Presentation on theme: "TRICARE® Your Military Health Plan"— Presentation transcript:
1 TRICARE® Your Military Health Plan TRICARE Benefits TRICARE Reserve Select TRICARE Retired Reserve TRICARE Retiree EntitlementPresenter TipsReview slides before briefingPrint out briefing with notes prior to presentationEnsure “slide show” settingDelete any slides that do not apply to your audienceYou may add slides from other briefings as appropriate for your audienceEstimated Briefing Time: 15–20 minutesRecommended Handouts: (available atTRICARE Retired Reserve brochureTRICARE Resources for the National Guard and Reserve flyerTRICARE Reserve Select brochureTRICARE Choices for the National Guard and Reserve brochureBriefing Objectives:Increase awareness of TRICARE benefits for National Guard and Reserve members and familiesTell beneficiaries the necessary steps for accessing the TRICARE benefitOptional Presenter Comments: Welcome to the TRICARE Benefits/Programs for National Guard and Reserve Members New to TRICARE/Active Less Than 30 Days briefing for members who are new to TRICARE and on inactive duty status. The goal of today’s presentation is to give you information about your TRICARE benefit.Denise BinkleyBeneficiary Service and Education RepresentativeUpdated January 20111
2 TRICARE Stateside Regions (50 United States & Washington, DC) What Is TRICARE?TRICARE is available worldwide and managed regionallyHealth Net Federal Services, LLCTriWest Healthcare Alliance Corp.TRICARE is available worldwide and managed regionally. There are three TRICARE regions in the United States—TRICARE West, TRICARE North, and TRICARE South. Your benefits are the same regardless of where you live, but you will have different customer service contacts based on your region.Because you are in the [West, North, South] region, your contractor is [TriWest Healthcare Alliance; Health Net Federal Services; Humana Military Healthcare Services]. [TriWest; Health Net; Humana Military] partners with the Military Health System to provide you with health, medical, and administrative support including customer service, claims processing, and authorizations for certain health care services.Customer service information for each region will be provided at the end of this presentation.While TRICARE programs and services exist overseas and I’ll provide you with contact information to learn more about TRICARE overseas, we’ll focus on stateside regions for this particular presentation.Humana Military Healthcare Services, Inc.2
3 TRICARE EligibilityUpdating DEERSKeep your contact information up to date:Online:By Phone:By Fax:Visit an ID card-issuing facility:More information:Remember to register/update DEERS whenever there is a change in the family (marriage, birth, adoption, divorce, death, etc.) or when you moveOnce you and your family are registered in DEERS, be sure to keep addresses and other contact information up to date for all family members.Keeping DEERS information current, especially your address, is critical to ensuring uninterrupted TRICARE coverage for you and your family.While only the sponsor can add or remove family members in DEERS, both the sponsor and adult family members can update contact information. Anytime there is a change in family status, marriage, birth, adoption, divorce, death, etc., the sponsor must update DEERS.Promptly update your information when any change occurs, regardless of whether or not you are on active duty at the time.You can contact DEERS online, by phone, or by fax. For more information, go toIf you prefer to update your information in person, you can visit an ID card-issuing facility.Note: Be sure to register newborn or newly adopted children in DEERS within 60 days of birth or adoption. Prompt registration of children in DEERS can minimize delays or problems with coverage and claims processing.3
4 TRICARE Reserve Select When you retire, you have new health care choices. While on active duty, you could only be enrolled in TRICARE Prime or TRICARE Prime Remote. Now you will have many of the same choices as your family members. This portion of our seminar will discuss you new health care options and explain differences that your family members will see after you retire.Note: If you were enrolled in TRICARE Prime Remote and your family was enrolled in TRICARE Prime Remote for Active Duty Family Members, these options are no longer available to you.BR402101BET0504C
5 TRICARE Reserve Select (TRS): Step 1 – Qualify Medical CoverageTRICARE Reserve Select (TRS): Step 1 – QualifySelected Reserve Member may qualify if:Not eligible for, or enrolled in, Federal Employees Health Benefits (FEHB) programFor more information, visitLog onto the “Reserve Component Purchased TRICARE Application”Follow the instructions to qualifyIf qualified, print-out and sign the completed DD Form , Reserve Component Health Coverage Request formTRICARE Reserve Select, or TRS, is a premium-based health plan available for purchase by qualified members of the Selected Reserve.You will not qualify for TRS if you are eligible for the Federal Employees Health Benefits, or FEHB, program based on your civilian employment or if you are enrolled in FEHB through a family member.You can visit the Reserve Component Purchased TRICARE Application to determine your qualification.Any questions regarding eligibility, especially if you or your spouse is a Federal employee and may be eligible for FEHB, contact your Reserve Component personnel office.If you have any questions regarding your TRICARE Reserve Select eligibility, please contact your Reserve Representative at5
