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TRICARE Prime Handbook Your guide to program benefits
TRICAREPrime Handbook
Your guide to program benefits
TRICARE National Web site: www.tricare.mil
TRICARE Mail Order Pharmacy (Express Scripts, Inc.): 1-866-DoD-TMOP (1-866-363-8667)
TRICARE Retail Pharmacy (Express Scripts, Inc.): 1-866-DoD-TRRx (1-866-363-8779)
TRICARE North Region Contractor
Health Net Federal Services, Inc. (Health Net): 1-877-TRICARE (1-877-874-2273)
Health Net Web site: www.healthnetfederalservices.com
TRICARE South Region Contractor
Humana Military Healthcare Services, Inc. (Humana Military): 1-800-444-5445
Humana Military Web site: www.humana-military.com
TRICARE West Region Contractor
TriWest Healthcare Alliance (TriWest): 1-888-TRIWEST (1-888-874-9378)
TriWest Web site: www.triwest.com
TRICARE Overseas (TRICARE Europe,TRICARE Latin America and Canada, and TRICARE Pacific)
Overseas Toll-Free Number: 1-888-777-8343
Overseas Web site: www.tricare.mil/overseas
An Important Note About TRICARE Program ChangesAt the time of printing, the information in this handbook is current. It is important to remember that TRICARE policies and benefits are governed by public law. Changes to TRICARE programs are continually made as public law is amended. For the most recent information, contact your regional contractor or local TRICARE Service Center.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.
Important Information
Dear TRICARE Prime Member:
Your decision to enroll in TRICARE Prime wasan important one. To make the best use of yourbenefits, read this TRICARE Prime Handbook. If you have questions about your benefit afterreading this handbook, there are many resourcesavailable to help you.
Health Care Services
With TRICARE Prime, you will receive most of your care from an assigned primary caremanager (PCM). Your PCM can be either amilitary treatment facility (MTF) provider or acivilian TRICARE network provider. We willdiscuss your PCM and other provider types laterin this handbook.
A TRICARE Prime enrollment card and letterhave been, or will be, mailed to you. Write yourPCM’s name and telephone number on yourenrollment card and refer to this informationwhen you need to make an appointment.
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Welcome toTRICARE Prime
TRICARE North Region
The TRICARE North Region includesConnecticut, Delaware, the District of Columbia,Illinois, Indiana, Kentucky, Maine, Maryland,Massachusetts, Michigan, New Hampshire, New Jersey, New York, North Carolina, Ohio,Pennsylvania, Rhode Island, Vermont, Virginia,West Virginia, Wisconsin, and portions of Iowa(Rock Island Arsenal area), Missouri (St. Louisarea), and Tennessee (Ft. Campbell area only).
TRICARE South RegionThe TRICARE South Region includes Alabama,Arkansas, Florida, Georgia, Louisiana,Mississippi, Oklahoma, South Carolina,Tennessee (excluding the Ft. Campbell area), and Texas (excluding the El Paso area).
TRICARE West Region
The TRICARE West Region includes Alaska,Arizona, California, Colorado, Hawaii, Idaho,Iowa (excluding Rock Island Arsenal area),Kansas, Minnesota, Missouri (except the St. Louis area), Montana, Nebraska, Nevada,New Mexico, North Dakota, Oregon, SouthDakota, Texas (the southwestern corner,including El Paso), Utah, Washington, andWyoming.
TRICARE Prime offers enhanced benefits and personalized care. Look in the mail for theTRICARE Health Matters newsletter, a regularpublication for all TRICARE Primebeneficiaries. This publication will highlightcovered services, customer service options,news, and other important updates.
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Regional contractor
Health Net Federal Services, Inc.(Health Net)
Phone 1�877�TRICARE (1�877�874�2273)
Web site www.healthnetfederalservices.com
Regional contractor
Humana Military HealthcareServices, Inc. (Humana Military)
Phone 1�800�444�5445
Web site www.humana�military.com
Regional contractor
TriWest Healthcare Alliance(TriWest)
Phone 1�888�TRIWEST (1�888�874�9378)
Web site www.triwest.com
Your TRICARE Regional Contractor
The regional contractors administer TRICARE Prime in each region. We will refer regularly to yourregional contractor throughout this handbook, and describe differences in each region. In cases wherethere are differences, refer to the information specific to your region. We encourage you to visit yourregional contractor’s Web site, which includes information about how to change PCMs, how to enroll anewborn or adopted child, covered and non�covered services, referral and authorization requirements,and other helpful information. You can also call your regional contractor toll�free for assistance at thenumbers listed below. Regional contractors also have TRICARE Service Centers (TSCs) locatedthroughout the region, typically at MTFs, that have customer service representative to assist you.
NORTHWEST
SOUTH
Keep Your DEERS InformationCurrent!
It is essential that you keep information in theDefense Enrollment Eligibility Reporting System(DEERS) current for you and your family.DEERS is a worldwide computerized database ofuniformed service members (active duty andretired), their family members, and others whoare eligible for military benefits, includingTRICARE. The key to receiving timely, effectiveTRICARE benefits—including doctorappointments, prescriptions, payment of healthcare expenses, etc.—is proper and currentregistration in DEERS.
To update DEERS:
Important Note for NationalGuard and Reserve Membersand their Families
National Guard and Reserve members who arecalled or ordered to active duty for more than 30consecutive days become eligible for TRICAREas active duty service members, and familymembers become eligible for TRICARE asactive duty family members. Active duty meansfull�time duty in the active military service of theUnited States.
Throughout this TRICARE Prime Handbook, we will refer to active duty service members and active duty family members. Be aware thatwe also are referring to activated National Guardand Reserve members and their familiesenrolled in TRICARE Prime. If you have anyquestions about TRICARE Prime, contact yourregional contractor.
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• Visit a uniformed services personnel office.Find one near you at www.dmdc.osd.mil/rsl.
• Call 1�800�538�9552.
• Fax address changes to DEERS at 1�831�655�8317.
• Mail address changes to:
Defense Manpower DataCenter Support Office Attn: COA 400 Gigling Road Seaside, CA 93955�6771
• Update addresses online atwww.tricare.mil/DEERS.
Table of Contents1. Getting Started . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
TRICARE Provider Types . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6Your Primary Care Manager . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7Enrollment Card . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8Disenrollment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8
2. Getting Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Making an Appointment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10Access Standards for Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10Emergency Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10Urgent Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11Routine (Primary) Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11Speciality Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11Prior Authorizations for Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12Getting a Second Opinion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13Point of Service Option . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13
3. Covered Services, Limitations, and Exclusions. . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Outpatient Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14Inpatient Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15Clinical Preventive Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15Behavioral Health Care Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16Pharmacy Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19Maternity Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21Dental Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21Services or Procedures with Significant Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22Exclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23
4. Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Health Care Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26Pharmacy Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27Coordinating Benefits with Other Health Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27Third�Party Liability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28Explanation of Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28Debt Collection Assistance Officers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28
5. Life Events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Getting Married or Divorced . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29Having a Baby or Adopting a Child . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30Going to College . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31Traveling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32Moving . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34Separating from the Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34Retiring from Active Duty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35Becoming Entitled to Medicare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36Deceased Sponsor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36Loss of Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37
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6. Information and Assistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Beneficiary Counseling and Assistance Coordinators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38Appealing a Decision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38Filing a Grievance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39Reporting Suspected Fraud and Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41
7. Acronyms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
8. Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
9. Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
North Region Explanation of Benefits Statement Sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46South Region Explanation of Benefits Statement Sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .48West Region Explanation of Benefits Statement Sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50
10. List of Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
11. Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
For information about your patient rights and responsibilities, see the inside back cover of thishandbook.
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TRICARE Provider Types
TRICARE defines a provider as a person,business, or institution that provides health care.For example, a doctor, hospital, or ambulancecompany is a provider. Providers must beauthorized under TRICARE regulations and havetheir status certified by the regional contractorsto provide services to TRICARE beneficiaries.
Military Treatment Facilities
A military treatment facility (MTF) is a medicalfacility (hospital, clinic, etc.) owned and operated
by the uniformed services—usually located on ornear a military base. To locate an MTF near you,visit www.tricare.mil/mtf.
Civilian Providers
Figure 1.1 explains the different types of civilianTRICARE providers.
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TRICARE Provider Types Figure 1.1
TRICARE-authorized Providers
• A provider who meets TRICARE’s licensing and certification requirements and has been certified byTRICARE to provide care to TRICARE beneficiaries. TRICARE�authorized providers include doctors,hospitals, ancillary providers (laboratories and radiology centers), and pharmacies. If you see a provider who is not TRICARE�authorized, you are responsible for the full cost of care.
• There are two types of TRICARE�authorized providers: Network and Non�network.
Network Providers Non-network Providers
• Network providers have a signedagreement with your regionalcontractor to provide care at anegotiated rate. Networkproviders file claims for you.
• You will receive most of yourcare from TRICARE networkproviders.
• Non�network providers do not have a signed agreement with yourregional contractor and are therefore “out of network.” In most cases, youwill not receive care from non�network providers unless approved by yourregional contractor. You may seek care from a non�network provider in anemergency or if you are using the point of service (POS) option.
• There are two types of non�network providers: Participating andNonparticipating.
Participating Nonparticipating
• Participating* providers haveagreed to file claims for you, toaccept payment directly fromTRICARE and to accept theTRICARE allowable charge lessany applicable cost�shares paid byyou as payment in full for theirservices.
• Using a participating provider isyour best option if you must visita non�network provider.
• Nonparticipating providers havenot agreed to accept theTRICARE allowable charge orfile your claims. If you use thePOS option and seek care from anonparticipating provider, theprovider may charge you up to15% above the TRICAREallowable charge for services (inaddition to POS fees). Thisamount is your responsibility andwill not be shared by TRICARE.
• If you visit a nonparticipatingprovider, you may have to pay theprovider first and file a claim withTRICARE for reimbursement.
Getting Started
*Providers may decide to participate on a claim�by�claim basis.
Department of Veterans Affairs HealthCare Facilities
Many Department of Veterans Affairs (VA) healthcare facilities participate in TRICARE as networkproviders. While VA facilities may or may notprovide primary care, many do provide specialtycare. Be sure to find out the VA facility’s status as aTRICARE network or non�network provider beforeyou receive TRICARE�covered health care at a VAfacility.
Note: Active duty service members who arereferred to a VA medical facility for a service�connected condition must receive health care benefits under the VA program.When an active duty service member with aservice�connected condition is referred to/beingtreated by the VA, the Department of Defense(DoD) is still responsible for payment for thecare rendered.
Some retired service members may be eligible forboth TRICARE and VA benefits (the VA offershealth care programs separate from TRICARE—refer to the VA Web site at www.va.gov for details),so you will have to choose which program youwant to use. When choosing between TRICAREand VA benefits, carefully compare the costs andthe financial demands of each option to make thebest decision.
Your Primary Care Manager
When you enrolled in TRICARE Prime, youselected or were assigned a primary caremanager (PCM). Your PCM provides yourroutine health care and coordinates referrals forspecialty care that he or she cannot provide. YourPCM may be an MTF provider or a civilianTRICARE network provider within a Primeservice area (PSA).
A PSA is a geographic area where TRICAREPrime benefits are offered. It’s typically ageographic area around an MTF and specificareas with a significant concentration ofuniformed service personnel and retirees andtheir families.
A PSA must also have a substantial medicalcommunity to support most or all TRICAREPrime enrolled beneficiary medical needs.
On-Call Providers
PCMs are required to provide access to care 24hours a day, seven days a week. To cover allhours, your PCM may designate an on�callprovider who will act on their behalf to supportyour health care needs. Therefore, theinformation, instructions, care, or carecoordination you receive from the on�callprovider should be treated as if it was comingfrom your PCM.
Changing Your Primary Care Manager
You may change your PCM at any time providedthe new PCM is accepting new patients and yourrequest complies with local MTF guidelines.Once you have selected a new PCM from yourregional contractor’s provider directory(viewable online at each contractor’s Web site),complete a TRICARE Prime Enrollment andPCM Change Form with the new PCM’s nameand address.
You only need to complete the portion of theform related to the PCM change. The changewill become effective once the application isreceived and processed by your regionalcontractor. You may also call your regionalcontractor to change your PCM. Once your PCMchange is processed, you will be mailed aconfirmation letter with the new PCM name andtelephone number.
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Enrollment Card
You and each enrolled family member willreceive his or her own TRICARE Primeenrollment card. Included with the card is a letteridentifying your PCM’s name and telephonenumber. Write your PCM’s name and telephonenumber on your card. TRICARE networkproviders may require you to show theenrollment card as well as your uniformedservices identification (ID) or Common AccessCard (CAC) at the time of service. YourTRICARE Prime enrollment effective date isprinted on this card.
The TRICARE Prime enrollment card does notverify your eligibility for TRICARE. Only yourDEERS record can verify eligibility.
Disenrollment
Enrollment in TRICARE Prime is continuous—you do not have to re�enroll every year tomaintain coverage. Certain events will, however,cause you to be disenrolled from TRICAREPrime.
Sponsor Status Change
Any change in the sponsor’s status (e.g.,retirement or National Guard and Reservemember deactivation) will cause you to bedisenrolled automatically from TRICARE Prime.If you will remain eligible for TRICARE Prime(after the status change), you should submit anew enrollment application to your regionalcontractor before the status change occurs toavoid a lapse in coverage.
Non-Payment of Enrollment Fees
If you are required to pay enrollment fees andyou do not pay them when due, you will bedisenrolled from TRICARE Prime. Whendisenrolled for non�payment, you are subject to a12�month lockout during which you will not bepermitted to re�enroll in TRICARE Prime. Toavoid missing an appointment, learn aboutautomatic payment options in the TRICARE:Summary of Beneficiary Costs flyer or contactyour regional contractor.
Becoming Medicare-Eligible at Age 65
When you become entitled to premium�freeMedicare Part A at age 65, you automaticallylose eligibility for TRICARE Prime andbecome eligible for TRICARE For Life (TFL)if you have Medicare Part B coverage. Visitwww.tricare.mil/tfl for more informationabout TFL.
Note: If you are not entitled to premium�freeMedicare Part A when you become age 65, youremain eligible for TRICARE Prime, Standard,and Extra, and you are not required to haveMedicare Part B coverage. You must present aSocial Security Administration Letter ofDisallowance to an ID card�issuing facility toretain TRICARE coverage.
Voluntary Disenrollment
If you choose to disenroll from TRICARE Primebefore the annual enrollment renewal date, youare subject to a 12�month lockout,* during whichyou will not be permitted to re�enroll inTRICARE Prime. You must contact yourregional contractor to initiate a voluntarydisenrollment.
Active duty service members must enroll ineither TRICARE Prime or TRICARE PrimeRemote. Voluntary disenrollment is not anoption.
* The 12�month lockout provision does not apply to activeduty family members of sponsors grade E�1 through E�4.
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SAMPLE
Name: John Q. SampleStatus: Active Duty SponsorPrimary Care Manager:Primary Care Manager Phone:Effective Date: 01 Jan 2000
Valid with presentation of current military ID cardContact your personnel office if any of the aboveinformation is incorrect.
TRICARE: The World’s Best Health Carefor the World’s Best Military
TRICARE PRIME
Loss of Eligibility
If you lose your TRICARE eligibility as shownin DEERS, your TRICARE Prime coverage willend automatically. If you believe you are stilleligible for TRICARE, you will need to updateyour DEERS record to re�establish youreligibility. Once DEERS is updated, you must re�enroll in TRICARE Prime, or you will becovered under TRICARE Standard andTRICARE Extra.
If your DEERS record is correct and you havelost eligibility, you may qualify for transitionalhealth care. See the Life Events, “Separatingfrom the Service” section for details abouttransitional health care options. You will receivea certificate of creditable coverage whenTRICARE eligibility is lost. See the Life Events,“Loss of Eligibility” section for moreinformation about the certificate of creditablecoverage.
