Prime

TRICARE Prime and
TRICARE Prime Remote

Handbook
Your guide to program benefits
November 2014
Important Information
TRICARE Web Site:
www.tricare.mil
TRICARE North Region
TRICARE North Region Contractor
The TRICARE North Region includes Connecticut, Delaware, the District

of Columbia, Illinois, Indiana, Iowa (Rock Island Arsenal area only), Kentucky
(excluding the Fort Campbell area), Maine, Maryland, Massachusetts, Michigan,
Missouri (St. Louis area only), New Hampshire, New Jersey, New York,
North Carolina, Ohio, Pennsylvania, Rhode Island, Vermont, Virginia,
West Virginia, and Wisconsin.
Health Net Federal Services, LLC
TRICARE South Region
TRICARE South Region Contractor
The TRICARE South Region includes Alabama, Arkansas, Florida, Georgia,

Kentucky (Fort Campbell area only), Louisiana, Mississippi, Oklahoma, South
Carolina, Tennessee, and Texas (excluding the El Paso area).
Humana Military, a division of

Humana Government Business
www.hnfs.com
1-877-TRICARE (1-877-874-2273)
Humana-Military.com
1-800-444-5445
TRICARE West Region
TRICARE West Region Contractor
The TRICARE West Region includes Alaska, Arizona, California, Colorado,

Hawaii, Idaho, Iowa (excluding the Rock Island Arsenal area), Kansas, Minnesota,
Missouri (excluding the St. Louis area), Montana, Nebraska, Nevada, New Mexico,
North Dakota, Oregon, South Dakota, Texas (the southwestern corner only,
including El Paso), Utah, Washington, and Wyoming.
UnitedHealthcare Military & Veterans
TRICARE Overseas Program*
TRICARE Overseas Program Contractor
www.uhcmilitarywest.com
1-877-988-WEST (1-877-988-9378)
International SOS Government Services, Inc.

www.tricare-overseas.com
TRICARE Eurasia-Africa: 1-877-678-1207
TRICARE Latin America and Canada: 1-877-451-8659
TRICARE Pacific: 1-877-678-1208 (Singapore)
1-877-678-1209 (Sydney)
* For overseas contact information, visit www.tricare-overseas.com.
An Important Note About TRICARE Program Changes

At the time of publication, this information is current. It is important to remember that TRICARE policies and benefits are governed
by public law and federal regulations. Changes to TRICARE programs are continually made as public law and/or federal regulations
are amended. Military hospital and clinic guidelines and policies may be different than those outlined in this publication. For the
most recent information, contact your TRICARE regional contractor or local military hospital or clinic. 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. See the inside back cover of this handbook for TRICARE Expectations for Beneficiaries.
Keep Your DEERS Information Up To Date!

It is essential to keep information in the Defense Enrollment Eligibility Reporting System (DEERS) current for you and your family.
Failure to update DEERS to accurately reflect the sponsors or family members residential address and/or the ineligibility of a former
dependent could be considered fraud and a basis for administrative, disciplinary, and/or other appropriate action.
TRICARE Meets the Minimum Essential Coverage Requirement Under the Affordable Care Act
The Affordable Care Act, also known as the health care reform law, requires that individuals maintain health insurance or other
health coverage that meets the definition of minimum essential coverage. Please note that the TRICARE program is considered
minimum essential coverage. Most people who do not meet this provision of the law will be required to pay a fee for each month
they do not have adequate coverage. The fee will be collected each year with federal tax returns. Watch for future communications
from TRICARE or visit www.tricare.mil/aca for more information about your minimum essential coverage requirement. You can
also find other health care coverage options at www.healthcare.gov.
Important Contact Information

Use this page as a guide for the most important resources available to you.
TRICARE Web site: www.tricare.mil
TRICARE Regional Contractors
TRICARE West Region

1-877-TRICARE (1-877-874-2273)
www.hnfs.com

1-800-444-5445
Humana-Military.com
UnitedHealthcare
Military & Veterans
1-877-988-WEST (1-877-988-9378)
TRICARE Overseas Program1

International SOS Government Services, Inc.
TRICARE Eurasia-Africa: 1-877-678-1207
TRICARE Latin America and Canada: 1-877-451-8659
TRICARE Pacific: 1-877-678-1208 (Singapore)

1-877-678-1209 (Sydney)
TRICARE Overseas Program Web site: www.tricare-overseas.com
1. For overseas contact information, visit www.tricare-overseas.com.
Service Points of Contact

U.S. Army, U.S. Navy, U.S. Air Force, U.S. Marine Corps
Defense Health AgencyGreat Lakes

1-888-647-6676
U.S. Coast Guard
Coast Guard Benefits Line

1-800-942-2422
Commissioned Corps of the U.S. Public Health Service

and National Oceanic and Atmospheric Administration
Medical Affairs Branch

1-800-368-2777
Defense Enrollment Eligibility Reporting System (DEERS)

You have several options for updating and verifying DEERS information:
In Person
Phone
Visit a local uniformed services identification card-issuing

facility. Find a facility near you at www.dmdc.osd.mil/rsl.
Call to verify location and business hours.
1-800-538-9552
1-866-363-2883 (TDD/TTY)
Online
Fax
Visit the milConnect Web site at http://milconnect.dmdc.mil.
1-831-655-8317
Visit www.dmdc.osd.mil/appj/bwe to access the

Beneficiary Web Enrollment Web site.
Mail
Defense Manpower Data Center Support Office
400 Gigling Road
Seaside, CA 93955-6771
TRICARE Dental Options

Visit www.tricare.mil/dental for information on all of TRICAREs dental program options.
Active Duty Dental Program
TRICARE Dental Program
TRICARE Retiree Dental Program
United Concordia Companies, Inc.

www.addp-ucci.com
MetLife
www.metlife.com/tricare
Delta Dental of California

www.trdp.org
Health Care Claims

You can download forms and instructions from your regional contractors Web site or from the TRICARE Web site
at www.tricare.mil/claims. Submit claims to the addresses provided. You can also check the status of your claims at
the Web sites provided. For information about filing claims for care received overseas, visit www.tricare.mil/claims.
TRICARE West Region

c/o PGBA, LLC/TRICARE
P.O. Box 870140
Surfside Beach, SC 29587-9740

Claims Department
P.O. Box 7031
Camden, SC 29021-7031
TRICARE West Region

Claims Department
P.O. Box 7064
Camden, SC 29021-7064
www.myTRICARE.com
www.hnfs.com
www.myTRICARE.com
Humana-Military.com
TRICARE Pharmacy Program

Register for TRICARE Pharmacy Home Delivery, find a TRICARE retail network pharmacy, or find information
on how to save money and make the most of your pharmacy benefit.
Express Scripts, Inc.
www.express-scripts.com/TRICARE
TRICARE Pharmacy Home Delivery
TRICARE Retail Network Pharmacy
1-877-363-1303
1-877-540-6261 (TDD/TTY)
Download the Express Scripts New

Patient Home Delivery Form from
to register for TRICARE Pharmacy
Home Delivery. Mail the form to:
Send pharmacy claims to:
Express Scripts Member

Choice Center (convert retail
prescriptions to home delivery):
1-877-363-1433

TRICARE Claims
P.O. Box 52132
Phoenix, AZ 85082

P.O. Box 52150
Phoenix, AZ 85072-9954
Prescription Drug Formulary Search

www.tricare.mil/pharmacyformulary
Other Resources
TRICARE Forms
www.tricare.mil/forms
Beneficiary Web Enrollment
www.tricare.mil/bwe
US Family Health Plan
www.tricare.mil/usfhp
TRICARE Mental Health
www.tricare.mil/mentalhealth
Continued Health Care Benefit Program
www.tricare.mil/chcbp
Customer Service Community Directory
www.tricare.mil/bcacdcao
TRICARE is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved.
Welcome to TRICARE Prime,

TRICARE Prime Remote, and
TRICARE Prime Remote for
Active Duty Family Members
TRICARE Prime offers enhanced benefits and personalized care. To make the best use of your benefit,
please read this TRICARE Prime and TRICARE Prime Remote Handbook. Look in the mail and on your
regional contractors Web site for the TRICARE Health Matters newsletter, a regular publication for all
TRICARE Prime beneficiaries. This newsletter highlights covered services, customer service options, news,
and other important updates.
Your TRICARE Resources
www.tricare.mil
Visit the TRICARE Web site for more information on any of the topics
covered in this handbook.
www.tricare.mil/smart
The SMART Site is your best resource for TRICARE materials online.
View, print, or download TRICARE brochures, fact sheets, handbooks,
and other materials.
www.tricare.mil/subscriptions
Sign up online to receive TRICARE news and publications via e-mail.
http://milconnect.dmdc.mil
Verify eligibility, update information, and sign up online to receive benefits

correspondence via e-mail instead of postal mail.
Your TRICARE Regional

Contractor
Important Note for National

Guard and Reserve Members
and Their Families
Regional contractors administer the TRICARE

medical benefit in each TRICARE region
(North, South, and West). This handbook refers
regularly to your regional contractor. Visit your
regional contractors Web site for information
about how to change your primary care manager,
how to enroll family members, covered services,
referral and prior authorization requirements, and
other helpful information. You can get assistance
from your regional contractor by calling the
toll-free phone numbers provided on the cover
of this handbook. You may also seek assistance
from Beneficiary Counseling and Assistance
Coordinators (BCACs), who are located at military
hospitals and clinics and at the TRICARE Regional
Offices. Visit the Customer Service Community
Directory at www.tricare.mil/bcacdcao to find
a BCAC near you.
National Guard and Reserve members called

or ordered to active service for more than
30 consecutive days become eligible for
TRICARE as active duty service members,
and their family members become eligible for
TRICARE as active duty family members.
Family members may choose TRICARE Prime,
TRICARE Prime Remote for Active Duty Family
Members, or TRICARE Standard and TRICARE
Extra, depending on the programs available at
your location and your eligibility status. If you
have questions about these programs, contact
your regional contractor. Your service personnel
office determines eligibility for pre-activation
benefits. Contact your unit personnel office
regarding your eligibility. Your activation orders
should contain your unit personnel office address
and contact information.
Table of Contents
1. Eligibility and Enrollment.........................................................................................5
TRICARE Prime......................................................................................................................................5
Enrolling in TRICARE Prime..................................................................................................................5
TRICARE Prime Remote and TRICARE Prime Remote
for Active Duty Family Members.............................................................................................................5
Support for Active Duty Service Members Enrolled in TRICARE Prime Remote.................................8
US Family Health Plan.............................................................................................................................8
Supplemental Health Care Program.........................................................................................................8
2. Getting Started..........................................................................................................9
Your Primary Care Manager....................................................................................................................9
Changing Your Primary Care Manager...................................................................................................9
TRICARE Provider Types......................................................................................................................10
U.S. Department of Veterans Affairs Health Care Facilities.................................................................. 11
TRICARE Prime Annual Enrollment Fees............................................................................................ 11
Social Security Number Reduction........................................................................................................12
3. Getting Care.............................................................................................................13
Making an Appointment.........................................................................................................................13
Emergency Care.....................................................................................................................................13
Nonemergency Care for Active Duty Service Members........................................................................13
Avoid Using the Emergency Room for Nonemergency Conditions........................................................13
Services That Do Not Require Referrals................................................................................................13
Access Standards for Care...................................................................................................................... 14
Waiving Access Standards.....................................................................................................................15
Prior Authorization for Care...................................................................................................................15
Point-of-Service Option..........................................................................................................................15
4. Covered Services.....................................................................................................16
Mental Health Care Services.................................................................................................................. 16
TRICARE Tobacco-Cessation Program................................................................................................ 17
Clinical Preventive Services................................................................................................................... 18
Dental Options........................................................................................................................................22
Hospice Care..........................................................................................................................................23
Maternity Care.......................................................................................................................................23
TRICARE Extended Care Health Option..............................................................................................23
TRICARE Pharmacy Program...............................................................................................................23
5. Claims.......................................................................................................................25
Health Care Claims................................................................................................................................25
Pharmacy Claims...................................................................................................................................26
Proof-of-Payment Requirement Overseas..............................................................................................26
Coordinating Benefits with Other Health Insurance..............................................................................26
Appealing a Claim or Authorization Denial..........................................................................................26
6. Changes to Your TRICARE Coverage......................................................................27
Having a Baby or Adopting a Child.......................................................................................................28
TRICARE Young Adult.........................................................................................................................28
Traveling.................................................................................................................................................28
Moving and Transferring TRICARE Prime Enrollment........................................................................29
Separating from the Service...................................................................................................................30
Retiring from Active Duty...................................................................................................................... 31
Becoming Entitled to Medicare.............................................................................................................. 31
Survivor Coverage..................................................................................................................................32
Dependent Parent Coverage....................................................................................................................32
Disenrollment.........................................................................................................................................33
7. For Information and Assistance.............................................................................34
Beneficiary Counseling and Assistance Coordinators............................................................................34
Debt Collection Assistance Officers.......................................................................................................34
Appeals and Grievances.........................................................................................................................34
Reporting Suspected Fraud and Abuse...................................................................................................34
8. Index.........................................................................................................................35
may enroll by calling the regional contractor,

using the Beneficiary Web Enrollment (BWE)
Web site at www.dmdc.osd.mil/appj/bwe,
or submitting a TRICARE Prime Enrollment,
Disenrollment, and Primary Care Manager
(PCM) Change Form (DD Form 2876) to the
regional contractor. Enrollment is open year-round.
ADSM enrollment requests will be effective
the date the request is received by your regional
contractor. All other enrollment requests received
by your regional contractor by the 20th of the
month become effective at the beginning of
the following month (e.g., a request received
by December 20 becomes effective January 1).
If the request is received after the 20th of the
month, coverage becomes effective on the first
day of the second month following the receipt
of the enrollment request (e.g., an application
received on December 27 becomes effective
February 1). Visit www.tricare.mil/forms to
download DD Form 2876.
Eligibility for TRICARE Prime