6 TRICARE Reserve Select: Step 2 – Purchase Medical CoverageTRICARE Reserve Select: Step 2 – PurchaseMailSigned and completed request form (DD Form )To TRICARE contractor address on formMake initial premium payment as indicated on formNote: For continuous TRICARE coverage, purchase TRS up to 60 days before TAMP ends, but no later than 30 days after endWith TRICARE Reserve Select, you can purchase either member-only or member-and-family coverage.To purchase coverage, visit the Reserve Component Purchased TRICARE Application website.Follow the instructions to complete, print, and sign the Reserve Component Health Coverage Request form, which is DD Form Note: Handwritten forms will NOT be accepted.Mail the completed and signed form along with the first month’s premium payment.If you wish to continue TRICARE coverage with no lapse and qualify to purchase TRICARE Reserve Select, you must do so within 60 days of the end of your TAMP period for uninterrupted coverage, but no later than 30 days after TAMP ends. It is best to apply for TRS before your TAMP ends.Note: Any premium payment that is late or not made at all, will result in a 12-month lock-out.Photo courtesy of the National Guard6
7 Continuous Open Enrollment If you qualify, you may purchase TRS coverage to begin in any month throughout the year.Coverage begins on the first day of the first or second month after the postmark date of your TRS Request Form. The member can choose which month he or she wishes to begin coverage.Coverage begins on the first day of the first or second month following postmark of your TRS Request Form.For example, if your TRS Request Form is postmarked in July, you may select coverage to begin on the first of the next month, August, or you may select that coverage begin the first of the second month, which would be September.
8 TRICARE Reserve Select: Getting Care Medical CoverageTRICARE Reserve Select: Getting CareNo referrals necessaryCertain services require prior authorizationIn the event of an emergency, call 911 or go to the nearest hospitalLocate a MTF for space-available careMTF locator:For TRICARE Extra, locate a TRICARE network providerContact the TRICARE regional contractor, check their website, visit a TRICARE Service Center (TSC)TRICARE Reserve Select beneficiaries have the flexibility to visit any TRICARE-authorized provider, which is a doctor or other provider who is approved to provide care to TRICARE beneficiaries.Although referrals are not required for most health care services, some services require prior authorization to determine medical necessity.Visit your regional contractor’s website for information about authorization requirements.In the event of an emergency, call 911 or go to the nearest emergency room.Referral or prior authorization is not required, but, if admitted, contact your regional contractor within 24 hours or the next business day to coordinate ongoing care.TRICARE Reserve Select beneficiaries may also receive care at military hospitals and clinics on a space-available basis, but space is very limited.8
9 TRICARE Reserve Select: Getting Care Medical CoverageTRICARE Reserve Select: Getting CareFor TRICARE Standard, locate a non-network TRICARE-authorized providerCheck your phone book orAsk provider’s office, “Do you accept TRICARE?”If not, invite the provider to become TRICARE authorizedGive your provider the phone number of your regional contractor or send them toHowever, your out-of-pocket costs will be lower if you see a TRICARE network provider, thus utilizing TRICARE Extra. A network provider is a TRICARE-authorized provider who has an agreement with your regional contractor to accept TRICARE rates as payment in full and file claims on your behalf. To find a network provider, visit or contact your regional contractor toll free or visit the nearest TRICARE Service Center.If you plan to see a non-network provider, ask if he or she is authorized and accepts TRICARE before receiving care. If they are not an authorized TRICARE provider, invite them to become so.9
10 TRICARE Reserve Select Costs Medical CoverageMonthly PremiumsTRS Member-only: $53.16TRS Member and family:$197.76Annual Deductibles(per fiscal year)Rank E-4 & below:$50/individual or $100/familyRank E-5 & above:$150/individual or $300/familyCost-Shares(after annual deductible is met)Network Provider: 15%Non-network Provider: 20%Catastrophic Cap$1000 per enrollmentWith TRICARE Reserve Select, you are responsible for monthly premiums, an annual deductible, cost-shares, and copayments.Premiums are monthly payments due the first of every month for TRS members. The 2011 premiums are $53.16 for member-only coverage and $ for member-and-family coverage. These rates are effective through December 31, Note: It is important to know that any premium payment that is late or not made at all, will result in a 12 month lock-out period.Your deductible is the amount you pay out-of-pocket per year before your TRICARE coverage begins and is based on the sponsor’s pay grade.The deductible for E4s and below is $50 per individual and $100 per family.The deductible for E5s and above is $150 per individual or $300 per family.BR414001BET0405W
11 New Child EnrollmentTo have your newborn or newly adopted child covered under TRICARE Reserve Select (TRS):First: Register in DEERSThe sponsor (or parent/guardian with power of attorney) must register the child in DEERS.Second: Submit the TRS Request FormGo to https://www.dmdc.osd.mil/appj/trs/index.jspSelect Qualifying Life Event (QLE)Submit the application to TriWest within 60 days of birth or adoption to have coverage start at birth or adoption.NOTE: If not enrolled in TRS within 60 days, the child’s coverage will begin upon enrollment, not at birth or adoption.
