In looking at the varied benefit systems for military members, what are the positive aspects of the Active Duty Benefit Systems?U.S Department of Veterans Affairs. (n.d). VA Burial Benefits (Links to an external site.)Links to an external site.. Retrieved from http://www.cem.va.gov/cem/burial_benefits/index.as…minimum of 250 words to include references and citation
tricare_prime_and_tricare_prime_remote_handbook.pdf
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TRICARE Prime and
TRICARE Prime Remote
Handbook
®
Your guide to program benefits
February 2014
Important Information
TRICARE Web Site:
www.tricare.mil
TRICARE North Region
TRICARE North Region Contractor
The TRICARE North Region includes Connecticut, Delaware, the District
of Columbia, Illinois, Indiana, Kentucky (excluding the Fort Campbell area),
Maine, Maryland, Massachusetts, Michigan, New Hampshire, New Jersey,
New York, North Carolina, Ohio, Pennsylvania, Rhode Island, Vermont,
Virginia, West Virginia, Wisconsin, Iowa (Rock Island Arsenal area only),
and Missouri (St. Louis area only).
Health Net Federal Services, LLC
TRICARE South Region
TRICARE South Region Contractor
The TRICARE South Region includes Alabama, Arkansas, Florida, Georgia,
Kentucky (Fort Campbell area only), Louisiana, Mississippi, Oklahoma, South
Carolina, Tennessee, and Texas (excluding the El Paso area).
Humana Military, a division of
Humana Government Business
www.hnfs.com
1-877-TRICARE (1-877-874-2273)
Humana-Military.com
1-800-444-5445
TRICARE West Region
TRICARE West Region Contractor
The TRICARE West Region includes Alaska, Arizona, California, Colorado,
Hawaii, Idaho, Iowa (excluding the Rock Island Arsenal area), Kansas, Minnesota,
Missouri (excluding the St. Louis area), Montana, Nebraska, Nevada, New Mexico,
North Dakota, Oregon, South Dakota, Texas (the southwestern corner only,
including El Paso), Utah, Washington, and Wyoming.
UnitedHealthcare Military & Veterans
TRICARE Overseas Program*
TRICARE Overseas Program Contractor
www.uhcmilitarywest.com
1-877-988-WEST (1-877-988-9378)
International SOS Assistance, Inc.
www.tricare-overseas.com
TRICARE Eurasia-Africa: 1-877-678-1207
TRICARE Latin America and Canada: 1-877-451-8659
TRICARE Pacific: 1-877-678-1208 (Singapore)
1-877-678-1209 (Sydney)
* For overseas contact information, visit www.tricare-overseas.com.
An Important Note About TRICARE Program Changes
At the time of publication, this information is current. It is important to remember that TRICARE policies and benefits are governed
by public law and federal regulations. Changes to TRICARE programs are continually made as public law and/or federal regulations are
amended. For the most recent information, contact your regional contractor. More information regarding TRICARE, including the
Health Insurance Portability and Accountability Act (HIPAA) Notice of Privacy Practices, can be found online at www.tricare.mil.
See the inside back cover of this handbook for “TRICARE Expectations for Beneficiaries.”
Keep Your DEERS Information Up To Date!
It is essential to keep information in the Defense Enrollment Eligibility Reporting System (DEERS) current for you and your family.
Failure to update DEERS to accurately reflect the sponsor’s or family member’s residential address and/or the ineligibility of a former
dependent could be considered fraud and a basis for administrative, disciplinary, and/or other appropriate action.
TRICARE Meets the Minimum Essential Coverage Requirement Under the Affordable Care Act
The Affordable Care Act, also known as the health care reform law, requires that individuals maintain health insurance or other health
coverage that meets the definition of “minimum essential coverage” beginning in 2014. Please note that the TRICARE program is
considered minimum essential coverage. Most people who do not meet this provision of the law will be required to pay a fee for each
month they do not have adequate coverage. The fees will be collected each year with tax returns. Watch for future communications
from TRICARE or visit www.tricare.mil/aca for more information about your minimum essential coverage requirement. You can
also find other health care coverage options at www.healthcare.gov.