For active duty service members (ADSMs) located
in areas where TRICARE Prime is available,
enrollment in TRICARE Prime is mandatory.
Active duty family members (ADFMs) and retirees
and their family members may also enroll in
TRICARE Prime if they live in Prime Service
Areas (PSAs). A PSA is a geographic area where
TRICARE Prime is offered. It is typically an area
near a military hospital or clinic.
Within PSAs, TRICARE Prime is available to:
ADFMs
Transitional survivors
Certain former spouses who have not remarried
Retirees, retiree family members, and survivors
National Guard and Reserve members who
are called or ordered to active service for more
than 30 consecutive days and their eligible
family members
TRICARE Prime Remote and

TRICARE Prime Remote for
Medal of Honor recipients and their families

For more information about these beneficiary
categories, visit www.tricare.mil/eligibility.
TRICARE Prime includes care at military hospitals
and clinics, TRICARE network provider care, and
the US Family Health Plan (USFHP). For more
information about USFHP, see US Family Health
Plan later in this section.
Active Duty Service Members

Eligibility for TRICARE Prime Remote
To be eligible for TRICARE Prime Remote
(TPR), you must be an ADSM* and your DEERS
information must be accurate and current.
Regardless of your status, if your DEERS
information is incorrect or outdated, you may not
be eligible to enroll. Finally, your home and work
ZIP codes must be designated as TPR ZIP codes
to indicate that you live and work more than
50 miles (or approximately a one-hour drive)
from the closest military hospital or clinic.
Note: Enrollment in TRICARE Prime is not

automatic. An enrollment action must be taken
to ensure your Defense Enrollment Eligibility
Reporting System (DEERS) enrollment data
is current and claims are processed correctly.
There are no enrollment fees for ADSMs and their
family members. Retired service members and
their eligible family members, surviving spouses,
eligible former spouses, and others pay TRICARE
Prime enrollment fees.
Visit www.tricare.mil/tprzipcode and type in

your home and work ZIP codes to determine your
eligibility for TPR. You can also contact your
regional contractor.
Enrolling in TRICARE Prime
* ADSMs also include National Guard and Reserve members

who are called or ordered to active service for more than
30 consecutive days.
Eligible beneficiaries must be registered in DEERS

to enroll in TRICARE Prime. Beneficiaries
5
SECTION 1
TRICARE Prime
ELIGIBILITY AND ENROLLMENT
Eligibility and Enrollment
Exceptions to TRICARE Prime Remote

Eligibility Requirements

for Active Duty Family Members
If you live or work within 50 miles of a military

hospital or clinic, you will generally not be eligible
for TPR. You may submit a TPR Determination of
Eligibility Enrollment Request Form if you believe
geographic boundaries cause you to drive more
than one hour to a military hospital or clinic.
The request must be directed through your unit
commander to the TRICARE Regional Office in
your area. Visit www.tricare.mil/tpr to submit
your request online.
If your sponsor lives or works within 50 miles of

a military hospital or clinic, you will generally
not be eligible for TPRADFM. Your sponsor
may submit a TPR Determination of Eligibility
Enrollment Request Form if he or she believes
geographic boundaries cause you to drive more
than one hour to a military hospital or clinic. The
request must be directed through your sponsors
unit commander to the TRICARE Regional Office
in your area. Visit www.tricare.mil/tpr to submit
the request online.

Eligibility for TRICARE Prime Remote for
Enrolling in TRICARE Prime Remote for

To be eligible for TRICARE Prime Remote for

Active Duty Family Members (TPRADFM),
you must reside at your TPR-enrolled sponsors
qualifying TPR location. A TPR-enrolled
sponsor lives and works more than 50 miles
(or approximately a one-hour drive) from the
closest military hospital or clinic. Additionally,
your DEERS information must be accurate and
current. Regardless of sponsor status, if your
DEERS information is incorrect or outdated,
you may not be eligible to enroll in TPRADFM.
Your sponsor can include all eligible family

members on his or her DD Form 2876. The
enrollment application must be completed and
submitted to your regional contractor. Follow the
instructions on the form or contact your regional
contractor for guidance.
Visit www.tricare.mil/forms to download the
form. You can also contact your regional contractor
to enroll by phone. To enroll online, visit the BWE
Web site at www.dmdc.osd.mil/appj/bwe.
Note: The DEERS address information listed for

you and your sponsor is used to determine residency.
If your sponsor is stationed in a remote location and
you live with your sponsor, then you are eligible for
TPRADFM as long as your DEERS information
is accurate.
National Guard and Reserve Members

Eligibility for TRICARE Prime Remote
To be considered an ADSM and eligible for
TRICARE active duty coverage, you must be
a National Guard or Reserve member called
or ordered to active service for more than
30 consecutive days or within 180 days of
mobilization based on early activation orders in
support of a contingency operation. In the case
of early eligibility, the effective date is the later
of either (1) the date of issuance of the delayedeffective-date active duty orders or (2) 180 days
before the date on which the period of active duty
is to begin. Until then, you should coordinate
care with your unit commander. If eligible, your
family members may enroll in TPRADFM during
the early-eligibility period. You cannot enroll
in TPR until you reach your final duty location.
For questions regarding eligibility, contact your
service personnel office.
You remain eligible for TPRADFM as long as

your sponsor is enrolled in TPR and you reside
in the same TPR-qualifying location, or if your
sponsor receives a subsequent unaccompanied
permanent change of assignment and you continue
to reside in the same TPR location. If you choose
not to enroll in TPRADFM, you will receive
care under TRICARE Standard and TRICARE
Extra, with applicable deductibles and cost-shares.
Note: TRICARE Extra is not available overseas.
Visit www.tricare.mil/tprzipcode and type in your
sponsors home and work ZIP codes to determine
your eligibility for TPRADFM. You can also contact
your regional contractor.
6
Sponsors of National Guard and Reserve family

members who are called or ordered to active service
for a period of more than 30 consecutive days are
not required to be eligible for, or be enrolled in,
TPR for their family members to be eligible for
TPRADFM. (Some sponsors may be enrolled at
a small government clinic, troop medical clinic,
or other facility not capable of primary care
management functions that are available only
to ADSMs.)
Visit www.tricare.mil/tprzipcode and type in

your home and work ZIP codes to determine your
eligibility for TPR. You can also contact your
regional contractor.
Your DEERS information must be accurate and

current. Regardless of your sponsors status, if
your DEERS information is incorrect or outdated,
you may not be eligible to enroll.
If you live or work within 50 miles of a military

hospital or clinic, you will generally not be eligible
for TPR. But you may submit a TPR Determination
of Eligibility Enrollment Request Form if you
believe geographic boundaries cause you to drive
more than one hour to a military hospital or clinic.
The request must be directed through your unit
commander to the TRICARE Regional Office in
your area. Visit www.tricare.mil/tpr to submit
your request online.
Once you enroll in TPRADFM, you may remain in

TPRADFM as long as your National Guard and
Reserve sponsor remains on active duty and you
continue to reside at your sponsors TPR-qualifying
address, even if your sponsor receives a subsequent
unaccompanied permanent change of assignment.
However, if you move from the TPRADFM location
where you are enrolled or if your sponsor retires,
you will lose TPRADFM coverage and may be
eligible for other TRICARE programs depending
on your location and sponsors status.
Enrolling in TRICARE Prime Remote

Complete and submit DD Form 2876 to your
regional contractor. Follow the instructions on
the form or contact your regional contractor
for guidance.
Verify your eligibility in DEERS or contact your

regional contractor to determine your eligibility
for TPRADFM.

Enrolling in TRICARE Prime Remote for

National Guard and Reserve

Family Members
Your sponsor can include all eligible family

members on his or her DD Form 2876. To qualify
for TPR, active duty family members must live at
the sponsors TPR-qualifying address with a TPRenrolled sponsor. However, this rule does not apply
to family members of National Guard and Reserve
sponsors called or ordered to active service for a
period of more than 30 consecutive days. As long as
family members live at the sponsors TPR-qualifying
address on the day of the sponsors activation or the
effective date of early eligibility, they are able to
enroll in TPRADFM, regardless of whether or
Eligibility for TRICARE Prime Remote for

You are eligible for TPRADFM if your sponsor is
called or ordered to active service for more than
30 consecutive days and you reside at your sponsors
TPR-qualifying residence address on the day of the
sponsors activation or the effective date of early
eligibility. You are considered an ADFM when your
sponsor is on active duty orders. Additionally,
family members of National Guard and Reserve
members who are issued delayed-effective-date
7
SECTION 1
active duty orders for more than 30 consecutive

days in support of a contingency operation may
be TRICARE-eligible.
Your DEERS information must be accurate and

current regardless of your status. If your DEERS
information is incorrect or outdated, you may not
be eligible to enroll. While on orders, you must live
and work more than 50 miles (or approximately a
one-hour drive) from the closest military hospital
or clinic.
US Family Health Plan
not their sponsor is enrolled in TPR. Follow the

instructions on DD Form 2876 or contact your
regional contractor for guidance.
USFHP is a TRICARE Prime option. Care is

provided through networks of community-based,
not-for-profit health care systems in six areas of
the United States. Eligible beneficiaries must
be registered in DEERS and live within one of
the designated USFHP service areas to enroll.
For more information on USFHP, visit
www.usfhp.com.

Support for Active Duty Service

Members Enrolled in TRICARE
Prime Remote
USFHP is available to ADFMs and retirees

and their family members until becoming
entitled to Medicare at age 65. Beneficiaries
age 65 and older who were enrolled in USFHP on
September 30, 2012, may continue their USFHP
enrollment. Beneficiaries under age 65 who become
Medicare Part A-eligible may participate in USFHP.
Contact a Beneficiary Counseling and Assistance
Coordinator (BCAC) for more information
regarding USFHP eligibility. To find a BCAC
near you, visit the Customer Service Community
Directory at www.tricare.mil/bcacdcao.
The Defense Health AgencyGreat Lakes

(DHA-GL) (formerly known as the Military
Medical Support Office) is available to coordinate
civilian health care for TPR-enrolled ADSMs
of the uniformed services. The Medical Affairs
Branch of the Office of Commissioned Corps
Support Services is available to assist members of
the Commissioned Corps of the U.S. Public Health
Service and National Oceanic and Atmospheric
Administration. U.S. Coast Guard personnel
should call the Coast Guard Benefits Line.
Supplemental Health
Care Program
DHA-GL reviews requests for specialty and

inpatient care to determine how it might affect
your fitness for duty and determines if you should
receive care at a military hospital or clinic or
from a civilian provider. DHA-GL makes these
determinations based on clinical standards and
current service-specific guidelines and will ensure
medical care related to your fitness for duty is
covered. If DHA-GL determines there is no impact
on fitness for duty, they will authorize civilian care.
If it is determined that there are fitness for duty
implications, they will redirect your care to a
military hospital or clinic.
The Supplemental Health Care Program (SHCP)

is a program for eligible uniformed service members
and certain others who need medical care that is
not available at a military hospital or clinic. The
SHCP allows this care to be purchased from civilian
providers under TRICARE payment rules when
approved by DHA-GL, a military hospital or clinic
commander, or the director, Defense Health Agency,
as required.
Support for Active Duty Service Members Enrolled in TRICARE Prime Remote
Service Branch
Contact Information
U.S. Army, U.S. Navy, U.S. Air Force, and

U.S. Marine Corps
Defense Health AgencyGreat Lakes

1-888-647-6676
U.S. Coast Guard
Coast Guard Benefits Line

1-800-942-2422
Commissioned Corps of the U.S. Public Health

Service and National Oceanic and Atmospheric
Administration
Medical Affairs Branch

1-800-368-2777
On-Call Providers
PCMs are required to provide services 24 hours a
day, 7 days a week. To cover all hours, your PCM
may designate an on-call provider who will act on
his or her behalf to support your health care needs.
Therefore, the information, instructions, care, or
care coordination you receive from the on-call
provider should be treated as if it were coming
from your PCM.
Whether enrolled in TRICARE Prime, TPR,

or TPRADFM, your PCM will provide all of
your routine (primary) care and most authorized
urgent care, and will refer you for specialty care
services. If you do not have an assigned network
PCM, you or your primary care provider must
coordinate specialty care referrals with your
regional contractor. If you have any questions
about your PCM assignment, contact your
regional contractor for assistance.
Changing Your Primary