12 Changes to TRS Coverage Change in family compositionMarriage, divorce, newborn, etc.Take one of the following actionsPurchase new coverageChange type of coverage(e.g., member-only to member-and-family)Terminate coverageIf change impacts type of coverage (e.g., member-only to member-and-family), premium increase (or decrease) is effective based on date of changeLife-changing events that affect your family composition include:Birth or adoption of a childPlacement of a child in the legal custody of the member by an order of the courtDivorce or annulmentDeath of a spouse or family memberLast family member becomes ineligible (e.g., child ages out)You must take one of the following actions to change your TRS coverage:Purchase new coverageChange in type of coverageTerminate existing coverageWhen you experience a change to your family composition you must take specific actions on your TRS coverage. If the qualifying life event changes your type of coverage, for example, member-only coverage becoming member-and-family coverage, you will be responsible for paying the change in premium.You must report all changes in family composition to a military personnel office with Real-Time Automated Personnel Identification System (RAPIDS) capability to appropriately update DEERS. You must also submit a TRS Request Form to your regional contractor no later than 60 days after the date of the qualifying life event. The effective date of coverage is the date the qualifying life event occurred (i.e., date of marriage, date of birth, etc.).
13 Disenrollment from TRS You must submit a TRS Request Form to disenroll from TRS.Do—Log on to the “Reserve Component Purchased TRICARE Application” to complete the TRS Request Form.Do—Mail your completed TRS Request Form to your TRICARE regional contractor.Don’t—Stop paying premiums.Note: If you are activated for more than 30 days you will automatically be disenrolled from TRICARE Reserve Select – Do Not fill out a disenrollment form.If you decide you no longer want TRS coverage, do not just stop making payments.You must take action to terminate/disenroll from TRS:Log on to the Guard and Reserve Web PortalComplete the TRS Request Form.Mail your completed TRS Request Form to your TRICARE regional contractor.The contractor will process your request and return any excess premium amounts paid within 10 days of receipt of the termination request.You can request to disenroll/terminate coverage at any time. A one-year TRS purchase lockout from the effective date of the termination will apply to all family members under the sponsor’s Social Security number. A termination of coverage request initiated by the member is effective the last day of the month the request was postmarked/received.
14 Termination of TRS Coverage Failure to pay premiumsLoss of Selected Reserve statusGain eligibility for other TRICARE programMay purchase TRS again if you qualify at time of purchaseYour TRS coverage will be automatically terminated if you and your family members become eligible for a non-premium TRICARE program (e.g., TRICARE Prime). When your eligibility for the non-premium TRICARE program ends, you must re-enroll in TRS within 60 days to continue uninterrupted TRICARE coverage.Members who lose Selected Reserve status are no longer qualified for TRS, and coverage will be terminated immediately upon notification of the status change.Your payment is due no later than the 30th day of each month. Your payment will apply to the following month of coverage. Failure to pay monthly premiums on time will result in termination of coverage. You will be responsible for any medical bills for care received after coverage was terminated.Termination of coverage due to non-payment will also result in a TRS purchase lockout for one year or until the overdue premiums are paid, whichever is longer.As of September 30, 2007, TRS coverage will be terminated for those members currently enrolled in the three-tiered TRS program who gain eligibility for other TRICARE programs (e.g., activated for greater that 30 days, Early Identified Deployers [EID] status, or Transitional Assistance Management Program [TAMP]).Contact your regional contractor for questions about terminating TRS coverage.