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You receive routine or primary health care fromyour primary care manager (PCM), and yourPCM will refer you to a specialist for necessaryspecialty care. You are guaranteed access to carewithin specific time frames, and you may qualifyfor a travel reimbursement if referred to specialtycare that is more than 100 miles from yourPCM’s office. This section explains these andother details about using TRICARE Prime.
Making an Appointment
Contact your PCM’s office directly to make anappointment. There is no need to contact yourregional contractor to schedule appointments.
Access Standards for Care
There are certain access standards for care.
• The wait time for an urgent care appointmentshould not exceed 24 hours (one day).
• The wait time for a routine appointment shouldnot exceed one week (seven days).
• The wait time for a specialty care appointmentor wellness visit should not exceed four weeks(28 days).
These access standards begin at the time of yourcall to or contact with the provider. It isimportant to contact your provider as soon aspossible. At times, appointments may not beavailable within the time frames listed above dueto high demand for specialty care services. If theprovider does not have appointments availablewithin the access standards, you can choose toschedule the earliest�available appointment withthe provider or contact your regional contractorfor assistance in locating another provider.
You should have access to a PCM whose officeis within 30 minutes of your home under normalcircumstances. Specialty care should be availablewithin one hour from your home. See the sectiontitled, Specialty Care far From Home forinformation about travel reimbursement if youare referred for specialty care more than 100miles from your PCM’s office.
Additionally, it is important to understand yourprovider’s specific policies regarding cancelledor missed appointments. Some providers chargea missed appointment fee, which is not coveredby TRICARE. Please be sure to notify yourprovider’s office within the appropriate time,usually 24 to 48 hours prior, if you will not beable to make your scheduled appointment.
Emergency Care
TRICARE defines an emergency as a medical,maternity, or psychiatric condition that wouldlead a “prudent layperson” (someone withaverage knowledge of health and medicine) tobelieve that a serious medical condition exists, orthe absence of immediate medical attentionwould result in a threat to life, limb, or eyesight,or when the person has painful symptomsrequiring immediate attention to relievesuffering. If you need emergency care, go to thenearest emergency room or call 911. It isimportant that you know the emergencytelephone numbers in your area. Take a minute tolook these numbers up and write them here or onthe inside front cover of this book.
Emergency Assistance:
_______________________________________
Ambulance:
_______________________________________
Poison Control: 1�800�222�1222
You do not need to call your PCM or regionalcontractor before receiving emergency medicalcare. However, in all emergency situations, youmust notify your PCM within 24 hours, or thenext business day, so that ongoing care can becoordinated, and to ensure you receive properauthorization for care.
Getting Care
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Urgent Care
Urgent care is for an illness or injury that wouldnot result in further disability or death if nottreated immediately, but does requireprofessional attention within 24 hours. Youwould require urgent care for conditions such asa sprain, sore throat, or rising temperature thathave the potential to develop into an emergencyif treatment is delayed longer than 24 hours.
In most cases, you can receive urgent care fromyour PCM by making a “same�day” appointment.If you are away from home, contact your regionalcontractor for assistance in obtaining urgent care.If you do not coordinate urgent care with yourPCM or regional contractor, the care will becovered under the point of service (POS) option,resulting in higher out�of�pocket costs. See theTRICARE: Summary of Beneficiary Costs flyer tolearn about POS fees.
Routine (Primary) Care
Routine (primary) care includes general officevisits for the treatment of symptoms, chronic oracute illnesses and diseases, and follow�up carefor an ongoing medical condition. Routine carealso includes preventive care measures to helpkeep you healthy. You will receive most of yourroutine or primary care from your PCM.
You do not need a referral to visit your PCM. Ifyour PCM is unable to provide the care needed,he or she will refer you to another provider. Ifyou receive any routine care without a referralfrom your PCM, you will be utilizing the POSoption, resulting in higher out�of�pocket costs.See the TRICARE: Summary of BeneficiaryCosts flyer to learn about POS fees.
Services That Do Not RequireReferrals
Some services may be obtained without a PCMreferral. These include clinical preventiveservices and the first eight outpatient behavioralhealth care visits per fiscal year (October 1�September 30). When seeking clinical preventiveservices or behavioral health care, you must usea network provider. If you seek care from a
non�network provider without a referral fromyour PCM, you will be utilizing the POS option,resulting in higher out�of�pocket costs. See theTRICARE: Summary of Beneficiary Costs flyerto learn about POS fees.
For more information about these services, seethe Covered Benefits, Limitations, andExclusions section. Remember, you will neverneed a referral for emergency care. Note: Activeduty service members require a referral for anyclinical preventive services, behavioral healthcare, or specialty care.
Specialty Care
There are times when you will need to see aspecialist for a diagnosis or treatment that yourPCM cannot provide. Your PCM will providereferrals to access services from specialtyproviders and will coordinate the referral requestwith your regional contractor, when necessary. Ifyou receive specialty care without a referral fromyour PCM, you will be utilizing the POS option,resulting in higher out�of�pocket costs. See theTRICARE: Summary of Beneficiary Costs flyerto learn about POS fees.
Referrals for Specialty Care
Visit your regional contractor’s Web site or call the toll�free number to learn about region�specific referral requirements and for detailsabout obtaining referrals.
If you live near an MTF and are referred forspecialty care, inpatient admissions, orprocedures requiring prior authorization, yourregional contractor will attempt to coordinateyour care at the MTF first. When the services are not available at the MTF, the care will becoordinated with a TRICARE network provider.
Specialty to Specialty Referrals
If your PCM refers you to a specialist whowould like to refer you to another specialist, thespecialist will need to contact your PCM. YourPCM or the specialist will contact your regionalcontractor to obtain authorization for additionalspecialty care, when necessary.
Specialty Care Far From Home—TravelReimbursement
Non�active duty TRICARE Prime enrollees whoare referred by their PCM for specialty care at alocation more than 100 miles (one way) from thePCM’s office may be eligible to have“reasonable travel expenses” reimbursed byTRICARE. Reasonable travel expenses are theactual costs incurred while traveling, includingmeals, gas/oil, tolls, parking, and tickets forpublic transportation (i.e., airplane, train, bus,etc.). You must submit receipts for expensesabove $75.
TRICARE will use government rates to estimatethe reasonable cost. You are expected to use theleast costly mode of transportation. TRICAREwill reimburse the actual costs of lodging(including taxes and tips) and the actual cost ofmeals (including taxes and tips, but excludingalcoholic beverages) up to the government ratefor the area concerned.
In some cases, a non�medical attendant may also be authorized for travel reimbursement. The non�medical attendant must be a parent,guardian, or another adult family member 21years of age or older.
To qualify, you must have a valid referral andtravel orders from a TRICARE representative atyour MTF (if enrolled to an MTF PCM) or fromthe TRICARE Regional Office (TRO) (ifenrolled to a civilian PCM). You should obtainthe travel orders before traveling. Contact yourlocal MTF or TRO travel representative if youthink you may qualify for this travelreimbursement.
You may also visit the TRICARE Web site atwww.tricare.mil/primetravel for moreinformation.
Note: Travel for active duty service members isreimbursed through other travel regulations.Active duty service members should contact theirunit representatives for information abouttraveling long distances for medical care.
Prior Authorizations for Care
A prior authorization is a review of the requestedhealth care service to determine if it is medicallynecessary at the requested level of care. Priorauthorization is required for certain types of careand must be obtained before services arerendered.
Your PCM will request prior authorization fromyour regional contractor when required. If theservice is authorized, the regional contractor willgive your PCM an authorization number alongwith specific instructions. For example, priorauthorizations for medical or surgical serviceswill have a begin date and end date. Priorauthorizations for behavioral health services willspecify a number of visits as well as a begin dateand end date. You must receive care under theauthorization before it expires. If not, you willneed to get another referral and authorizationfrom your PCM.
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TRO-NorthVisit www.tricare.mil/tronorth
or call 1�866�307�9749
TRO-South Call 1�800�554�2397 or 1�210�292�3256
TRO-West Call 1�619�236�5324
TRO Contact Information for Travel Reimbursement Figure 2.1
Services Requiring PriorAuthorization
Active duty service members require priorauthorization for all inpatient and outpatientspecialty services. An additional fitness�for�dutyreview is required for maternity care, physicaltherapy, mental/behavioral health services,family counseling, and smoking cessationprograms.
For all other TRICARE Prime enrollees, thefollowing services require prior authorization inall three TRICARE regions:
• Adjunctive dental services
• Home health services
• Hospice care
• Nonemergency inpatient admissions forsubstance�use disorders or behavioral health
• Outpatient behavioral health care beyond theeighth visit
• Transplants—all solid organ and stem cell
• TRICARE Extended Care Health Optionservices
Each regional contractor has additional priorauthorization requirements. Visit your regionalcontractor’s Web site or call their toll�free numberto learn about each region’s requirements, as theymay change periodically. See page 2 for a list ofregional toll�free numbers.
Getting a Second Opinion
You have every right to request a consultationwith another provider for a second medicalopinion when the initial provider is uncertainabout a contemplated course of action. You, yourPCM, or your regional contractor may request asecond medical opinion. If you wish to seek asecond opinion, go to your PCM and explainyour situation and any questions you may haveabout the first specialist’s suggested care. Then,ask your PCM to coordinate a referral to anotherspecialist and request a referral from yourregional contractor if necessary.
Point of Service Option
The TRICARE Prime point of service (POS)option gives you the freedom to seek and receivenonemergency health care services from anyTRICARE�authorized provider without requestinga referral from your PCM for additional costs. Seethe TRICARE: Summary of Beneficiary Costs flyerfor details about POS fees.
The POS option does not apply to the following:
• Active duty service members
• Newborns or adopted children in their first 60days
• Emergency care
• Preventive care services from a networkprovider
• First eight behavioral health outpatient visitsfrom a network provider
• If you have other health insurance
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TRICARE Prime covers most care that is medically necessary and considered proven. However, thereare special rules or limits on certain types of care, while other types of care are not covered at all. Thischapter is not intended to be all�inclusive. Visit your regional contractor’s Web site for additionalinformation about covered services and benefits.
Outpatient Services
Figure 3.1 provides coverage details for covered outpatient services. Note: This chart is not intended tobe all�inclusive.
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Covered Services, Limitations, and Exclusions
Service Description
Ambulance Services Covers emergency transfers to or from a beneficiary’s home, accident scene, or otherlocation to a hospital and transfers between hospitals; ambulance transfers from ahospital�based emergency room to a hospital more capable of providing the requiredcare; and transfers between a hospital or skilled nursing facility and another hospital�based or freestanding outpatient therapeutic or diagnostic department/facility.
Excludes ambulance service used instead of taxi service when the patient’s conditionwould have permitted use of regular private transportation; transport or transfer of apatient primarily for the purpose of having the patient nearer to home, family, friends,or personal physician; and Medicabs or ambicabs that function primarily as publicpassenger conveyances transporting patients to and from their medical appointments.
Ancillary Services Certain diagnostic radiology and ultrasound, diagnostic nuclear medicine, pathologyand laboratory services, and cardiovascular studies.
Durable MedicalEquipment (DME)
Generally covered if medically necessary and appropriate, and if prescribed by aphysician for the specific use of the beneficiary. Duplicate items of DME which areessential to provide a fail�safe, in�home, life�support system are covered. In this case,“duplicate” means an item that meets the definition of DME and serves the samepurpose but may not be an exact duplicate of the original DME item. For example, aportable oxygen concentrator may be covered as a backup for a stationary oxygengenerator.
Emergency Services Emergency services are covered for medical, maternity, or psychiatric conditions thatwould lead a “prudent layperson” (someone with average knowledge of health andmedicine) to believe that a serious medical condition exists; that the absence ofmedical attention would result in a threat to the patient's life, limb, or eyesight; that thepatient may be a danger to self or others and requires immediate medical treatment; orthat the patient manifests painful symptoms requiring immediate palliative effort torelieve suffering.
Eye Examinations • Infants (regardless of beneficiary category): Covered for one eye and vision screeningby the PCM during a routine exam at birth and 6 months of age
• Active duty service members and family members: Covered for one eye exam per year
• All other TRICARE Prime enrollees: Covered for one eye exam every two years
• Diabetic patients (regardless of beneficiary category): Covered for one eye exam per year
Home Health Care Part�time or intermittent skilled nursing services and home health services; physical,speech, and occupational therapy; medical social services; and routine and non�routinemedical services. All care must be provided by a participating home health care agencyand be authorized in advance by the regional contractor.
Individual ProviderServices
Office visits; outpatient office�based medical and surgical care; consultation, diagnosis,and treatment by a specialist; allergy tests and treatment; osteopathic manipulation;rehabilitation services (e.g., physical therapy, speech pathology services, andoccupational therapy); and medical supplies used within the office.
Outpatient Services: Coverage Details Figure 3.1
Inpatient Services
Figure 3.2 provides coverage details for covered inpatient services. Note: This chart is not intended to beall�inclusive.
Clinical Preventive Services
Figure 3.3 provides coverage details for clinical preventive services. Note: This chart is not intended tobe all�inclusive.
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Laboratory and X�ray Services
Generally covered if prescribed by a physician (some exceptions apply, e.g., chemo�sensitivity assays and bone density X�ray studies for routine osteoporosis screening).
Papanicolaou (Pap)Smear
Covered as either a diagnostic or routine preventive procedure. Note: The HPV Paptest is not covered as a routine screening Pap smear.
Prosthetic Devices andMedical Supplies
Generally covered if prescribed by a physician and is directly related to a medicalcondition. Prosthetic devices must be FDA�approved.
Outpatient Services: Coverage Details (continued)
Service Description
Hospitalization Semiprivate room (and when medically necessary, special care units), general nursing,and hospital service. Includes inpatient physical and surgical services; meals (includingspecial diets); drugs and medications while an inpatient; operating and recovery room;anesthesia; laboratory tests; X�rays and other radiology services; necessary medicalsupplies and appliances; and blood and blood products.
Skilled Nursing FacilityCare
Semiprivate room; regular nursing services; meals, including special diets; physical,occupational, and speech therapy; drugs furnished by the facility; and necessarymedical supplies and appliances. Unlike Medicare, unlimited number of days asmedically necessary.
Inpatient Services: Coverage Details Figure 3.2
Service Description
Health Promotion andDisease PreventionExaminations
Office visits may be covered for the following services (subject to age and othercriteria):
• Cancer screening examinations and services (breast cancer, cancer of femalereproductive organs, colorectal cancer, and prostate cancer)
• Infectious diseases (Hepatitis B screening, human immunodeficiency virus [HIV]testing) and preventive therapy when at�risk (tetanus, animal bite, Rh immuneglobulin, and exposure to certain infectious diseases, including tuberculosis)
• Genetic testing and counseling for certain clinical indications during pregnancy
• Other: Routine chest X�rays and electrocardiograms required for admission when apatient is scheduled to receive general anesthesia on an inpatient or outpatient basis
Immunizations Covered for age�appropriate dose of vaccines as recommended by the Centers forDisease Control and Prevention. Immunizations for active duty family members whosesponsors have permanent change of station orders to overseas locations also arecovered.
Clinical Preventive Services: Coverage Details Figure 3.3
Behavioral Health Care Services
Active Duty Service Members
Active duty service members must have priorauthorization before seeking behavioral healthcare. We do not want to discourage you fromseeing a behavioral health specialist, but we wantto make sure that your condition does notadversely affect your health and your ability toperform worldwide duty. Contact your regionalcontractor before obtaining behavioral healthcare services.