Care Manager
You may change your PCM at any time. PCM
changes are subject to military hospital and clinic
guidelines. If you are changing your PCM because
you are moving, see Moving and Transferring
TRICARE Prime Enrollment in the Changes
to Your TRICARE Coverage section of this
handbook for more information.
You are encouraged to make initial contact with

your new PCM within 30 days to establish yourself
as a new patient. Maintaining an open and active
relationship with your PCM allows you to work
together to meet your health care needs.
SECTION 2
When enrolled in TRICARE Prime Remote (TPR)

or TRICARE Prime Remote for Active Duty
Family Members (TPRADFM), your PCM will
either be a civilian TRICARE network provider or,
if a network provider is not available, you will not
have a PCM and must use a TRICARE-authorized
provider for primary care services.
GETTING STARTED
When enrolled in TRICARE Prime, your primary

care manager (PCM) may be: (1) at a military
hospital or clinic, (2) a civilian TRICARE network
provider within a TRICARE Prime Service Area
(PSA), or (3) a primary care physician in the
US Family Health Plan. Your assigned PCM may
be an individual or a site such as a practice or clinic.
A PSA is a geographic area where TRICARE Prime
is offered. It is typically an area near a military
hospital or clinic. TRICARE Prime beneficiaries
who live within a one-hour drive of a military
hospital or clinic may be required to first seek
specialty care, ancillary services (e.g., services from
laboratories and radiology centers), and physical
therapy at the military hospital or clinic. Your PCM
and/or specialty care provider should coordinate
any required referrals and/or prior authorizations
with the regional contractor. This includes services
that may need to be provided at a military hospital
or clinic.
SECTION 1
Your Primary Care Manager
Getting Started
TRICARE Provider Types

TRICARE defines a provider as a person, organization, or institution that provides health care.
For example, doctors, hospitals, or ambulance companies are providers. Providers must be authorized
under TRICARE regulations and have their status certified by the regional contractors to provide services
to TRICARE beneficiaries.
Military Hospitals and Clinics
Military hospitals and clinics provide medical and/or dental care to eligible individuals including
members of the uniformed services and their eligible family members. Military hospitals and clinics
are usually located on or near military installations. To locate a military hospital or clinic near you,
visit www.tricare.mil/mtf.
TRICARE Provider Types
TRICARE-Authorized Providers
TRICARE-authorized providers meet TRICARE licensing and certification requirements and are certified by
TRICARE to provide care to TRICARE beneficiaries. TRICARE-authorized providers may include doctors,
hospitals, ancillary providers (e.g., laboratories, radiology centers), and pharmacies that meet TRICARE
requirements. If you see a provider that is not TRICARE-authorized, you are responsible for the full cost of care.
To find a list of TRICARE-authorized providers, visit www.tricare.mil/findaprovider.
There are two types of TRICARE-authorized providers: network and non-network.
Network Providers
Non-Network Providers
Regional contractors have

established networks and you
may be assigned a primary care
manager (PCM) who is part of
the TRICARE network.
Non-network providers do not have a signed agreement with your

regional contractor and are considered out of network. In most cases,
you will not receive care from non-network providers unless authorized
by your regional contractor. You may seek care from a non-network
provider in an emergency or if you are using the point-of-service (POS)
option (using the POS option results in higher out-of-pocket costs).
When specialty care is needed,

your best option is for your
PCM to coordinate care with
a network provider.
TRICARE network providers:
There are two types of non-network providers: participating and

nonparticipating.
Participating
Have a signed agreement with

your regional contractor to
provide care
Using a participating provider is

your best option if you are seeing
a non-network provider.
Agree to file claims for you
Participating providers:
May choose to participate on a
claim-by-claim basis
Have agreed to accept payment
directly from TRICARE and
accept the TRICARE-allowable
charge (less any applicable
patient costs paid by you) as
payment in full for their services
Nonparticipating
If you visit a nonparticipating
provider, you may have to pay
the provider first and later file
a claim with TRICARE for
reimbursement.
Nonparticipating providers:
Have not agreed to accept the
TRICARE-allowable charge or
file your claims
Have the legal right to charge
you up to 15 percent above the
TRICARE-allowable charge for
services (You are responsible for
paying this amount in addition
to any applicable patient costs.)1
1. Overseas, there may be no limit to the amount that nonparticipating non-network providers may bill, and you may be
responsible for paying any amount that exceeds the TRICARE-allowable charge. Visit www.tricare.mil/overseas for
more information.
10
U.S. Department of Veterans

Affairs Health Care Facilities
Each VA facility has established a TRICARE

beneficiary point of contact and check-in process.
It is important to indicate, prior to receiving care,
that you are using your TRICARE benefit. Failure to
do so could result in higher out-of-pocket expenses
and/or denial of payment for services rendered.
former spouses, and others enrolled in TRICARE

Prime are required to pay an annual enrollment
fee, which is applied to the catastrophic cap. The
catastrophic cap is the maximum out-of-pocket
amount a beneficiary pays each fiscal year (FY)
(October 1September 30) for TRICARE-covered
services. TRICARE Prime enrollment fees are
subject to change each FY. Surviving beneficiaries
and medically retired uniformed service members
and their dependents will have their TRICARE
Prime enrollment fees frozen at the rate in effect
at the time they become survivors or medically
TRICARE Prime Annual

Enrollment Fees
There are no enrollment fees for ADSMs and active
duty family members enrolled in TRICARE Prime,
TPR, or TPRADFM. Retired service members and
their eligible family members, survivors, eligible
TRICARE Prime Enrollment Fee Payment Options
Payment Options1
Payment Instructions
Automated Deduction
from Retirement Pay
Complete an Enrollment Fee Allotment Authorization, available from your

regional contractor. You can also contact your regional contractor by phone to
establish an allotment. Once authorized, your TRICARE Prime enrollment fee is
deducted automatically from your retirement pay on a monthly basis. An initial
three-month payment is required to allow time for the allotment to be established.
Electronic Funds
Transfer (EFT)
To allow time for the EFT to be established, provide your correct banking
information to your regional contractor. Once authorized, your TRICARE Prime
enrollment fee is deducted automatically from your bank account on a monthly
basis. An initial three-month payment is required to allow time for the EFT to
be established.
Visa, MasterCard,
or Discover
(where available)2
Your initial and recurring monthly payment will be charged to your credit/debit card.
Initial payments can be made through TRICAREs Beneficiary Web Enrollment
1. TRICARE has a limited refund policy. In most cases, TRICARE Prime enrollment fees will not be refunded. If you are close
to age 65 and nearing eligibility for TRICARE For Life, you should not choose the annual payment option.
2. Debit/credit card on file must be active (not expired) for payment to process successfully.
11
SECTION 2
GETTING STARTED
All U.S. Department of Veterans Affairs (VA)

health care facilities have signed agreements with
the regional contractors to become TRICARE
network providers, agree to accept a negotiated
rate as the full fee for services, file claims, and
handle paperwork for you. While VA facilities may
or may not provide primary care, many provide
specialty care. If you need care and a participating
VA health care facility near you can provide that
care (within TRICARE access standards), you may
be asked to use that VA facility. All active duty
service members (ADSMs) and other TRICARE
Prime enrollees who are referred to a VA medical
facility for care must have prior authorization.
retired and are enrolled in a TRICARE Prime

option. Beneficiaries in this category will not
be charged a fee increase as long as at least one
family member remains enrolled.
You do not need to make a special trip to have your

uniformed services ID card updated until 30 days
prior to expiration. Your health care providers and
pharmacists will be able to access your benefits
using either your SSN or your DBN. For more
information, visit www.tricare.mil/ssn.
Note: The TRICARE Prime enrollment fee is

waived for any TRICARE Prime enrollee who
has Medicare Part B, regardless of age.
Note: A health care provider photocopying your

ID card or CAC for authorized purposes is legal.
Social Security Number Reduction

The Department of Defense (DoD) is removing
Social Security numbers (SSNs) from uniformed
services identification (ID) cards, including the
Common Access Card (CAC), as part of the
continued effort to protect the privacy and security
of TRICARE beneficiaries. SSNs are being
replaced with 10-digit DoD ID numbers. If you
have DoD benefits (e.g., health care, commissary,
exchange privileges), an 11-digit DoD Benefits
Number (DBN) is also printed on the card. The
DBN is a unique number that ensures your records
are clearly aligned with your treatments. The DBN
is located above the bar code on the back of your
uniformed services ID card or CAC.
When submitting health, pharmacy, and dental
claims, include either the sponsors SSN or the DBN
listed on the back of the ID card (eligible former
spouses should use their own SSN or DBN, not the
sponsors). The DoD ID number that appears on
the front of the ID card should not be used when
filing claims.
The ID card replacement process is expected
to last several years until all current uniformed
services ID cards are replaced as they come up
for renewal.
12
Getting Care
GETTING CARE
SECTION 3
Making an Appointment
SECTION 2
members (ADSMs) enrolled in TPR should

contact the Defense Health AgencyGreat Lakes
(DHA-GL) as soon as possible.
GETTING STARTED
You receive routine (primary) care and most

authorized urgent care from your primary care
manager (PCM). Your PCM will refer you to
another health care provider for services he or she
cannot provide. If you do not have an assigned
network PCM, you or your primary care provider
must coordinate specialty care referrals with your
regional contractor. You are guaranteed access to
care within specific time frames. You may qualify
for travel reimbursement if referred to specialty
care that is more than 100 miles from your PCMs
office. This section explains details about using
TRICARE Prime, TRICARE Prime Remote (TPR),
and TRICARE Prime Remote for Active Duty
Family Members (TPRADFM).
Nonemergency Care for Active

Duty Service Members
To make a primary care appointment, contact

your PCMs office or the TRICARE appointment
center (where available). There is no need to contact
your regional contractor to schedule primary
care appointments.
If you are an ADSM traveling or between duty

stations, you must receive all nonemergency care
at a military hospital or clinic if one is available.
If a military hospital or clinic is not available,
prior authorization from your regional contractor
is required before receiving nonemergency
civilian care.
Enrollees without an Assigned

Primary Care Manager
If you are enrolled in TPR or TPRADFM and
do not have an assigned PCM, you may seek
care from any TRICARE-authorized provider.
If you are not sure if a provider is TRICAREauthorized, contact your regional contractor or
visit www.tricare.mil/findaprovider.
Avoid Using the Emergency Room

for Nonemergency Conditions
Using the emergency room for nonemergency
conditions can result in longer wait times and
higher costs. You can often be treated more quickly
and appropriately by a military hospital or clinic,
your PCM or family doctor, or an urgent care center.
The Definitions and Examples of Types of Care
figure on the following page provides information
that can help you seek the most appropriate level
of service.
Emergency Care
TRICARE defines an emergency as a serious
medical condition that the average person would
consider to be a threat to life, limb, sight, or safety.
If you have an emergency, call 911 or go to the
nearest emergency room. You do not need to call
your PCM or regional contractor before receiving
emergency medical care (including overseas
care). However, in all emergencies, your PCM
must be notified within 24 hours or on the next
business day following admission to coordinate
ongoing care and to ensure you receive proper
authorization. Additionally, active duty service
Services That Do Not

Require Referrals
Some services may be obtained without a PCM
referral. These include clinical preventive services
and outpatient mental health care visits for a
medically diagnosed and covered condition to a
13
Definitions and Examples of Types of Care

Type
of Care
Definition
Primary Care
Manager Role
Examples
Emergency
TRICARE defines an emergency

as a serious medical condition
that the average person would
consider to be a threat to life,
limb, sight, or safety.
You do not need to call your

primary care manager (PCM)
before receiving emergency
medical care. Your PCM must
be notified within 24 hours
or on the next business day
following admission.
No pulse, severe bleeding,

spinal cord or back injury,
chest pain, broken bone,
inability to breathe
Urgent
Urgent care services are

medically necessary services
required for an illness or injury
that would not result in further
disability or death if not treated
immediately, but does require
professional attention within
24 hours. Urgent care services
require a referral if you do not
see your PCM for care.
Call your PCM first for

appropriate guidance.
Minor cuts, migraine

headache, urinary tract
infection, sprain, earache,
rising fever
Routine
Routine (primary) care is

general health care and includes
general office visits. Routine care
also includes preventive care to
help keep you healthy.
You will receive most of your

routine care from your PCM.
Treatment of symptoms,
chronic or acute illnesses and
diseases, follow-up care for an
ongoing medical condition
Specialty
Specialty care consists of

specialized medical services
provided by a physician
specialist. Specialty care
providers offer treatment that
your PCM cannot provide.
Your PCM will refer you to

another health care provider for
care he or she cannot provide
and will coordinate the referral
request with your regional
contractor when necessary.
Cardiology, dermatology,
gastroenterology, obstetrics
Access Standards for Care
network provider authorized under TRICARE

regulations to see patients independently. For mental
health care visits, a PCM referral is not required;
however, you must obtain prior authorization
from your regional contractor beginning with
the ninth outpatient mental health care visit per
fiscal year (FY) (October 1September 30).
TRICARE has access standards in place to

help ensure you receive timely health care.
These include:
The wait time for an urgent care appointment
should not exceed 24 hours (one day).
The wait time for a routine appointment should
not exceed one week (seven days).
A physician referral and supervision is always

required to see pastoral counselors and may be
required to see mental health counselors.
The wait time for a specialty care appointment

or wellness visit should not exceed four weeks
(28 days).
Note: ADSMs always require referrals for

any civilian care, including clinical preventive
services, mental health care, and specialty care
(except for emergency services).
The travel time for a routine appointment

should not exceed 30 minutes.
The travel time for a specialty care appointment
should not exceed one hour.
14
Waiving Access Standards
Outpatient mental health care beginning with

the ninth visit per FY
Non-active duty TRICARE Prime beneficiaries

may choose to receive care at military hospitals
and clinics. Assignment of a PCM at a military
hospital or clinic is determined by provider
availability and the military hospital or clinics
policy for the TRICARE Prime Service Area.
Transplantsall solid organ and stem cell