15 TRICARE Assistance Program Life is stressful. Help is available.ConfidentialNon-reportable24/7/365Call, click or chat today.1-888-TRIWEST
16 TRICARE Dental Program (TDP) Other Important InformationTRICARE Dental Program (TDP)Voluntary, premium-based programPremiums depend on sponsor’s statusServiceSponsorOne Family MemberMore Than One Family MemberSponsor and FamilyActive DutyN/A$12.69$31.72National Guard and Reserve$79.29$91.98Individual Ready Reserve$111.01The TRICARE Dental Program, or TDP, is a voluntary, premium-based dental program available to you and your family.TDP is administered by United Concordia Inc.Monthly premiums depend on your duty status. As you can see on this chart, costs are lower when you are activated for more than 30 consecutive days. These premiums apply through July 31, Note: Premiums are typically subject for renewal or change on February 1st of each calendar year, but the current contract for TDP is under a six-month extension.Most TDP care is provided by participating dentists in civilian networks. You can use the “Find a Participating Dentist” tool on the TDP website to find a dentist, or you can obtain services from a nonparticipating dentist, which may result in higher costs.TDP website:16
17 TRICARE Retired Reserves When you retire, you have new health care choices. While on active duty, you could only be enrolled in TRICARE Prime or TRICARE Prime Remote. Now you will have many of the same choices as your family members. This portion of our seminar will discuss you new health care options and explain differences that your family members will see after you retire.Note: If you were enrolled in TRICARE Prime Remote and your family was enrolled in TRICARE Prime Remote for Active Duty Family Members, these options are no longer available to you.BR402101BET0504C
18 TRICARE Retired Reserve (TRR) TRICARE Retired Reserve (TRR) is a premium-based healthcare plan available to eligible retired members of the National Guard and Reserves, their families and qualified survivors. Members pay a monthly premium and are responsible for annual deductibles and cost-shares.Members of the Retired Reserve of a Reserve Component are eligible for TRR when they are:Qualified for non-regular retirement under 10 U.S.C., Chapter 1223.Not yet age 60.Not eligible for, or enrolled in, the Federal Employees Health Benefits (FEHB) program.
19 TRR Monthly PremiumEffective for coverage beginning January 1, 2011, TRR monthly premiums are:$ for Member-only coverage$1, for Member and family coverageThe monthly premium amount could change every year on January 1.Send in payment for the first two month’s premium with the enrollment form. You can pay the initial premium payment by credit/debit card and sign up for automatic monthly credit/debit card payments on the application.
20 TRR Coverage Termination Termination Due to NonpaymentYour premium payment is due no later than the last day of the month for the next month’s coverage. Failure to pay overdue premium amounts will result in a termination of coverage due to nonpayment. A 12-month TRR purchase lockout will go into effect.Your TRR coverage will automatically terminate for the sponsor and family members when:You (the sponsor) reach age 60 (or for surviving family members, when the sponsor would have reached age 60).You (the sponsor) are recalled to active duty service for more than 30 days. If eligible, you may qualify for and purchase TRR after the loss of any other TRICARE coverage.
21 TRICARE Standard and Extra Costs: Retirees, Their Families and All Others TRICARE OptionTRICARE StandardTRICARE ExtraOutpatient DeductibleAmount due each fiscal year before cost-sharing begins.$150/individual or $300/familyOutpatient Cost-share25%*20%Inpatient CostsCheck with your regional contractor about inpatient behavioral health costs.Lesser of $535/day or 25% of charges plus 25% of professional feesLesser of $250/day or 25% of charges plus 20% of professional feesCatastrophic Cap$3,000 per family per fiscal yearBy visiting a network provider when you can, you can save 5% on outpatient cost-shares. Additionally, non-network providers may charge up to 15% above the TRICARE allowable charge—an amount you are responsible for.The dollar amounts on this slide are for fiscal year 2007 and are subject to change on Oct. 1 each year.The federal fiscal year is Oct. 1- Sept. 30.* Non-network providers may charge up to 15% above the TRICARE allowable charge.Get extra cost-savings with TRICARE Extra!
