Tricare Prime

Last Updated on June 13, 2023

Choosing the right TRICARE Plan is a difficult and daunting task. The following information will explain the key factors you need to know to choose the best program for your family. These factors include:

• Primary Care Manager
• The Point of Service Option
• Prime Pros and Cons
• TRICARE Cost Comparison
• Helpful Hints
• TRICARE Prime Enrollment Forms

Note: According to TRICARE, all active duty servicemembers are eligible for TRICARE Prime. However, they must fill out an enrollment form and submit it to the regional contractor.

In addition, servicemembers receive most of their care from military medical personnel.

For active-duty families, there is no enrollment fee for TRICARE Prime. However, they must complete an enrollment form to select Prime as their coverage plan.

With TRICARE Prime, most health care will come from a military treatment facility (MTF), along with the TRICARE contracted Civilian Medical Providers called Preferred Provider Network (PPN).

Sponsors should ensure their family members have up-to-date uniformed services identification cards and that they are properly enrolled in the Defense Enrollment Eligibility Reporting System (DEERS).

Primary Care Manager

Your Primary Care Manager (or team of providers) will see you first for your healthcare needs.

The Primary Care Manager:

• Provides and/or coordinates your care
• Maintains your health records
• Refers you to specialists, if necessary (To be covered, specialty care must be arranged and approved by your Primary Care Manager)

With Prime, care is usually provided in a military treatment facility, but civilian clinics may be used in some cases. If you live outside of a certain radius of an MTF, you can be assigned to a civilian PCM.

If you are on active duty and live too far away from an MTF, you and your family may be eligible for Tricare Prime Remote. The coverage is very similar.

TIP: TRICARE Prime members should always seek the advice of their Primary Care Manager (or local MTF) before seeking medical attention from any specialists or other medical facilities.

Those who are retired with Tricare Prime are more likely to be able to use civilian providers.

Point of Service (POS) Option

The POS Option under TRICARE Prime allows enrollees the freedom to seek and receive non-emergency health care services from any TRICARE authorized civilian provider, in or out of the TRICARE network, without requesting a referral from their Primary Care Manager (PCM) or the Health Care Finder (HCF).

When Prime enrollees choose to use the POS option, all TRICARE Standard requirements apply except the Nonavailability Statement(NAS) requirement.

However, POS claims are subject to outpatient deductibles ($300 individual and $600 family), 50% cost-shares for outpatient and inpatient claims, and excess charges up to 15% over the allowed amount.

The 50% cost-share continues to be applied even after the Enrollment Year catastrophic cap has been met.

So, in other words, it’s not cheap! Do your best to find a provider in the network.

TRICARE Prime – Advantages

• No enrollment fee for active duty and families
• A small fee (co-pay) per visit to civilian providers and no fee for active duty members
• No balance billing
• Guaranteed appointments (access standards)
• The primary care manager supervises and coordinates care
• Away-from-home emergency coverage
• Point-of-Service option
• Low catastrophic cap for retirees of $3,000
• Claims are filed for you

TRICARE Prime – Disadvantages

• Enrollment fees for retirees and their families, though premiums for retirees are typically much less than typical civilian plans
• Provider choice is more limited
• Specialty care by referral only
• Not universally available

TRICARE Prime Summary

• Guaranteed access to timely medical care
• Priority for care at military hospitals and clinics
• Primary Care Manager provides and guides healthcare delivery
• Lowest cost for treatment among three options
• Requires enrollment for one year
• Retirees pay an enrollment fee
• Very expensive to receive care outside TRICARE Prime (Point-of-Service Option)
• Not available everywhere

Helpful Hint in Choosing Your PCM

If you are using a civilian PCM and require care from specialists, it is imperative to verify they understand the TRICARE referral approval process. You would assume that any doctor who accepts Prime knows how to make a referral request. But we have found that not to be the case.

I have had PCMs in the past who I had to walk through the process of how to do a referral EVERY time I needed one. Needless to say, I switched to a PCM who understands the process and life is much easier.