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Benefits of Tricare

The Tricare name, formerly labeled under the moniker of Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), remains at the forefront of healthcare providers aimed directly at meeting the medical insurance needs of military-based families.

Tricare insurance is sponsored by the United States Department of Defense and available to many military members and their families.

Eleven distinct health plans are offered, and costs vary according to a sponsor’s duty location and military status.

Many of Tricare’s health plans include special provisions for the young children and other dependents of Active Duty sponsors. No Active Duty service member is ever asked to pay out of pocket for Tricare services.

Making the Most of your Tricare Coverage

Eligibility for Tricare

Eligibility extends to all uniformed service members and their families, National Guard/Reserve personnel and their families, as well as survivors and former spouses of any such military member.

Enrolled military personnel are referred to as “sponsors” and any family members which that military member brings aboard a plan is referred to as a “member.”

Tricare eligibility coverage is determined by two governing factors: the beneficiary’s relationship to the sponsor and the sponsor’s military status. Specific groups with specific eligibility include the following:

● Active Duty

● Includes all active duty military personnel and families. Eligibility for plans depends on designated Prime areas.

o Check to see if your location qualifies for Prime service here. If your home and duty location both fall outside of a 50-mile radius or one hour’s drive time from a military hospital or clinic, you will be eligible for Tricare Prime Remote care.

● National Guard and Reserve

● National Guard/Reserve members and their families may be eligible for Tricare coverage if they are on active duty orders or have been recently deactivated.

● The Defense Manpower Data Center (DMDC) requires a Common Access Card, DFAS Account (MyPay) or DoD Self-Service Logon in order to check eligibility for Tricare online. Check your eligibility for enrollment at the DMDC website.

● All National Guard and Reserve members remain eligible for Line of Duty care, but availability of other Tricare services often depends on is a member

has been on active orders in the last 30 days or if the member is retired.

● Retired Service Members

● Retired military personnel and their families are eligible for Tricare Prime, Tricare for Life, Tricare Select, Tricare Select Overseas and U.S. Family Health Plans.

● Children of retired members who may have aged out of other Tricare programs at 21 or 23 often qualify for the Tricare Young Adult program.

● Continued Tricare benefits will vary depending on the age of the sponsor at retirement. Tricare Retired Reserve is offered to most Reserve retirees who are younger than 60 years of age.

● After reaching 60 years of age, Reserve retirees and their families are eligible for the same Tricare retirement benefits as any other retired service personnel.

● The Tricare Retiree Dental Program is also available to retired Reserve members at any time.

● Survivors and Children

● Spouses and children remain in “transitional” coverage for three years post the death of an Active Duty sponsor.

● Spouses of Active Duty sponsors remain eligible for the remainder of their lives unless they remarry, and children are covered until they age out of the system at 21 or 23 years of age.

● The spouses and children of National Guard/Reserve members who die while on active duty, are within 30 days of active duty service or have officially retired remain eligible for medical/dental benefits.

● If the family member was covered under Tricare Reserve Select on the day of the sponsor’s death, he or she may be

eligible for another six months of coverage under the same plan.

● If the sponsor died while covered by the Transitional Assistance Management Program (TAMP), the family member may qualify for TAMP coverage until reaching a 180-day TAMP period.

● Dual Eligibility for Tricare and Medicare

● Learn more about important Tricare and Medicare intersections here

Medal of Honor recipients, whether on active duty, retired or separated from active duty, enjoy the same Tricare coverage for themselves and their families as any other Active Duty or Retired sponsor.

Dependent parents and parents-in-law are eligible for coverage under Tricare Plus and care in military hospitals and clinics once a sponsor has been on active duty for 30 days or more.

If you are a Foreign Force Member who is from a country affiliated with NATO, the NATO Status of Forces Agreement (SOFA), the Partnership for Peace Agreement (PFP) or the Reciprocal Health Care Agreement, you can get medical care in the United States through the Department of Defense (DoD).

You must be registered in DEERS and be in the United States on military orders or conducting business with the DoD in order to take advantage of these benefits. Family members of NATO or PFP nations are not eligible for the Tricare Overseas Program.

Special Tricare eligibility provisions are in place for victims of abuse from an Active Duty sponsor, the family of a court-martialed sponsor and the family of any sponsor who is missing in action.

For further Tricare eligibility questions, the DMDC Support Office can be reached at 1-800-538-9552. Phone services for the deaf or hard of hearing are available at 1-866-363-2883.