All Others Enrolled in TRICARE Prime
You may receive the first eight behavioral healthoutpatient visits per fiscal year (October 1�September 30) from a network provider withouta referral or prior authorization from your PCM.If you obtain these visits from a non�networkprovider without referral from your PCM andyour regional contractor, POS fees will apply.After the first eight visits (beginning on the 9thvisit), you must obtain a referral from your PCMand receive prior authorization from yourregional contractor.
Authorized Behavioral HealthProviders
The following types of behavioral healthproviders may be authorized providers underTRICARE:
• Psychiatrists
• Clinical psychologists
• Certified psychiatric nurse specialists
• Clinical social workers
• Certified marriage and family therapists witha TRICARE participation agreement
• Pastoral counselors—with physician referraland supervision
• Mental health counselors—with physicianreferral and supervision
• Licensed professional counselors—withphysician referral and supervision
If you are unsure which type of provider wouldbest meet your needs, contact your regionalcontractor for assistance.
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Service Description
Other HealthPromotion and Disease PreventionServices
The following services may be covered if provided in connection with a visit forimmunizations, Pap smears, mammograms, or examinations for colon and prostatecancer:
• Cancer screening (testicular, skin, oral cavity, pharyngeal, and thyroid)
• Infectious disease (tuberculosis screening, Rubella antibodies)
• Cardiovascular disease (cholesterol screening, blood pressure screening)
• Body measurements (height and weight)
• Vision screening
• Audiology screening (only allowed under well�child services)
• Counseling services expected of good clinical practice that are included with theappropriate office visit at no additional charge (dietary assessment and nutrition;physical activity and exercise; cancer surveillance; safe sexual practices; tobacco,alcohol, and substance abuse; promoting dental health; accident and injuryprevention; and stress, bereavement, and suicide risk assessment)
School Physicals Covered for children ages 5�11 if required in connection with school enrollment.
Note: Annual sports physicals are not a covered benefit.
Well�child Services Covered for beneficiaries from birth to age 6; includes visits, immunizations, andvision screening.
Clinical Preventive Services: Coverage Details (continued)
Figure 3.4 provides coverage details for covered behavioral health care services. Note: This chart is notintended to be all�inclusive.
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Service Description
Acute Inpatient Psychiatric Care
Acute inpatient psychiatric care may be covered on an emergency or nonemergencybasis. Prior authorization from your regional contractor is required for allnonemergency inpatient admissions. In emergency situations, authorization is requiredfor continued stay.
Limitations
• Patients age 19 and older are limited to 30 days per fiscal year.*
• Patients age 18 and under are limited to 45 days per fiscal year.*
• Inpatient admissions for substance use disorder detoxification and rehabilitationcount toward the 30� or 45�day limit.
Note: Day limits may be waived if determined to be medically or psychologicallynecessary (See 10 USC 1079 (i)).
MedicationManagement
If you are taking prescription medications for a behavioral health care condition, youmust be under the care of a provider who is authorized to prescribe those medications.Your provider will manage the dosage and duration of your prescription to ensure youare receiving the best care possible.
Partial Hospitalization Psychiatric partial hospitalization provides interdisciplinary therapeutic services at least three hours per day, five days a week, in any combination of day, evening, night,and weekend treatment programs.
• Prior authorization from your regional contractor is required.
• Facility must be TRICARE�authorized.
• Partial hospitalization programs must agree to participate in TRICARE.
Limitations
• Limited to 60 treatment days (whether a full� or partial�day treatment) in a fiscal year.* These 60 days are not offset or counted toward the 30� or 45�dayinpatient limit.
Psychological Testingand Assessment
Covered when medically or psychologically necessary and provided in conjunctionwith otherwise�covered psychotherapy. Psychological tests are considered to bediagnostic services and are not counted against the limit of two psychotherapy visitsper week.
Limitations
Testing and assessment is generally limited to six hours in a fiscal year.
Exclusions
Psychological testing is not covered for the following circumstances:
• Academic placement
• Job placement
• Child custody disputes
• General screening in the absence of specific symptoms
• Teacher or parental referrals
• Diagnosed specific learning disorders or learning disabilities
Behavioral Health Care Services: Coverage Details Figure 3.4
* Fiscal year is October 1�September 30.
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Service Description
Psychotherapy Prior authorization is required after the first eight behavioral health outpatient visits perbeneficiary per fiscal year.* Covered psychotherapy includes:
• Individual, conjoint, family, or group sessions
• Collateral visits
• Play therapy (This is a form of individual therapy used with children.)
• Psychoanalysis (Prior authorization from your regional contractor is required.)
Limitations
• Outpatient psychotherapy is limited to a maximum of two sessions per week in anycombination of individual, family, collateral, or group sessions and is not covered when the patient is an inpatient in an institution.
• Inpatient psychotherapy is limited to five sessions per week in any combination ofindividual, family, collateral, or group sessions. The duration and frequency of care is dependent upon medical necessity.
Residential Treatment Center(RTC) Care
RTC care provides extended care for children and adolescents with psychological disordersthat require continued treatment in a therapeutic environment.
• Unless therapeutically contraindicated, the family and/or guardian should activelyparticipate in the continuing care of the patient either through direct involvement at thefacility or geographically distant family therapy.
• Facility must be TRICARE�authorized.
• Prior authorization from your regional contractor is required.
• RTC care is considered elective and will not be covered for emergencies.
• Admission primarily for substance�use rehabilitation is not authorized.
• Care must be recommended and directed by a psychiatrist or clinical psychologist.
Limitations
• Limited to 150 days per fiscal year* (limitation may be waived if determined to bemedically or psychologically necessary).
Note: No qualified RTCs were available in overseas locations at time of printing.
Behavioral Health Care Services: Coverage Details (continued)
* Fiscal year is October 1�September 30.
For additional information about covered andnon�covered behavioral health care services andhow to access care, contact your regionalcontractor.
Pharmacy Services
TRICARE offers comprehensive prescriptiondrug coverage and several options for filling your prescriptions. To have a prescription filled,you’ll need a written prescription and a validuniformed services identification (ID) orCommon Access Card (CAC). Refer to theTRICARE: Summary of Beneficiary Costs flyeror www.tricare.mil/pharmacy for pharmacycost information.
Military Treatment Facility Pharmacy
Prescriptions may be filled (up to a 90�daysupply for most medications) at an MTF
pharmacy at no cost as long as the medication ison the MTF formulary. You should contact theMTF to find out what is on the formulary and forspecific details about filling prescriptions at theMTF pharmacy.
TRICARE Mail Order Pharmacy
The mail�order pharmacy is your least expensiveoption when not using the MTF. You may receiveup to a 90�day supply for most medicationsdelivered to your home for a small copayment.Refills may be requested by mail, phone, oronline. Express Scripts, Inc. (ESI) administersthe mail�order pharmacy, and registering is easy.
1. Register online. Complete the registrationform and follow the instructions available atwww.express�scripts.com/TRICARE.
2. Register by phone. Call 1�866�363�8667.
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Treatment forSubstance UseDisorders
A substance use disorder includes alcohol or drug abuse or dependence. TRICARE maycover services for the treatment of substance use disorders, including detoxification,rehabilitation, and outpatient group and family therapy. Emergency and inpatient hospitalservices are considered medically necessary only when the patient’s condition is such thatthe personnel and facilities of a hospital are required.
Note: All treatment for substance use disorders requires prior authorization from yourregional contractor.
Coverage and Limitations
• Benefit Period—Only three substance use disorder treatment benefit periods in a lifetime(waiver possible in accordance with policy criteria) are covered. A benefit period beginswith the first date of covered treatment and ends 365 days later, regardless of the totalservices actually used within the benefit period. Emergency and inpatient hospital servicesfor detoxification, stabilization, and for treatment of medical complications of substanceuse disorders do not count for purposes of establishing the beginning of a benefit period.
• Detoxification—If chemical detoxification is needed, but does not require the personnel or facilities of a general hospital setting, detoxification services are covered inaddition to rehabilitative care. In a diagnosis�related group (DRG)�exempt facility,detoxification services are limited to seven days per year, unless the limit is waived.
• Rehabilitation—Rehabilitation (residential or partial) is limited to 21 days per year or one inpatient stay in a facility subject to the DRG�based reimbursement system, perbenefit period; you are limited to three benefit periods in your lifetime. All inpatient stayscount toward the 30� or 45�day inpatient limit.
• Outpatient Care—Must be provided by an approved substance use disorder facility in a group setting. Coverage is limited up to 60 visits per fiscal year.* Individual outpatientcare for substance use disorder is not covered.
• Family Therapy—Outpatient family therapy is covered beginning with the completion ofrehabilitative care. You are covered for up to 15 visits in a benefit period.
Behavioral Health Care Services: Coverage Details (continued)
* Fiscal year is October 1�September 30.
3. Register by mail. Download the form atwww.express�scripts.com/TRICARE andmail it to: P.O. Box 52150, Phoenix, AZ85072�9954. Include the written prescriptionand the appropriate copayment when youmail your registration.
For faster processing of your mail�orderprescription, you can register before placing your first order. Once you are registered, yourprovider can fax or call in your prescriptions.
ESI will send your medications directly to yourhome within about 14 days after receiving yourprescription. If you have prescription drugcoverage from another health insurance plan, you can use the mail�order pharmacy if themedication is not covered under the other plan orif you exceed the dollar limit of coverage underthe other plan.
TRICARE Retail Pharmacy Network
You may have prescriptions filled (up to a 30�day supply) at any pharmacy in the TRICAREretail pharmacy network for a small copayment.ESI also administers the retail pharmacynetwork. For more information or to locate aTRICARE network pharmacy, call 1�866�DoD�TRRX (1�866�363�8779) or visitwww.express�scripts.com/TRICARE.Note: Network pharmacies are available in theUnited States, Guam, Puerto Rico, and the U.S.Virgin Islands.
Non-network Pharmacies
Filling prescriptions at a non�network pharmacy isthe most expensive option. You may have to pay forthe total amount first and then file a claim with ESIto receive a partial reimbursement after yourdeductible is met. (For more information aboutpharmacy claims, see the Claims section.) Note: Non�active duty beneficiaries are using the POS option at non�network pharmacies.
Quantity Limits and PriorAuthorization
TRICARE has established quantity limits oncertain medications, which means that the DoDwill only pay for up to a specified quantity per30�, 60�, or 90�day supply. Quantity limits areapplied to ensure the medications are safely and
appropriately used. Exceptions to establishedquantity limits may be made if the prescribingprovider is able to justify medical necessity.
Some drugs require prior authorization from ESI.For a general list of prescription drugs that arecovered under TRICARE and for drugs requiringprior authorization or having quantity limits, visitwww.tricare.mil/pharmacy or call toll�free 1�866�DoD�TRRX (1�866�363�8779) or 1�866�DoD�TMOP (1�866�363�8667).
Generic Drug Use Policy
It is DoD policy to use generic medications,instead of brand�name medications, wheneverpossible. Brand�name drugs that have a genericequivalent may be dispensed only if theprescribing physician is able to justify medicalnecessity for use of the brand�name drug in placeof the generic equivalent. If a generic equivalentdrug does not exist, the brand�name drug will bedispensed at the brand�name copayment. If youinsist on having a prescription filled with abrand�name drug that is not consideredmedically necessary, and when a genericequivalent is available, you will be responsiblefor paying the entire cost of the prescription outof pocket.
Non-formulary Drugs
Any drug in a therapeutic class determined to benot as relatively clinically effective or not ascost�effective as other drugs in the class may berecommended for placement in the third,“non�formulary” tier. Any drug placed into thethird tier is available to beneficiaries from themail�order or retail pharmacies, but at a highercost. You may be able to have non�formularyprescriptions filled at formulary costs if yourprovider can establish medical necessity.
To learn more about any medication andcommon drug interactions, to check for genericequivalents, or to determine if a drug is classifiedas a non�formulary medication, visit the onlineTRICARE Formulary Search Tool atwww.tricareformularysearch.org.
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For information on how to save money and makethe most of your pharmacy benefit, visitwww.tricare.mil/pharmacy, or call 1�877�DoD�MEDS (1�877�363�6337).
Maternity Services
Prenatal care is important, and we stronglyrecommend that those who are pregnant, or whoanticipate becoming pregnant, seek appropriatemedical care. TRICARE Prime covers maternitycare, including prenatal care, delivery, andpostpartum care. Newborns are coveredseparately.
Maternity Ultrasounds
TRICARE covers maternity ultrasounds whenmedically necessary. Such situations include:
• Estimating gestational age
• Evaluating fetal growth
• Conducting a biophysical evaluation for fetalwell�being
• Evaluating a suspected ectopic pregnancy
• Defining the cause of vaginal bleeding
• Diagnosing or evaluating multiple gestations
• Confirming cardiac activity
• Evaluating maternal pelvic masses or uterineabnormalities
• Evaluating suspected hydatidiform mole
• Evaluating the fetus’s condition in lateregistrants for prenatal care
A physician is not obligated to performultrasonography on a patient who is a low risk and has no medical indications.
Some providers offer patients routine ultrasoundscreening as part of the scope of care after 16�20weeks of gestation. TRICARE does not coverroutine ultrasound screening. Only maternityultrasound with a valid medical indication thatconstitutes medical necessity is covered byTRICARE. Refer to your regional contractor’sWeb site for additional details on maternityultrasound coverage.
If TRICARE coverage ends during pregnancy,TRICARE will not cover any remainingmaternity costs unless your family qualifies for other TRICARE health coverage or haspurchased the Continued Health Care BenefitProgram (CHCBP).
To ensure your newborn is covered byTRICARE, see “Having a Baby or Adopting aChild” in the Life Events section.
Dental Options
Active duty service members receive dental carefrom military dental treatment facilities. For allother beneficiaries, TRICARE offers two dentalprograms—the TRICARE Dental Program (TDP)and the TRICARE Retiree Dental Program(TRDP). Each program is administered by aseparate dental contractor and has its own monthlypremiums and cost�shares.
TRICARE Dental Program
The TDP is a voluntary dental insurance programavailable to eligible active duty family membersand to members of the National Guard andReserve and/or their families. United ConcordiaCompanies, Inc., (United Concordia) currentlyadministers the program. For information aboutthe TDP, visit the TDP Web site atwww.TRICAREdentalprogram.com or callUnited Concordia toll�free at 1�800�866�8499.
TRICARE Retiree Dental Program
The TRDP is a voluntary dental insurance programavailable to retired service members and theireligible family members. Delta Dental Plan ofCalifornia (Delta Dental) currently administers theprogram. For information about the TRDP, visitthe TRDP Web site at www.trdp.org or call DeltaDental toll�free at 1�888�838�8737.
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Services or Procedures with Significant Limitations
Below is a list of medical, surgical, and behavioral health care services that may not be covered unlessexceptional circumstances exist. This list is not intended to be all�inclusive. Check with your regionalcontractor’s Web site for additional information.
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Service Description
Abortions Abortions are covered only when the life of the mother would be endangered if thepregnancy were carried to term. The attending physician must certify in writing that the abortion was performed because a life�threatening condition existed. Medicaldocumentation must be provided.
Cardiac andPulmonaryRehabilitation
Both are covered only for certain indications. Phase III cardiac rehabilitation forlifetime maintenance performed at home or in medically unsupervised settings isexcluded.
Cosmetic, Plastic, or ReconstructiveSurgery
Only covered when used to restore function, correct a serious birth defect, restore body form after a serious injury, improve appearance of a severe disfigurement, or after a medically necessary mastectomy.
Cranial OrthoticDevice or MoldingHelmet
Cranial orthotic devices are excluded for treatment of nonsynostic positionalplagiocephaly.
Dental Care and Dental X�rays
Both are covered only for adjunctive dental care (i.e., dental care that is medicallynecessary in the treatment of an otherwise covered medical—not dental—condition).
