FALLS CHURCH, Va.– Did you or a family member recently enroll in a TRICARE health plan or change plans? Now is a good time to review how your plan works.
“Knowing what to do before and after you get care is key to making the most of your TRICARE plan,” said Zelly Zim, a senior analyst with TRICARE Policy and Programs at the Defense Health Agency. “Understanding your plan, TRICARE covered services, and costs will help you and your family prepare for your health care needs in the year ahead.”
Here are some key things to do and know before getting care.
Different TRICARE plans have different rules and out-of-pocket costs for getting care, as detailed in the TRICARE Plans Overview Fact Sheet. That’s why it’s important to know which TRICARE plan you’re enrolled in.
If you aren’t sure which plan you have, there are two ways to check. You can log in to the Defense Enrollment Eligibility Reporting System (DEERS) through milConnect or call your regional contractor.
Don’t forget to update DEERS whenever you have a change in your sponsor’s status, get married or divorced, have a baby, move, become eligible for Medicare, or if your sponsor or family member dies. These are Qualifying Life Events (QLEs), which may open a period where you can make changes to your plan.
Remember to keep your contact information (address, email address, and phone number) updated in DEERS and with your regional contractor.
Knowing where you can get care with your plan is one way to avoid unexpected costs.
You may be able to get care at a military hospital or clinic. This depends on your plan, location, and beneficiary category. You have priority at military hospitals and clinics if you’re an active duty service member (ADSM) or you have a TRICARE Prime plan. (This doesn’t include the US Family Health Plan.)
You may also be able to get care from TRICARE-authorized civilian providers. Use the provider directories to search for TRICARE-authorized providers near you. Civilian providers may be either network or non-network:
- Network providers have signed an agreement with a TRICARE contractor to follow TRICARE’s policies and procedures. If you see a network provider, you’ll only pay your in-network copayment or cost-share.
- Non-network providers haven’t signed an agreement with a TRICARE contractor. There are two types of non-network providers: participating and non-participating. Non-participating providers are typically the most expensive provider option.
Your plan determines if you need a referral or pre-authorization to see these providers. ADSMs and other TRICARE Prime beneficiaries need referrals for any care their primary care manager (PCM) does not provide. In these cases, your PCM will refer you to another provider or specialist.
Beneficiaries enrolled in all other TRICARE plans only need referrals or pre-authorizations for certain services.
TRICARE covers care that’s medically necessary and considered proven. This includespreventive careandmental health and substance use disorder care.You can use theTRICARE Covered Servicestool to see if a health service or supply is covered or not.
Your health care costs may include deductibles, copayments, and cost-shares. These costs depend on your plan, your sponsor, where you get care, and the type of care you get.
Knowing your plan’s out-of-pocket costs up front can help you choose providers with lower costs and avoid unexpected costs. If you don’t follow your plan’s rules for getting care, you may end up paying more out-of-pocket.
TRICARE Prime beneficiaries can also use the point-of-service option. This lets you see any TRICARE-authorized provider without a referral. With this option, you’ll pay more out-of-pocket. The point-of-service option doesn’t apply to ADSMs.
To learn more about costs for covered services, use the TRICARE Compare Costs tool or check out the TRICARE Costs and Fees Fact Sheet.
Usually, your provider will file your claims for you. But if you get care while traveling, or from a non-participating provider, you may need to file your own claim.
It’s best to file your claim as soon as possible. File within one year of the date of service if you’re in the U.S. or U.S. territory, or within three years of the date of service if overseas. TRICARE claims processors process most claims within 30 days.
When submitting a claim, keep a copy of all paperwork for your records. If your claim is denied or you need help, contact your regional contractor.
TRICARE is here to support your family’s wellness and help you make the most of your benefits. To learn more about how to get care with your plan, visit Getting Care. If you have questions, call your regional contractor.
Would you like the latest TRICARE news sent to you by email? VisitTRICARE Subscriptions, and create your personalized profile to get benefit updates, news, and more.
FAQs
With TRICARE Select and our premium-based plans, you can get care from any TRICARE-authorized network provider without a referral or pre-authorization, in most situations.