This list is not all-inclusive.
If you live more than a 30-minute drive from the

military hospital, clinic, or civilian PCM where
you want to enroll, you must waive TRICAREs
access standards for both routine care and specialty
care using one of the following options:
Each regional contractor has additional prior

authorization requirements. Visit your regional
contractors Web site or call the toll-free number
to learn about your regions requirements, as they
may change periodically. See the Important
Contact Information section at the beginning
of this handbook for your regional contractors
Web site and toll-free number.
Enroll through the Beneficiary Web Enrollment

Web site at www.dmdc.osd.mil/appj/bwe to
confirm that you waive your access standards.
* For more information on TRICARE dental coverage,

see Dental Options in the Covered Services section
of this handbook.
Submit a TRICARE Prime Enrollment,

Disenrollment, and Primary Care Manager
(PCM) Change Form (DD Form 2876) to your
regional contractor, and sign Section V.
Point-of-Service Option
The TRICARE point-of-service (POS) option
gives you the freedom, at an additional cost, to
receive nonemergency health care services from
any TRICARE-authorized provider without
requesting a referral from your PCM. For cost
details, visit www.tricare.mil/costs.
Enroll by phone and confirm with your regional

contractor that you waive your access standards.
Prior Authorization for Care
ADSMs
Newborns or newly adopted children in the
first 60 days after birth or adoption
Emergency care
Clinical preventive care received from a
network provider
For all other TRICARE Prime enrollees, the

following services require prior authorization:
Beneficiaries with other health insurance

The first eight outpatient mental health
visits per FY for a medically diagnosed
and covered condition to a network provider
authorized under TRICARE regulations to
see patients independently
Adjunctive dental services (i.e., dental care

that is medically necessary in the treatment of
an otherwise covered medicalnot dental
condition)*
Extended Care Health Option services
(active duty family members only)
Home health care services
Home infusion therapy
Hospice care
Nonemergency inpatient admissions for
substance use disorders or mental health care
15
SECTION 3
The POS option does not apply to the following:
ADSMs require prior authorization for all inpatient

and outpatient specialty services. An additional
fitness-for-duty review is required for maternity
care, physical therapy, occupational and speech
therapy, mental health care services, and
family counseling.
GETTING CARE
Services Requiring Prior Authorization
Covered Services
TRICARE covers most care that is medically
necessary and considered proven. Some types of
care are not covered at all, and there are special
rules and limits for certain types of care. TRICARE
policies are very specific about which services are
covered and which are not. It is in your best interest
to take an active role in verifying coverage.
health providers generally include psychiatrists or

other physicians, clinical psychologists, certified
psychiatric nurse specialists, clinical social workers,
certified mental health counselors who meet
TRICARE standards for independent practice,
and certified marriage and family therapists.
The first eight visits only apply to an initial
appointment and up to seven follow-on visits
that are related to a diagnosed medical or mental
condition. If you need non-medical or non-mental
health condition short-term counseling, you may
also be eligible for services through a Military
Family Support Center, Military OneSource
at www.militaryonesource.mil, or counseling
services in your community. Your mental health
care provider must obtain prior authorization from
your regional contractor beginning with the ninth
visit per FY. If you obtain care from a non-network
provider without prior authorization from your
regional contractor, point-of-service fees will apply.
This section is not all-inclusive. For more

information on covered services, visit
www.tricare.mil/coveredservices.
Mental Health Care Services

For detailed coverage information on outpatient
mental health care services, inpatient mental
health care services, and substance use disorder
services, visit www.tricare.mil/mentalhealth.
For additional information about covered and
non-covered mental health care services and how
to access care, contact your regional contractor.
Note: In the event of a mental health emergency,
call 911 or go immediately to the nearest
emergency room.
Telemental Health Program

The Telemental Health program uses secure
audio-visual conferencing to provide certain
mental health care services to eligible beneficiaries,
including TRICARE Prime, TRICARE Prime
Remote (TPR), and TRICARE Prime Remote
for Active Duty Family Members (TPRADFM)
enrollees in the United States.

Except in emergencies, active duty service
members (ADSMs) must have a referral and prior
authorization before seeking mental health care
outside of a military hospital or clinic. TRICARE
does not want to discourage you from getting
help but wants to make sure that your condition
does not adversely affect your health and your
ability to perform worldwide duty. Your primary
care manager (PCM) will coordinate all of your
mental health care referrals and authorizations.
Covered services provided through the

Telemental Health program have the same
limitations and referral and prior authorization
requirements as mental health care services.
Visit www.tricare.mil/mentalhealth or contact
your regional contractor for more information.
All Others Enrolled in TRICARE

Prime or TRICARE Prime Remote
for Active Duty Family Members
Inpatient Mental Health Care Services

Prior authorization from the regional contractor
is required for all nonemergency inpatient mental
health care services. Psychiatric emergencies do
not require prior authorization for admission to
an inpatient unit, but the regional contractor must
authorize continued stay. Admissions resulting from
psychiatric emergencies should be reported to your
regional contractor within 24 hours of admission
or on the next business day, and must be reported
You may see a network provider authorized under

TRICARE regulations to see patients independently
for the first eight outpatient mental health visits
per fiscal year (FY) (October 1September 30)
for a medically diagnosed and covered condition
without a PCM referral or prior authorization
from your regional contractor. Independent mental
16
within 72 hours of an admission. Authorization for

continued stay is coordinated between the inpatient
unit and the regional contractor.
for the active medical treatment of an acute phase

of substance abuse withdrawal) requires prior
authorization from your regional contractor.
Note: ADSMs who receive care at military hospitals

and clinics do not require prior authorization.
Suicide Prevention
If you or a loved one has suicidal thoughts,
call the National Suicide Prevention Lifeline at
1-800-273-TALK (1-800-273-8255) and select
option 1. Visit www.militaryonesource.mil for
additional resources and information.
Substance Use Disorder Services

Substance use disorders include alcohol or drug
abuse or dependence. For TRICARE to reimburse
the cost of care, you must see TRICARE-authorized
institutional providersan authorized hospital or
an organized treatment program in an authorized
freestanding or hospital-based substance use
disorder rehabilitation facility. Treatment includes
detoxification; rehabilitation in an inpatient or
partial hospitalization program setting; and
outpatient individual, group, and family therapy.
TRICARE covers three substance use disorder
treatment benefit periods in a lifetime and one
per benefit period. A benefit period begins with
the first date of the covered treatment and ends
365 days later.
TRICARE Tobacco-Cessation
Program
TRICARE is dedicated to helping ADSMs,
veterans, retirees, and their families succeed in
the attempt to quit tobacco. Below are several
ways to help you get the necessary assistance to
break the cycle:
TRICARE-covered tobacco-cessation products
Tobacco-cessation counseling services
The Department of Defenses Web site,

www.ucanquit2.org, provides education
and a wide range of tools to help you become
tobacco-free
Visit www.tricare.mil/quittobacco for more
information to help you quit.
17
SECTION 4
Emergency and inpatient hospital services are

considered medically necessary only when the
patients condition requires hospital personnel and
facilities. Generally, these services may be medically
necessary in certain detoxification circumstances
or for stabilization of a medical condition. All
treatment for substance use disorders (except for
emergency services that are medically necessary
COVERED SERVICES
TRICAREs Tobacco Quitline is a telephone

support and referral service with trained
tobacco-cessation coaches
Tobacco-Cessation Products
smokers concerned about relapsing may call

the Tobacco Quitline in their area to speak with
a trained tobacco-cessation coach who will
recommend appropriate treatment and resources.
TRICARE covers prescription and over-thecounter products to help you quit. Covered
tobacco-cessation products are available at
no cost through TRICARE Pharmacy Home
Delivery and at military pharmacies. Tobaccocessation products are not covered when
purchased at retail pharmacies.
Note: The Tobacco Quitline is only available to

TRICARE beneficiaries in the 50 United States
and the District of Columbia who are not eligible
for Medicare.
Tobacco-Cessation Counseling Services
Regional TRICARE Tobacco Quitline

Contact Information
Tobacco-cessation counseling is covered for all

TRICARE beneficiaries age 18 and older who are
not Medicare-eligible and who reside and receive
counseling in the 50 United States or the District
of Columbia.
TRICARE
North Region

1-866-459-8766
TRICARE
South Region

1-877-414-9949
TRICARE
West Region
UnitedHealthcare
Military & Veterans
1-888-713-4597
TRICARE Tobacco Quitlines

TRICARE Tobacco Quitlines provide toll-free
telephone support and referral services and
are available 24 hours a day, 7 days a week.
Current smokers who want to quit or former
Clinical Preventive Services

Comprehensive Health Promotion and Disease Prevention Examinations
Clinical Preventive Services: Coverage Details
Service
Description
Comprehensive
Health Promotion
and Disease
Prevention
Examinations
Adult: A comprehensive clinical preventive examination is covered if it includes

an immunization, Pap test, mammogram, colon cancer screening, or prostate cancer
screening. Beneficiaries in each of the following age groups may receive one comprehensive
clinical preventive examination without receiving an immunization, Pap test, mammogram,
colon cancer screening, or prostate cancer screening (one examination per age group):
1839 and 4064.
Pediatric: A comprehensive clinical preventive examination is covered if it includes
an immunization. Beneficiaries in each of the following age groups may receive one
comprehensive clinical preventive examination without receiving an immunization
(one examination per age group): 24, 511, and 1217. School enrollment physicals
for children ages 511 are also covered.
18
Targeted Health Promotion and Disease Prevention Services

The following screening examinations may be covered if provided in conjunction with a comprehensive
clinical preventive examination. The intent is to maximize preventive care.
Clinical Preventive Services: Coverage Details
Cancer Screenings
Colonoscopy:
Average risk: Individuals at average risk for colon cancer are covered once every
10 years beginning at age 50.
Increased risk: Once every five years for individuals with a first-degree relative diagnosed
with colorectal cancer or an adenomatous polyp before age 60, or in two or more
first-degree relatives at any age. Optical colonoscopy should be performed beginning
at age 40 or 10 years younger than the earliest affected relative, whichever is earlier.
Once every 10 years, beginning at age 40, for individuals with a first-degree relative
diagnosed with colorectal cancer or an adenomatous polyp at age 60 or older, or
colorectal cancer diagnosed in two second-degree relatives.
High risk: Once every one to two years for individuals with a genetic or clinical diagnosis
of hereditary non-polyposis colorectal cancer (HNPCC) or individuals at increased risk
for HNPCC. Optical colonoscopy should be performed beginning at age 2025 or 10 years
younger than the earliest age of diagnosis, whichever is earlier. For individuals diagnosed
with inflammatory bowel disease, chronic ulcerative colitis, or Crohns disease, cancer
risk begins to be significant eight years after the onset of pancolitis or 1012 years after
the onset of left-sided colitis. For individuals meeting these risk parameters, optical
colonoscopy should be performed every one to two years with biopsies for dysplasia.
Fecal occult blood testing: Testing is covered annually starting at age 50.
Breast cancer:
Clinical breast examination: For women until reaching age 40, a clinical breast
examination may be performed during a preventive health visit. For women age 40
and older, a clinical breast examination should be performed annually.
Mammograms: Covered annually for all women beginning at age 40. Covered annually
beginning at age 30 for women who have a 15 percent or greater lifetime risk of breast
cancer (according to risk assessment tools based on family history such as the Gail,
Claus, and Tyrer-Cuzick models), or who have any of the following risk factors:
History of breast cancer, ductal carcinoma in situ, lobular carcinoma in situ,
atypical ductal hyperplasia, or atypical lobular hyperplasia
Extremely dense breasts when viewed by mammogram
Known BRCA1 or BRCA2 gene mutation
First-degree relative (parent, child, sibling) with a BRCA1 or BRCA2 gene
mutation, and have not had genetic testing themselves
Radiation therapy to the chest between ages 10 and 30
History of Li-Fraumeni, Cowden, or hereditary diffuse gastric cancer syndrome,
or a first-degree relative with a history of one of these syndromes
Breast screening magnetic resonance imaging (MRI): Covered annually, in addition
to the annual screening mammogram, beginning at age 30 for women who have a
20 percent or greater lifetime risk of breast cancer (according to risk assessment tools
based on family history such as the Gail, Claus, and Tyrer-Cuzick models), or who
have any of the following risk factors:
Known BRCA1 or BRCA2 gene mutation
First-degree relative (parent, child, sibling) with a BRCA1 or BRCA2 gene
mutation, and have not had genetic testing themselves
Radiation to the chest between ages 10 and 30
History of Li-Fraumeni, Cowden, or hereditary diffuse gastric cancer syndrome,
or a first-degree relative with a history of one of these syndromes
19
SECTION 4
Description
COVERED SERVICES
Service
Clinical Preventive Services: Coverage Details (Continued)