How to Enroll in Tricare

In order to enroll into the Tricare system, you must start by purchasing or signing up for one of the following Tricare health care insurance plans:

● TRICARE Prime

● TRICARE Prime Remote

● TRICARE Prime Overseas

● TRICARE Prime Remote Overseas

● TRICARE Select

● TRICARE Select Overseas

● US Family Health Plan

● TRICARE Reserve Select

● TRICARE Retired Reserve

● TRICARE Young Adult

● Continued Health Care Benefit Plan

The following are the general steps to follow to complete the enrollment process:

● Choose a manager – You must select a primary care manager to oversee your Tricare plan. In order to do this you must determine if you are in the East or West region as they are serviced by different offices, managers, and have different locations.

● Complete Application –Any of your family members you expect to be covered by your Tricare insurance must be included on the same application form. You may also apply to Tricare in one of three ways:

● Tricare enrollment online – You can use the web portal to begin applying.

● By telephone – The East and West zones have toll-free numbers to a contractor to complete the application process.

▪East – Humana Military: 1-800-444-5445

▪West – Health Net: 1-844-866-9378▪Overseas – If you are stationed

overseas you may contact your contractor office here.

● Mail –You can download and print your application forms and mail them to your regional office. The addresses for the offices are located on the forms. The form for the East region here, and for the West region, here. If you are stationed overseas your application can be downloaded here.

● Activate your plan – Activating your Tricare health insurance often requires you to take action online including setting up a proper online account. You can do that by visiting the Tricare online web portal which is located here.

DEERS

If you are using Tricare for Life, or your family members are, and are registered with the Defense Enrollment Eligibility Reporting System (DEERS), you do not need to enroll. Enrolling in DEERS requires the applicant to submit to an interview process that is separate from the normal Tricare procedure.

DEERS enrollment requires that applicants fill out DD Form 1172 and submit it with the necessary supporting documentation. Family members who must submit their DEERS applications without you may do so within 90 days, so as long as the form is signed by you or your power of attorney.

To find a complete listing of required documents for adding a spouse or child to DEERS for Tricare enrollment, you can go here.

Tricare Costs and Coverage

Active Duty service members will be covered under one of four Tricare Prime programs or two distinct Tricare Select programs.

Most of this coverage will be determined by the geographic location of the sponsor’s active duty.

Tricare offers two types of Reserve care (Select and Retired), Tricare for Life for overseas options where Medicare may not extend, and five separate Tricare Young Adult programs.

Newborn or adopted children are covered by Tricare for 90 days post birth (or 120 days if overseas) so long as one family member is enrolled in some form of Tricare Prime.

The Continued Health Care Benefit Program is a premium-based option that extends another eighteen to 36 months of health coverage once Tricare eligibility has ended for children who have aged out or unmarried former spouses.

Utilize the Tricare Plan Finder to select the health care plan that most suits the needs of your family.

Copayments and Cost-Shares

Tricare is set up in such a way to prevent any Active Duty service members from paying anything out-of-pocket for any medical costs, whether the costs are associated with line-of-duty work or not.

There are no enrollment fees and family members of Active Duty sponsors who are on a Tricare Prime plan will only pay for services when they receive care without a referral, when they use a network pharmacy, when they use

the Home Delivery option from a Tricare pharmacy or when they use Tricare Select.

Any medical services rendered to Active Duty sponsors or family members at a military treatment facility (MTF) are free outside of a nominal per diem charge for any inpatient care received.

Catastrophic caps will vary depending on when an Active Duty sponsor joined uniformed military service; one set of costs exists for those who joined prior to January 1, 2018 (Group A) and another set of costs for those who joined after January 1, 2018 (Group B). Review Tricare’s most current costs and fees here.

Point-of-Service Option

This plan allows patients to visit an authorized Tricare provider without an official referral, as long as the patient pays some out-of-pocket costs.

Active Duty sponsors, Tricare beneficiaries utilizing non-Prime plans, adopted or newborn children, beneficiaries with other health insurance plans and beneficiaries needing urgent or emergency care are excluded from the Tricare POS Option.

Fees for point-of-service care include any deemed fit by the provider and are paid instead of a normal Tricare copayment.

The outpatient deductible for point-of-service care is $300 for individuals and $600 for a family. This deductible must be met before any cost-sharing can begin for outpatient services.

Once cost-sharing begins, Tricare pays 50 percent of the allowable charge for both hospitalization and outpatient care. Tricare allowable charges are governed by law in affiliation with Medicare’s allowable charges.

Dental Coverage

Active Duty sponsor or National Guard/Reserve family members receive most of their dental care at military dental clinics through the Tricare Active Duty Dental Program.