Education and Training
Outpatient diabetic self�management and training programs are covered when theservices are provided by a TRICARE�authorized individual provider who also meets national standards for diabetes self�management education programsrecognized by the American Diabetes Association (ADA). The provider’s “Certificateof Recognition” from the ADA must accompany the claim for reimbursement.
Eyeglasses or Contact Lenses
Active duty service members may receive eyeglasses at MTFs at no cost. For all otherbeneficiaries, contact lenses and/or eyeglasses are only covered for treatment of:
• Infantile glaucoma
• Corneal or scleral lenses for treatment of keratoconus
• Scleral lenses to retain moisture when normal tearing is not present or is inadequate
• Corneal or scleral lenses to reduce corneal irregularities other than astigmatism
• Intraocular lenses, contact lenses, or eyeglasses for loss of human lens functionresulting from intraocular surgery, ocular injury, or congenital absence
Note: Adjustments, cleaning, and repairs for eyeglasses are not covered.
Facility Charges forNon�Adjunctive DentalServices
Covered only to safeguard a patient’s life.
Food, Food Substitutesor Supplements, orVitamins
When used as the primary source of nutrition for enteral, parenteral, or oral nutritionaltherapy, intraperitoneal nutrition therapy is covered for malnutrition as a result of end�stage renal disease.
Services or Procedures with Significant Limitations Figure 3.5
Exclusions
In general, TRICARE excludes services andsupplies that are not medically orpsychologically necessary for the diagnosis ortreatment of a covered illness (including mentaldisorder) or injury or for the diagnosis andtreatment of pregnancy or well�baby care. Allservices and supplies (including inpatientinstitutional costs) related to a non�coveredcondition or treatment, or provided by anunauthorized provider, are excluded. Thefollowing specific services are excluded underany circumstance. This list is not intended to beall�inclusive. Check your regional contractor’sWeb site for additional information.
• Acupuncture
• Air conditioners, humidifiers, dehumidifiers,and purifiers
• Artificial insemination, including in�vitrofertilization, gamete intrafallopian transfer, andall other such reproductive technologies
• Autopsy services or post�mortem examinations
• Bariatric surgery, except as outlined underGastric Bypass and Weight Reduction inFigure 3.5, “Services or Procedures withSignificant Limitations”
• Birth control/contraceptives (non�prescription)
• Camps (e.g., weight loss)
• Charges that providers may apply due to amissed or rescheduled appointment
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Service Description
Gastric Bypass Gastric bypass, gastric stapling, or gastroplasty—to include vertical bandedgastroplasty—is covered when one of the following conditions is met:
1. The patient is 100 pounds over the ideal weight for height and bone structure andhas one of these associated medical conditions: diabetes mellitus, hypertension,cholecystitis, narcolepsy, Pickwickian syndrome (and other severe respiratorydiseases), hypothalamic disorders, and severe arthritis of the weight�bearing joints.
2. The patient is 200 percent or more of the ideal weight for height and bone structure. An associated medical condition is not required for this category.
3. The patient has had an intestinal bypass or other surgery for obesity and, because of complications, requires a second surgery (a takedown).
Genetic Testing Covered only under certain conditions.
Hearing Aids Covered only for active duty family members who meet specific hearing lossrequirements.
Intelligence Testing Covered only when medically necessary for the diagnosis or treatment planning ofcovered psychiatric disorders.
Laser/LASIK/RefractiveCorneal Surgery
Covered only to relieve astigmatism following a corneal transplant.
Marital Therapyand/or CouplesCounseling
Covered only for beneficiaries with behavioral health disorder as a primary diagnosis,and the marital or couples therapy must be medically necessary.
Private Hospital Rooms
Not covered unless ordered for medical reasons or a semiprivate room is not available.Hospitals that are subject to the TRICARE diagnosis�related group (DRG) paymentsystem may provide the patient with a private room but will receive only the standardDRG amount. The hospital may bill the patient for the extra charges if the patientrequests a private room.
Weight Reduction Services and supplies related to obesity or weight reduction, whether surgical or non�surgical, are excluded except for gastric bypass, gastric stapling, or gastroplastyprocedures in connection with morbid obesity.
Services or Procedures with Significant Limitations (continued)
• Chiropractic care (Visitwww.tricare.mil/chiropractic for detailsabout the Chiropractic Health Care Programfor active duty service members.)
• Clothing or shoes, even if required by virtue ofan allergy
• Counseling services that are not medicallynecessary in the treatment of a diagnosedmedical condition. For example, educationalcounseling, vocational counseling, andcounseling for socioeconomic purposes, stressmanagement, life�style modification, etc.
• Custodial care
• Diagnostic admissions
• Diagnostic tests to establish paternity of achild or tests to determine the sex of a fetus
• Domiciliary care
• Dyslexia treatment
• Electrolysis
• Elevators or chair lifts
• Exercise equipment, spas, whirlpools, hot tubs,swimming pools, health club memberships, orother such charges or items
• Experimental or unproven procedures
• Foot care (routine), except those required as aresult of a diagnosed systemic medical diseaseaffecting the lower limbs, such as severediabetes
• General exercise programs, even ifrecommended by a physician and regardless ofwhether rendered by an authorized provider
• Inpatient stays:
• For rest or rest cures
• To control or detain a runaway child,whether or not admission is to an authorizedinstitution
• To perform diagnostic tests, examinations,and procedures that could have been and areperformed routinely on an outpatient basis
• In hospitals or other authorized institutionsabove the appropriate level required toprovide necessary medical care
• Learning disability services
• Megavitamins and orthomolecular psychiatrictherapy
• Mind expansion and elective psychotherapy
• Naturopaths
• Orthopedic shoes (except if an integral part ofa brace), arch supports, shoe inserts, and othersupportive devices for the feet, includingspecial�ordered, custom�made built�up shoes,or regular shoes later built up
• Personal, comfort, or convenience items, suchas beauty and barber services, radio, television,and telephone
• Postpartum inpatient stay of a mother forpurposes of staying with the newborn infant(usually primarily for the purpose ofbreastfeeding the infant) when the infant (but not the mother) requires the extendedstay; or continued inpatient stay of a newborninfant primarily for purposes of remaining with the mother when the mother (but not thenewborn infant) requires extended postpartuminpatient stay
• Preventive care such as routine annual oremployment�requested examinations; routinescreening procedures; immunizations; exceptsuch preventive care, immunizations, andcancer screenings provided in the ClinicalPreventive Services list (see “ClinicalPreventive Services” in this section).
• Psychiatric treatment for sexual dysfunction
• Services and supplies:
• Provided under a scientific or medical study,grant, or research program
• Furnished or prescribed by an immediatefamily member
• For which the beneficiary has no legalobligation to pay or for which no chargewould be made if the beneficiary or sponsorwere not eligible under TRICARE
• Furnished without charge (e.g., cannot fileclaims for services provided free�of�charge)
• For the treatment of obesity, except asoutlined in “Services or Procedures withSignificant Limitations.” Diets, weight losscounseling, weight loss medications, wiringof the jaw, or any similar procedure isexcluded.
• Including inpatient stays, directed or agreedto by a court or other governmental agency(unless medically necessary)
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• Required as a result of occupational diseaseor injury for which any benefits are payableunder a worker’s compensation or similarlaw, whether such benefits have been appliedfor or paid, except if benefits provided undersuch laws are exhausted.
• That are (or are eligible to be) fully payableunder another medical insurance or program,either private or governmental, such ascoverage through employment or Medicare(TRICARE will be secondary for anyremaining charges.)
• Sex changes or sexual inadequacy treatment(However, treatment of ambiguous genitaliawhich has been documented to be present atbirth is covered.)
• Sterilization reversal surgery
• “Stop smoking” regimens
• Surgery performed primarily for psychologicalreasons (such as psychogenic)
• Therapeutic absences from an inpatient facility,except when such absences are specificallyincluded in a treatment plan approved byTRICARE
• Transportation, except by ambulance
• X�ray, laboratory, and pathological servicesand machine diagnostic tests not related to aspecific illness or injury or a definitive set ofsymptoms, except for cancer screeningmammography, cancer screening, Pap tests,and other tests allowed under the ClinicalPreventive Services benefit
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Health Care Claims
In most cases, you will not need to file claimsfor health care services. There may be times,however, when you will need to pay for care andthen file the claims yourself to receive payment.You will be reimbursed for TRICARE�coveredservices at the TRICARE allowable amount, lessany copayments, cost�shares, or deductibles.
Claims must be filed within one year of the dateof service or within one year of the date of aninpatient discharge. To file a claim, obtain andfill out a DD Form 2642 Patient’s Request forMedical Payment. You can download forms andinstructions from your regional contractor’s Web site or from the TRICARE Web site atwww.tricare.mil/claims.
You can also visit a local TRICARE ServiceCenter (TSC) or military treatment facility(MTF) to pick up a copy. If you have questionsabout a claim, call your regional contractor.
When filing a claim, attach a readable copy ofthe provider’s bill to the claim form, making sureit contains the following:
• Sponsor’s Social Security number (SSN)(eligible former spouses should use their SSN)
• Provider’s name and address (If more than oneprovider’s name is on the bill, circle the nameof the person who treated you.)
• Date and place of each service
• Description of each service or supply furnished
• Charge for each service
• Diagnosis (If the diagnosis is not on the bill,be sure to complete block 8a on the form.)
Be sure to complete all 12 blocks of the formcorrectly and sign it. Note: Your provider willsubmit inpatient facility claims.
Send your claims to the claims processor for theregion in which you live. If you receive carewhile traveling, you must file your TRICAREclaims in the region in which you live, not theregion in which you received care. Always keepa copy of the paperwork for your records. Figure4.1 lists regional claims processing information.
Call your regional contractor, visit your regionalcontractor’s Web site, or visit the TRICARE Website at www.tricare.mil/claims for additionalclaims processing information.
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Claims
TRICARE North Region TRICARE South Region TRICARE West Region
Send claims to:Health Net Federal Services, Inc.c/o PGBA, LLC/TRICAREP.O. Box 870140Surfside Beach, SC 29587�9740
Check the status of your claim atwww.myTRICARE.com orwww.healthnetfederalservices.com.
Send claims to:TRICARE South RegionClaims DepartmentP.O. Box 7031Camden, SC 29020�7031
Check the status of your claim atwww.myTRICARE.com or atwww.humana�military.com.
Send claims to:West Region ClaimsP.O. Box 77028 Madison, WI 53797�7028
Check the status of your claim atwww.triwest.com.
Regional Claims Processing Information Figure 4.1
Pharmacy Claims
If you have other health insurance (OHI), youwill need to submit pharmacy claims to ExpressScripts, Inc. (ESI) for payment. Pharmacy claimsmust be filed within one year of the date ofservice. To file a pharmacy claim, obtain and fillout a DD Form 2642 Patient’s Request forMedical Payment. Prescription claims require thefollowing information for each drug:
• Name of the patient
• Name, strength, date filled, days’ supply,quantity dispensed, and price of each drug
• National Drug Code, if available
• Prescription number of each drug
• Name and address of the pharmacy
• Name and address of the prescribing physician
You can download forms and instructions from the TRICARE Web site atwww.tricare.mil/claims or fromwww.tricare.mil/pharmacy/claims.cfm.
Mail the claim to:
Express Scripts, Inc.TRICARE ClaimsP.O. Box 66518St. Louis, MO 63166�6518
See “Coordinating Benefits with Other HealthInsurance” later in this section or call 1�866�DoD�TRRX (1�866�363�8779) withquestions about filing a pharmacy claim.
Note: Non�active duty beneficiaries who haveprescriptions filled at a non�network pharmacyare using the point of service option. Active dutyservice members may be required to pay for theprescriptions in full and will receive a fullreimbursement when the claim is filed.
Coordinating Benefits withOther Health Insurance
TRICARE is the primary payer for active dutyservice members. For all other beneficiaries,TRICARE is the secondary payer to all healthbenefits and insurance plans, except for
Medicaid, TRICARE supplements, the IndianHealth Service, and other programs/plans asidentified by the TRICARE ManagementActivity (TMA).
If you have OHI, you need to follow the OHI’srules for filing claims and file the claim withthem first. If there is an amount your OHI doesnot cover, you can file the claim with TRICAREfor reimbursement. It is important to follow therequirements of your OHI. If your OHI denies aclaim for failure to follow their rules, such asobtaining care without authorization or use of anon�network provider, TRICARE may also denyyour claim.
Keep your regional contractor and health careproviders informed about your OHI so they canbetter coordinate your benefits and help ensurethat there is no delay (or denial) in the paymentof your claims.
Pharmacy Claims and OHI (Processedby ESI)
When you have OHI, your OHI is the first payerfor pharmacy coverage, and the rules of thatinsurer apply. After your OHI has paid, yourTRICARE coverage may reimburse you for partor all of your out�of�pocket costs, includingcopayments. Your best option with OHI is to usea retail pharmacy that is covered by your OHIand is in the TRICARE retail network to avoidusing the POS option.
You may not use TRICARE’s mail�order optionif you have prescription drug coverage fromOHI, unless the medication is not covered underyour OHI, or you exceed the dollar limit ofcoverage under your OHI.
Contact ESI at 1�866�DoD�TRRX (1�866�363�8779) with questions aboutfiling pharmacy claims with OHI.
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Third-Party Liability
The Federal Medical Care Recovery Act allowsTRICARE to be reimbursed for its costs oftreatment if you are injured in an accident thatwas caused by someone else. The DD Form2527 Statement of Personal Injury Third PartyLiability form will be sent to you if a claim isreceived that appears to have third�partyinvolvement. Within 35 calendar days, you mustcomplete and sign this form and follow thedirections for returning the form to theappropriate claims processor. You can downloadthe DD Form 2527 from the TRICARE Web siteat www.tricare.mil/claims or from your regionalcontractor’s Web site.
Explanation of Benefits
A TRICARE explanation of benefits (EOB) isnot a bill. It is an itemized statement that showswhat action TRICARE has taken on your claims.An EOB is for your information and files.
After reviewing the EOB, you have the right toappeal certain decisions regarding your claims.You can file an appeal in writing within 90 daysof the date of the EOB notice. (For moreinformation about appeals, see the Informationand Assistance section.) You should keep EOBswith your health insurance records for reference.
For a sample of the EOB in your region, alongwith instructions for reading the EOB, see thefollowing figure numbers in the Appendixsection:
• North Region: Figure 9.1
• South Region: Figure 9.2
• West Region: Figure 9.3
Debt Collection AssistanceOfficers
Debt Collection Assistance Officers (DCAOs)are located at military treatment facilities(MTFs) and the TRICARE Regional Offices(TROs) to assist you in resolving health carecollection�related issues. Contact a DCAO if youhave received a negative credit rating or havebeen sent to a collection agency due to an issuerelated to TRICARE services.
When you visit a DCAO for assistance, you mustbring or submit documentation associated with acollection action or adverse credit rating,including debt collection letters, EOBstatements, and medical/dental bills fromproviders. The more information you canprovide, the faster the cause of the problem willbe determined. The DCAO will research yourclaim, provide you with a written resolution ofyour collection problem, and inform thecollection agency that action is being taken toresolve the issue. DCAOs cannot provide legaladvice or repair your credit rating, but they canhelp you through the debt collection process byproviding documentation for the collection orcredit�reporting agency to explain thecircumstances relating to the debt. To find aDCAO near you, visit the DCAO directoryonline at www.tricare.mil/bcacdcao.
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TRICARE Prime continues to provide healthcoverage for you and your family as youexperience major life events. You will, however,need to take specific actions to make sure youremain eligible for TRICARE. With every lifeevent listed in this section, the first step is toupdate your information in the DefenseEnrollment Eligibility Reporting System(DEERS).