Important Contact Information
Use this page as a guide for the most important resources available to you.
TRICARE Web site: www.tricare.mil
TRICARE Regional Contractors
TRICARE North Region
TRICARE South Region
TRICARE West Region
Health Net Federal Services, LLC
1-877-TRICARE (1-877-874-2273)
www.hnfs.com
Humana Military, a division of
Humana Government Business
1-800-444-5445
Humana-Military.com
UnitedHealthcare
Military & Veterans
1-877-988-WEST (1-877-988-9378)
www.uhcmilitarywest.com
TRICARE Overseas Program1
International SOS Assistance, Inc.
TRICARE Eurasia-Africa: 1-877-678-1207
TRICARE Latin America and Canada: 1-877-451-8659
TRICARE Pacific: 1-877-678-1208 (Singapore)
1-877-678-1209 (Sydney)
TRICARE Overseas Program Web site: www.tricare-overseas.com
1. For overseas contact information, visit www.tricare-overseas.com.
Service Points of Contact
U.S. Army, U.S. Navy, U.S. Air Force, U.S. Marine Corps
Reserve and Service Member Support Office, Great Lakes
1-888-647-6676
U.S. Public Health Service and National Oceanic and
Atmospheric Administration
Medical Affairs Branch
1-800-368-2777
U.S. Coast Guard
Coast Guard Benefits Line
1-800-942-2422
Defense Enrollment Eligibility Reporting System (DEERS)
You have several options for updating and verifying DEERS information:
In Person
Phone
Visit a local uniformed services identification card-issuing
facility. Find a facility near you at www.dmdc.osd.mil/rsl.
Call to verify location and business hours.
1-800-538-9552
1-866-363-2883 (TDD/TTY)
Online
Fax
Visit the milConnect Web site at http://milconnect.dmdc.mil.
1-831-655-8317
Visit www.dmdc.osd.mil/appj/bwe/ to access the
Beneficiary Web Enrollment Web site.
Mail
Defense Manpower Data Center Support Office
400 Gigling Road
Seaside, CA 93955-6771
TRICARE Dental Options
Visit www.tricare.mil/dental for information on all of TRICARE’s dental program options.
Active Duty Dental Program
TRICARE Dental Program
TRICARE Retiree Dental Program
United Concordia Companies, Inc.
www.addp-ucci.com
MetLife
www.metlife.com/tricare
Delta Dental
www.trdp.org
Health Care Claims
You can download forms and instructions from your regional contractor’s Web site or from the TRICARE Web site
at www.tricare.mil/claims. Submit claims to the addresses provided. You can also check the status of your claims at
the Web sites provided. For information about filing claims for care received overseas, visit www.tricare.mil/claims.
TRICARE North Region
TRICARE South Region
TRICARE West Region
Health Net Federal Services, LLC
c/o PGBA, LLC/TRICARE
P.O. Box 870140
Surfside Beach, SC 29587-9740
TRICARE South Region
Claims Department
P.O. Box 7031
Camden, SC 29020-7031
TRICARE West Region
Claims Department
P.O. Box 7064
Camden, SC 29020-7064
www.myTRICARE.com
www.hnfs.com
www.myTRICARE.com
Humana-Military.com
www.uhcmilitarywest.com
TRICARE Pharmacy Program
Register for TRICARE Pharmacy Home Delivery, find a TRICARE retail network pharmacy, or find information
on how to save money and make the most of your pharmacy benefit.
Express Scripts, Inc.
www.express-scripts.com/TRICARE
TRICARE Pharmacy Home Delivery
TRICARE Retail Network Pharmacy
1-877-363-1303
1-877-540-6261 (TDD/TTY)
Download the Express Scripts New
Patient Home Delivery Form from
www.express-scripts.com/TRICARE
to register for TRICARE Pharmacy
Home Delivery. Mail the form to:
Send pharmacy claims to:
Member Choice Center (convert retail
prescriptions to home delivery):
1-877-363-1433
Express Scripts, Inc.
TRICARE Claims
P.O. Box 52132
Phoenix, AZ 85082
Express Scripts, Inc.