22 TRICARE Retired (Entitlement Coverage) When you retire, you have new health care choices. While on active duty, you could only be enrolled in TRICARE Prime or TRICARE Prime Remote. Now you will have many of the same choices as your family members. This portion of our seminar will discuss you new health care options and explain differences that your family members will see after you retire.Note: If you were enrolled in TRICARE Prime Remote and your family was enrolled in TRICARE Prime Remote for Active Duty Family Members, these options are no longer available to you.BR402101BET0504C
23 Decision Process Where will you live? Will you accept employment? How is your health (and family)?What health plans are available?Cost of competing health plans?Insurability?Do I need supplemental insurance?You will need to make several decisions when you retire. These are just a few examples of the questions you may ask yourself. The answers to these questions will determine the TRICARE options you have for you and your family.BR402101BET0504C
24 TRICARE Standard Fee-for-service option No enrollment required Seek care from any TRICARE-authorized providerResponsible for annual deductibles and cost- shares— highest out-of-pocket expenseMay have to pay provider then file claim for reimbursementAnother option now available to you is TRICARE Standard. TRICARE Standard offers the freedom for you to seek care from any TRICARE-authorized provider. After meeting an annual deductible, you will be responsible for a 25 percent cost-share—slightly higher than with TRICARE Extra.You don’t have to enroll in TRICARE Standard; in most cases, you simply select your doctor at time of need, pay for services, and submit the paperwork to TRICARE for reimbursement for covered services.When using TRICARE Standard, you may continue to seek care in an MTF, which is usually available on a space-available basis. In many areas, space-available appointments are becoming increasingly difficult to obtain.BR402101BET0504C
25 TRICARE Standard—Costs Annual deductible$150 individual/$300 for familyCost-shares after deductible has been met25% of allowed chargesMay be responsible for up to 15% above the TRICARE allowable charge for services if providers do not participate in TRICAREMay have to pay provider then file claim for reimbursementYou are responsible for an annual deductible with TRICARE Standard each fiscal year (October 1–September 30). After your annual deductible has been met, your cost-share is 25 percent for TRICARE Standard—slightly higher than with TRICARE Extra. If your family members were using TRICARE Standard while you were still on active duty, they will notice a 5 percent increase (20 percent to 25 percent) upon your retirement.In addition to your cost-share, you may be responsible for up to 15 percent above the TRICARE allowable charge for services if the provider does not participate in TRICARE.You may also have to file your own claims if your provider does not participate in TRICARE.The amount paid toward your deductible is listed on the Explanation of Benefits (EOB) statement. You receive this statement in the mail each time a claim is processed.BR402101BET0504C
26 TRICARE Extra Preferred provider option (PPO) No enrollment required Seek care from any TRICARE network providerResponsible for annual deductibles and discounted cost-sharesProviders will file claims for youMay seek care in an MTF on a space-available basisActive duty service members are not eligible to use TRICARE Extra. But, as a retired service member, you now have that option. If you decide not to enroll in TRICARE Prime, deciding to use TRICARE Extra is the next best choice for you.TRICARE Extra is a preferred provider option (PPO). With TRICARE Extra, you choose civilian physicians and specialists from a list of providers who have joined the TRICARE network and have agreed to provide care at approved rates. Also, with TRICARE Extra, you must pay an annual deductible before TRICARE will begin sharing costs, after that deductible has been reached, you are responsible for discounted cost-shares—20 percent for retirees and their families.Because network providers have contractually agreed to accept TRICARE’s negotiated rate as payment in full, you will not be responsible for any additional charges for covered benefits when using the TRICARE Extra option. Additionally, since you’ll be seeing a TRICARE network provider, you will not have to file your own claims.BR402101BET0504C
27 Cost-shares after deductible has been met TRICARE Extra—CostsAnnual deductible$150 individual/$300 for familyCost-shares after deductible has been met20% of negotiated rateProviders cannot charge more than the negotiated rate for services renderedYou are responsible for an annual deductible with TRICARE Extra each fiscal year (October 1–September 30). After your annual deductible has been met, your cost-share is 20 percent for TRICARE Extra. If your family members were using TRICARE Extra while you were still on active duty, they will notice a 5 percent increase (15 percent to 20 percent) upon your retirement.Network providers are not allowed to balance bill, so you will only be responsible for your cost-share for the services rendered—they cannot bill for anything above the TRICARE allowable charge.To locate a network provider and begin using TRICARE Extra, visit the provider directory online at or contact your regional contractor for assistance.When using TRICARE Extra, you may continue to seek care in an MTF, which is usually available on a space-available basis. In many areas, space-available appointments are becoming increasingly difficult to obtain.BR402101BET0504C