National Guard/Reserve sponsor dental care is based on whether the sponsor is not activated, activated or deactivated.

Activated Guard/Reserve members enjoy active duty dental care like any other active duty sponsor, non-activated Guard/Reserve sponsors can enroll themselves and their families in the Tricare Dental Program and deactivated Guard/Reserve sponsors can either qualify for the Transitional Assistance Management Program (TAMP) or enroll in the Tricare Dental Program.

The Tricare Active Duty Dental Program offers care from civilian dentists in:

● The United States and U.S. Virgin Islands

● Puerto Rico and Guam

● The American Samoa and Northern Mariana Islands

Active Duty members in all other overseas service will have their dental care handled by the Tricare Overseas Program (TOP).

Type of Service Pay Grades E1 – E4 (CONUS)

All Other Pay Grades (CONUS)

OCUNUS

Diagnostic 0% 0% 0%

Preventative (except sealants)

0% 0% 0%

Emergency treatment

0% 0% 0%

Sealants 20% 20% 0%

Basic Restorative 20% 20% 0%

Endodontic 30% 40% 0%

Periodontic 30% 40% 0%

Oral Surgery 30% 40% 0%

Other Restorative 50% 50% 50%

Implant Services 50% 50% 50%

Prosthodontic 50% 50% 50%

Orthodontics 50% 50% 50%

Misc. Services 50% 50% 0%

The following table outlines the cost shares for Tricare dental plans.

For more Tricare Dental information, click here.

Vision Coverage

Tricare vision insurance coverage is especially tailored to those individuals who are active duty

members of the United States Armed Forces (USAF) as well as their family members.

A basic vision benefits package for active military duty members and their families includes a yearly eye exam.

You can find out about Tricare’s policies on corrective lenses and eyewear here.

Tricare offers an online tool with which to compare various plans and prices in order to find the one that best suits the needs and budgets of those seeking coverage.

Prescription Coverage

The Tricare Formulary can help you to research in advance any pre-approved drugs that will be covered by most Tricare plans.

Prescriptions that may require prior authorization:

● A drug that has age limits

● A drug that is recommended by the DoD Pharmacy and Therapeutics Committee

● A drug that is prescribed at a dosage higher than the normal established limit

● A brand-name drug with a generic substitute

Copayment costs for prescriptions are determined by the guidelines set by Tricare Pharmacy Home Delivery service. Express Scripts, a federal pharmacy service, handles most Tricare prescription payments and offers multiple payment options.

Dependent parents and parents-in-law may also fill prescriptions at military pharmacies.

Find more detailed information about how to fill a prescription using Tricare coverage here. For Express Scripts billing questions call 877-363-1303.

Mental Health Coverage

Tricare mental health care coverage is one of the health insurance plans available through Tricare services.

Those seeking Tricare mental health care coverage plans must first meet with the strict eligibility requirements.

The list of the types of issues and needs addressed by these insurance plans includes the following covered treatments.

Other services offered with Tricare mental health plans include programs to help adjusting back to life after a deployment area, help with addiction and substance abuse, crisis hotlines and specialized mental help.

Other programs and resources provided by Tricare mental health care insurance plans are easy to view and learn about here.

There are many options to choose from for a mental health care plan here. Other information about the programs and what may or may not be included with your Tricare mental health care insurance plan can be found in this handbook.

Exclusions

As a general rule, Tricare coverage only extends to prescriptions and procedures that are proven to be medically necessary for the treatment of covered illnesses, pregnancies or well-child care.

Discover a more detailed list of excluded illnesses, treatments and procedures here.

Extensions

Tricare members who need supplemental coverage for mental or physical conditions requiring deeper care have the option of enrolling in Tricare’s Extended Health Care Option (ECHO) for no additional enrollment fees.

Review helpful details about the Tricare Extended Health Care Option to determine which program may best serve your family’s needs.

To enroll in a Supplemental insurance plan through Tricare, click here. To find out the overall costs for premiums depending on the age of the applicant, click here.

Using Tricare Insurance

There are two types of Tricare-authorized providers that you can search from: Network and Non-Network providers.

If you choose a network provider, it will accept payments from Tricare as the full payment. It will also file claims for you.

You can also choose a non-network provider. However, you will need to pay the out-of-pocket costs.

A Tricare-authorized network provider is defined as a business, hospital, pharmacy or individual that provides health care.

To be part of the Tricare network, they must be licensed by a state, accredited by a national organization, or meet specific standards of the medical community. Tricare must also certify and authorized at a minimum all providers, and the regional contractions must verify them.