P.O. Box 52150
Phoenix, AZ 85072-9954
Prescription Drug Formulary Search
www.tricare.mil/pharmacyformulary
Other Resources
TRICARE Forms
www.tricare.mil/forms
Beneficiary Web Enrollment
www.tricare.mil/bwe
US Family Health Plan
www.tricare.mil/usfhp
TRICARE Behavioral Health
www.tricare.mil/mentalhealth
Continued Health Care Benefit Program
www.tricare.mil/chcbp
Customer Service Community Directory
www.tricare.mil/bcacdcao
TRICARE is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved.
Welcome to TRICARE Prime®,
TRICARE Prime Remote, and
TRICARE Prime Remote for
Active Duty Family Members
TRICARE Prime offers enhanced benefits and personalized care. To make the best use of your benefit,
please read this TRICARE Prime and TRICARE Prime Remote Handbook. Look in the mail and on your
regional contractor’s Web site for the TRICARE Health Matters newsletter, a regular publication for all
TRICARE Prime beneficiaries. This newsletter highlights covered services, customer service options, news,
and other important updates.
Your TRICARE Resources
www.tricare.mil
Visit the TRICARE Web site for more information on any of the topics
covered in this handbook.
www.tricare.mil/smart
The SMART Site is your best resource for TRICARE materials online.
View, print, or download TRICARE brochures, fact sheets, handbooks, and
other materials.
www.tricare.mil/subscriptions
Sign up online to receive TRICARE news and publications via e-mail.
http://milconnect.dmdc.mil
Sign up online to receive benefits correspondence via e-mail instead of
postal mail.
1
Your TRICARE Regional
Contractor
Important Note for National
Guard and Reserve Members
and Their Families
Regional contractors administer the TRICARE
medical benefit in each TRICARE region (North,
South, and West). This handbook refers regularly
to your regional contractor. Visit your regional
contractor’s Web site for information about how
to change your primary care manager, how to
enroll family members, covered services, referral
and prior authorization requirements, and other
helpful information. You can call your regional
contractor toll-free for assistance at the numbers
provided on the cover of this handbook. You may
also seek assistance from Beneficiary Counseling
and Assistance Coordinators (BCACs), who are
located at military hospitals and clinics and at
the TRICARE Regional Offices. To find a BCAC
near you, visit the Customer Service Community
Directory at www.tricare.mil/bcacdcao.
National Guard and Reserve members called
or ordered to active service for more than
30 consecutive days become eligible for
TRICARE as active duty service members
and their family members become eligible for
TRICARE as active duty family members.
Family members may choose TRICARE Prime,
TRICARE Prime Remote for Active Duty Family
Members, or TRICARE Standard and TRICARE
Extra, depending on the programs available at
your location and your eligibility status. If you
have questions about these programs, contact
your regional contractor. Your service personnel
office determines eligibility for pre-activation
benefits. Contact your unit personnel office
regarding your eligibility. Your activation orders
should contain your unit personnel office address
and contact information.