Service
Description
Cancer Screenings
(Continued)
Proctosigmoidoscopy or sigmoidoscopy:
Average risk: Individuals at average risk for colon cancer are covered once every
three to five years beginning at age 50.
Increased risk: Once every five years, beginning at age 40, for individuals with a
first-degree relative diagnosed with a colorectal cancer or an adenomatous polyp at
age 60 or older, or two second-degree relatives diagnosed with colorectal cancer.
High risk: Annual flexible sigmoidoscopy, beginning at age 1012, for individuals
with known or suspected familial adenomatous polyposis.
Prostate cancer: A digital rectal examination and prostate-specific antigen screening
is covered annually for certain high-risk men ages 4049 and all men over age 50.
Routine Pap tests: Covered annually for women starting at age 18 (younger if sexually
active) or less often at patient and provider discretion (though not less than every three
years). Human papillomavirus (HPV) DNA testing is covered as a cervical cancer
screening only when performed in conjunction with a Pap test, and only for women
age 30 and older.
Skin cancer: Examinations are covered at any age for individuals at high risk due to
family history or increased sun exposure.
Cardiovascular
Diseases
Cholesterol test (non-fasting): Testing is covered for a lipid panel at least once every
five years beginning at age 18.
Blood pressure screening: Screening is covered annually for children ages 36 and a
minimum of every two years after reaching age 6 (children and adults).
Eye Examinations
Well-child care coverage (infants and children until reaching age 6):
Infants (until reaching age 3): One eye exam and vision screening is covered at birth
and at 6 months.
Children (age 3 until reaching age 6): One routine eye examination is covered every
two years. Active duty family member (ADFM) children are covered for one routine
eye examination annually.
Adults and children (age 6 and older): One routine eye examination every two years.
Active duty service members (ADSMs) and ADFMs receive one eye examination
each year.
Diabetic patients (any age): Eye examinations are not limited. One eye examination
per year is recommended.
Note: ADSMs enrolled in TRICARE Prime must receive all vision care at military hospitals
or clinics unless specifically referred by their primary care managers to civilian network
providers, or to non-network providers if a network provider is not available. ADSMs
enrolled in TRICARE Prime Remote may obtain periodic eye examinations from network
providers without authorizations as needed to maintain fitness-for-duty status.
Hearing
Preventive hearing examinations are only covered under the well-child care benefit (birth
until reaching age 6). A newborn audiology screening should be performed on newborns
before hospital discharge or within the first month after birth. Evaluative hearing tests
may be performed at other ages during routine exams.
20
Clinical Preventive Services: Coverage Details (Continued)

Service
Description
Immunizations
Age-appropriate doses of vaccines, including annual influenza vaccines, are covered as

recommended by the Centers for Disease Control and Prevention (CDC).
The HPV vaccine is a limited benefit and may be covered when the beneficiary has not
been previously vaccinated or completed the vaccine series.
Females: The HPV vaccine Gardasil (HPV4) or Cervarix (HPV2) is covered for females
ages 1126. The series of injections must be completed before reaching age 27 for
coverage under TRICARE.
Males: The HPV vaccine Gardasil is covered for all males ages 1121 and is covered
for males ages 2226 who meet certain criteria.
A single dose of the shingles vaccine Zostavax is covered for beneficiaries age 60
and older.
Note: Immunizations for ADFMs whose sponsors have permanent change-of-station
orders to overseas locations are also covered. Immunizations for personal overseas travel
are not covered.
Infectious Disease
Screening
TRICARE covers screening for the following infectious diseases: hepatitis B, rubella
antibodies, and HIV, and screening and/or prophylaxis for tetanus, rabies, hepatitis A
and B, meningococcal meningitis, and tuberculosis.
Patient and
Parent Education
Counseling
Counseling services expected of good clinical practice that are included with the
appropriate office visit are covered at no additional charge for dietary assessment and
nutrition; physical activity and exercise; cancer surveillance; safe sexual practices;
tobacco, alcohol, and substance abuse; dental health promotion; accident and injury
prevention; stress; bereavement; and suicide risk assessment.
School Physicals
Covered for children ages 511 if required in connection with school enrollment.
Note: Annual sports physicals are not covered.
Well-Child Care
(birth until
reaching age 6)
Covers routine newborn care; comprehensive health promotion and disease prevention exams;
vision and hearing screenings; height, weight, and head circumference measurement;
routine immunizations; and developmental and behavioral appraisal. TRICARE covers
well-child care in accordance with American Academy of Pediatrics (AAP) and CDC
guidelines. Your child can receive preventive care well-child visits as frequently as the
AAP recommends, but no more than nine visits in two years. Visits for diagnosis or
treatment of an illness or injury are covered separately under outpatient care.
SECTION 4
COVERED SERVICES
21
Dental Options
This section highlights your dental program options and costs when using the TRICARE Active Duty
Dental Program, the TRICARE Dental Program, or the TRICARE Retiree Dental Program. These dental
options are separate from TRICARE health care options. Your out-of-pocket expenses for any of the costs
listed in this section are not applied to the TRICARE catastrophic cap.
TRICARE Dental Program Options
Dental Program
Option
Beneficiary Types
Description of Program Option
TRICARE Active
Duty Dental
Program (ADDP)
Active duty service

members (ADSMs)
Benefit administered by United Concordia Companies, Inc.
TRICARE Dental
Program (TDP)1
Eligible active duty

family members
Benefit administered by MetLife
Survivors
Single and family plans with monthly premiums
National Guard and

Reserve members and
their family members
Lower specialty care cost-shares for pay grades E-1

through E-4
Individual Ready
Reserve members and
their family members
100% coverage for most preventive and diagnostic services
TRICARE Retiree
Dental Program
(TRDP)
National Guard and

Reserve members called
or ordered to active
service for more than
30 consecutive days
Retirees and their

eligible family members
worldwide
National Guard and
Reserve retirees until
reaching age 60 (when
they may continue as
retirees with retired pay)
For ADSMs who are either referred for care by a military

dental clinic to a civilian dentist or have a duty location
and live greater than 50 miles from a military dental clinic
Voluntary enrollment and worldwide portable coverage
Comprehensive coverage for most dental services
Benefit administered by Delta Dental of California

Voluntary enrollment and worldwide portable coverage
Single, dual, and family plans
Monthly premiums vary by ZIP code; deductible and
cost-shares apply
Comprehensive coverage for most dental services; visit
any dentist within the TRDP service area
100% coverage for most preventive and diagnostic services
1. The TDP is divided into two geographical service areas: stateside (or CONUS) and overseas (or OCONUS). The TDP stateside
service area includes the 50 United States, the District of Columbia, Puerto Rico, Guam, and the U.S. Virgin Islands. The TDP
overseas service area includes areas not in the stateside service area and covered services provided aboard a ship or vessel
outside the territorial waters of the stateside service area, regardless of the dentists office address.
22
Maternity Care
Prenatal care is important, and TRICARE strongly
recommends that those who are pregnant or who
anticipate becoming pregnant seek appropriate
medical care. TRICARE Prime, TPR, and
TPRADFM cover all necessary maternity care,
from your first obstetric visit through six weeks
after your child is born. TRICARE does not cover
routine ultrasound screening. Only medically
necessary maternity ultrasounds are covered by
TRICARE. For detailed coverage information,
visit www.tricare.mil/maternitycare.
TRICARE Extended Care

Health Option
TRICARE Extended Care Health Option (ECHO)
provides supplemental health and non-health
care services to active duty family members
who qualify based on specific mental or physical
disabilities. ECHO offers beneficiaries integrated
services and supplies beyond those offered by the
TRICARE Basic Program.
Active duty sponsors with family members
seeking ECHO registration must enroll in their
services Exceptional Family Member Program
(EFMP) (unless waived in specific situations) and
register for ECHO with their regional contractors
to be eligible for ECHO benefits. There is no
retroactive registration for the ECHO program.
Prior authorization must be obtained from the
regional contractor for all ECHO services.
For more information about EFMP, contact
your service branchs EFMP representative
or visit www.militaryonesource.mil/efmp.
For more information about ECHO, visit
www.tricare.mil/echo.
Hospice Care
If you or another TRICARE-eligible family
member is faced with a terminal illness, hospice
care is available from TRICARE. Hospice care
emphasizes supportive services, rather than
cure-oriented treatment, for patients with a life
expectancy of six months or less. The benefit
allows for personal care and home health aide
services, which are otherwise limited under
the TRICARE Basic Program.
TRICARE Pharmacy Program
23
SECTION 4
Note: Hospice care is only covered in the

United States and U.S. territories (American
Samoa, Guam, the Northern Mariana Islands,
Puerto Rico, and the U.S. Virgin Islands).
COVERED SERVICES
TRICARE offers comprehensive prescription

drug coverage and several options for filling your
prescriptions. To fill a prescription, you need
a written prescription and a valid uniformed
services identification (ID) card or Common
Access Card (CAC). The TRICARE pharmacy
benefit is administered by Express Scripts, Inc.
Military Pharmacies
TRICARE Retail Network Pharmacies
Military pharmacies (located at military hospitals

or clinics) are your least expensive option for
filling prescriptions. At a military pharmacy,
you may receive up to a 90-day supply of most
medications at no cost. Most military pharmacies
accept prescriptions written by both civilian and
military providers.
Another option for filling your prescriptions is

through a TRICARE retail network pharmacy.
You may fill prescriptions (one copayment for
each 30-day supply) when you present your
written prescription along with your uniformed
services ID card to the pharmacist. This option
allows you to fill your prescriptions at network
pharmacies without having to submit a claim.
You have access to a network of more than
56,000 retail pharmacies in the United States
and the U.S. territories of Guam, the Northern
Mariana Islands, Puerto Rico, and the U.S. Virgin
Islands. Currently, there are no TRICARE retail
network pharmacies in American Samoa.
Note: Beneficiaries enrolled in the US Family

Health Plan may not use military pharmacies to
fill their prescriptions.
TRICARE Pharmacy Home Delivery is your
least expensive option when not using a military
pharmacy. There is no cost for TRICARE
Pharmacy Home Delivery for ADSMs. For all
other beneficiaries, there is no cost to receive up to
a 90-day supply of formulary generic medications.
Copayments apply for brand name and nonformulary medications (up to a 90-day supply).
Home delivery is best suited for maintenance
medications (medications you take on a regular
basis). Prescriptions are delivered to you with free
standard shipping, and refills can be ordered easily
online, by phone, or by mail. Some medications
are not available for home delivery.
Non-Network Pharmacies
At non-network pharmacies, you will pay the
full price for your medication and file a claim
for reimbursement. Reimbursements are subject
to deductibles, out-of-network cost-shares, and
TRICARE-required copayments. All deductibles
must be met before any reimbursement can
be made.
Note: Beneficiaries residing in Germany cannot use

the home delivery option due to country-specific
legal restrictions.
Registration Methods
Online
Phone
1-877-363-1303
1-877-540-6261 (TDD/TTY)
Mail
Download the registration form from

and mail it to:
P.O. Box 52150
Phoenix, AZ 85072-9954
24
SECTION 5
COVERED SERVICES
SECTION 4
Health Care Claims
CLAIMS
Claims
service or the date of inpatient discharge. Overseas,
claims must be filed within three years of either the
date of service or the date of inpatient discharge. You
must submit proof of payment with overseas claims.
In most cases, you will not need to file claims for

health care services received under TRICARE
Prime. However, there may be times when you
will need to pay for care up front and then file a
claim for reimbursement.
To file a claim, obtain and complete a

TRICARE DoD/CHAMPUS Medical Claim
Patients Request for Medical Payment form
(DD Form 2642). You can download forms and
instructions from the TRICARE Web site at
www.tricare.mil/claims or from your regional
contractors Web site.
In the United States and U.S. territories (American

Samoa, Guam, the Northern Mariana Islands,
Puerto Rico, and the U.S. Virgin Islands), claims
must be filed within one year of either the date of
Stateside Health Care Claims-Processing Information

TRICARE West Region
Send claims to:

c/o PGBA, LLC/TRICARE
P.O. Box 870140
Surfside Beach, SC 29587-9740
Send claims to:

Claims Department
P.O. Box 7031
Camden, SC 29021-7031
Send claims to:

TRICARE West Region
Claims Department
P.O. Box 7064
Camden, SC 29021-7064
Check the status of your claim

at www.myTRICARE.com or
www.hnfs.com.
Check the status of your claim

at www.myTRICARE.com or
Humana-Military.com.
Check the status of your claim at

www.uhcmilitarywest.com.
TRICARE Overseas Program Claims-Processing Information

Active Duty Service Members (ADSMs)
(all overseas areas)
TRICARE Active Duty Claims

P.O. Box 7968
Madison, WI 53707-7968
Non-ADSMs, TRICARE Eurasia-Africa

(Africa, Europe, and the Middle East)
TRICARE Overseas Program

P.O. Box 8976
Non-ADSMs, TRICARE Latin America

and Canada
(Canada, the Caribbean Basin, Central and South
America, Puerto Rico, and the U.S. Virgin Islands)

P.O. Box 7985
Non-ADSMs, TRICARE Pacific

(Asia, Australia, Guam, India, Japan, New Zealand,
South Korea, and Western Pacific Remote countries)

P.O. Box 7985
25
Pharmacy Claims
When submitting your DD Form 2642, you

should also include an itemized bill or invoice,
diagnosis describing why you received medical
care, and/or an explanation of benefits from your
OHI, if applicable.
To file a pharmacy claim:

1. Download DD Form 2642 at
www.tricare.mil/claims.
2. Complete the form and attach the required
paperwork as described on the form.
Visit www.tricare.mil/proofofpayment
for more information on proof-of-payment
requirements overseas.
3. Mail the form and paperwork to:

TRICARE Claims
P.O. Box 52132
Phoenix, AZ 85082
Coordinating Benefits with

Other Health Insurance
TRICARE is the primary payer for ADSMs. For
all other beneficiaries, TRICARE is the last payer
to all health benefits and insurance plans, except
for Medicaid, TRICARE supplements, the Indian
Health Service, and other programs and plans as
identified by the Defense Health Agency.
Prescription claims require the following

information for each drug:
Patients name
Drug name, strength, date filled, days supply,
quantity dispensed, and price
If you have OHI, fill out the TRICARE Other

