Prime
All other eligible beneficiaries
If spouse is still active duty, use status as
Active Duty Family Member when
accessing medical care

12
Catastrophic Cap

Annual (fiscal year) out-of-pocket expense for
TRICARE-covered benefits
Deductibles
Co-payments
Active duty families
1000/year
Retiree and retiree families
3000/year

13
TRICARE Options

Prime
Managed Care Plan/HMO
Extra
PPO
Standard
Fee for Service

14
TRICARE Standard

Fee-for-service option (old CHAMPUS)
No enrollment required
Seek care from any TRICARE-authorized provider
Responsible for annual deductibles and cost-
shareshighest out-of-pocket expense
May have to pay up-front, then file claim for
reimbursement
May seek care in an MTF on a space-available basis

15
TRICARE Standard Costs

Deductible
150 individual/300 family per fiscal year
Cost-shares after deductible has been met
Outpatient care 25 of TMAC (when using a
non-participating provider, patient may be
responsible for 15 above the TMAC)
Inpatient Care lesser of 535 per day or 25 of
billed charges for facility bill, plus 25 of
allowable professional fees
Catastrophic Cap
3000 per fiscal year

16
TRICARE Extra

Preferred provider option (PPO)
No enrollment required
Seek care from any TRICARE network provider
Responsible for annual deductibles and discounted
cost-shares
Providers required to file claims for you
May seek care in an MTF on a space-available basis

17
TRICARE Extra Costs

Deductible
150 individual/300 family annually
Cost-shares after deductible has been met
Outpatient care 20 of negotiated rate
Inpatient care lesser of 250 per day or 25 of
negotiated charges for facility bill, plus 20 of
negotiated professional fees
Catastrophic Cap
3000 per fiscal year

18
TRICARE Standard Extra a Comparison

Annual deductible
Active duty E-4 and below 50 individual/100
for family
Active duty E-5 and above 150 individual/300
for family
Retirees and families 150 individual/300 for
family
Extra cost-shares (outpatient, after deductible)
Active duty family members 15 of negotiated
rate
Retirees and their family members 20 of
negotiated rate
No balance-billing claims filed for you
Standard cost-shares (outpatient, after
deductible)
Active duty family members 20 of TMAC
Retirees and their family members 25 of TMAC
Can balance bill up to 15 more than TMAC may
have to file your own claims

19
TRICARE Prime Enrollment

Prime does not automatically carry over into
retirement
A new enrollment application must be completed
for the Region where you will live to continue in
TRICARE Prime
Deadline for submission 20th of each month
Annual enrollment fees will apply
230/Individual 460/Family
Paid monthly, quarterly, or annually
Include the Enrollment Fee Allotment
Authorization Letter with application if paying
by allotment
If your spouse is active duty, enroll in Prime as
an Active Duty Family Member (ADFM)
Former spouse, if eligible, considered own
sponsor
Separate enrollment fees apply
Must select or be assigned a PCM

20
TRICARE Prime Enrollment Types

New Enrollment
First time enrollment as a retiree
PCM Change
Changing PCMs within the same Region
Portability
Changing PCMs from one Region to another
Split Enrollment
When family members live and enroll in different
Regions enrollment fee paid in Region where the
sponsor lives

21
Primary Care Manager (PCM)

MTF or network provider
Provides most of your primary care and
coordinates specialty care when needed
Knows your family medical history, lifestyle, and
habits
Helps you develop and carry out a personal health
maintenance and improvement program
Prevents and detects health problems through
regular screenings and wellness education
Retirees enrolled in Prime are entitled to one
preventive vision check every two years at no
cost

22
TRICARE Prime Costs

MTF Care
Outpatient care at no cost
Inpatient care at subsistence rate
Civilian Care
PCM/Specialty outpatient visit 12 copayment
Inpatient visit 11 per day (25 minimum)
Emergency services 30 copayment
Behavioral health outpatient visit
25/individual
17/group
Behavioral health inpatient visit 40 per day

23
TRICARE Prime Point of Service (POS)

Unauthorized, non-emergent care
Retro-authorizations not granted
Allows freedom of choice
Outpatient fiscal year deductible
300/individual
600/family
Patient responsibility 50 of TMAC
Plus 15 more is possible for non-participating
providers
No upper limit to POS Catastrophic Cap

24
TRICARE Prime Newborn Enrollment

Conditional Enrollment
Newborns are covered under TRICARE Prime for
the first 60 days after birth - as long as one
additional family member is enrolled in Prime

25
Traveling with TRICARE Prime

Use MTF if near a military base
All routine medical care should be taken care of
before traveling, or delayed until after
returning
Including immunizations, routine exams, and
medication refills
For out-of-area acute or urgent care, the PCM or
the Regional contractor should be contacted for
an authorization before obtaining care
For out-of-area emergency care, call 911 or go to
the nearest hospital-based emergency room
(military or civilian Prudent Lay Person Rule)

