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Updated June 11, 2003
TRICARE: The Basics
TRICARE is the Department of Defense’s worldwide health care program for active duty and retired uniformed services members and their families. TRICARE consists of TRICARE Prime, a managed care option; TRICARE Extra, a preferred provider option; and TRICARE Standard, a fee-for-service option. TRICARE For Life is also available for Medicare-eligible beneficiaries age 65 and over (effective Oct. 1, 2001).*
TRICARE Prime:
TRICARE Prime is a managed care option similar to a civilian health maintenance organization (HMO). This option requires enrollment. Active duty service members are required to enroll in Prime. Active duty family members, retirees and their family members are encouraged, but not required, to enroll in Prime. However, to receive the TRICARE Prime benefit, they must reside where TRICARE Prime is offered. Ask your local TRICARE service center (TSC) about the TRICARE Prime availability in your area. If you are stationed in a remote area, TPR/TRICARE Prime Remote for Active Duty Family Members (TPRADFM) may be the option available to you and your family members.* This option also requires enrollment. If enrollment for TRICARE Prime and TPR/TPRADFM is received by the 20th of the month, it is effective the first day of the next month. For instance, if an enrollment is received by March 20, coverage will begin April 1. If a family enrolls March 25, they will be covered under the TRICARE Prime benefit starting May 1. If an individual disenrolls from TRICARE Prime, he or she is locked out for 12 months.
TRICARE Prime offers less out-of-pocket costs than any other TRICARE option. Active duty members and their families do not pay enrollment fees, annual deductibles or co-payments for care in the TRICARE network. Retired service members pay an annual enrollment fee of $230 for an individual or $460 for a family, and minimal co-pays apply for care in the TRICARE network. Although Prime offers a "point-of-service" option for care received outside of the TRICARE Prime network, receiving care from a nonparticipating provider is not encouraged.*
TRICARE Prime enrollees receive most of their care from military providers or from civilian providers who belong to the TRICARE Prime network. Enrollees are assigned a primary care manager (PCM) who manages their care and provides referrals for specialty care. All referrals for specialty care must be arranged by the PCM to avoid point-of-service* charges.
TRICARE Prime enrollees are guaranteed certain access standards for care. The chart below describes the access standards for Prime enrollees.
Urgent Care | Routine Care | Referred/Specialty Care | Wellness/ Preventive Care | |
| Appointment wait time | Not to exceed 24 hours | Not to exceed seven days | Not to exceed four weeks | Not to exceed four weeks |
| Drive time | Within 30 minutes from home | Within 60 minutes from home | ||
| Wait time in office | Not to exceed 30 minutes for nonemergency situations. | |||
TRICARE Extra & TRICARE Standard:
TRICARE Extra and TRICARE Standard are available for all TRICARE-eligible beneficiaries who elect or are not able to enroll in TRICARE Prime. Active duty service members are not eligible for Extra or Standard. There is no enrollment required for TRICARE Extra or Standard—no annual enrollment fees, no enrollment forms. Beneficiaries are responsible for annual deductibles and cost-shares. Beneficiaries may see any TRICARE authorized provider they choose, and the government will share the cost with the beneficiaries after deductibles.
TRICARE Extra is a preferred provider option (PPO) in which beneficiaries choose a doctor, hospital, or other medical provider within the TRICARE provider network. Network providers can be located by calling your local TRICARE service center or visiting our Web page.
TRICARE Standard is a fee-for-service option. You can see an authorized TRICARE provider of your choice. Having this flexibility means that care generally costs more. See the chart below for the differences between Extra and Standard.
TRICARE Extra | TRICARE Standard | |
| Physician/Provider | In network | Not in network, but still an authorized provider |
| Cost share after deductibles | 15% active duty families 20% retirees and their families | 20% active duty families; non-participating providers may also "balance bill" up to 15% above the TRICARE allowable charge 25% retirees and their families; non-participating providers may also "balance bill" up to 15% above the TRICARE allowable charge |
TRICARE For Life and TRICARE Plus:
When beneficiaries age 65 and over become eligible for Medicare Part A, they can use TRICARE For Life (TFL)* if they purchase Medicare Part B. These beneficiaries are not eligible for TRICARE Prime but are eligible to use Medicare, network and non-network providers. Under TFL, TRICARE acts as a second payer to Medicare for benefits payable by both Medicare and TRICARE. Beneficiaries can use an authorized Medicare provider and claims will be automatically sent to TRICARE after Medicare pays its portion. There are no enrollment fees for TFL—beneficiaries are only required to pay the Medicare Part B premium. TRICARE is first payer for TRICARE benefits not covered by Medicare, such as pharmacy, which is available only under TRICARE.
Some military treatment facilities will have capacity to offer a primary care affiliation program called TRICARE Plus.* Enrolled beneficiaries have priority access to care at military treatment facilities; however, beneficiaries who choose to use TRICARE Extra, TRICARE Standard or TRICARE For Life may also continue to receive care in a military treatment facility on a space-available basis.
For more information about any of the TRICARE options, please contact your local TRICARE service center or visit the TRICARE Web site at www.tricare.osd.mil
*See also: TRICARE For Life Fact Sheet
TRICARE Plus Fact Sheet
TRICARE Prime Point-of-Service Option Fact Sheet
TRICARE Regional Contractors for the United States Fact Sheet
TRICARE Prime Remote Web site
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