Health Insurance Coverage Questionnaire to
keep your regional contractor informed about your
OHI so they can coordinate your benefits and help
ensure that your claims are not delayed or denied.
Find the questionnaire at www.tricare.mil/forms.
National Drug Code, if available

Prescription number
Name and address of the pharmacy
Name and address of the prescribing physician
If you have other health insurance (OHI) with
pharmacy benefits, see Coordinating Benefits
with Other Health Insurance later in this section.
Call Express Scripts, Inc. at 1-877-363-1303 with
questions about filing pharmacy claims.
Follow the OHIs rules for filing claims and file

the claim with the OHI first. If there is an amount
your OHI does not cover, you or your provider can
file the claim with TRICARE for reimbursement.
It is important to meet your OHIs requirements.
If your OHI denies a claim for failure to follow its
rules, such as obtaining care without authorization
or using a non-network provider, TRICARE may
also deny your claim.
Note: Active duty family members (ADFMs)

who fill prescriptions at non-network pharmacies
are using the point-of-service option. Active duty
service members (ADSMs) may be required to
pay the full price of prescriptions up front and will
receive reimbursement after the claim is filed.
Appealing a Claim or
Authorization Denial
Proof-of-Payment
Requirement Overseas
TRICARE has a multilevel appeals process

to address claim and authorization denials.
You may appeal the denial of a requested
authorization of services as well as TRICARE
decisions regarding the payment of claims.
Submit appeals to your regional contractor.
For more detailed information on the appeals
process, visit www.tricare.mil/claims or contact
your regional contractor.
You must submit proof of payment with all claims

for care received overseas. Proof of payment is
necessary for TRICARE to validate claims and
safeguard benefit dollars. Proof of payment may
include a receipt, canceled check, credit card
statement, or invoice from the provider that clearly
states payment was received. If you paid for care
or supplies in cash, TRICARE may ask for proof
of cash withdrawal from your bank or credit union
along with a receipt from your provider.
26
CLAIMS
SECTION 5
CHANGES TO YOUR TRICARE COVERAGE
SECTION 6
Changes to Your TRICARE Coverage

TRICARE Prime continues to provide health coverage for you and your family as you experience major life
events. However, you will need to take specific actions to make sure you remain eligible for TRICARE and
enrolled in TRICARE Prime. With every life event listed in this section, the first step is to update your
information in the Defense Enrollment Eligibility Reporting System (DEERS). You have several options for
updating and verifying DEERS information. See the Important Contact Information section at the beginning
of this handbook for details.
This section provides information about what to do when you get married or divorced, have or adopt a child,
move, retire, and more. For more information about how TRICARE coverage may change when you become
Medicare-eligible, visit www.tricare.mil/medicare.
Life Changes and TRICARE
Life Change
Eligibility
Marriage
Register new spouses in the Defense Enrollment Eligibility Reporting System (DEERS) to
ensure they are eligible for TRICARE. Your new spouses TRICARE Prime or TRICARE
Prime Remote for Active Duty Family Members (TPRADFM) enrollment is effective based
on the 20th-of-the-month rule. Requests received by your regional contractor by the 20th of
the month become effective at the beginning of the following month (e.g., a request received
by December 20 becomes effective January 1). If the request is received after the 20th of
the month, coverage becomes effective on the first day of the month following the next
month (e.g., a request received on December 27 becomes effective February 1).
Divorce
Sponsors must update DEERS when there is a divorce. The sponsor will need to provide a
copy of the divorce decree, dissolution, or annulment. Former spouses who are not eligible
for TRICARE may not continue seeking health care services under the TRICARE benefit.
Children1
Any child who retains eligibility under the sponsor remains TRICARE-eligible until reaching
age 21 (or age 23 if enrolled in a full-time course of study at an approved institution of
higher learning, and if the sponsor provides over 50 percent of the financial support), as
long as his or her DEERS information is current. Your dependent childs TRICARE Prime
or TPRADFM coverage ends if his or her DEERS record is not updated before age 21.
Dependent children who have aged out of TRICARE coverage, but have not yet reached
age 26, may be eligible to purchase TRICARE Young Adult. It is available for purchase by
unmarried adult children who do not have access to an employer-sponsored health plan.
Going to College
Children of a TRICARE-eligible sponsor remain TRICARE-eligible until reaching age 21

(or age 23 if enrolled in a full-time course of study at an approved institution of higher
learning, and if the sponsor provides over 50 percent of the financial support), as long as
their DEERS information is current. If attending college in a different region from their
sponsors residence, students enrolled in TRICARE Prime can keep their TRICARE Prime
enrollment in their sponsors region, or may opt for split enrollment and transfer their
enrollment if TRICARE Prime is available in their new region. Note: If you keep your
TRICARE Prime enrollment in your sponsors location, you need to coordinate with your
primary care manager to get referrals for urgent and specialty care services received in
your colleges location.
Dependent children who have aged out of TRICARE coverage, but have not yet reached
age 26, may be eligible to purchase TRICARE Young Adult. It is available for purchase by
unmarried adult children who do not have access to an employer-sponsored health plan.
1. Children with disabilities may remain TRICARE-eligible beyond the normal age limits. Check with your sponsors service
for eligibility criteria.
27
Having a Baby or Adopting

a Child
to purchase TYA Prime and/or TYA Standard.

TYA coverage includes medical and pharmacy
benefits, but excludes dental coverage. Those who
purchase TYA Prime have access to care through
their assigned military or civilian primary care
managers (PCMs). Unless enrolled to a PCM at
a military hospital or clinic, TYA beneficiaries
are generally limited to primary care access at
military hospitals and clinics on a space-available
basis. TYA beneficiaries enrolled in the US Family
Health Plan are not eligible for care at military
hospitals or clinics or military pharmacy benefits,
except in an emergency. TYA is only available
for individuals and is not offered as a family
plan. For more information about TYA, including
eligibility requirements and how to purchase it,
visit www.tricare.mil/tya.
If you are a new parent, please remember there are

two important steps you must take within 60 days
from the date of birth or adoption to have continuous
TRICARE Prime or TRICARE Prime Remote
for Active Duty Family Members (TPRADFM)
coverage for your newborn or newly adopted child.
First, register your child in DEERS at a uniformed
services identification (ID) card-issuing facility.
A birth certificate or certificate of live birth from
the hospital is required. While a Social Security
number is not required to register a newborn in
DEERS, you will need to update the DEERS
record as soon as it is acquired.
Traveling
Second, enroll your child in TRICARE Prime

or TPRADFM. You may enroll your child
by calling your regional contractor, using
the Beneficiary Web Enrollment Web site at
www.dmdc.osd.mil/appj/bwe, or submitting a
TRICARE Prime Enrollment, Disenrollment, and
Primary Care Manager (PCM) Change Form
(DD Form 2876) to your regional contractor.

If an emergency occurs, call 911 or go to the nearest
emergency room and notify your PCM or the local
TRICARE Overseas Program (TOP) Regional
Call Center (if overseas) within 24 hours or on the
next business day. Prior authorization is not required
for emergency care (including overseas care) before
receiving treatment. If you are hospitalized, contact
your regional contractor. If possible, active duty
service members (ADSMs) traveling overseas
should contact the local TOP Regional Call Center
before seeking care or before making a payment.
If you do not enroll your child in a TRICARE

Prime option by day 61, he or she will be covered
under TRICARE Standard and TRICARE Extra.
If your child is not registered in DEERS within one
year after the date of birth, DEERS will show loss
of eligibility, and your child will lose all TRICARE
coverage until he or she is registered in DEERS.
If traveling or between duty stations, you must

receive all nonemergency care, including urgent
care, at a military hospital or clinic if one is
available. If a military hospital or clinic is not
available, a referral from your PCM is required
before receiving nonemergency care. Routine care,
which includes routine dental care and general
office visits for treatment and ongoing care, should
be handled before you travel or postponed until you
return. For urgent care overseas, ADSMs should
contact the TOP Regional Call Center.
Note: You must complete DEERS registration

before you enroll your child in TRICARE Prime
or TPRADFM. Contact your regional contractor
for enrollment assistance once DEERS has
been updated.
TRICARE Young Adult

The TRICARE Young Adult (TYA) program
is a premium-based health care plan available
for purchase by qualified dependents. The TYA
benefit includes both TRICARE Prime and
TRICARE Standard coverage worldwide. The
sponsors status, the dependents geographic
location, and other factors determine eligibility
All Other TRICARE Prime Enrollees

If you need emergency care while traveling in the
United States, call 911 or visit the nearest emergency
room. If you are admitted, your PCM or regional
contractor must be notified within 24 hours or
28
Filling Prescriptions on the Road
on the next business day so that ongoing care can

be coordinated and to ensure you receive proper
authorization for care.
You may use any TRICARE pharmacy option when

traveling, but be sure your DEERS information
is current. To fill a prescription, you need a valid
uniformed services ID card. At overseas host nation
pharmacies, you will pay up front for medications
and then file a claim with the TOP claims processor.
If urgent treatment cannot wait until you return

home to see your PCM, you must contact your
PCM for a referral. If you are unable to reach your
PCM, you may contact your regional contractor for
assistance before receiving care. Failure to obtain
a referral may cause your care to be covered under
the point-of-service (POS) option,* and you will
incur higher out-of-pocket costs.
Moving and Transferring

TRICARE Prime Enrollment
Traveling Overseas
When traveling overseas, plan for possible health
care needs in advance of the trip. If you need
emergency care, go to the nearest emergency care
facility or call the TOP Medical Assistance number
for the overseas area where you are traveling. If you
are admitted, you must call your PCM and the
TOP Regional Call Center within 24 hours or the
next business day after admission, or at the very
latest, before leaving the facility. Call the TOP
Regional Call Center to coordinate authorization,
continued care, and payment, if applicable. Contact
your PCM and the TOP Regional Call Center for
urgent care.
Note: Beneficiaries must meet eligibility

requirements to enroll in TRICARE Prime
Remote (TPR) and TPRADFM. For more
information, see the Eligibility and Enrollment
section of this handbook.
Active Duty Service Members and
If you are an ADSM or active duty family
member (ADFM) moving within your current
region, your regional contractor will help you
transfer to a new PCM. If you are moving to
a new region, contact your current regional
contractor so that they can send your information
to your new regional contractor, who will follow
up with you to complete the enrollment transfer
after you arrive at your new location. If you wish,
you can also call your new regional contractor after
you move to transfer your enrollment. Your new
regional contractor will work with you to assign a
PCM best suited to your needs and the location of
your work or home.
Note: When seeking care from a host nation

(overseas) provider, be prepared to pay up
front for services and then file a claim with the
TOP claims processor. To process your claims
reimbursements quickly and efficiently, you must
submit proof of payment with all overseas claims.
In the Philippines, you must use TRICAREcertified providers and pharmacies. Visit
www.tricare-overseas.com/philippines.htm
to find a certified provider.
* The POS option does not apply to ADSMs, children for the
first 60 days following their birth or adoption, emergency
care, beneficiaries with other health insurance, or the
first eight mental health outpatient visits per fiscal year
(October 1September 30) to a network provider for a
medically diagnosed and covered condition.
All Other TRICARE Prime Enrollees

If you move to another TRICARE Prime Service
Area (PSA) in the same TRICARE region, you
will only need to change your PCM once you
arrive at your new location. If you move to a PSA
in another region, you will need to transfer your
29
SECTION 6
Note: If you plan to travel for more than 60 days,

you may choose to transfer your TRICARE Prime
enrollment to the new TRICARE region where
you will be living.
TRICARE Prime coverage is portableyou can

easily transfer your TRICARE Prime enrollment
when you move within your TRICARE region
or to a new TRICARE region. ADSMs and their
families may transfer their enrollment as often as
needed. Retired service members and their families,
survivors, eligible former spouses, and others are
currently limited to two enrollment transfers each
enrollment year.
TRICARE Prime enrollment if you wish to keep

your TRICARE Prime coverage. Do not disenroll
from TRICARE Prime before you move to your
new location.
to civilian life. The sponsor and eligible family

members may be covered for health benefits under
TAMP if the sponsor is:
Involuntarily separating from active service
under honorable conditions
If you move to an area where TRICARE Prime

is not available (same or new region), you must
disenroll from TRICARE Prime. You will be
covered automatically by TRICARE Standard
and TRICARE Extra as long as your DEERS
information is current. If you do not disenroll,
you will be using the POS option resulting in
higher out-of-pocket costs.
A National Guard or Reserve member separating

from a period of active service that was more
than 30 consecutive days in support of a
contingency operation
Separating from active service following
involuntary retention (stop-loss) in support
of a contingency operation
Separating from active service following
a voluntary agreement to stay on active
duty for less than one year in support of a
contingency operation
You may transfer your TRICARE Prime enrollment

or change your PCM online, by phone, or by mail.
Separating from active service with an

agreement to become a member of the
Selected Reserve
Moving Overseas
If you are moving overseas, contact the appropriate
TOP Regional Call Center before you move to
determine TOP Prime eligibility requirements.
When calling, select option 4 for the Global
TRICARE Service Center, which provides
customer service 24 hours a day, 7 days a week.
TOP Regional Call Center phone numbers can be
found at www.tricare-overseas.com. ADFMs
must meet command sponsorship requirements
for TOP Prime or TOP Prime Remote coverage.
Retirees and their family members are not
eligible for TOP Prime options, but may be
eligible for TOP Standard. TRICARE Extra
is not available overseas.
Separating from active service due to

sole-survivorship discharge
Contact your regional contractor or a Beneficiary
Counseling and Assistance Coordinator to
discuss your familys eligibility for this program.
You also can visit www.tricare.mil/tamp for
more information.
CHCBP is a premium-based health care program
administered by Humana Military. Though not
a TRICARE program, CHCBP offers continued
health coverage (1836 months) after TRICARE
eligibility ends. If you qualify, you can purchase
CHCBP coverage within 60 days of loss of eligibility
for either regular TRICARE or TAMP coverage,
whichever is later. For more information, visit
www.tricare.mil/chcbp.
Separating from the Service