26
Access to Care when Living Overseas

You and your eligible family members have access
to MTF facilities overseas on a space-available
basis
You will not be eligible for enrollment in
TRICARE Prime while living overseas, but will be
covered for civilian health care under TRICARE
Standard
The same annual deductibles and cost-shares will
apply as when using TRICARE Standard in the
United States

27
TRICARE and Other Health Insurance (OHI)

TRICARE generally pays after all OHI plans
except
Medicaid
TRICARE supplements (which are used to pickup
remaining cost shares after TRICARE has processed
the claim)
Referrals and prior authorization are not
required for TRICARE-covered services (except for
adjunctive dental and behavioral health care)
However, any OHI referral and authorization
requirements must be followed
Submit claims to TRICARE (with copy of OHIs EOB)
for amounts not paid by OHI
Use OHI with TRICARE Standard/Extra
Not recommended with Prime

28
Comparison of TRICARE Prime and OHI Premiums
29
Claims Filing

Who is responsible for filing claims?
Network provider/participating provider
Beneficiary
Forms needed for filing claims
TRICARE Claim Form (DD-2642)
Full Itemized Statement (HCFA-1500)
Statement of Personal Injury (DD-2527)
OHI Explanation of Benefits (EOB)
Prescriptions

30
Claims Assistance

Contact the TRICARE contractor for your Region
(North, South or West)
Go online to www.myTRICARE.com
Contact the HBA/BCAC office at the nearest
military hospital or clinic
Claims normally process within 21 to 30 days of
the date medical care was received and you will
receive an Explanation of Benefits (EOB) in the
mail

31
TRICARE Pharmacy Program

MTF Pharmacy
TRICARE Mail Order Pharmacy (TMOP)
Express Scripts 1-866-DoD-TMOP (363-8667)
www.express-scripts.com/TRICARE
TRICARE Retail Network Pharmacy
Express Scripts 1-866-DoD-TRRx (363-8779)
www.tricare.mil/pharmacy
Non-network Retail Pharmacy

32
TRICARE Pharmacy Generic Drug Use Policy

Generic versions of prescription drugs will be
dispensed when available
Medical necessity must be justified when
specifically requesting brand name drugs over
generic versions
When generic equivalents do not exist, the brand
name version will be dispensed

33
Pharmacy Costs
34
Other Health Insurance (OHI) and Pharmacy

The MTF pharmacy can still be used, even if you
have OHI
If prescription drugs are covered by OHI
When using a retail pharmacy, OHI will be the
primary payer, and TRICARE will be secondary
Electronic coordination of benefits apply when
using a network retail pharmacy (pharmacy files
to both OHI and TRICARE)
The Mail Order Pharmacy (TMOP) program cannot
normally be used with OHI, unless you have
reached the OHI benefit cap, or the prescribed
drug is not covered by the OHI
If using a non-network retail pharmacy, the
pharmacy will generally file to OHI and you must
submit a claim to TRICARE
If prescription drugs are not covered by the OHI,
or if you have reached the OHI benefit cap, you
may use either the TMOP or retail pharmacy
benefits

BR402101BET0504C
35
TRICARE For Life

Eligibility
Medicare-eligible sponsors and family members,
including retired guardsmen and reservists age 65
and over, and widows and widowers
Certain former spouses if eligible for TRICARE
before age 65 (20/20/20 rule)
Requires enrollment in Medicare Part B
TFL coverage effective date
First day of month eligible beneficiary turns 65
DEERS and ID card must be updated

36
TRICARE For Life

Began October 1, 2001
Claims filed automatically from Medicare to
TRICARE (provider only needs to file to Medicare)
Claims processor is Wisconsin Physician Services
(WPS) - www.tricare4u.com
If OHI exists, Medicare will pay first, OHI
second, and TRICARE will pay last.
No enrollment fees (except for Medicare Part B
monthly premiums)
Space-available access at MTFs
Primary and specialty care appointments limited
Most ancillary services accessible

37
TRICARE Plus

MTF primary care enrollment program
Offered at certain MTFs
Limited enrollment capacity
No enrollment fees
All TRICARE-eligible beneficiaries (except those
enrolled in Prime or have a civilian HMO plan)
may seek enrollment in TRICARE Plus
Offers only primary care access to specialty
care through the MTF is not guaranteed
Enrollment in TRICARE Plus does not affect TFL
benefits or other existing programs

38
Dental

TRICARE Dental Program (TDP)
For active duty family members, National Guard
Reserve members their families
United Concordia is the contractor
TRICARE Retiree Dental Program (TRDP)
For retirees their families, Medal of Honor
recipients their families, certain survivors
former spouses
Delta Dental Plan of California is the contractor

39
Retiree Dental Program Premiums Locally (2008)
A prepayment of two months premiums is
required to enroll.
40
TRICARE Assistance Information