2
Table of Contents
1. Eligibility and Enrollment……………………………………………………………………………..5
TRICARE Prime……………………………………………………………………………………………………………………..5
Enrolling in TRICARE Prime……………………………………………………………………………………………………5
TRICARE Prime Remote and TRICARE Prime Remote
for Active Duty Family Members……………………………………………………………………………………………….5
Service Point of Contact for Active Duty Service Members
Enrolled in TRICARE Prime Remote…………………………………………………………………………………………8
US Family Health Plan……………………………………………………………………………………………………………..8
Supplemental Health Care Program……………………………………………………………………………………………8
2. Getting Started…………………………………………………………………………………………….9
Your Primary Care Manager……………………………………………………………………………………………………..9
Changing Your Primary Care Manager………………………………………………………………………………………9
TRICARE Provider Types……………………………………………………………………………………………………….10
U.S. Department of Veterans Affairs Health Care Facilities………………………………………………………… 11
TRICARE Prime Annual Enrollment Fees……………………………………………………………………………….. 11
Social Security Number Reduction…………………………………………………………………………………………..12
3. Getting Care……………………………………………………………………………………………….13
Making an Appointment………………………………………………………………………………………………………….13
Emergency Care…………………………………………………………………………………………………………………….13
Nonemergency Care for Active Duty Service Members………………………………………………………………13
Avoid Using the Emergency Room for Nonemergency Conditions………………………………………………..13
Services That Do Not Require Referrals……………………………………………………………………………………13
Access Standards for Care………………………………………………………………………………………………………. 14
Waiving Access Standards………………………………………………………………………………………………………15
Prior Authorization for Care…………………………………………………………………………………………………….15
Point-of-Service Option…………………………………………………………………………………………………………..15
4. Covered Services………………………………………………………………………………………..16
Behavioral Health Care Services……………………………………………………………………………………………… 16
TRICARE Smoking Cessation Program…………………………………………………………………………………… 17
Clinical Preventive Services……………………………………………………………………………………………………. 18
Dental Options……………………………………………………………………………………………………………………….22
Hospice Care…………………………………………………………………………………………………………………………23
Maternity Care………………………………………………………………………………………………………………………23
TRICARE Extended Care Health Option………………………………………………………………………………….23
TRICARE Pharmacy Program…………………………………………………………………………………………………23
3
5. Claims………………………………………………………………………………………………………..25
Health Care Claims………………………………………………………………………………………………………………..25
Pharmacy Claims…………………………………………………………………………………………………………………..26
Proof-of-Payment Requirement Overseas………………………………………………………………………………….26
Coordinating Benefits with Other Health Insurance……………………………………………………………………26
Appealing a Claim or Authorization Denial………………………………………………………………………………26
6. Changes to Your TRICARE Coverage…………………………………………………………….27
Having a Baby or Adopting a Child………………………………………………………………………………………….28
TRICARE Young Adult………………………………………………………………………………………………………….28
Traveling……………………………………………………………………………………………………………………………….28
Moving and Transferring TRICARE Prime Enrollment………………………………………………………………29
Separating from the Service…………………………………………………………………………………………………….30
Retiring from Active Duty………………………………………………………………………………………………………. 31
Becoming Entitled to Medicare……………………………………………………………………………………………….. 31
Survivor Coverage………………………………………………………………………………………………………………….32
Dependent Parent Coverage……………………………………………………………………………………………………..32
Disenrollment………………………………………………………………………………………………………………………..32
7. For Information and Assistance…………………………………………………………………..34
Beneficiary Counseling and Assistance Coordinators………………………………………………………………….34
Debt Collection Assistance Officers………………………………………………………………………………………….34
Filing an Appeal or Grievance…………………………………………………………………………………………………34
Reporting Suspected Fraud and Abuse………………………………………………………………………………………34
8. Index………………………………………………………………………………………………………….35
4
Disenrollment, and Primary Care Manager (PCM)
Change Form (DD Form 2876) to their regional
contractors. Beneficiaries may also enroll online by
visiting the Beneficiary Web Enrollment (BWE)
Web site at www.dmdc.osd.mil/appj/bwe/.
Enrollment is open year-round. Enrollment forms
received by your regional contractor by the 20th of
the month become effective at the beginning of the
following month (e.g., an application received
by December 20 becomes effective January 1).
If the application is received after the 20th of the
month, coverage will become effective on the first
day of the second month following the receipt of
the enrollment form (e.g., an application received
on December 27 becomes effective February 1).
Visit www.tricare.mil/forms to download
this form.
Eligibility for TRICARE Prime
For active duty service members (ADSMs) located
in areas where TRICARE Prime is available,
enrollment in TRICARE Prime is mandatory.
Active duty family members (ADFMs) and retirees
and their family members may also enroll in
TRICARE Prime if they live in Prime Service
Areas (PSAs). A PSA is a geographic area where
TRICARE Prime is offered. It is typically an area
near a military hospital or clinic.
Within PSAs, TRICARE Prime is available to:
• ADFMs
• Transitional survivors
• Certain former spouses who are not remarried
TRICARE Prime Remote and
TRICARE Prime Re …
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