If you are separating from the uniformed services,
TRICARE coverage may or may not continue,
depending on the circumstances of your separation.
You have several transitional health care options
the Transitional Assistance Management Program
(TAMP), the Continued Health Care Benefit
Program (CHCBP), and the Transitional Care for
Service-Related Conditions (TCSRC) program
that provide temporary coverage.
Transitional Care for

Service-Related Conditions
If you are eligible under TAMP and have a newly
diagnosed medical condition that is related to your
active duty service, you may qualify for the TCSRC
program, which provides 180 days of care for your
condition with no out-of-pocket costs. If you believe
you have a service-related condition that may qualify
you for TCSRC, visit www.tricare.mil/tcsrc for
instructions on how to apply.
Transitional Assistance
Management Program
TAMP provides up to 180 days of transitional
health care benefits to help certain members of the
uniformed services and their families transition
30
Retiring from Active Duty
date or contact your regional contractor by phone

no later than 30 days after your retirement date
to request enrollment; otherwise, the 20th-of-themonth rule may apply.
When you retire from active service, you and your

eligible family members experience a change in
status, and, after you update your DEERS record,
you will receive a new uniformed services ID card
that reflects your status as a retiree.
Becoming Entitled to Medicare

Active Duty Status
Note: TPR and TPRADFM are not available to

retirees and their families. If you are enrolled
in TPR or TPRADFM and stay at your current
residence, you may be able to enroll in TRICARE
Prime if you waive your access standards. Contact
your regional contractor for details.
If you enroll in TRICARE Prime after you retire,
the following changes will apply:
You will pay an annual enrollment fee
(network copayments apply).
You will be responsible for copayments for
certain medical services.
There will be an increase in your catastrophic
cap (the maximum out-of-pocket amount a
beneficiary pays each fiscal year [October 1
September 30] for TRICARE-covered services).
Note: ADSMs and ADFMs with end-stage renal

disease do not have a special enrollment period
and should enroll in Medicare Part A and Part B
when first eligible.
There will be minor differences in covered

services (e.g., eye examinations are now only
covered every two years and hearing aids are
no longer covered).
Retired Status
Retirees and their dependents who are entitled to
premium-free Medicare Part A must also have
Medicare Part B to remain TRICARE-eligible
regardless of their age or place of residence.
TRICARE For Life coverage automatically begins
the first month both Medicare Part A and Part B
are effective. TRICARE eligibility is terminated
for any period of time in which a retiree or retiree
family member is entitled to Medicare Part A and
does not have Medicare Part B. To avoid a break
in TRICARE coverage, ADSMs and ADFMs must
sign up for Medicare Part B before the sponsors
active duty status ends.
There will be a change in dental coverage

(see Dental Options in the Covered Services
section of this handbook).
Note: Retirees and family members who use
TRICARE Standard and TRICARE Extra will
see a cost-share increase of 5 percent compared
to ADFMs.
You and your family members should look at
your health care options together and determine
which option best meets your needs after you retire.
If you decide to reenroll in TRICARE Prime, you
may submit your DD Form 2876 to your regional
contractor up to 30 days prior to your retirement
Note: Retirees and their family members are not

eligible for TPR or TPRADFM.
31
SECTION 6
ADSMs and ADFMs who are entitled to premiumfree Medicare Part A regardless of the reason
remain eligible for TRICARE Prime and TRICARE
Standard and TRICARE Extra program options
without signing up for Medicare Part B. However,
when the sponsor retires, you must have Medicare
Part B to remain TRICARE-eligible. You may
sign up for Medicare Part B during the special
enrollment period, which is available anytime while
the sponsor is still active duty, or within the first
eight months following either (1) the month your
sponsors active duty status ends or (2) the month
TRICARE coverage ends, whichever comes first.
To avoid a break in TRICARE coverage, ADSMs
and ADFMs must sign up for Medicare Part B
before the sponsors active duty status ends. Sign up
for Medicare Part A and Part B when first eligible
to avoid the Medicare Part B premium surcharge
for late enrollment.
You will have new TRICARE coverage options

after you retire. Understanding these options will
help you and your family make the best health
care decisions. After you retire, it is still essential
to keep your DEERS information current.
Survivor Coverage
If you are not enrolled in TRICARE Prime or

TPRADFM and are eligible, you may enroll
at any time after your sponsors death. Normal
enrollment rules apply; there is no retroactive
enrollment. Transitional survivors not enrolled in
TRICARE Prime or TPRADFM will be covered
as ADFMs under TRICARE Standard and
TRICARE Extra.
If your sponsor dies while serving on active duty

for a period of more than 30 consecutive days,
you are automatically eligible for transitional
TRICARE survivor benefits as long as your
DEERS information is current and you are:
A surviving spouse who has not remarried prior
to age 55 (eligibility cannot be regained later,
even if you divorce or your new spouse dies)
Upon the death of a sponsor, you will receive a

letter from the Defense Manpower Data Center
(DMDC) describing your program options and
how your benefits will eventually change. Contact
your regional contractor if you have any questions.
A surviving unmarried child until reaching

age 21 (or age 23 if enrolled in a full-time
course of study at an approved institution of
higher learning, and if the sponsor provided
over 50 percent of the financial support)
* You will need to reenroll at that time and pay retiree

enrollment fees.
Note: Children with disabilities may remain

TRICARE-eligible beyond the normal age
limits. Check with your sponsors service for
eligibility criteria.
Dependent Parent Coverage

As a TRICARE Prime beneficiary, if your parents
or parents-in-law reside with you and are dependent
on you for over 50 percent of their support, your
local military hospital or clinic may be able to
help with their health care. Although dependent
parents are not eligible for most TRICARE
benefits, they may be eligible to receive health
care at certain military hospitals or clinics on a
space-available basis.
Surviving spouse: You remain eligible as a

transitional survivor for three years following
your sponsors death and will have ADFM
benefits and costs, including TRICARE Prime
and TPRADFM eligibility. After three years,
you remain eligible as a survivor, and are eligible
for benefits as a retiree family member. You pay
retiree rates* under TRICARE Prime (if available)
or TRICARE Standard and TRICARE Extra. As
a survivor, you are not eligible for TPRADFM, but
you may enroll in TRICARE Prime, if it is available
where you live and you meet enrollment criteria.
If you do not enroll in TRICARE Prime, coverage
automatically continues under TRICARE
Standard and TRICARE Extra.
Dependent parents or parents-in-law may also

enroll in TRICARE Plus if your military hospital
or clinic offers it and space permits. TRICARE Plus
allows them to make primary care appointments
at the military hospital or clinic with the same
access standards as beneficiaries enrolled in
TRICARE Prime.
Surviving children: Surviving children whose

sponsor died on or after October 7, 2001, remain
eligible for TRICARE benefits as ADFMs. Unlike
spouses, eligibility will not change after three
years, and children remain covered as ADFMs
until eligibility ends due to the age limits previously
noted or for another reason (e.g., marriage).
Dependent parents or parents-in-law can also fill

prescriptions at military pharmacies and through
the other TRICARE Pharmacy Program options
once they become entitled to Medicare Part A and
have Medicare Part B. Visit www.tricare.mil for
more information regarding coverage and eligibility.
Transitional survivors enrolled in TRICARE

Prime at the time of their sponsors death will
not be disenrolled. Coverage continues as long
as DEERS information is up to date or until
eligibility ends.
32
Disenrollment
members who voluntarily disenroll from TRICARE

Prime before their annual enrollment renewal date
are subject to a 12-month lockout. You must contact
your regional contractor to initiate a voluntary
disenrollment. If you are disenrolled from
TRICARE Prime, you may be covered under
TRICARE Standard and TRICARE Extra if all
eligibility requirements are met.
Enrollment in TRICARE Prime is continuous

you do not have to reenroll every year to maintain
coverage. However, certain events will cause you
to be disenrolled.
Sponsor Status Change
A change in your sponsors status (e.g., retirement or
National Guard and Reserve member deactivation)
will cause you to be disenrolled automatically from
TRICARE Prime. To avoid a lapse in coverage,
you must submit a new enrollment request to your
regional contractor before the date of the status
change for you and your family members to remain
enrolled in TRICARE Prime, if you are still
eligible after the status change. In some cases, such
as during the TAMP period, you may not be able
to reenroll in TPR or TPRADFM. For example,
if you were enrolled in TPR and you retire from
active duty, the TPR option is no longer available.
To continue TRICARE Prime coverage, you will
need to move to an area where TRICARE Prime
is offered and enroll or waive access standards.
Otherwise, coverage will continue under
TRICARE Standard and TRICARE Extra.
Voluntary disenrollment is not an option for

ADSMs; active duty personnel must enroll in
either TRICARE Prime or TPR.
Nonpayment of Enrollment Fees

Loss of Eligibility
If you are required to pay enrollment fees and you

do not pay them when due, you will be disenrolled
from TRICARE Prime. When disenrolled for
nonpayment, you are subject to a 12-month
lockout, during which you will not be permitted to
reenroll in TRICARE Prime. To avoid missing a
payment, learn about automated payment options
at www.tricare.mil or contact your regional
contractor. If you are disenrolled from TRICARE
Prime, you may be covered under TRICARE
Standard and TRICARE Extra if all eligibility
requirements are met.
If your DEERS record indicates loss of TRICARE

eligibility, your TRICARE Prime coverage will
automatically end. If you believe you are still
eligible for TRICARE, you will need to update
your DEERS record to reestablish your eligibility.
Contact DMDC directly at 1-800-538-9552.
Once DEERS is updated, you must reenroll in
TRICARE Prime or, if you are a family member,
you will be covered under TRICARE Standard
and TRICARE Extra.
If your DEERS record is correct and you have lost
eligibility, you may qualify for transitional health
care. See Separating from the Service earlier
in this section for details about transitional health
care options.
Voluntary Disenrollment
ADFMs who choose to change their enrollment
status (i.e., from enrolled to disenrolled or vice
versa) more than twice in an enrollment year
(October 1September 30) for any reason are
subject to a 12-month lockout,* during which they
will not be permitted to reenroll in TRICARE
Prime or TPRADFM. Retirees and their family
33
SECTION 6
* The 12-month lockout does not apply to ADFMs of

sponsors with pay grades E-1 through E-4.
Note for TPRADFM beneficiaries: If your

sponsor is deployed, you may remain enrolled
during his or her deployment. However, if you
move from your current TPR ZIP code area while
your sponsor is deployed, you no longer qualify for
TPRADFM. If you are moving to an area where
TRICARE Prime is available, you may change
from TPRADFM to TRICARE Prime. If you are
moving to an area where TRICARE Prime is not
available, you must disenroll from TPRADFM,
and you will be covered by TRICARE Standard
and TRICARE Extra.
For Information and Assistance

Beneficiary Counseling and
Assistance Coordinators
Appeals and Grievances

If you believe a service or claim was improperly
denied, in whole or in part, you (or another
appropriate party) may file an appeal with
your regional contractor. An appeal must involve
an appealable issue, such as benefit coverage
or medical necessity determination. For nonappealable issues regarding health care quality
or service, you can file a grievance with your
regional contractor. For information about filing
an appeal or grievance about care received
overseas, visit www.tricare-overseas.com.
Beneficiary Counseling and Assistance Coordinators

(BCACs) can help you with TRICARE and Military
Health System inquiries and concerns and can
advise you about obtaining health care. BCACs
are located at military hospitals and clinics and
TRICARE Regional Offices. To find a BCAC
near you, visit the Customer Service Community
Directory at www.tricare.mil/bcacdcao.
Debt Collection
Assistance Officers
Note: If you are eligible for TRICARE

and Medicare and wish to file an appeal,
Medicare-related appeals should be submitted
to Medicare.
Debt Collection Assistance Officers (DCAOs)

are located at military hospitals and clinics and
TRICARE Regional Offices to help you resolve
health care collection-related issues. A DCAO
is also located at the Defense Health Agency
Great Lakes (formerly known as the Military
Medical Support Office), for active duty service
members and National Guard and Reserve
members with service-documented line-of-duty
injuries. Contact a DCAO if you have received
a negative credit rating or have been contacted
by a collection agency due to an issue related to
TRICARE services.
Reporting Suspected Fraud

and Abuse
Report suspected fraud and abuse to your regional
contractor. You also can report fraud or abuse issues
directly to TRICARE at www.tricare.mil/fraud.
Appeals-Filing Information
TRICARE West Region
Claims Appeals:
TRICARE Claim Appeals
P.O. Box 105266
Atlanta, GA 30348-5266
Claims Appeals:
TRICARE South Region Appeals
P.O. Box 202002
Florence, SC 29502-2002
Claims Appeals:
TRICARE West Region
Appeals Department
P.O. Box 105493
Claims Appeals Fax:

1-888-458-2554
Prior Authorization Appeals:
TRICARE Authorization Appeals
P.O. Box 105087
Prior Authorization Appeals Fax:
1-888-881-3622

