TRICARE Prime

TRICARE Prime is a managed care option similar to a civilian health maintenance organization. TRICARE Prime offers fewer out-of-pocket costs than any other TRICARE option. TRICARE Prime enrollees receive most of their care from a military treatment facility (MTF), augmented by the TRICARE contractor's Preferred Provider Network. TRICARE Prime enrollees are assigned a primary care manager (PCM).

The PCM

Provides and coordinates your care
Maintains your health records
Refers you to specialists, if necessary. (To be covered, specialty care must be arranged and approved by your PCM.)

Care is usually provided in an MTF, but civilian clinics may be used in some cases.

Who is Eligible for TRICARE Prime?

Active duty service members
Family members and survivors of active duty personnel
Retirees and their family members and survivors under age 65
Reserve component (RC) members and their families if RC member is activated for more than 30 consecutive days

All eligible beneficiaries must be enrolled in the Defense Enrollment Eligibility Reporting System (DEERS) and must reside in a service area where TRICARE Prime is offered.

Enrollment

Active duty service members are covered under the TRICARE Prime benefit but are required to complete a TRICARE Prime enrollment form.

To participate in TRICARE Prime, active duty family members, retirees, and their family members must also complete a TRICARE Prime enrollment form. There is no enrollment fee for active duty family members. Retirees and their family members must pay an annual enrollment fee of $230 for an individual or $460 for a family.

If the TRICARE Prime enrollment form is received by the 20th of the month, coverage 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, it will be covered under the TRICARE Prime benefit starting May 1.

Enrollment in TRICARE Prime is continuous. During the period of enrollment, TRICARE Prime beneficiaries are "locked in" to using only TRICARE Prime. Beneficiaries can choose to disenroll or can be disenrolled due to a move to a non-TRICARE Prime area, a move out of their service area, or nonpayment of enrollment fees. If beneficiaries choose to disenroll from TRICARE Prime, or are disenrolled for nonpayment, they are subject to a 1-year lockout for early disenrollment. The lockout provision does not apply to active duty family members of E-1 through E-4.

Point of Service (POS) Option

Option under TRICARE Prime that allows enrollees the freedom to seek and receive non-emergent health care services from any TRICARE authorized civilian provider, in or out of the network, without requesting a referral from their PCM or the Health Care Finder (HCF). When TRICARE Prime enrollees choose to use the POS option, all requirements applicable to TRICARE Standard apply. POS claims are subject to outpatient deductibles ($300 individual and $600 family), 50% cost-shares for outpatient and inpatient claims, and excess charges up 15% over the allowed amount. The 50% cost-share continues to be applied even after the catastrophic cap has been met.

Advantages

No enrollment fee for active duty and families
Small fee per visit to civilian providers, and no fee for active duty members
No balance billing
Guaranteed appointments (access standards)
PCM supervises and coordinates care
Away-from-home emergency coverage
POS option (see Glossary)
Reduced catastrophic cap for retirees ($7,500 now decreased to $3,000)

Disadvantages

Enrollment fee for retirees and their families
Provider choice limited
Specialty care by referral only
Not universally available