28 TRICARE Extra vs. Standard Any TRICARE network providerCost-share: 20% of negotiated rateProviders will file claims for youNot responsible for additional charges for covered benefitsStandardAny TRICARE- authorized providerCost-share: 25% of allowable chargeMay have to file claimsNonparticipating providers may charge up to 15% above allowable charge for servicesIn comparing the two plans, the similarities are same deductible, no enrollment, and no monthly or annual premiums.The differences are:Provider Type:A network provider is first a TRICARE-authorized provider, then he/she is certified as a network provider.TRICARE Extra—Network Provider (who is first TRICARE-authorized)TRICARE Standard—TRICARE-authorized onlyCost-Share:20 percent after meeting deductible for TRICARE Extra25 percent for Standard and you may have to pay up to 15 percent above the TRICARE allowable charge if provider does not participate in TRICARE (TRICARE will not share the cost of this amount)Both options allow for care at the MTF on a space-available basis. You do not have to use either of these options exclusively. You can use TRICARE Extra or TRICARE Standard together—depending on which type of provider you visit—network or TRICARE-authorized.BR402101BET0504C
29 Access standards for care Most care received from primary care manager TRICARE PrimeEnrollment requiredPortable: Easy to transfer when you moveSplit enrollment: Families can enroll together in different regionsAccess standards for careMost care received from primary care managerMinimal out-of-pocket costsTRICARE Prime is a managed care option offering the most affordable and comprehensive health care. TRICARE Prime is available in areas near an MTF and where regional contractors have established TRICARE Prime networks. To use TRICARE Prime, you must enroll. Active duty service members are required to enroll in TRICARE Prime. TRICARE Prime is portable and easy to transfer when you move. And, if you have family members living in separate locations (i.e. college students, children living with a custodial parent, etc.) you can all enroll in TRICARE Prime with a single enrollment fee (when applicable) with TRICARE Prime’s split enrollment feature.Beneficiaries eligible for TRICARE Prime include active duty service members and their families, retired service members and their families, National Guard or Reserve members called to active duty on federal orders for more than 30 consecutive days and their families, survivors, certain former spouses and other eligible beneficiaries such as Medal of Honor recipients and their families.
30 Outpatient visit: $12 copayment TRICARE PrimeEnrollment feesIndividual: $230 per yearFamilies: $460 per yearNetwork provider feesOutpatient visit: $12 copaymentInpatient visit: $11 per day ($25 minimum)Emergency services: $30 copaymentBehavioral health outpatient visit:$25/individual$17/groupBehavioral health inpatient visit: $40 per dayTRICARE Prime is your best option if you are residing in a TRICARE Prime Service area, so deciding where to live after you retire is an important decision. If you are taking a job that offers comprehensive health care, you should compare the employer-sponsored plan with TRICARE Prime and decide which offers the most coverage at the best value for you.We mentioned the changes in TRICARE Prime earlier. It’s important to note that TRICARE Prime coverage for you and your family does not change. What we’ll highlight now are those things that do change.To participate in TRICARE Prime, retirees and their family members pay annual enrollment fees of $230 for an individual or $460 for a family. Payments can be made in annual, quarterly, or monthly installments. If you enroll to the MTF, you will not pay any copayments for outpatient care in the MTF.When enrolled to a network provider or visiting a network specialty provider, however, you are responsible for a small copayment per visit. Primary care services incur a $12 copayment for retirees and their family members. Check with your regional contractor for other copayment requirements or consult the TRICARE Choices booklet.BR402101BET0504C
31 Each fiscal year—$3,000 for all retirees and family members Catastrophic CapEach fiscal year—$3,000 for all retirees and family membersTRICARE PrimeTRICARE ExtraTRICARE StandardThe catastrophic cap limits your out-of-pocket liability on copayments, cost-shares, and deductibles. The catastrophic cap for all retirees is as follows:• Fiscal year (October 1–September 30)—$3,000TRICARE PrimeTRICARE ExtraTRICARE StandardBR402101BET0504C
