TRICARE Prime

 

TRICARE Prime is a Health Maintenance Organization (HMO) medical plan. HMOs provide guaranteed access to health care by assigning you to a specific facility for your care. HMOs use primary care managers to manage your health care needs and determine access to specialists.

By enrolling in TRICARE Prime, you agree to coordinate your health care needs through a primary care manager (PCM). Enrollees receive care through a military treatment facility (MTF) or through an assigned Prime-designated network of civilian providers.

If you're on active duty, you must enroll in TRICARE Prime. All others can choose to enroll in TRICARE Prime or TRICARE Select.

TRICARE Prime offers fewer out-of-pocket costs than TRICARE Select but less freedom of choice for providers.

When you enroll in TRICARE Prime, you should expect to drive no more than 30 minutes to your PCM for primary care and 60 minutes for specialty care. Retirees have to sign a waiver of the drive time standards when they enroll if they want to select a military or network PCM that’s outside of the 30-minute drive time standard or a specialist outside the 60-minute drive.

If you have other health insurance in addition to TRICARE, such as Medicare or an employer-sponsored health insurance, Tricare Prime is probably not a good choice for you. Enroll in Tricare Select instead.

TRICARE Prime eligibility
  • Active duty servicemembers and their families,
  • retired service members and their families (until you become eligible for TRICARE For Life),
  • Guard/Reserve members and their families activated to active duty service for more than 30 days in a row,
  • non-activated Guard/Reserve members and their families who qualify for care under the Transitional Assistance Management Program,
  • retired Guard/Reserve members at age 60 and their families,
  • survivors,
  • Medal of Honor recipients and their families, and
  • qualified former spouses.
Tricare Prime Costs

Costs are different for Group A and Group B members. Group A are members who entered the service prior to 2018. Group B is members who entered the service in 2018 and after.

Prime enrollment for active duty service members and their families has no enrollment fee or co-payments.

Retirees must enroll to use Tricare Prime and pay the annual enrollment fee and the co-pays.

Annual enrollment fees are here. The Prime annual fee is adjusted each year based on the retired pay COLA.

Outpatient visits require a $20 co-pay for primary care and $30 for specialty care. Hereis the full list of co-payment amounts by service.

The catastrophic cap, which is the maximum annual out of pocket cost, for active duty families is $1,000. For retirees and their families it is $3,000. Costs you incur that contribute to the catastrophic cap are annual deductibles (if applicable), pharmacy copayments and other copays and cost shares based on TRICARE-allowable charges.

The cap does not apply to:

  • services not covered by TRICARE,
  • any amount non-participating providers charge above the Tricare maximum allowable charge.
  • TRICARE Prime Point of Service charges,
  • enrollment fees for TRICARE Prime, nor
  • monthly premiums for TRICARE Reserve Select, Tricare Retired Reserve, or Tricare Young Adult.

NOTE: The Prime Point-of-Service Option. If you have TRICARE Prime and choose to go outside your assigned PCM, you will pay dearly. This is known as the Point of Service option, and it is not an effective option. We suggest that if you will not follow the rules of Prime by going where you are assigned, you are better served by enrolling in TRICARE Select.

TRICARE Point-of-Service Option costs are here.

Positives

  • No enrollment fee for active duty and families.
  • Guaranteed access — you are assigned a medical facility.
  • Managed health care.
  • Assistance from primary care manager.
Negatives
  • Requires a copayment.
  • Annual enrollment fee for retirees.
  • Limited options when choosing a provider.
  • Mandatory referral for specialty care.
  • Not available everywhere.
  • The Point-of-Service Option.
Enrollment

TRICARE Prime requires enrollment in the Defense Enrollment and Eligibility Reporting System (DEERS) and reoccurring annual enrollment during the Open Season in November and December. If you are enrolled in Prime during the year, no additional enrollment action is necessary during future Open Season periods as it is assumed you will automatically continue in the Prime plan until you choose otherwise.

 

If you want to switch TRICARE plans, Prime to Select or vice versa, this must be done during the Open Season period unless you require TRICARE enrollment due to a “qualifying life event.” This would be a death, marriage, divorce, loss of another health care plan, etc. See TRICAREfor the complete list.

 

You can choose to drop from all TRICARE plans if you prefer to use a different health care plan. We suggest you always enroll in a TRICARE plan as a backup. TRICARE Select works as a backup because there are no costs if you don’t use Select because of another plan.

 

Enroll at your ID card office or base hospital or online during the Open Season window.

 

Notify DEERS, of any changes in personal information, including address, marital status, and other health insurance.

 

Maintain an up-to-date Uniformed Services Identification Card. You can locate your nearest ID card issuing facility by viewing the DoD RAPIDS Site Locator online.

If you have questions about your TRICARE eligibility or coverage, please email beninfo@moaa.org or call the Member Service Center at (800) 234-6622 and ask to speak to a benefits counselor.

MEDIPLUS® TRICARE Supplement Insurance

To help reduce your unexpected out-of-pocket expenses, MOAA sponsors the MEDIPLUS® TRICARE Supplement Insurance Plans that help cover cost-shares not fully reimbursed by TRICARE for covered doctor visits, hospital stays, surgeries, prescription drug cost-shares and excess charges (up to 15% above the TRICARE allowed amount), once any applicable TRICARE and MEDIPLUS deductibles have been met.

MEDIPLUS has you covered:

 

  • Pays cost-shares and co-pays
  • Pays excess charges (up to 15% above the TRICARE allowed amount)
  • Affordable members-only group rates
  • Guaranteed acceptance for eligible MOAA members and their families – you’re covered immediately for all new health conditions. Any current injuries or illnesses are subject to the Pre-Existing Conditions Limitation and are covered after six months.

For more information on the MOAA MEDIPLUS TRICARE Supplement Plans, call 1-800-247-2192, e-mail moaa.service@mercer.com, or visit www.moaainsurance.com.