TRICARE is the health insurance program for military servicemembers, their families, and other eligible beneficiaries. Medical, dental, and pharmacy services are offered through TRICARE.
Who is eligible for coverage?
Run by the Department of Defense, TRICARE is open to those serving in and retired from the U.S. Air Force, U.S. Army, U.S. Marine Corps, U.S. Navy, U.S. Coast Guard, Commissioned Corps of the U.S. Public Health Service, and National Oceanic and Atmospheric Administration. Eligibility is determined by law, and enrollment in the Defense Enrollment Eligibility Reporting System (DEERS) is required. Enrollment is open year-round.
TRICARE offers coverage based on beneficiary category — active-duty servicemembers; eligible family members of active-duty servicemembers; retired servicemembers and eligible family members; survivors; Medal of Honor recipients and their families; qualified former spouses; and National Guard and Reserve members and their family members. Eligibility for certain programs can change if the servicemember moves to a new region, experiences a life event, or becomes eligible for Medicare Part A. Visit TRICARE’s website,TRICARE.mil,for specific information.
The cost for TRICARE varies by program and also by the servicemember’s rank and status. Deductibles also vary depending on the program in which the beneficiary is enrolled. TRICARE meets the minimum essential coverage requirement under the Affordable Care Act.
Here’s a look at some of the TRICARE programs
TRICARE Prime/Prime Remote
Available to active-duty servicemembers, their families, and certain other eligible beneficiaries, this option is generally the most cost-effective because there are fewer out-of-pocket costs. However, because users typically receive medical care at a military hospital or clinic (or by a civilian TRICARE network provider), they usually must live close to a military base to take advantage of the benefits. In areas where TRICARE Prime is available, enrollment in Prime is required. There are no enrollment fees for active-duty servicemembers and their eligible family members. However, retirees and their family members, surviving spouses, eligible former spouses, and others must pay an annual enrollment fee. When visiting a provider, active-duty servicemembers do not incur any out-of-pocket expenses for care received; nor do active-duty family members, except when using the point-of-service option when receiving medical care from a TRICARE-authorized provider without a referral from a primary-care physician (with certain exceptions).
TRICARE Standard and TRICARE Extra
These fee-for-service programs enable eligible beneficiaries to receive medical care from TRICARE-authorized providers. With TRICARE Standard, beneficiaries can choose providers outside the network. With TRICARE Extra, beneficiaries must choose an in-network provider. The beneficiary is responsible for covering the annual deductible and a cost-share for covered services. (The cost-share is a percentage of costs that must be paid for inpatient or outpatient care once the annual deductible is met.) Though TRICARE Standard offers more flexibility in choosing providers, beneficiaries pay higher cost-shares than they would with TRICARE Extra.
TRICARE for Life
TRICARE for Life (TFL) provides supplemental coverage for TRICARE beneficiaries who are enrolled in Medicare Part A and Part B. TFL beneficiaries can use providers regardless of whether they take Medicare, or can receive treatment at a military hospital or clinic if space is available. For services covered by both Medicare and TRICARE, Medicare is billed and pays the provider for its share; TRICARE covers the remaining portion. If services are received that are covered only by TRICARE and not Medicare, TRICARE will pay its allowable amount and the beneficiary is responsible for the deductible and cost-share. (There may be circumstances in which neither Medicare nor TFL provides coverage for certain health-care costs, such as nonmedically necessary treatments or procedures. In these instances, the member is responsible for all billed charges.)
TRICARE Young Adult
This plan covers an eligible sponsor’s unmarried, adult children who are at least age 21 but not older than 26. (If the young adult is enrolled full-time in college and the sponsor provides 50% or more financial assistance, eligibility may not begin until age 23 or upon graduation, whichever occurs first.) A beneficiary is not eligible for TRICARE Young Adult if he or she has access to health insurance through an employer or is eligible for TRICARE on his or her own. The cost of the TRICARE Young Adult program is determined by whether enrollment is in TRICARE Prime or TRICARE Standard, the sponsor’s military status, and where the care is received.
TRICARE Pharmacy Program
Open to all TRICARE-eligible beneficiaries, the pharmacy program provides prescription medications through a military pharmacy, a home-delivery service, or retail pharmacies (both network and non-network). Military pharmacies are the most cost-efficient option, providing up to a 90-day supply of medications at no cost to beneficiaries. Most military pharmacies accept written prescriptions from both military and civilian providers.
TRICARE Pharmacy Home Delivery is a low-cost option when a military pharmacy is not used. The service is free for active-duty servicemembers. Beneficiaries may also receive a 90-day supply of generic medications at no cost. Copayments apply for brand-name and non-formulary medications.
Prescriptions may also be filled through a TRICARE retail network pharmacy. A copayment is required for each 30-day supply of medication. A non-network pharmacy can also fill the prescription, although the beneficiary is responsible for paying the full price for the prescription and then submitting a claim for reimbursement, which is subject to deductibles, cost-shares, and co-payments. A special consideration for TRICARE for Life enrollees: There is no added benefit to purchasing Medicare Part D (prescription drug plan) as long as the beneficiary remains eligible for TRICARE.
TRICARE Dental Program
Active-duty servicemembers receive dental care at military clinics. Active-duty family members, eligible National Guard and Reservists and their families are covered by the voluntary TRICARE Dental Program (TDP). A network or non-network dentist may be seen for dental care, but non-network dentists may bill for their full fee at the time of service, and beneficiaries may have to submit their own claims. With an in-network provider, the beneficiary is not responsible for more than the cost-share for covered services. Premiums for the TDP vary and depend on the sponsor’s status. Retirees have access to the TDP, as long as eligibility requirements are met. Premiums vary depending on the sponsor’s military status, as do cost-shares, which are based on where services are received and the sponsor’s pay grade.
Tricare Vision Benefits
Routine eye exams are available at military hospitals or clinics for active-duty servicemembers unless a referral for civilian care is received. Family members enrolled in TRICARE Prime are allowed one annual eye examination and may receive care from a network provider without the need for a referral. Retirees and their family members enrolled in Prime can receive eye exams once every two years; those with TRICARE Standard and Extra are not covered for eye exams, except for children under age six.