32 TRICARE Prime Point-of-Service (POS) Option Freedom to use any TRICARE-authorized providerIn or out of network—no referrals neededNonavailability statement is not necessarySubject to higher deductibles and cost-sharesPoint-of-service option is more costly to the enrolleeThe Point-of-Service (POS) Option under TRICARE Prime allows enrollees the freedom to seek and receive nonemergent health care services from any TRICARE-authorized civilian provider, in or out of the network, without requesting a referral from their PCM or your regional contractor.When TRICARE Prime enrollees choose to use the POS option, all requirements applicable to TRICARE Standard apply except the requirement for a Nonavailability Statement (NAS). POS claims are subject to outpatient deductibles and cost-shares, and is the most costly TRICARE option to the enrollee.BR402101BET0504C
33 POS Cost-shares and Deductibles Annual outpatient deductibles are $300 for an individual and $600 for a family50% cost-shares for outpatient and inpatient claimsExcess charges up to 15% above the TRICARE allowable chargeThe 50 percent cost-share continues to be applied even after the catastrophic cap has been metAnnual outpatient deductibles are $300 for an individual and $600 for a family, 50 percent cost-shares for outpatient and inpatient claims, and excess charges up to 15 percent over the allowed amount. The 50 percent cost-share continues to be applied even after the catastrophic cap has been met.BR402101BET0504C
34 TRICARE Retiree Dental Program Voluntary dental insurance program administered by the Federal Services division of Delta Dental PlanAvailable to:Retired service members and their eligible family membersCertain surviving family members of deceased active duty sponsorsMedal of Honor recipients and their immediate family members and survivorsThe TRICARE Retiree Dental Program (TRDP) is a voluntary dental insurance program administered and underwritten by the Federal Services division of Delta Dental Plan (DDP) of California, located in Sacramento, California.The TRDP offers comprehensive, cost-effective dental coverage for uniformed services retirees and their eligible family members, as well as certain surviving family members of deceased active duty sponsors, and Medal of Honor recipients and their immediate family members and survivors.The retiree dental program requires that the sponsor be enrolled in order for family members to enroll unless the sponsor is 100 percent disabled, covered by his/her employer, or has a debilitating disease.Other details of TRDP benefits, requirements, and restrictions can be found at the TRDP Web site atBR402101BET0504C
35 TRDP—Enrollment Delta Dental handles all enrollments There is an initial 12-month commitment for new enrollees after which enrollment may be continued on a month-to-month basis30-day grace period from the coverage effective date during which voluntary termination of enrollment is allowed without further enrollment obligation provided that no benefits have been usedDelta Dental handles all the enrollments. There is an initial 12-month commitment for new enrollees after which enrollment may be continued on a month-to-month basis. There is a 30-day grace period from the coverage effective date during which voluntary termination of enrollment is allowed without further enrollment obligation provided that no benefits have been used.BR402101BET0504C
36 $150 deductible cap per family TRDP—CostsAnnual deductible$50 per person$150 deductible cap per familyAnnual maximum coverage$1,200 per personDeductible and maximum do not apply to:Diagnostic and preventive servicesDental accident procedures or orthodontiaFor more information:orThe annual deductible is $50 per person with a $150 deductible cap per family. The annual maximum coverage is $1,200 per person. The deductible and maximum do not apply to the diagnostic and preventive services or to dental accident procedures or orthodontia.For more information about the TRICARE Retiree Dental Plan, call toll-free at , or visit DeltaSelect USA online atBR402101BET0504C
37 TRICARE and Other Health Insurance Other Important InformationTRICARE and Other Health InsuranceTRICARE serves as the secondary payer.If you have other health insurance (OHI):Fill out a TRICARE Other Health Insurance Questionnaire (www.tricare.mil/mybenefit/Forms.do)Follow the referral and authorization rules for your OHITell your provider about your OHI and TRICAREShow him or her your insurance cardTRICARE is the sole payer for the Guard/Reserve sponsor when activated (or during early eligibility)No payment is sought from OHI for the sponsor’s careIf you have other health insurance, or OHI, and you choose to purchase TRICARE Reserve Select, TRICARE is your secondary payer.That means when your family member goes to the doctor, the doctor files a claim with your other health insurance first and TRICARE pays what is left, up to the TRICARE-allowable charge. Note: Does not apply to Medicaid and certain other state programs.If your other health insurance runs out, or for services covered by TRICARE that are not covered by your OHI, TRICARE becomes your primary payer.If you have other health insurance:Fill out a TRICARE Other Health Insurance Questionnaire and follow the guidelines for submission. You can download the questionnaire from TRICARE.mil, or you can pick one up at your TRICARE Service Center.Because your other health insurance pays first, you must follow their rules for getting care.Make sure your provider knows you have other health insurance and TRICARE. Keeping your regional contractor and health care providers informed about your other health care coverage will allow them to better coordinate your benefits.Note: Unlike OHI, supplemental insurance pays after TRICARE pays its portion of the bill, reimbursing you for out-of-pocket medical expenses paid to civilian providers based on the plan’s policies. Remember that you have a $1,000 catastrophic cap when considering supplemental insurance.37
