TRICARE / TRICARE Pharmacy

TRICARE is the health insurance program for military beneficiaries. Active duty servicemembers' and their dependents are mostly exempt from TRICARE fees; however, this changes with a change in status (e.g. retired, National Guard/Reserve, or TRICARE Young Adult). Coverage and fees vary with regard to the TRICARE coverage elected, and depend on whether:

(a) the military sponsor is on active duty or retired,
(b) the beneficiary is eligible for Medicare, or
(c) the beneficiary uses military or civilian facilities for health care and medications.

TRICARE Standard will be changing to TRICARE Select in January of 2018, please visit here to read about how this new change will affect your healthcare insurance.

Why do I need health insurance?

TRICARE PROGRAMS FOR ACTIVE DUTY SERVICEMEMBERS AND FAMILY MEMBERS STARTING JANUARY 2018

TRICARE PRIME

TRICARE SELECT

Description

TRICARE Prime is an HMO-style plan that uses a specific network of doctors. It guarantees appointments with participating providers within specific time standards. In most cases, TRICARE Prime care is delivered through military hospitals or clinics.

TRICARE Prime is the only option available to active duty servicemembers.

Active duty family members are enrolled in Prime automatically unless they specifically request TRICARE Standard.

Appointments to see specialists or doctors other than a primary care manager (PCM) require a referral from the PCM.

A special program, TRICARE Prime Remote, provides Prime coverage for active duty family members who have been sent on military orders to locations without reasonable access to military facilities.

Family members may choose coverage under TRICARE Select, a fee-for-service plan under which beneficiaries find civilian doctors.

Visits with other doctors, including specialists, do not require PCM referrals in most cases.

TRICARE Standard has an annual deductible of $150 a person or $300 a family and 20-percent cost shares for active duty or 25-percent for retirees.

Those who use a network provider called TRICARE Extra get a 5-percent discount.

Enrollment Fee

None

None

Annual Outpatient Deductible

None

E-1 to E-4: $50 an individual/$100 a family
E-5+: $150 an individual/$300 a family

Outpatient Visit Copay

None

20 percent of TRICARE-allowed charges

Inpatient Copay

None

$17.35 a day ($25 minimum)

Catastrophic Cap (Maximum out-of-pocket payment for TRICARE-allowed charges)

$1,000 a family per year

$1,000 a family per year

What are the TRICARE Pharmacy benefits?
Beneficiaries have four ways to fill prescriptions, listed below in the order of least to most costly to beneficiaries. Please note: Class III narcotics are not covered.

  • Pharmacies at military treatment facilities fill prescriptions for both 30 and 90 days at no cost as long as they carry your medication.
  • TRICARE Pharmacy Home Delivery provides a 90-day prescription, filled by mail, with a zero-dollar copay for formulary generic, $13 for brand name, and $43 for non-formulary,
  • Retail pharmacies provide a 30-day prescription fill with cost shares of $5 for generic, $17 for brand name, or $44 for non-formulary.
  • The most costly is a non-network pharmacy that provides a 30-day prescription fill for $44 or of 20 percent of the cost of the drug.

Initial medication prescriptions should be filled in military or retail pharmacies. TRICARE Pharmacy Home Delivery is for refills of longer-term maintenance medications.

Beneficiaries without regular access to military pharmacies would benefit from home delivery, which offers 67-percent or greater savings on refills compared to retail drug stores.

TRICARE declares certain drugs as “non-formulary” if they are no more effective than other available drugs for the same purpose but cost more for the military to buy. If your doctor prescribes a non-formulary drug, talk to him or her about substituting a generic or brand-name drug that’s equally effective for you but has lower copayment. If your doctor believes a non-formulary drug is medically necessary for you, the doctor can request that TRICARE grant a waiver to give you the drug at the regular, lower copayment.

Visit the TRICARE website for additional details.

Use the TRICARE Formulary Search Tool to determine the point-of-delivery options available for your prescription and the copayment as well as any applicable medical necessity or preauthorization forms.