Tricare Prime

Last updated November 24, 2022

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).

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.

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
The small fee 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
Reduced catastrophic cap for retirees ($7,500 now decreased to $3,000)

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 Hints:
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).

Beneficiaries of active duty soldiers may find that the closest MTF is outside their area. In that case, they will be enrolled in TRICARE Prime Remote.

Beneficiaries may be required to file their own claims when using TRICARE Standard.

Beneficiaries may find more information about filing claims and downloading claims forms on the TRICARE Website.

Although TRICARE Standard beneficiaries have a lower priority for access to care in MTFs than TRICARE Prime enrollees, Standard beneficiaries may attempt to receive their care from an MTF. This will save money and paperwork.