To update DEERS:
Read the following sections to learn what to dowhen you get married, have a child, move, retire,and more.
Getting Married or Divorced
Marriage
It’s extremely important for sponsors to registertheir new spouses in DEERS to ensure they areeligible for TRICARE. To register a new spouse inDEERS, the sponsor will need to provide a copyof your marriage certificate to the nearestuniformed services identification (ID) card�issuingfacility. Once your spouse is registered in DEERS,he or she will receive a uniformed services ID card and will be eligible for TRICARE. Whenaccessing care, your spouse will be asked to showhis or her ID card.
Registration in DEERS is not the same as enrollingin TRICARE Prime. Once your spouse is
registered in DEERS, he or she will need to enrollin TRICARE Prime, or he or she will be coveredby TRICARE Standard and TRICARE Extra. ForTRICARE Prime enrollment, download anenrollment application from your regionalcontractor’s Web site, visit a local TRICAREService Center (TSC), or call your regionalcontractor to request an enrollment application.
Your new spouse’s TRICARE Prime enrollment iseffective based on the 20th�of�the�month rule.With the 20th�of�the�month rule, as long as yourregional contractor receives the completedenrollment application by the 20th of the month,coverage will begin on the first day of the nextmonth. The application must be received by the20th of the month, not postmarked by the 20th ofthe month. If the form is received after the 20th ofthe month, then coverage begins on the first day ofthe following month. See the Figure 5.1 todetermine when TRICARE Prime coverage begins.
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• Visit a uniformed services personnel office.Find one near you at www.dmdc.osd.mil/rsl.
• Call 1�800�538�9552.
• Fax address changes to DEERS at 1�831�655�8317.
• Mail the address change to:
The Defense Manpower Data Center Support Office Attn: COA 400 Gigling Road Seaside, CA 93955�6771
• Update addresses electronically atwww.tricare.mil/DEERS.
Application Received Enrollment Start
January 1�20 February 1January 21�31 March 1
February 1�20 March 1
February 21�28 April 1March 1�20 April 1
March 21�31 May 1
April 1�20 May 1April 21�30 June 1
May 1�20 June 1
May 21�31 July 1June 1�20 July 1
June 21�30 August 1
July 1�20 August 1
July 21�31 September 1
August 1�20 September 1
August 21�31 October 1
September 1�20 October 1
September 21�30 November 1
October 1�20 November 1
October 21�31 December 1
November 1�20 December 1
November 21�30 January 1December 1�20 January 1December 21�31 February 1
Figure 5.1
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After your regional contractor processes yourapplication, your new spouse will receive a letteridentifying his or her primary care manager(PCM) along with an enrollment card.
Note: If you are a retired service member andcurrently paying the individual enrollment fee,your enrollment fee will increase to the familyplan rate when you enroll your new spouse inTRICARE Prime.
Divorce
Sponsors must update DEERS when there is adivorce. You, the sponsor, will need to provide acopy of the divorce decree.
Children
After a divorce, children (biological andadopted) remain eligible for TRICARE up to age21 (or age 23 if enrolled in college full time andthe sponsor provides at least 50 percent of thefinancial support) as long as their information iskept up to date in DEERS. Please contactDEERS to verify what documentation is neededto extend coverage.
While a child normally does not get his or herown uniformed services ID card until age 10, achild under age 10 should have an ID card whenin custody of a parent or guardian who is noteligible for TRICARE benefits or who is not thecustodial parent. Patient privacy may be a factorfor divorced parents attempting to obtaininformation about received health care services.Contact your regional contractor for assistance. Note: Children with a disability may remaineligible for TRICARE beyond the normal agelimits. Please check with DEERS for eligibilitycriteria.
If children are living in a separate region with aformer spouse, they may continue TRICAREPrime coverage using the split�enrollmentfeature. See page 32 for a description ofTRICARE Prime’s split�enrollment feature.
Former Spouses
Certain former spouses are eligible forTRICARE coverage if the followingrequirements are met:
1. Must not remarry (If a former spouseremarries, the loss of benefits remainsapplicable even if the remarriage ends in deathor divorce.)
2. Must not be covered by an employer�sponsored health plan
3. Must not be the former spouse of a NorthAtlantic Treaty Organization (NATO) or“Partners for Peace” nation member
4. Must meet the requirements of one of thethree situations in Figure 5.2 on page 31.
When a former spouse is eligible for TRICAREcoverage, he or she must change their personalinformation in DEERS so that their name andSocial Security number (SSN) is listed as theprimary contact. The former spouse’s TRICAREeligibility will be shown in DEERS under his orher SSN.
Having a Baby or Adopting aChild
You should register your newborn or adopted childin DEERS as soon as possible. To register yourchild in DEERS, you need only a certificate of livebirth or adoption. The document does not need tobe a certified copy of the official birth certificate. Itcan be a certificate of live birth authenticated byeither the attending physician or other responsibleparty from the hospital. Note: Registration inDEERS is a separate step from enrolling in Prime.
Children are covered as TRICARE Primebeneficiaries for 60 days after birth as long asone other family member is enrolled inTRICARE Prime. If you wish to keep your childenrolled in TRICARE Prime, you must submitan enrollment application to your regionalcontractor within 60 days of birth or adoption forcontinuous Prime coverage.
On day 61, if you have not enrolled the child inTRICARE Prime, he or she will be coveredautomatically under TRICARE Standard andTRICARE Extra until 365 days after the child’sbirth or adoption. On day 366, if the child is notregistered in DEERS, DEERS will show “loss ofeligibility,” and he or she will no longer be able
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to receive TRICARE benefits until they areregistered in DEERS.
Going to College
Eligibility
Your children remain eligible for TRICARE up to age 21 (or age 23 if enrolled in collegefull�time and the sponsor provides at least 50percent of the financial support) as long as theirinformation is kept up to date in DEERS. Toextend benefits for your college student beyondhis or her 21st birthday, please contact DEERSto verify what documentation is needed to extendcoverage. Representatives there will be able toadvise you about the documentation you need toupdate DEERS and extend coverage. Note: Inmost cases, children going overseas to attendcollege on their own are eligible only forTRICARE Standard in the overseas area.
If your child loses DEERS eligibility, his or herTRICARE Prime coverage will end automatically.If you believe your child is still eligible forTRICARE, you will need to contact DEERS toupdate his or her record. Once DEERS is updated,
you must contact your regional contractor forinformation if you want to re�enroll your child inTRICARE Prime. Otherwise, your child will becovered under TRICARE Standard and TRICAREExtra.
TRICARE benefits end when your collegestudent reaches age 23 or when full�time studentstatus ends, whichever comes first. For example,if your child turns 23 on January 3, but doesn’tgraduate until May, coverage ends at midnighton January 2.
Note: Children with a disability may remaineligible for TRICARE beyond the normal agelimits. Please check with DEERS for eligibilitycriteria.
Health Care Options
If TRICARE Prime is available where your childis attending school and the school is in yourTRICARE region, your child only needs to select anew primary care manager (PCM). If the school isin a different TRICARE region, your child mayremain enrolled in TRICARE Prime using thesplit�enrollment feature if TRICARE Prime isavailable in that area.
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• Must have been married to the same member or former member for at least 20 years, and at least 20 of those years must have been creditable in determining the member’s eligibility for retirement pay.
• If the date of the final decree of divorce or annulment was on or after February 1, 1983, the formerspouse is eligible for TRICARE coverage of health care that is received after the date of the divorce or annulment.
• If the date of the final decree is before February 1, 1983, the former spouse is eligible for TRICAREcoverage of health care received on or after January 1, 1985.
• Eligibility continues as long as the preceding requirements continue to be met.
2
• Must have been married to the same military member or former member for at least 20 years, and at least 15—but less than 20—of those married years must have been creditable in determining themember’s eligibility for retirement pay.
• If the date of the final decree of divorce or annulment is before April 1, 1985, the former spouse iseligible only for care received on or after January 1, 1985, or the date of the decree, whichever is later.
• Eligibility continues as long as the preceding requirements continue to be met. However, if the date of the final divorce decree or annulment is on or after April 1, 1985, but before September 29, 1988,the former spouse is eligible for care received from the date of the decree until December 31, 1988, or two years from the date of the decree, whichever is later.
3• Must have been married to the same military member or former member for at least 20 years, and
at least 15—but less than 20—of those married years must have been creditable in determining themember’s eligibility for retirement pay.
• If the date of the final decree of divorce or annulment is on or after September 29, 1988, the formerspouse is eligible only for care received for one year from the date of the decree.
Eligibility Requirements for Former Spouses Figure 5.2
Split Enrollment
Split enrollment allows families living in separateTRICARE regions to enroll in TRICARE Primetogether. To use split enrollment, you must notifyeach family member’s regional contractor of thesplit enrollment status and establish one familypayer for enrollment fees (where applicable). Theregional contractors will coordinate enrollmentfees and send the statements to the designatedpayer. An enrollment fee left unpaid causes theentire family to be disenrolled. Key points toremember with split enrollment:
• Families with college students, children livingwith former spouses, or families otherwiseseparated can enroll together in separateregions.
• Active duty families are not required to payenrollment fees, but they can still enroll inseparate regions.
• Retiree families have only one enrollment feeand one enrollment anniversary date.
• There is no limit on the number of familymembers enrolling.
• In most cases, only those family members whoaccompany their active duty sponsor on his orher orders overseas will be enrolled inTRICARE Overseas Program Prime options.
If your child does not enroll in TRICARE Prime,he or she will be covered automatically byTRICARE Standard and TRICARE Extra aslong as his or her information is kept up to date
in DEERS. Visit your regional contractor’s Website or call the toll�free number if you havequestions about using TRICARE Standard andTRICARE Extra.
Traveling
Active Duty Service Members
If you need emergency medical or dental carewhile traveling in the Continental United States,visit the nearest emergency room or call 911. Ifnear an MTF when traveling, you should go tothe MTF or military dental treatment facility forservices.
If you require urgent care while traveling,coordinate with your PCM and/or regionalcontractor before receiving care.
Routine medical and dental care is notauthorized when you are traveling. You shouldobtain all routine care before you travel or afteryou return. If you are traveling between dutylocations, you should delay the care until you getto your new duty location.
If traveling overseas, contact the TRICAREGlobal Remote Overseas (TGRO) Call Center inthe overseas area where you are traveling forassistance in obtaining care.
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TRICARE Europe TRICARE Latin America andCanada (TLAC) TRICARE Pacific
Europe, Africa, and the Middle East Central and South America, theCaribbean Basin, Canada, PuertoRico, and the U.S. Virgin Islands
Guam, Japan, Korea, Asia, NewZealand, India, and Western Pacificremote countries
Collect: 011�44�20�8762�8133Fax: 011�44�20�8762�[email protected]
Collect: 1�215�701�2800Fax: 1�215�244�[email protected]
Singapore: Collect: 011�65�6338�[email protected]
Sydney: Collect: 011�61�2�9273�[email protected]
TGRO Call Center Information Figure 5.3
All Other TRICARE Prime Enrollees
If you need emergency care while traveling inthe Continental United States, visit the nearestemergency room or call 911. You must notifyyour PCM or regional contractor within 24 hoursor the next business day so that ongoing care canbe coordinated and to ensure you receive properauthorization for care.
If you require urgent, routine, or specialty carewhile traveling, you must coordinate with yourPCM and/or regional contractor before receivingcare to avoid using the point of service (POS)option.
When traveling overseas, plan for health carecontingencies in advance of the trip. If you needemergency or urgent care, contact the TRICAREArea Office (TAO) for the overseas area whereyou are traveling or the nearest AmericanEmbassy Health Unit for assistance finding ahost nation provider. Visit http://travel.state.govfor a list of every American Embassy orConsular Office worldwide. Figure 5.4 listscontact information for the TAO in each overseasarea. Note: When overseas, be prepared to payfor any care received from host nation providersat the time of service, and file a claim forreimbursement.
Filling Prescriptions on the Road
TRICARE recommends that you have all yourprescriptions filled before you travel, but thereare several options for filling prescriptions on theroad.
TRICARE Network Pharmacy
You can have prescriptions filled at anyTRICARE network pharmacy in the UnitedStates, Guam, Puerto Rico, and the U.S. VirginIslands. To locate a network pharmacy, call toll�free 1�866�363�8779 or visit www.express�scripts.com/TRICARE.
Military Treatment Facility Pharmacy
If you’re near an MTF while traveling, you canhave a new prescription filled at any MTFpharmacy free of charge if the medication is onthe MTF formulary and the pharmacy stocks themedication you need. All you’ll need is thewritten prescription and your uniformed servicesID or Common Access Card. Refilling aprescription originally filled at another MTF is atthe discretion of the MTF you are visiting.
TRICARE Mail Order Pharmacy
If you will be staying away from home for alonger period of time, you can plan ahead toreceive prescriptions through the mail. ProvideESI with your temporary address so prescriptionscan be mailed to you at your travel destination.Note: The mail�order option is not available
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TRICARE Europe TLAC TRICARE Pacific
Includes Europe, Africa, and theMiddle East
Central and South America,the Caribbean Basin,Canada, Puerto Rico, and theU.S. Virgin Islands
Guam, Japan, Korea, Asia, NewZealand, India, and WesternPacific remote countries
Phone Comm.: 011�49�6302�67�7432
DSN: 496�7432
Toll�free: 1�888�777�8343
Comm.: 1�706�787�2424
DSN: 773�2424
Toll�free: 1�888�777�8343
Comm.: 011�81�6117�43�2036
DSN: 643�2036
Remote Sites: 011�65�6�338�9277
Toll�free: 1�888�777�8343
Fax Comm.: 011�49�6302�67�6374
DSN: 496�6374
1�706�787�3024 Comm.: 011�81�611�743�2037
DSN: 643�2037
E�mail [email protected] [email protected] [email protected]
Online www.tricare.mil/europe www.tricare.mil/tlac www.tricare.mil/pacific
TRICARE Area Office Contact Information Figure 5.4
overseas unless you have an APO or FPOaddress. Call toll�free 1�866�363�8667 or visitwww.express�scripts.com/TRICARE forassistance.
Non-Network Pharmacy
If there is no other option, you can haveprescriptions filled at a non�network pharmacy. If you have prescriptions filled at a non�networkpharmacy you will be using the POS option. Youmay be required to pay for prescriptions up frontand file a claim with ESI for reimbursement. Seethe Claims section for details about filing apharmacy claim.
Filling Prescriptions Overseas
Your pharmacy coverage is limited overseas.TRICARE recommends that you have all yourprescriptions filled before you travel overseas.
• TRICARE network pharmacies are onlylocated in the United States, Puerto Rico,Guam, and the U.S. Virgin Islands.
• You must have an APO or FPO address to usethe mail�order pharmacy overseas.
• The prescription must be from a U.S.�licensedprovider.
• Be prepared to pay up front and file a claimfor reimbursement for non�MTF and non�network pharmacy services when travelingoverseas.
Moving
TRICARE Prime coverage is portable—you caneasily transfer your TRICARE Prime enrollmentwhen you move within your TRICARE region orto a new TRICARE region. Follow these simplesteps to ensure you have no break in coveragewhen you move.
1. Do not disenroll from TRICARE Prime beforeyou move to your new location.
2. Once you arrive at your new location, updateDEERS immediately.
3. Select a new PCM or transfer your TRICAREPrime enrollment within 30 days of arriving atyour new location.
If you move to another TRICARE Prime servicearea (PSA) in the same TRICARE region,
contact your current regional contractor—youwill only need to change your PCM. If you move to a TRICARE PSA in anotherTRICARE region, contact the new regionalcontractor to transfer your enrollment. Theenrollment transfer is effective when your newenrollment application is received by your newregional contractor.