Finding a Tricare Provider

Tricare is available around the world and is managed in three separate regions: The East Region Network Providers, the West Region Network Providers and the Overseas Region.

To see which region you belong to, you can check the map here. Once you establish which region you belong to, you can visit either the West or East network provider’s websites for more information. You can also call 1-(844)-866-9378 for the West Region and 1-(800)-444-5445 for the East Region.

If you are overseas, you can visit the overseas website here if you are located in the Eurasia-Africa area, the Latin America and Canada area or the Pacific area.

The quickest way to book an appointment with a Tricare network provider is online through the patient portal. To do so, click here.

When scheduling an appointment, you must know that the rules are based on which Tricare

plan you have, and active duty service members have specific rules in which they must abide by. You can click on your Tricare plan for more details about the rules of your plan.

Filing a Tricare Claim

According to program guidelines, your Tricare provider will file your medical claims on your behalf in most instances.

However, there are circumstances in which you will need to file your own claims, such as if you see a non-participating provider. To file a claim, you can do so by mail or online, depending on where you are located.

To file a Tricare claim, you will need to obtain a copy of the request for medical payment form. You can do so online or by calling your regional office. Once you submit the form and necessary paperwork, you can check the status of your claim in your region.

Not every claim submitted will be approved, and that there are many reasons for Tricare to deny a claim. However, you can file an appeal if you believe that your claim is denied inappropriately either in part or in whole.

When will I need to file a Tricare claim?

You will need to file a claim if you fall into one of the below categories:

● You are traveling

● If you receive a health care service from a non-participating provider

● If you have a Tricare for Life plan and you see a Medicare, non-participating provider

For you or your provider to receive reimbursement, you must submit a Tricare claim as soon as possible after you receive a health care service.

If you are in the U.S. or a U.S. territory, then you must file a claim within one year from the date of service. If you are overseas, you must do so within three years from the date of service. If you fail to meet the appropriate deadline, you may not be able to seek reimbursement. Information for a Tricare Claim

You must first obtain a copy of the Patient’s Request for Medical Payment (DD Form 2642).

You will need to attach a readable copy of the provider’s bill to your signed DD Form 2642. Information provided should include the:

● Sponsor's Social Security Number (SSN) or Department of Defense Benefits Number (DBN)

● Eligible former spouses need to use their SSN

● Date and place of each service

● Description and charges of each service or supply furnished

● Diagnosis

● If not included on the bill, you must complete block 8a of the DD Form 2642

Before you submit a Tricare claim, be sure to make and keep a copy of all paperwork for your records.

You can visit either the West or East network provider’s websites for more information. You can also call 1-(844)-866-9378 for the West Region and 1-(800)-444-5445 for the East Region.

Submitting a Tricare Claim

To find the claims filing address for your region, click here. If you are in the U.S. or a U.S. territory, you must mail your claims.

If you are overseas, you can file some overseas claims online, such as overseas medical claims and overseas Tricare Retiree Dental program claims. All other claims must be filed by mail.

If you are involved in an accident with possible third-party liability, your regional contractor will send you a copy of the Statement of Personal

Injury- Possible Third-Party Liability form (DD Form 2527). You must sign and mail the form back to your regional contractor within 35 calendar days.

You can check a Tricare claim status online through the claim processor’s website for your region:

● East Region

● West Region

● Overseas

● Tricare For Life claims

● If you are in the U.S. or a U.S. territory.

The sooner that you submit a claim, the sooner you or your provider will be paid. However, most Tricare claims are processed within 30 days.

Once your DD Form 2527 and paperwork are approved, you will be reimbursed for Tricare-covered services at the Tricare allowed amount.

Note:Deductibles, cost shares are copayments are not included in the reimbursement costs.

A claim is typically denied due to a simple error, such as incorrect filing. If this occurs, you must correct the mistake then resubmit the claim to your regional claim’s processor.

If your Tricare claim is denied, you will receive a letter detailing how to file an appeal. If you believe that it has been denied inappropriately, you or another party may file an appeal. The appeal process is different based on the denial issue. For more information about how to file an appeal regarding your Tricare claim, click here.

Additional Resources

Department of Veterans Affairs (VA) Health Benefits Explorer

VA Discharge Upgrade Information

Veterans Choice Program

Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA)

Program of Comprehensive Assistance to Family Caregivers of Post-9/11 Veterans (PCAFC)

Children of Women Vietnam Veterans Health Care Benefits Program (CWVV)

VA Disability Compensation Rates

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