38 TRICARE Pharmacy Program Other Important InformationPharmacy OptionFormularyNon-FormularyGenericBrand NameMTF Pharmacy (up to a 90-day supply)$0N/ATRICARE Pharmacy Home Delivery (up to a 90-day supply)$3$9$22Retail Network Pharmacy (up to a 30-day supply)Non-Network Retail Pharmacy (up to a 30-day supply)TRICARE Prime: 50% cost-share after point-of-service deductible is metOther Programs: $9 or 20% of total cost (whichever is greater) after the annual deductible is metOther Programs: $22 or 20% of total cost (whichever is greater) after the annual deductible is metYou may use the TRICARE pharmacy benefit unless you are enrolled in the US Family Health Plan.To have a prescription filled, you will need the prescription, a valid uniformed services ID card, and up-to-date information in DEERS.Note: Pharmacies are legally permitted to copy military and dependent ID cards to verify TRICARE eligibility.You will normally receive a generic drug rather than a brand-name drug. Your doctor or other provider must justify medical necessity for you to receive a brand-name medication if a generic version is available.Pharmacy costs depend on the pharmacy option you choose, whether the drug is generic or brand name, and whether it’s listed in the TRICARE formulary, which is the list of drugs covered by TRICARE.There is no copayment when you fill a prescription at a military pharmacy.If you have recurring prescriptions, such as allergy or blood pressure medicine, you can use TRICARE Pharmacy Home Delivery to order up to a 90-day supply by phone, online, or by mail. TRICARE Pharmacy Home Delivery copayments are $3 for generic formulary drugs, $9 for brand-name formulary drugs, and $22 for non-formulary drugs.If you need a prescription filled immediately, your best option is find one of TRICARE’s 60,000 plus retail network pharmacies. The costs are the same as TRICARE Pharmacy Home Delivery, but only for a 30-day supply. To find a retail network pharmacy, visit the Express Scripts website provided at the bottom of the screen.The most expensive option is a non-network retail pharmacy.Express Scripts, Inc. website:38
39 TRICARE Mail Order Pharmacy (TMOP) Convenient home delivery (FPO or APO for overseas locations)Low CostGeneric medication—$3 for up to a 90-day supplyBrand name medication—$9 for up to a 90-day supplyNon-formulary medication—$22 for up to a 90-day supplyNote: Up to a 30-day supply for controlled substancesFree Shipping and HandlingFor more information:Visit1-866-DoD-TMOP ( )TRICARE Mail Order Pharmacy is available for prescriptions that beneficiaries take on a regular basis. Beneficiaries may receive up to a 90-day supply for most medications. TMOP is administered by Express Scripts, Inc. Through this program, beneficiaries mail their health care provider’s written prescription, along with the appropriate copayment, to TMOP, and the medications will be sent directly to the beneficiary. Prescriptions may be refilled by mail, phone, or online.NOTE: For non-formulary prescriptions, you are responsible for a $22 cost-share with TMOP. For more information about TMOP, you may visit the Express Scripts Web site at or call DoD-TMOP ( ).BR402101BET0504C
40 Guard & Reserve Resource Center All TRICARE Prime/Prime Remote, TRICARE Reserve/Select, and Standard beneficiaries are eligible to registerIf the beneficiary is not the sponsor, he/she must have the sponsor’s SSN to registerBeneficiaries must have a record in DEERS, and info provided at time registration MUST MATCH what is on file with DEERSRegistered beneficiaries have access to minor dependent information.Registered beneficiaries DO NOT automatically have access to spouse or dependent (18 +) medical information.Each family member must register onRegistered beneficiaries may grant account access to other registered family members.No sensitive diagnosis information is displayed on the portal.40
41 For Information and Assistance Stateside Regional ContractorsOverseas Regional ContractorInternational SOS Assistance, Inc.Eurasia-Africa:Latin America & Canada:Pacific:Singapore:Sydney:TRICARE North Region Health Net Federal Services1-877-TRICARE ( )TRICARE South RegionHumana Military Healthcare ServicesTRICARE West RegionTriWest Healthcare Alliance1-888-TRIWEST ( )Connect with TRICARE Online!The following contact information provides the stateside and overseas regional contractors, as well as other important information outlets.Remember, your regional contractor is tied to where you reside.General Contact InformationTRICARE Website: Contacts:MMSO:PP4111BEC05101W41