If you move to an area where TRICARE Primeis not available (same or new region):
• Active duty service members: Transfer yourenrollment to TRICARE Prime Remote (TPR)by submitting a new enrollment form. Theenrollment transfer is effective when yourregional contractor receives your form.
• Active duty family members: If you live withyour TPR�enrolled sponsor, your enrollmentwill transfer to TRICARE Prime Remote forActive Duty Family Members (TPRADFM).Your sponsor can include you on his or herenrollment form. Or, you can disenroll fromTRICARE Prime and you are automaticallycovered by TRICARE Standard and TRICAREExtra as long as your DEERS informationstays current.
• Retired service members, their families, andall other TRICARE Prime enrollees: Youmust disenroll from TRICARE Prime and youare covered automatically by TRICAREStandard and TRICARE Extra as long as yourDEERS information is current. If you do notdisenroll, you will be utilizing the POS option.
Active duty service members and their familiesmay transfer TRICARE Prime enrollment asoften as needed. Retired service members, theirfamily members, survivors, eligible formerspouses, and others are limited to two enrollmenttransfers each enrollment year, as long as thesecond transfer is back to the original region ofenrollment.
If you are moving overseas, contact theappropriate overseas TAO in advance of themove to determine TRICARE Overseas Program(TOP) Prime eligibility requirements. Retireesand their family members are not eligible for anyTOP Prime options. See Figure 5.4 on theprevious page for TAO contact information.
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Separating from the Service
If you are separating from the uniformedservices, TRICARE coverage may or may notcontinue, depending on the circumstances ofyour separation. TRICARE offers transitionalhealth care options—the Transitional AssistanceManagement Program (TAMP) and theContinued Health Care Benefit Program(CHCBP)—that provide temporary coverageuntil you have a new health plan.
Transitional Assistance ManagementProgram
TAMP provides 180 days of transitional healthcare benefits to certain uniformed servicesmembers and their families, if the active dutysponsor is:
1. Involuntarily separating from active dutyunder honorable conditions
2. A member of the National Guard or Reservesseparating from active duty for a period ofmore than 30 consecutive days in support of acontingency operation
3. Separating from active duty followinginvoluntary retention (stop�loss) in support ofa contingency operation
4. Separating from active duty following avoluntary agreement to stay on active duty forless than one year in support of a contingencyoperation
If you qualify for coverage under TAMP, you and your family will have 180 days oftransitional health benefits after you separate.During this 180�day period, you may enroll inTRICARE Prime if you reside in a TRICAREPSA, or you will be covered under TRICAREStandard and TRICARE Extra. You and yourfamily members will be covered as active dutyfamily members, and copayments, cost�shares,deductibles, rules, and processes for theseprograms will apply.
Continued Health Care BenefitProgram
CHCBP is a premium�based health care programadministered by Humana Military Health CareServices, Inc. (Humana Military). CHCBP offerstemporary transitional health coverage (18�36
months) after TRICARE eligibility ends. If youqualify, you can purchase CHCBP within 60days of loss of eligibility for either regularTRICARE or TAMP coverage.
CHCBP acts as a bridge between military healthbenefits and your new civilian health plan. CHCBPbenefits are comparable to TRICARE Standardwith the same benefits, providers, and programrules. The main difference is that you paypremiums to participate. For more informationabout CHCBP visit www.humana�military.comor call 1�800�444�5445.
Contact your regional contractor or a beneficiarycounseling and assistance coordinator (BCAC) to discuss your family’s eligibility for theseprograms. You also can visit www.tricare.mil formore information.
TRICARE Reserve Select
Some members of the National Guard andReserve may be eligible for TRICARE ReserveSelect—a voluntary, premium�based health plan available for members who qualify whenthey separate from active duty. Visitwww.tricare.mil/reserve/reserveselect forinformation about how to qualify for thisprogram.
Retiring from Active Duty
When you retire from active duty, you and youreligible family members experience a “change instatus,” and you will all receive new “retired”uniformed services ID card when DEERS isupdated.
As a “retired service member” you will have newhealth care options. When on active duty, youwere enrolled in either TRICARE Prime or TPR.After you retire, you can choose to re�enroll inTRICARE Prime, or you can use TRICAREStandard and TRICARE Extra. TPR is notavailable to retirees.
Here’s a quick glance at some of the changes inTRICARE when you retire:
• If you re�enroll in TRICARE Prime:
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• You begin paying annual enrollment fees.
• Network copayments/cost�shares will apply.
• Your catastrophic cap increases.
• Minor differences in covered services
• Annual eye exams are no longer covered, butif you stay in TRICARE Prime, they arecovered every two years.
• Hearing aids are no longer covered.
• If family members were using TRICAREStandard and TRICARE Extra before youretired, the cost�shares will now increase byfive percent.
• You must have Medicare Part B coverage forall Medicare�eligible family members toremain eligible for TRICARE.
Review the costs, including applicableTRICARE Prime enrollment fees, in theTRICARE: Summary of Beneficiary Costs flyer.You and your family members should look atyour health care options together and determinewhich option best meets your needs after youretire. If you decide to re�enroll in TRICAREPrime, the 20th�of�the�month rule will apply foryou and your family members. See Figure 5.1 onpage 29 for enrollment deadlines.
Becoming Entitled to Medicare
When you or another family member becomeentitled to premium�free Medicare A—at age 65or due to a disability or end�stage renaldisease—TRICARE becomes the second payerafter Medicare, if you have Medicare Part Bcoverage.
Medicare�eligible beneficiaries under age 65have the option to continue enrollment inTRICARE Prime or use TRICARE For Life. Ifthey remain enrolled in TRICARE Prime, annualenrollment fees are waived, if applicable.
Note: Active duty family members are notrequired to have Medicare Part B coverage toremain eligible for TRICARE. When the activeduty sponsor retires, Medicare�eligible familymembers must have Medicare Part B or they loseeligibility for TRICARE.
Deceased Sponsor
When a sponsor dies, TRICARE coveragecontinues for eligible family members. Survivingspouses remain eligible for TRICARE as long asthey do not remarry. If a surviving spouseremarries, he or she loses eligibility forTRICARE and cannot regain eligibility in thecase of divorce or the death of the new spouse. Surviving children remain eligible for TRICAREuntil they turn age 21 (or 23 if enrolled incollege full time and you, the parent, providemore than 50 percent of your child’s financialsupport). Note: Children with a disability mayremain eligible for TRICARE beyond the normalage limits.
After the death of an active duty service member,all surviving family members continue to betreated as active duty dependents for three years.During this three�year “transitional survivor”period, all family members receive the samebenefits at the same costs as active duty familymembers.
After three years, surviving spouses remaineligible for TRICARE Prime, Standard, andExtra at retired family member rates. TRICAREPrime enrollment fees will apply for survivingspouses who choose to enroll in TRICAREPrime after the three�year transitional survivorperiod. Surviving children remain eligible forTRICARE (TRICARE Prime, TPRADFM,TRICARE Standard, and TRICARE Extra) forthree years after the date of the member’s deathor up to age 21, whichever is longer. This agelimit extends to age 23 if the surviving childrenwere, at the time of the member’s death,dependent upon the former member for morethan 50 percent of their financial support or ifthey were pursuing a full�time course ofeducation in a secondary school or an institutionof higher education. Note: The effective date ofthis benefit is retroactive to October 7, 2001.
Upon the death of a sponsor, you will receive aletter from DEERS telling you about yourprogram options and how your benefits willeventually change. Contact your regionalcontractor if you have any questions.
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Loss of Eligibility
Upon loss of TRICARE eligibility, each familymember will automatically receive a certificate ofcreditable coverage. The certificate of creditablecoverage is a document that serves as evidence ofprior health care coverage under TRICARE so that you cannot be excluded from a new healthplan for pre�existing conditions. Examples of when certificates may be issued include:
• Upon the sponsor’s separation from activeduty, a certificate will be issued to the sponsorlisting all eligible family members.
• Upon the loss of eligibility for a dependentchild (age 21, or 23 if a full�time student), acertificate will be issued to the dependentchild.
• Upon loss of coverage after divorce, acertificate will be issued to the former spouse,as soon as the information is updated inDEERS.
Certificates automatically reflect the most recentperiod of continuous coverage under TRICARE.Certificates issued upon request of a beneficiarywill reflect each period of continuous coverageunder TRICARE that ended within the 24months prior to the date of loss of eligibility.Each certificate identifies the name of thesponsor or family member for whom it is issued,the dates TRICARE coverage began and ended,and the certificate issue date.
Send written requests for a certificate ofcreditable coverage to the Defense ManpowerData Center Support Office (DSO) at:
Defense Manpower Data Center Support Office Attn: Certificate of Creditable Coverage400 Gigling RoadSeaside, CA 93955�6771
The request must include:
• Sponsor’s name and SSN
• Name of person for whom the certificate isrequested
• Reason for the request
• Name and address to which the certificateshould be sent
• Requester’s signature
Certificates cannot be requested by phone. Ifthere is an urgent need for a certificate ofcreditable coverage, fax your request to the DSOat 1�831�655�8317 and/or request that DSO faxthe certificate to a particular number.
Additional information is available atwww.tricare.mil/certificate.
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Beneficiary Counseling andAssistance Coordinators
Beneficiary counseling and assistancecoordinators (BCACs) can help you withTRICARE and Military Health System inquiriesand concerns and can advise you about obtaininghealth care. BCACs are located at militarytreatment facilities (MTFs) and at the TRICARERegional Offices (TROs). To locate a BCAC, visit www.tricare.mil/bcacdcao for an onlinedirectory.
Appealing a Decision
If you believe a service or claim was improperlydenied, in whole or in part, you (or anotherappropriate party) may file an appeal. An appealmust involve an appealable issue. For example,you have the right to appeal TRICARE decisionsregarding the payment of your claims.
You also may appeal the denial of a requestedauthorization of services even though no care hasbeen provided and no claim submitted. There aresome things you may not appeal. For example,you may not appeal the denial of a serviceprovided by a health care provider not eligiblefor TRICARE certification.
When services are denied based on a medicalnecessity or a benefit decision, you are notifiedautomatically in writing. The notification willinclude an explanation of what was denied orwhy a payment was reduced and the reasoningbehind that decision.
Appeal Requirements
Your appeal must meet the requirements listed inFigure 6.1.
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Information and Assistance
1
An appropriate appealing party must submit the appeal. Proper appealing parties include:
• You, the beneficiary
• Your custodial parent (if you are a minor) or your guardian
• A person appointed in writing by you to represent you for the purpose of the appeal
• An attorney filing on your behalf
• Non�network participating providers
If a physician or other party is going to submit the appeal, you must complete and sign the Appointmentof Representative and Authorization to Disclose Information form, which is available on your regionalcontractor’s Web site. If the appeal is submitted without this form, it will not be processed. Note: Network providers are not appropriate appealing parties (unless appointed by you in writing).
2 The appeal must be in writing. See Figure 6.2 on the next page for addresses to submit different appeals.
3
The issue in dispute must be an appealable issue. The following are non�appealable issues:
• Allowable charges
• Eligibility
• Denial of services from an unauthorized provider
• Denial of treatment plan when an alternative treatment plan is selected
• Refusal by a PCM to provide services or refer a beneficiary to a specialist
• Point of service issues, except for whether the services were related to an emergency
4 The appeal must be filed in a timely manner. An appeal must be filed within 90 days after the date onthe EOB or denial notification letter.
5There must be an amount in dispute to file an appeal. In the case involving an appeal of a denial of anauthorization in advance of receiving the actual services, the amount in dispute is deemed to be theestimated TRICARE allowable charge for the services requested. There is no minimum amount indispute necessary to request a reconsideration.
TRICARE Appeal Requirements Figure 6.1
Filing an Appeal
Appeals must be filed with your regionalcontractor within particular deadlines. If you arenot satisfied with a decision rendered on anappeal, there are further levels of appeal. Forspecific information about filing an appeal inyour region, contact your regional contractor.
Prior authorization denial appeals may be eitherexpedited or non�expedited, depending on theurgency of the situation. You or an appointedrepresentative must file an expedited review of aprior authorization denial within three calendardays after receipt of the initial denial. A non�expedited review of a denial must be filedno later than 90 days after receipt of the initialdenial.
Appeals should contain the following:
• Beneficiary’s name, address, and telephonenumber
• Sponsor’s Social Security number (SSN)
• Beneficiary’s date of birth
• Beneficiary’s or appealing party’s signature
A description of the issue or concern mustinclude:
• The specific issue in dispute
• A copy of the previous denial determinationnotice
• Any appropriate supporting documents
Send your appeal to your regional contractor. SeeFigure 6.2 for appeals filing information.
Filing a Grievance
A grievance is a written complaint or concernabout a non�appealable issue regarding aperceived failure by any member of the healthcare delivery team—including TRICARE�authorized providers, military providers, regionalcontractors, or subcontractor personnel—toprovide appropriate and timely health careservices, access or quality, or to deliver theproper level of care or service.
The grievance process allows full opportunity toreport in writing any concern or complaintregarding health care quality or service. Any
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TRICARE North Region TRICARE South Region TRICARE West Region
Claims Appeals:
Health Net Federal Services, Inc.c/o PGBA LLC/TRICARE Claims AppealsP.O. Box 870148Surfside Beach, SC 29587�9748
Claims Appeals Fax:
1�888�458�2554
Prior Authorization Appeals:
Health Net Federal Services, Inc.c/o PGBA, LLC/TRICAREAuthorization AppealsP.O. Box 870142Surfside Beach, SC 29587�9742
Prior Authorization Appeals Fax:
1�888�881�3622
Claims Appeals:
TRICARE South Region AppealsP.O. Box 202002Florence, SC 29502�2002
Prior Authorization Appeals:
Humana Military HealthcareServicesAttn: Clinical AppealsP.O. Box 740044Louisville, KY 40201�9973
Behavioral Health Appeals:
ValueOptions Behavioral HealthAttn: Appeals and ReconsiderationDepartmentP.O. Box 551138Jacksonville, FL 32255�1138
Claims Appeals:
TriWest Healthcare AllianceClaims AppealsP.O. Box 86508Phoenix, AZ 85080
Prior Authorization Appeals:
TriWest Healthcare AllianceClaims AppealsP.O. Box 86508Phoenix, AZ 85080
Regional Appeals Filing Information Figure 6.2
TRICARE civilian or military provider,TRICARE beneficiary, sponsor, parent orguardian, or other representative of an eligibledependent child may file a grievance. Yourregional contractor is responsible for theinvestigation and resolution of all grievances.Grievances are resolved no later than 60 daysfrom receipt. Following resolution, the party whosubmitted the grievance will be notified of thereview completion.
Grievances may include such issues as:
• The quality of health care or services aspectslike accessibility, appropriateness, level,continuity, or timeliness of care
• The demeanor or behavior of providers andtheir staff
• The performance of any part of the health caredelivery system
• Practices related to patient safety
When filing a grievance, include the following:
• The beneficiary’s name, address, and telephonenumber
• Sponsor’s SSN
• Beneficiary’s date of birth
• Beneficiary’s signature
• A description of the issue or concern mustinclude:
• Date and time of the event
• Name of the provider(s) and/or person(s)involved
• Location of the event (address)
• The nature of the concern or complaint
• Details describing the event or issue
• Any appropriate supporting documents
File your grievance with your regionalcontractor. See Figure 6.3 for grievance filinginformation.