What services are not covered by TRICARE? ›
TRICARE doesn't cover services and supplies:
- from a scientific or medical study, grant or research program.
- provided for free.
- that would be free if you or your sponsor weren't eligible for TRICARE.
With TRICARE Select and our premium-based plans, you can get care from any TRICARE-authorized network provider without a referral or pre-authorization, in most situations.
Is TRICARE worth it? ›
Is TRICARE good health insurance? While there can be occasional issues, generally speaking, TRICARE plans offer generous coverage for treatments, tests, services, and prescriptions with relatively low out-of-pocket costs compared to many civilian health plans.
Does TRICARE cover well visits? ›
TRICARE covers well-child visits from birth through age 5.
Why do doctors not accept TRICARE? ›
The problem stems from the fact that most Tricare managed care support contractors have negotiated physician reimbursem*nt rates that are even lower than those paid by Medicare. Unhappy with their fees, some major health care provider groups have simply dropped out of the system.
What are some disadvantages of TRICARE? ›
Network Limitations
| Network Limitations | Description |
|---|
| Out-of-Network Costs | Potential increase in out-of-pocket expenses for seeing non-network providers |
| Specialized Services | Access to specialized services within the network |
| Out-of-Network Authorization | Process for obtaining approval for out-of-network care |
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TRICARE is the health care program for service members, retirees and their families worldwide. TRICARE provides comprehensive coverage, health plans, special programs, prescriptions and dental plans.
Can I see a non military doctor with TRICARE? ›
If enrolled in TRICARE Prime, you may see a non-network provider only if: You decide to use the point-of-service option, or. It's approved by your regional contractor because no other providers are available.
Does TRICARE cover all medical expenses? ›
TRICARE covers services that are medically necessary. and considered proven. However, there are special rules or limits on certain types of care, while other types of care aren't covered at all.
“For example, if you want a primary care manager to coordinate your care, TRICARE Prime might be right for you. If you would prefer more flexibility when picking specialty providers, consider TRICARE Select.”
How much is TRICARE monthly? ›
Table 5: Calendar Year 2024 TRICARE Premium-Based Health Plans Monthly Premiums
| Premium-based health plan | Member Only | Member and Family |
|---|
| TRICARE Reserve Select | $51.95 | $256.87 |
| TRICARE Retired Reserve | $585.24 | $1,406.22 |
| TRICARE Young Adult Prime | $637.00 | Not applicable |
| TRICARE Young Adult Select | $311.00 | Not applicable |
TRICARE Select is a health plan that has contracts with a network of doctors, hospitals, and other health care professionals to provide services at a lower rate. TRICARE Select is a Preferred Provider Organization (PPO) plan.
What will TRICARE not pay for? ›
In general, TRICARE excludes services and supplies that are not medically or psychologically necessary for the diagnosis or treatment of a covered illness (including mental disorder), injury, or for the diagnosis and treatment of pregnancy or well-child care.
Do I have a copay with TRICARE? ›
When you see a TRICARE-authorized network provider, you'll pay a copayment. If you see a TRICARE-authorized non-network provider, you'll pay a cost-share after you meet your annual deductible.
Does TRICARE cover bloodwork? ›
TRICARE covers laboratory services.
Does TRICARE cover everything? ›
TRICARE covers services that are medically necessary and considered proven. To be medically necessary means it's appropriate, reasonable, and adequate for your condition. To be proven means it's safe and not considered experimental. There are special rules or limits on certain services, and some services are excluded.
Which of the following services are typically not covered by TRICARE Prime? ›
In general, TRICARE excludes services and supplies that are not medically or psychologically necessary for the diagnosis or treatment of a covered illness (including mental disorder), injury, or for the diagnosis and treatment of pregnancy or well-child care.
What does TRICARE for Life actually cover? ›
TFL typically covers your Medicare cost-sharing (deductibles, coinsurances, and copayments). TFL may pay when services are not covered by Medicare or when you have used up your Medicare benefits.
How do I know if something is covered by TRICARE? ›
Visit the Is It Covered page. You can search by keyword or browse by category. For cost information, use the TRICARE Compare Costs Tool.