Humana Military
ATTN: Clinical Appeals
P.O. Box 740044
Louisville, KY 40201-7444
Mental Health Appeals:
ValueOptions Behavioral Health
ATTN: Appeals and
Reconsideration Department
P.O. Box 551138
Jacksonville, FL 32255-1138
Appeals Online:
www.hnfs.com
34
Claims Appeals Fax:

1-877-584-6628
TRICARE West Region
Appeals Department
P.O. Box 105493
Prior Authorization Appeals Fax:
1-877-584-6628
Index
A
Contingency operation, 6, 7, 30
(CHCBP), 30
Copayments, 24, 31
Cost-shares, 6, 22, 24, 31
Counseling, 2, 8, 1518, 21, 30, 34
Access standards, 11, 14, 15, 3133

Accident, 21
Activation, 2, 6, 7
Active Duty Dental Program (ADDP), 22
Active duty family member (ADFM), 1, 2, 59,
11, 13, 15, 16, 2023, 2633
Active duty service member (ADSM), 2, 58, 11,
1317, 20, 22, 2426, 28, 29, 31, 33, 34
Active duty sponsor, 23
Adjunctive dental care, 15
Adoption, 15, 28, 29
Age limitations, 27, 32
Allowable charges, 10
Ambulance, 10
Ancillary care/services, 9
Appeal, 26, 34
Appointment, 13, 14, 16, 32
Authorization, 2, 9, 11, 1317, 20, 23, 26, 28, 29, 34
Cancer screenings, 1820

Catastrophic cap, 11, 22, 31
Children, 15, 1821, 23, 2729, 32
Civilian care, 8, 13, 14, 20, 28
Civilian providers, 8, 9, 20, 24
Claims, 5, 1012, 2426, 29, 34
Clinical preventive examination, 18, 19
Clinical preventive services, 13, 14, 1821
Collection agency, 34
College, 27
Colon cancer, 1820
Colonoscopy, 19
Commissioned Corps of the U.S. Public Health
Service, 8
Common Access Card (CAC), 12, 23
F
Family counseling, 15
Family therapy/therapist, 16, 17
Fecal occult blood testing, 19
Fitness-for-duty, 15, 20
Former spouse, 5, 11, 12, 27, 29
Fraud and abuse, 34
35
SECTION 8
Electronic funds transfer (EFT), 11

Emergency, 10, 1317, 28, 29
End-stage renal disease, 31
Examinations, 1820, 31
Exceptional Family Member Program (EFMP), 23
Exercise, 21
Explanation of benefits (EOB), 26
Express Scripts, Inc. (Express Scripts), 23, 24, 26
Extended Care Health Option (ECHO), 15, 23
Eye examination, 20, 31
INDEX
SECTION 7
Beneficiary Counseling and Assistance

Coordinator (BCAC), 2, 8, 30, 34
Beneficiary Web Enrollment (BWE), 58, 11,
15, 28
Benefit period, 17
Bill, 10, 26
Blood pressure screening, 20
Brand name medications, 24
Breast cancer, 19
FOR INFORMATION AND ASSISTANCE
Deactivation, 33
Debt Collection Assistance Officer (DCAO), 34
Deductible, 6, 22, 24
Defense Enrollment Eligibility Reporting System
(DEERS), 58, 2733
Defense Health AgencyGreat Lakes (DHA-GL),
8, 13, 34
Delta Dental of California (Delta Dental), 22
Dental care, 10, 15, 28
Dental clinic, 22
Dental options, 15, 22, 31
Department of Defense Benefits Number (DBN), 12
Dependent child, 27
Dependent parent, 32
Detoxification, 17
Diabetes, 20
Dietary assessment, 21
Disability, 14, 23, 27, 32
Disenrollment, 5, 15, 28, 30, 32, 33
Divorce, 27, 32
Generic drug/medication, 24
Genetic testing, 19
Grievance, 34
National Guard and Reserve, 2, 57, 22, 30, 33, 34

National Oceanic and Atmospheric
Administration, 8
Network pharmacy, 24
Network provider, 5, 911, 1416, 20, 29
Newborn, 20, 21, 28
Nonemergency, 13, 15, 16, 28
Non-formulary drugs, 24
Non-network pharmacy, 24, 26
Non-network provider, 10, 16, 20, 26
Nonparticipating provider, 10
North Region, 18, 25, 34
H
Health care records, 12
Health Net Federal Services, LLC (Health Net),
18, 25, 34
Hearing aids, 31
Hepatitis, 21
HIV, 21
Home health care, 15
Hospice care, 15, 23
Hospital/Hospitalization, 2, 510, 13, 1517, 20,
24, 28, 32, 34
Human papillomavirus (HPV), 20, 21
Humana Military Healthcare Services, Inc.
(Humana Military), 18, 30, 34
O
Other health insurance (OHI), 15, 26, 29
Out-of-pocket costs, 10, 11, 22, 29, 30
Outpatient care, 1317, 21, 29
P
Pap test, 18, 20

Parent education counseling, 21
Parents-in-law, 32
Partial hospitalization program (PHP), 17
Participating provider, 10
Pastoral counselor, 14
Payment, 8, 10, 11, 25, 26, 28, 29, 33
Payment options, 11, 33
PGBA, LLC (PGBA), 25
Pharmacy, 10, 12, 18, 23, 24, 26, 28, 29, 32
Physical therapy, 9, 15
Point-of-service (POS) option, 10, 15, 26, 29, 30
Pregnancy, 23
Prenatal care, 23
Prescriptions, 18, 23, 24, 26, 29, 32
Preventive care, 1315, 1821
Primary care manager (PCM), 2, 5, 9, 10, 1316,
20, 2730
Prime Service Area (PSA), 5, 9, 15, 29
Prior authorization, 2, 9, 11, 1317, 23, 28, 34
Privacy, 12
Proctosigmoidoscopy, 20
Program options, 22, 31, 32
Prostate cancer, 18, 20
Psychiatric condition, 16
Psychiatric nurse, 16
Psychiatrist, 16
Psychologist, 16
Identification (ID) card, 12, 23, 24, 28, 29, 31

Immunization, 18, 21
Indian Health Service, 26
Infant, 20
Infectious disease screening, 21
Inpatient care, 15
Inpatient mental health care, 16, 17
L
Lockout, 33
Loss of eligibility, 28, 30, 33
M
Magnetic resonance imaging (MRI), 19
Mammograms, 18, 19
Marriage, 16, 27, 32
Maternity care, 15, 23
Medicaid, 26
Medical necessity, 34
Medicare, 8, 12, 18, 27, 31, 32, 34
Medications, 24, 29
Meningococcal meningitis, 21
Mental health care/services, 1316, 29, 34
MetLife, 22
Military hospitals and clinics, 2, 510, 13, 1517,
24, 28, 32, 34
Military Medical Support Office (MMSO), 8, 34
Moving, 7, 9, 27, 29, 30, 33
36
R
Radiology, 9, 10
Reconsideration, 34
Rehabilitation, 17
Retired, 5, 7, 8, 11, 12, 17, 22, 27, 2933
Retiring, 31
Routine care, 9, 1315, 21, 28
Rubella, 21
TRICARE Pacific, 25
TRICARE Pharmacy Home Delivery, 18, 24
TRICARE Pharmacy Program, 23, 32
TRICARE Regional Office, 2, 6, 7, 34
TRICARE retail network pharmacy, 18, 24
TRICARE Retiree Dental Program (TRDP), 22
TRICARE Standard, 2, 6, 28, 3033
TRICARE Young Adult, 27, 28
School physicals, 21
Sigmoidoscopy, 20
Skin cancer, 20
Social Security number (SSN), 12, 28
South Region, 18, 25, 34
Space-available care, 28, 32
Specialist, 14, 16
Specialty care, 811, 1315, 22, 27
Split enrollment, 27
Stem cell, 15
Stress, 21
Substance use disorders, 1517
Suicide prevention, 17, 21
Supplemental Health Care Program (SHCP), 8
Supplements, 26
Survivors, 5, 11, 22, 29, 32
Ultrasound, 23
Uniformed services identification (ID) card, 12, 23,
24, 28, 29, 31
United Concordia Companies, Inc.
(United Concordia), 22
UnitedHealthcare Military & Veterans, 18
Urgent care, 9, 13, 14, 2729
US Family Health Plan (USFHP), 5, 8, 9, 24, 28
U.S. Department of Veterans Affairs (VA), 11
U.S. Public Health Service, 8
U.S. territories, 2225
V
Vaccines, 21
Veterans Affairs benefits, 11
Vision screening, 20
W
Well-child care, 20, 21

West Region, 18, 25, 34
37
SECTION 8
INDEX
Telemental Health Program, 16

Tetanus, 21
Therapist, 16
Tobacco cessation, 17, 18, 21
Tobacco Quitline, 17, 18
Transitional Assistance Management Program
(TAMP), 30, 33
Transitional Care for Service-Related Conditions
(TCSRC), 30
Transplants, 15
Travel, 13, 14, 21, 28, 29
Travel reimbursement, 13
TRICARE-allowable charge, 10
TRICARE-authorized provider, 9, 10, 13, 15
TRICARE Dental Program (TDP), 22
TRICARE Eurasia-Africa, 25
TRICARE Extended Care Health Option
(ECHO), 15, 23
TRICARE Extra, 2, 6, 28, 3033
TRICARE For Life, 11, 31
TRICARE Latin America and Canada, 25
TRICARE Overseas Program (TOP), 25, 2830
Notes
38
TRICARE Expectations for Beneficiaries

According to the Department of Defense (DoD), as
a TRICARE beneficiary, you should expect to have
the following abilities and support:
Get information: You should expect to receive
accurate, easy-to-understand information from
written materials, presentations, and TRICARE
representatives to help you make informed
decisions about TRICARE programs, medical
professionals, and facilities.
Choose providers and plans: You should expect
a choice of health care providers that is sufficient to
ensure access to appropriate high-quality health care.
Emergency care: You should expect to access
medically necessary and appropriate emergency
health care services as is reasonably available
when and where the need arises.
Participate in treatment: You should expect to
receive and review information about the diagnosis,
treatment, and progress of your conditions, and to
fully participate in all decisions related to your health
care, or to be represented by family members or
other duly appointed representatives.
Respect and nondiscrimination: You should
expect to receive considerate, respectful care from
all members of the health care system without
discrimination based on race, color, national origin,
or any other basis recognized in applicable law
or regulations.
Confidentiality of health information:
You should expect to communicate with health care
providers in confidence and to have the confidentiality
of your health care information protected to the
extent permitted by law. You also should expect
to have the ability to review, copy, and request
amendments to your medical records.
Complaints and appeals: You should expect a fair
and efficient process for resolving differences with
health plans, health care providers, and institutions
that serve you.
Additionally, the DoD has the following expectations

of you as a TRICARE beneficiary:
Maximize your health: You should maximize
healthy habits such as exercising, not smoking,
and maintaining a healthy diet.
Make smart health care decisions: You should
be involved in health care decisions, which means
working with providers to provide relevant
information, clearly communicate wants and
needs, and develop and carry out agreed-upon
treatment plans.
Be knowledgeable about TRICARE: You should
be knowledgeable about TRICARE coverage and
program options.
You also should:
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
TRICARE is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved.

www.hnfs.com
1-877-TRICARE (1-877-874-2273)
Humana-Military.com
1-800-444-5445
www.tricare.mil
HA5221BEC11144
TRICARE West Region

UnitedHealthcare Military & Veterans
1-877-988-WEST (1-877-988-9378)

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TRICARE Prime Remote

Your guide to program benefits

TRICARE North Region

TRICARE North Region Contractor

The TRICARE North Region includes Connecticut, Delaware, the District

Health Net Federal Services, LLC

TRICARE South Region

TRICARE South Region Contractor

The TRICARE South Region includes Alabama, Arkansas, Florida, Georgia,

Humana Military, a division of

TRICARE West Region

TRICARE West Region Contractor

The TRICARE West Region includes Alaska, Arizona, California, Colorado,

UnitedHealthcare Military & Veterans

TRICARE Overseas Program*

TRICARE Overseas Program Contractor

International SOS Government Services, Inc.

An Important Note About TRICARE Program Changes

Keep Your DEERS Information Up To Date!

Important Contact Information

TRICARE South Region

TRICARE West Region

Health Net Federal Services, LLC

Humana Military, a division of

TRICARE Overseas Program1

Service Points of Contact

Defense Health AgencyGreat Lakes

U.S. Coast Guard

Coast Guard Benefits Line

Commissioned Corps of the U.S. Public Health Service

Medical Affairs Branch

Defense Enrollment Eligibility Reporting System (DEERS)

Visit a local uniformed services identification card-issuing

Visit the milConnect Web site at http://milconnect.dmdc.mil.

Visit www.dmdc.osd.mil/appj/bwe to access the

TRICARE Dental Options

TRICARE Dental Program

TRICARE Retiree Dental Program

United Concordia Companies, Inc.

Delta Dental of California

Health Care Claims

TRICARE South Region

TRICARE West Region

Health Net Federal Services, LLC

TRICARE South Region

TRICARE West Region

TRICARE Pharmacy Program

TRICARE Pharmacy Home Delivery

TRICARE Retail Network Pharmacy

Download the Express Scripts New

Send pharmacy claims to:

Express Scripts Member

Express Scripts, Inc.

Express Scripts, Inc.

Prescription Drug Formulary Search

Beneficiary Web Enrollment

US Family Health Plan

TRICARE Mental Health