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TRICARE North Region TRICARE South Region TRICARE West Region
All grievances should be addressed to:
Health Net Federal Services, Inc.c/o PGBA, LLC/TRICARE GrievanceP.O. Box 870150Surfside Beach, SC 29587�9750
Submit online at:
www.healthnetfederalservices.com
Submit by fax:
1�888�317�6155
Submit your grievance in writing to the nearest location:
Regional Grievance CoordinatorHumana Military HealthcareServices8123 Datapoint DriveSuite 400San Antonio, TX 78229
For behavioral health careconcerns, send your information to:
Grievance SpecialistValueOptionsP.O. Box 551188Jacksonville, FL 32255�1188
All grievances should beaddressed to:
TriWest Healthcare AllianceAttn: Customer Relations Dept.P.O. Box 86036Phoenix, AZ 85080
Regional Grievance Filing Information Figure 6.3
Reporting Suspected Fraud andAbuse
Fraud happens when a person or organizationdeliberately deceives others to gain some sort ofunauthorized benefit. Health care abuse occurswhen providers supply services or products thatare medically unnecessary or that do not meetprofessional standards.
Beneficiaries are important partners in theongoing fight against fraud and abuse. Becausean explanation of benefits (EOB) is a tangiblestatement of services/supplies received, it is oneof the first lines of defense against health carefraud. Each EOB provides a toll�free number tocall if you have questions about services youbelieve are billed fraudulently, or you can accessthe TRICARE Program Integrity Web site atwww.tricare.mil/fraud for direct links to eachcontractor’s fraud and abuse reporting office.Through your regional contractor’s Web site, youcan use claims tools to view your EOBs, claimshistory, and track TRICARE costs paid. Westrongly encourage you to read your EOBscarefully.
Report suspected fraud and abuse to yourregional contractor. See Figure 6.4 for details.
To report fraud or abuse regarding the pharmacyprogram, contact ESI:
• Phone: 1�800�332�5455
• E�mail: fraudtip@express�scripts.com
You also can report fraud or abuse issues directlyto TRICARE at [email protected].
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TRICARE North Region TRICARE South Region TRICARE West Region
• Call 1�800�977�6761
• Fax 1�888�881�3644
• Report online atwww.healthnetfederalservices.com.
• Send an e�mail message to:[email protected]
• Mail information to:
Health Net Federal Services, Inc.Attn: Program IntegrityP.O. Box 870147Surfside Beach, SC 29587�9747
• Call 1�800�333�1620
• Report online at www.humana�military.com.
• Mail information to:
Humana Military HealthcareServices, Inc.Attn: Program Integrity500 W. Main Street, 19th floorLouisville, KY 40202
• Call 1�888�584�9378
• Fax 1�602�564�2458
• Report online atwww.triwest.com.
Regional Fraud and Abuse Reporting Information Figure 6.4
AcronymsADA American Diabetes AssociationBCAC Beneficiary Counseling and
Assistance CoordinatorCAC Common Access CardCHCBP Continued Health Care Benefit
ProgramDCAO Debt Collection Assistance
OfficerDEERS Defense Enrollment Eligibility
Reporting SystemDME Durable Medical EquipmentDoD Department of DefenseDRG Diagnosis�related GroupDSO Defense Manpower Data Center
Support OfficeEOB Explanation of BenefitsESI Express Scripts, Inc.MTF Military Treatment FacilityOHI Other Health InsurancePCM Primary Care ManagerPOS Point of ServicePSA Prime Service AreaRTC Residential Treatment CenterSNF Skilled Nursing FacilitySSN Social Security NumberTAMP Transitional Assistance
Management ProgramTAO TRICARE Area OfficeTDP TRICARE Dental ProgramTFL TRICARE For LifeTLAC TRICARE Latin America and
CanadaTMA TRICARE Management ActivityTMOP TRICARE Mail Order PharmacyTRDP TRICARE Retiree Dental
ProgramTRO TRICARE Regional OfficeTRRX TRICARE Retail Pharmacy TSC TRICARE Service Center
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Beneficiary Counseling and AssistanceCoordinator (BCAC)Persons at military treatment facilities andTRICARE Regional Offices who areavailable to answer questions, help solvehealth care�related problems and assistbeneficiaries in obtaining medical carethrough TRICARE. To locate a BCAC, visit www.tricare.mil/bcacdcao.
Catastrophic CapThe maximum out�of�pocket expenses forwhich TRICARE beneficiaries areresponsible for deductibles and cost�sharesbased on allowed charges for the servicesand supplies received in a given fiscal year(October 1–September 30).
Continued Health Care BenefitProgram (CHCBP)A premium�based health care program youmay purchase after loss of TRICAREeligibility if you qualify. The CHCBP offerstemporary transitional health coverage andmust be purchased within 60 days afterTRICARE eligibility ends.
Debt Collection Assistance Officer(DCAO)Persons located at military treatmentfacilities and TRICARE Regional Offices toassist you in resolving health care collection�related issues. Contact a DCAO if you havereceived a negative credit rating or have beensent to a collection agency due to an issuerelated to TRICARE services.
Defense Enrollment EligibilityReporting System (DEERS)A database of uniformed services members(sponsors), family members and othersworldwide who are entitled under law tomilitary benefits, including TRICARE.Beneficiaries are required to keep DEERSupdated.
Explanation of Benefits (EOB)A statement sent to beneficiaries showingthat claims were processed and the amountpaid to providers. If denied, an explanationof denial is provided.
Military Treatment Facility (MTF)A medical facility (hospital, clinic, etc.)owned and operated by the uniformedservices—usually located on or near amilitary base.
National Guard and ReserveIncludes the Army National Guard, the ArmyReserve, the Navy Reserve, the MarineCorps Reserve, the Air National Guard, theAir Force Reserve, and the U.S. Coast GuardReserve.
Negotiated RateThe rate network providers and participatingnon�network providers have agreed to acceptfor covered services.
Network ProviderNetwork providers have a signed agreementwith your regional contractor to provide careat a negotiated rate. Network providershandle claims for you.
Non-network ProviderNon�network providers do not have a signedagreement with your regional contractor andare therefore “out of network.” There are twotypes of non�network providers: participatingand nonparticipating.
Nonparticipating Non-networkProviderNonparticipating providers have not agreedto accept the TRICARE allowable charge orfile your claims. When you self�refer usingthe point of service (POS) option,nonparticipating providers may charge youup to 15 percent above the TRICAREallowable charge for services in addition toyour POS deductible and cost�shares. Thisamount is your responsibility and will not bepaid by TRICARE.
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Other Health Insurance (OHI)Any non�TRICARE health insurance that is not considered a supplement acquiredthrough an employer, entitlement program or other source. TRICARE pays second afterall other health plans except for Medicaid,TRICARE supplements, the Indian HealthService, or other programs or plans identifiedby the TRICARE Management Activity.
Participate on a ClaimWhen providers participate on a claim, alsoknown as “accepting assignment,” they agreeto file the claim for the patient, to acceptpayment directly from TRICARE and toaccept the amount of the TRICAREallowable charge, less any applicable patientcopayment paid by you, as payment in fullfor their services.
Participating Non-network ProviderParticipating providers have agreed to fileclaims for you, to accept payment directlyfrom TRICARE, and to accept theTRICARE allowable charge, less applicablecost�shares paid by you as payment in fullfor their services. Providers may participateon a claim�by�claim basis.
Point of Service (POS) OptionThe POS option allows you to receive non�emergency care from any TRICARE�authorized provider without requesting areferral from your PCM. However, POS hashigher out�of�pocket costs for care.
Prime Service AreaA geographic area where TRICARE Primebenefits are offered. Regional contractors arerequired to establish a TRICARE Primenetwork in TRICARE Prime Service areas.
Prior AuthorizationA review determination made by a licensedprofessional nurse or paraprofessional forrequested services, procedures or admissions.Prior authorizations must be obtained priorto services being rendered or within 24 hours of an admission. Visit your regionalcontractor’s Web site or call them for a listof services requiring prior authorization.
Regional ContractorA TRICARE civilian partner who provideshealth care services and support in theTRICARE regions (Health Net FederalServices, Inc.; Humana Military HealthcareServices, Inc.; and TriWest HealthcareAlliance).
Transitional Assistance ManagementProgram (TAMP)Transitional health care for certainuniformed services members (and eligiblefamily members) who separate from activeduty.
TRICARE Allowable ChargeThe maximum amount TRICARE will payfor services.
TRICARE-authorized Provider A provider who meets TRICARE’s licensingand certification requirements and has beencertified by TRICARE to provide care toTRICARE beneficiaries. If you see aprovider who is not TRICARE�authorizedand can never be certified, you areresponsible for the full cost of care.TRICARE�authorized providers includedoctors, hospitals, ancillary providers (suchas laboratory and radiology providers), and pharmacies. There are two types ofauthorized providers: network and non�network.
TRICARE SupplementA health plan you may purchase specificallyto supplement your TRICARE Primecoverage. It will pay second after TRICARE.A TRICARE supplement is not employer�sponsored health insurance.
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Sample Explanation of BenefitStatements
The following pages list figures and referencedetails for each regional contractor’s explanationof benefits (EOB) statements.
• North Region: Figure 9.1
• South Region: Figure 9.2
• West Region: Figure 9.3
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North Region Explanation of Benefits Statement Sample Figure 9.1
WWW.HEALTHNETFEDERALSERVICES.COM
(1-877-874-2273)
2 - GREAT NEWS! PGBA IS MAKING TRICARE EASIER. YOU CAN NOW VIEW THE STATUS OF YOUR CLAIMS AT WWW.MYTRICARE.COM FOR MORE INFORMATION VISIT OUR WEB SITE TODAY. 3 - PLEASE ALLOW UP TO 30 DAYS FOR YOUR CLAIMS TO PROCESS.4 - $51.00 HAS BEEN APPLIED TOWARD THE CATASTROPHIC CAP OF $1000.00.5 - AMOUNT ALLOWED IS BASED ON A DISCOUNT AGREEMENT.
1, 2, 3, 4, 5
TRICARE NORTH REGION CLAIMS
December 30, 2005
12/14/2005 75.00 50.61
75.00 50.61
50.61
50.6175.00
2005
51.00
24.39
How to Read Your TRICARE EOB forthe North Region
1. PGBA, LLC—PGBA processes allTRICARE claims for the region where youlive.
2. Regional Contractor—The name “HealthNet Federal Services” and the Health Netlogo will appear here.
3. Date of Notice—PGBA prepared yourTRICARE EOB on this date.
4. Sponsor SSN/Sponsor Name—We processyour claim using the Social Security numberof the military service member (active duty,retired, or deceased) who is your TRICAREsponsor.
5. Beneficiary Name—The patient whoreceived medical care and for whom thisclaim was filed.
6. Mail�to Name and Address—We mail theTRICARE EOB directly to the patient (orpatient’s parent or guardian) at the addressgiven on the claim. (Note: Be sure yourdoctor has updated your records with yourcurrent address.)
7. Benefits Were Payable To—This field willappear only if your doctor acceptsassignment. This means the doctor acceptsthe TRICARE maximum allowable charge aspayment in full for the services you received.
8. Claim Number—We assign each claim aunique number. This helps us keep track ofthe claim as it is processed. It also helps usfind the claim quickly whenever you call orwrite us with questions or concerns.
9. Service Provided By/Date of Services—This section lists who provided your medicalcare, the number of services and theprocedure codes, as well as the date youreceived the care.
10. Services Provided—This section describesthe medical services you received and howmany services are itemized on your claim. It also lists the specific procedure codes thatdoctors, hospitals, and labs use to identify the specific medical services you received.
11. Amount Billed—Your doctor, hospital, orlab charged this fee for the medical servicesyou received.
12. TRICARE Approved—This is the amountTRICARE approves for the services youreceived.
13. See Remarks—If you see a code or anumber here, look at the Remarks section(18) for more information about your claim.
14. Claim Summary—Here we give you adetailed explanation of the action we took onyour claim. You will find the following totals:amount billed, amount approved byTRICARE, non�covered amount, amount (if any) that you have already paid to theprovider, amount your primary healthinsurance paid (if TRICARE is yoursecondary insurance), benefits we have paidto the provider, benefits we have paid to thebeneficiary. A Check Number will appearhere only if a check accompanies your EOB.
15. Beneficiary Liability Summary—You maybe responsible for a portion of the fee yourdoctor has charged. If so, you’ll see thatamount itemized here. It will include anycharges that we have applied to your annualdeductible and any cost�share or copaymentyou must pay.
16. Patient Responsibility—The total amountyou owe for this claim.
17. Benefit Period Summary—This sectionshows how much of the individual andfamily annual deductible and maximum out�of�pocket expense you have met to date. Wecalculate your annual deductible andmaximum out�of�pocket expense by fiscalyear. See the Fiscal Year Beginning date inthis section for the first date of the fiscalyear.
18. Remarks—Explanations of the codes ornumbers listed in See Remarks will appearhere.
19. Toll�Free Telephone Number—Questionsabout your TRICARE explanation ofbenefits? Please call PGBA toll�free at 1�877�TRICARE (1�877�874�2273). Ourprofessional customer service representativeswill gladly assist you.
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South Region Explanation of Benefits Statement Sample Figure 9.2
How to Read Your TRICARE EOB forthe South Region
1. PGBA, LLC—PGBA processes allTRICARE claims for the region where youlive.
2. Regional Contractor—The name “HumanaMilitary” and the Humana Military logo willappear here.
3. Date of Notice—PGBA prepared yourTRICARE EOB on this date.
4. Sponsor SSN/Sponsor Name—We processyour claim using the Social Security number(SSN) of the military service member (activeduty, retired, or deceased) who is yourTRICARE sponsor. For security reasons,only the last four digits of your sponsor’sSSN will appear on the EOB.
5. Beneficiary Name—The patient whoreceived medical care and for whom thisclaim was filed.
6. Mail�to Name and Address—We mail theEOB directly to the patient (or patient’sparent or guardian) at the address given onthe claim. (Note: Be sure your doctor hasupdated your records with your currentaddress.)
7. Benefits Were Payable To—This field willappear only if your doctor acceptsassignment. This means the doctor acceptsthe TRICARE allowable charge as paymentin full for the services you received.
8. Claim Number—We assign each claim aunique number. This helps us keep track ofthe claim as it is processed. It also helps usfind the claim quickly whenever you call orwrite us with questions or concerns.
9. Service Provided By/Date of Services—This section lists who provided your medicalcare, the number of services, and theprocedure codes, as well as the date youreceived the care.
10. Services Provided—This section describesthe medical services you received and howmany services are itemized on your claim. Italso lists the specific procedure codes thatdoctors, hospitals, and labs use to identify the specific medical services you received.
11. Amount Billed—Your doctor, hospital, orlab charged this fee for the medical servicesyou received.
12. TRICARE Approved—This is the amountTRICARE approves for the services youreceived.
13. See Remarks—If you see a code or anumber here, look at the Remarks section(17) for more information about your claim.
14. Claim Summary—Here we give you adetailed explanation of the action we took on your claim. You will find the followingtotals: amount billed, amount approved byTRICARE, non�covered amount, amount that you have already paid to the provider (ifany), amount your primary health insurancepaid (if TRICARE is your secondaryinsurance), benefits we have paid to theprovider, and benefits we have paid to thebeneficiary. A check number will appear hereonly if a check accompanies your EOB.
15. Beneficiary Liability Summary—You maybe responsible for a portion of the fee yourdoctor has charged. If so, you’ll see thatamount itemized here. It will include anycharges that we have applied to your annualdeductible and any cost�share or copaymentyou must pay.
16. Benefit Period Summary—This sectionshows how much of the individual and family annual deductible and maximum out�of�pocket expense you have met to date.We calculate your annual deductible andmaximum out�of�pocket expense by fiscalyear. See the Fiscal Year Beginning date inthis section for the first date of the fiscalyear.
