Tricare Prime: Coverage Basics, Enrollment, & Costs

When faced with the ever-expanding and often complex menu of military healthcare options, it’s often difficult to determine which plan is best for you and your family....

When faced with the ever-expanding and often complex menu of military healthcare options, it’s often difficult to determine which plan is best for you and your family. Under the banner of Tricare — which is the health care program for U.S. uniformed servicemembers, retirees, and their families – there are various options to choose from depending on your status (e.g. active duty, Reservist, Guard, retiree, or dependent), location, and individual needs and preferences. Is Tricare Prime the right choice for you? Or maybe Tricare Select?

Do you prefer to choose your own health care providers, or have them selected for you based on availability and proximity? Are you seeking the lowest cost option, or are you more willing to pay higher deductibles and copayments in exchange for greater flexibility and choice? This Tricare Prime overview aims to provide you with the need-to-know facts about one of the core Tricare offerings.

Tricare Prime Top Five Facts You Need to Know

1. Automatic Enrollment for active duty Servicemember: There is no choice to be made for active duty servicemembers, who are automatically enrolled in Tricare Prime.
2. Lowest Cost Option: Assuming beneficiaries utilize in-network providers, Tricare Prime offers the most affordable coverage.
3. Available in Three Prime Service Areas: Tricare Prime service areas include Tricare East, West, and Overseas.
4. Less Freedom of Choice: Tricare Prime beneficiaries are largely restricted to using in-network providers in exchange for lower costs, and are typically required to receive services at military treatment facilities, when available.
5. Many ‘Flavors’ of Prime: Tricare Prime, Prime Remote, Prime Overseas, Remote Overseas, Young Adult Prime, and the US Family Health Plan all share the HMO-like feature.

What is Tricare Prime?

Tricare Prime is the military health care option that most closely resembles a health maintenance organization (HMO), which is a network-based option that provides health insurance coverage to beneficiaries using a group of providers who are under contract to that organization. What this means is that instead of being able to choose any health care provider, Tricare Prime beneficiaries are largely restricted to using “in-network” providers (although they can obtain referrals to visit “out-of-network” providers as well).

Tricare Prime is available in various “flavors” including Prime Remote, Prime Overseas, Remote Overseas, Young Adult Prime, and the US Family Health Plan. The common denominator among all these variations is the HMO-like structure: in exchange for lower out-of-pocket costs, beneficiaries are required to choose from in-network providers.

Tricare Prime Eligibility

Active duty servicemembers, retirees, activated Guard and Reserve members, and their eligible beneficiaries can all enroll in Tricare Prime. In fact, active duty members are automatically assigned to Tricare Prime – so that’s one fewer decision to make!

Low Out-of-Pocket Costs

Active duty servicemembers and eligible dependents (spouses and children who are enrolled in DEERS) will pay no out-of-pocket costs for covered in-network services, which is a tremendous benefit given the rising costs of health care. For this reason, Tricare Prime often equates to the lowest out-of-pocket costs.

For active duty personnel, there are no enrollment fees, no deductibles (the amount beneficiaries typically have to pay for health care services before insurance kicks in), no network copays, and no point-of-service fees (unless beneficiaries opt to use point-of-service).

For all non-active duty beneficiaries (e.g. retirees, reservists, Medicare-eligible, etc.), there are two main types of expenses immediately associated with Tricare Prime:

• Enrollment Fees, and
• Catastrophic Cap fees.

Annual enrollment fees differ depending on when the servicemember entered active duty. Those who entered active duty before 2018 (commonly referred to as Group A beneficiaries) will pay an enrollment fee of $300 for a single member or $600 for a family; if the servicemember entered active duty during or after 2018 (or, Group B beneficiaries), the enrollment fees are $366 and $732, respectively.

In addition to enrollment fees, all non-active duty servicemembers and their dependents are responsible for paying the catastrophic cap, which is the maximum annual amount to be paid out-of-pocket, including deductibles, cost-shares, and copays. An itemized list of out-of-pocket expenses for 2020 can be found on the Tricare Prime website via their calculator tool.

Finally, prescription medications — which are a huge cost-driver in the health care market —are filled at no-cost for Tricare Prime beneficiaries at military treatment facilities (MTFs). For those who fill their prescriptions at retail pharmacies or by mail, costs rose slightly as of January 2020 in order to fund increasing costs of the Tricare program.

Important Tricare Prime Resources

In order to better manage the Tricare system, which provides healthcare services for over 9.5 million beneficiaries worldwide, Tricare is divided into three distinct regions: east, west, and overseas. Health care services are administered via three different contractors, depending on your location:

• Tricare East: The eastern portion of the United States is serviced by Humana Military, 1-800-444-5445.
• Tricare West: The western United States is serviced by Health Net, 1-844-866-9378.
• Tricare Overseas: For beneficiaries located outside of the continental United States, the lead contractor is International SOS.

Enrollment Basics

In order to enroll in Tricare Prime, the first step is ensuring an up-to-date profile in DEERS. This is of paramount importance since DEERS information informs which Tricare plan you and your family are eligible for. Secondly, DEERS enrollment determines whether your location falls into Tricare East, West, or Overseas (see regional map here).

Once you’ve identified your region, contact the individual contractor to enroll. Officially the policy is that you’ll be required to select a Primary Care Manager (PCM), which is the medical professional (military or in-network provider) who is responsible for providing your care, or issuing referrals for specialist care.

However, in practice, it is far more common to be assigned a PCM at or near the closest military installation, and rarely are beneficiaries able to select their own provider. Additionally, appointments are more commonly booked through a central appointment phone service as opposed to individual contractor websites, which can be tricky to navigate.

Keep in mind that enrolling in Tricare Prime – or switching health care options mid-career – is only permitted during special times, either during Open Season or other events, known as Qualifying Life Events. This list includes retiring from active duty, the birth of a child, marriage, divorce, a permanent change of station move, and many other professional and personal instances.

Advantages & Disadvantages

Before selecting any health care option, it’s important to understand the relative advantages and disadvantages. Below are several pros and cons of Tricare Prime that will help you to determine what’s best for you:

Tricare Prime: Advantages

• Fewer Out-of-Pocket Costs: Of all Tricare-sponsored plans, Tricare Prime is often considered the most affordable option, with the fewest out-of-pocket costs.
• Free Enrollment: For active duty servicemembers and their families, there are no enrollment costs.
• Less Paperwork: Health care services performed by in-network providers do not require claims to be submitted, leading to fewer administrative burdens for Tricare Prime beneficiaries.

Tricare Prime: Disadvantages

• Less Freedom of Choice: Providers must be selected from an existing network, leading to less personal choice among providers and health care facilities.
• Referrals Often Required: Referrals authorized by the beneficiary’s Primary Care Manager (PCM) are typically required in order to see specialists, which can add an administrative burden and complicate the appointment-making process.
• Largely Restricted to Military Treatment Facilities: Beneficiaries who live in a Tricare Prime service area are usually assigned to the closest military treatment facility, which may not be the closest or most convenient location. This can also lead to long waitlists if the facility has limited providers. This is often a major pain point for military families with complex medical needs.