17. Remarks—Explanations of the codes ornumbers listed in the “See Remarks” sectionwill appear here.
18. Toll�Free Telephone Number—If you havequestions about your TRICARE explanationof benefits, please call PGBA at this toll�freenumber. Our professional customer servicerepresentatives will gladly assist you.
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West Region Explanation of Benefits Statement Sample Figure 9.3
How to Read Your TRICARE EOB forthe West Region
1. Mail�to Name and Address—We mail theTRICARE EOB directly to the patient (orpatient’s parent or guardian) at the addressgiven on the claim. Note: Be sure yourdoctor has updated your records with yourcurrent address.
2. Date of Notice—The date we prepared yourTRICARE EOB.
3. Sponsor SSN/Sponsor Name—We processyour claim using the Social Security numberof the military service member (active duty,retired, or deceased) who is your TRICAREsponsor.
4. Patient Name—The patient who receivedmedical care and for whom this claim wasfiled.
5. Claim Number—We assign each claim aunique number. This helps us keep track ofthe claim as it is processed. It also helps usfind the claim quickly whenever you call orwrite us with questions or concerns.
6. Check Number—A Check Number willappear here only if a check accompaniesyour EOB.
7. Toll�Free Number/Web Address—How youcan reach us (TriWest) if you have questions.
8. Service Provided By—Who provided yourmedical care, the number and type ofservices and the procedure codes
9. Date of Services—The date you received thecare.
10. Amount Billed—Your doctor, hospital, orlab charged this fee for the medical servicesyou received.
11. TRICARE Allowed—This is the amountTRICARE approves for the services youreceived.
12. Remarks—If you see a code or a numberhere, look at the Remark Codes section (16)for more information about your claim.
13. Claim Summary—Here we give you adetailed explanation of the action we took onyour claim. You will find the following totals:amount billed, amount approved byTRICARE, non�covered amount, amount (ifany) that you have already paid to theprovider, amount your primary healthinsurance paid (if TRICARE is yoursecondary insurance), benefits we have paid
to the provider, benefits we have paid to thebeneficiary.
14. Beneficiary Share—You may be responsiblefor a portion of the fee your doctor hascharged. If so, you’ll see that amountitemized here. It will include any charges that we have applied to your annualdeductible and any cost�share or copaymentyou must pay.
15. Out of Pocket Expense—This section shows how much of the individual and family annual deductible and maximum out�of�pocket expense you have met to date.We calculate your annual deductible andmaximum out�of�pocket expense by fiscalyear. See the Fiscal Year Beginning date inthis section for the first date of the fiscalyear.
16. Remark Codes—Explanations of the codesor numbers listed in Remarks (12) willappear here.
17. Paid To—The name of the provider orfacility who the claim was paid to.
18. Regional Contractor— The name “TriWestHealthcare Alliance” and the TriWest logowill appear here.
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Figure 1.1 TRICARE Provider Types . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6Figure 2.1 TRO Contact Information for Travel Reimbursement . . . . . . . . . . . . . . . . . . . .12Figure 3.1 Outpatient Services: Coverage Details . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14Figure 3.2 Inpatient Services: Coverage Details . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15Figure 3.3 Clinical Preventive Services: Coverage Details . . . . . . . . . . . . . . . . . . . . . . . . .15Figure 3.4 Behavioral Health Care Services: Coverage Details . . . . . . . . . . . . . . . . . . . . .17Figure 3.5 Services or Procedures with Significant Limitations . . . . . . . . . . . . . . . . . . . . .22Figure 4.1 Regional Claims Processing Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26Figure 5.1 Enrollment Deadlines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29Figure 5.2 Eligibility Requirements for Former Spouses . . . . . . . . . . . . . . . . . . . . . . . . . .31Figure 5.3 TGRO Call Center Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32Figure 5.4 TAO Contact Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33Figure 6.1 TRICARE Appeal Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38Figure 6.2 Regional Appeals Filing Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39Figure 6.3 Regional Grievance Filing Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40Figure 6.4 Regional Fraud and Abuse Reporting Information . . . . . . . . . . . . . . . . . . . . . . .41Figure 9.1 North Region Explanation of Benefits Statement Sample . . . . . . . . . . . . . . . . .46Figure 9.2 South Region Explanation of Benefits Statement Sample . . . . . . . . . . . . . . . . .48Figure 9.3 West Region Explanation of Benefits Statement Sample . . . . . . . . . . . . . . . . . .50
52
List of Figures
AAbortion, 22Accident, 14, 16, 28Active duty family member, 3, 8, 15, 21, 23, 32Active duty service member, 3, 7�8, 11�14, 16,
21�22, 24, 27, 32, 34, 36 Acupuncture, 23Adjunctive dental care, 22Adopting, 21, 30Allergy tests, 14Allowable charges, 6, 38, 43�44, 47, 49Ambulance services, 6, 14, 25Ancillary services, 14Anesthesia, 15Annual deductible, 47, 49, 51Appeal, 28, 38�39, 52Artificial insemination, 23Autopsy, 23
B
Baby, 30Behavioral health care, 11, 13, 16�19, 22, 40, 52Beneficiary Counseling and Assistance
Coordinators (BCAC), 35, 38, 42�43Birth control, 23Birth defect, 22Blood products, 15Blood pressure screening, 16Brace, 24Brand�name medications, 20Breast cancer, 15Breastfeeding, 24
C
Camps, 23Cancer screening, 15�16, 25Cardiac rehabilitation, 22Catastrophic cap, 36, 43, 46Certificate of Creditable Coverage, 9, 37Claims, 6, 20, 24, 26�28, 34, 38�39, 41,
43�44, 46�47Clinical preventive services, 11, 15�16, 24�25, 52Collection problem(s), 28College, 30�32, 36Colorectal cancer, 15Common Access Card (CAC), 8, 19, 33, 42Contact lenses, 22Contingency operation, 35
Continued Health Care Benefit Program(CHCBP), 21, 35, 42�43
Copayment, 19�20, 44, 47, 49, 51Cosmetic surgery, 22Cost�share(s), 6, 21, 26, 35�36, 43�44, 47, 49, 51Couples counseling, 23Couples therapy, 23Covered services, 2, 14�15, 17, 19, 21, 23,
25�26, 36, 43Custodial parent, 30, 38
D
Debt Collection Assistance Officers (DCAO), 28,42�43
Debt collection, 28Defense Enrollment Eligibility Reporting System
(DEERS), 3, 8�9, 29�32, 34�37, 42�43Defense Manpower Data Center Support Office
(DSO), 37, 42Delta Dental Plan of California, 21Denial, 27, 38�39, 43Dental care, 21�22, 32Detoxification, 17, 19Diabetes, 22�24, 42Disability, 24, 30�31, 36Divorce, 30�31, 36�37Drug abuse, 19Durable medical equipment (DME), 14, 42Dyslexia, 24
E
Eligibility, 8�9, 30�31, 34�38, 43, 52Emergency, 6, 10�11, 13�14, 17, 19, 32�33, 38Emergency care, 10�11, 13, 33End�stage renal disease, 22, 36Enrollment, 8, 29�32, 34�36, 52Examination, 15�16, 23�24Exclusions, 14�15, 17, 19, 21, 23, 25Explanation of benefits (EOB), 28, 38, 41�43,
45, 47, 49, 51Express Scripts, Inc. (ESI), 19�20, 27, 33�34,
41�42Eye examination, 14Eyeglasses, 22
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F
Family members, 3, 8, 14�15, 21, 23, 32,34�37, 43�44
Fiscal year, 11, 16�19, 43, 47, 49, 51Food, 22Foot care, 24Former spouses, 26, 30�32Fraud and abuse, 41
G
Gastric bypass, 23Generic drug use policy, 20Generic equivalent, 20Generic medication, 20Genetic testing, 15, 23Grievance, 39�40
H
Hearing Aids, 23, 36Hepatitis B screening, 15Home health services, 13�14Hospice care, 13Hospital, 6, 14�15, 19, 23�24, 30, 43�44,
47, 49, 51Hospitalization, 15, 17Human immunodeficiency virus (HIV), 15
I
Immunizations, 15�16, 24Indian Health Service, 27, 44Infant, 14, 24Infantile glaucoma, 22Inpatient admissions, 11, 13, 17Inpatient psychotherapy, 18Inpatient services, 15Intelligence testing, 23
K
Keratoconus, 22
L
Laboratory services, 14LASIK, 23Learning disability, 24Licensed professional counselors, 16Limitations, 11, 13�15, 17�19, 21�25Lockout provision, 8
M
Mammograms, 16Marital therapy, 23Marriage, 16, 29�30
Mastectomy, 22Maternity care, 13, 21Maternity services, 21Maternity ultrasounds, 21Medicabs, 14Medicaid, 27, 44Medical documentation, 22Medical necessity, 18, 20�21Medicare, 8, 15, 25, 36Medicare Part A, 8Medicare Part B, 8, 36Medications, 15, 17, 19, 20, 24Medication management, 17Megavitamins, 24Military ID card, 8Military treatment facility, 1�2, 6�7, 11�12, 19,
22, 26, 28, 32�34, 38, 42�43Mind expansion, 24Molding helmet, 22Moving, 34
N
National Guard and Reserve, 3, 8, 21, 43Naturopaths, 24Network pharmacies, 20, 33�34, 43Network provider, 1, 6�8, 11, 13, 16, 38, 43, 44Newborn, 2, 13, 21, 24, 30Nonemergency, 13, 17Non�formulary drugs, 20Non�network pharmacies, 20, 27, 34Non�network provider, 6�7, 11, 16, 27, 38, 43�44Nonparticipating provider, 6, 43Nonsynostic positional plagiocephaly, 22
O
Obesity, 23�24Occupational therapy, 14Orthomolecular psychiatric therapy, 24Orthopedic shoes, 24Osteopathic manipulation, 14Other health insurance, 13, 20, 27, 44Out�of�pocket costs, 11, 27, 44Outpatient behavioral health care, 13Outpatient care, 19Outpatient psychotherapy, 18Outpatient services, 14�15
P
Pap smear, 15�16Parenteral, 22Partial hospitalization, 17Participating provider, 6, 38, 44
54
Pastoral counselor, 16Pharmacy, 19�21, 27, 33�34, 41Physical therapy, 14Plastic surgery, 22Point of Service option, 6, 11, 13, 27, 33,
38, 43�44Postpartum, 21, 24Pregnancy, 15, 21�23Prenatal, 21Prescriptions, 3, 19�20, 27, 33�34Primary care manager (PCM), 1�2, 7�8, 10�14,
16, 30�34, 38Prime service area. 7, 34, 44Prior authorization, 11�13, 16�20, 39, 44Privacy, 30Prostate cancer, 15Prosthetic, 15Psychiatric treatment, 24Psychiatrist, 16, 18Psychoanalysis, 18Psychogenic, 25Psychological testing, 17Psychologist, 16, 18Psychotherapy, 17�18, 24Pulmonary rehabilitation, 22
Q
Quantity limits, 20
R
Radiology, 6, 14�15, 44Reconsideration, 38�39Reconstructive surgery, 22Referral, 2, 7, 11�13, 16�17, 44Refractive corneal surgery, 23Regions, 2, 13, 32, 44Regional contractor, 2�3, 6�8, 10�14, 16�19,
21�23, 26�27, 29�36, 38�41, 43�45, 47, 49, 51Rehabilitation, 14, 17�19, 22Reimbursement, 6, 10, 12, 19�20, 22, 27, 33, 34Residential Treatment Center (RTC), 18Retired service member, 7, 21, 30, 34, 35Retiring from active duty, 35Routine care, 11, 32Rubella, 16
S
School physicals, 16Sexual dysfunction, 24Sexual inadequacy treatment, 25Shoe inserts, 24
Skilled nursing facility, 14�15Social Security Number (SSN), 26, 30, 39, 47,
49, 51Sore throat, 11Specialist, 10�11, 13�14, 16, 38, 40Specialty care, 7, 10�12, 33Speech therapy, 15Split enrollment, 30�32Sponsor, 8, 15, 24, 26, 29�32, 34�37, 39�40, 43,
47, 49, 51Sprain, 11Stem cell, 13Stress management, 24Substance abuse, 16Substance use disorder, 13, 17, 19Suicide risk assessment, 16Supplements, 22, 27, 44Surgical care, 14Survivors, 34
T
Tetanus, 15Third�party liability, 28Transitional Assistance Management Program
(TAMP), 35Transplant, 13, 23Traveling, 12, 26, 32�34TRICARE allowable charge, 6, 38, 43�44, 49TRICARE Area Office (TAO), 33TRICARE�authorized provider, 6TRICARE costs, 41TRICARE Dental Program, 21TRICARE Europe, 32�33TRICARE Extra, 9, 29�32, 34�36TRICARE For Life, 8, 36TRICARE formulary search tool, 20TRICARE Latin America and Canada (TLAC), 32TRICARE Mail Order Pharmacy, 19, 33TRICARE Management Activity (TMA), 27, 44TRICARE Pacific, 32�33TRICARE Prime, 1�3, 7�10, 12�14, 16, 21,
29, 30�36, 44TRICARE Prime Remote, 34TRICARE Regional Office (TRO), 12, 28, 43TRICARE Retail Pharmacy (TRRx), 20TRICARE Retiree Dental Program (TRDP), 21TRICARE Service Center (TSC), 2TRICARE Standard, 9, 29�32, 34�36Tuberculosis, 15�16
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Ultrasound, 14, 21Uniformed services, 3, 6, 19, 33, 43�44Uniformed services identification (ID) card,
29�30, 35United Concordia Companies, Inc., 21Urgent care, 10�11, 32�33
V
Vaccines, 15Vitamins, 22
W
Weight reduction, 23Well�child services, 16
X
X�ray services, 15, 25
56
Please provide feedback on this handbook athttp://www.tricare.mil/evaluations/feedback.
As a patient in the military health system,you have the right to:
• Receive accurate, easy-to-understand information tohelp you make informed decisions about TRICAREprograms, medical professionals, and facilities.
• Have a choice of health care providers that is sufficientto ensure access to appropriate high-quality health care.
• Access emergency health care services when andwhere the need arises.
• Receive and review information about diagnosis,treatment, and the progress of your condition, and to fully participate in all decisions related to yourhealth care or to be represented by family members,conservators, or other duly appointed representatives.
• Receive considerate, respectful care from all membersof the health care system without discriminationbased on race, ethnicity, national origin, religion, sex,age, mental or physical disability, sexual orientation,genetic information, or source of payment.
• Communicate with health care providers in confidenceand to have the confidentiality of your health careinformation protected.You also have the right to review,copy, and request amendments to your medical records.
• Have a fair and efficient process for resolving differenceswith your health plan, health care providers, and the institutions that serve them.
For more information about your rights, visit www.tricare.mil/Patientrights/default.cfm.
As a patient in the military health system,you have the responsibility to:
• Maximize healthy habits, such as exercising, not smoking, and maintaining a healthy diet.
• Be involved in health care decisions, which meansworking with providers in developing and carrying out agreed-upon treatment plans, disclosing relevantinformation, and clearly communicating your wantsand needs.
• Be knowledgeable about TRICARE coverage and program options.
You also have the responsibility to:• Show respect for other patients and health
care workers.• Make a good-faith effort to meet financial obligations.• Use the disputed claims process when there is
a disagreement.• Report wrongdoing and fraud to appropriate
resources or legal authorities.
Patient Bill of Rights and Responsibilities
Printed: October 2006
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www.tricare.mil
TRICARE North RegionHealth Net Federal Services, Inc.www.healthnetfederalservices.com1-877-TRICARE (1-877-874-2273)
TRICARE South RegionHumana Military Healthcare Services, Inc.www.humana-military.com1-800-444-5445
TRICARE West RegionTriWest Healthcare Alliancewww.triwest.com1-888-TRIWEST (1-888-874-9378)
