TFL HBK

TRICARE® For Life
F E B R UA R Y 2 0 2 0
HANDBOOK
Learn how TRICARE and Medicare work together

Important Information
TRICARE Website: www.tricare.mil
TRICARE For Life Contractor

Wisconsin Physicians Service (WPS)—
Military and Veterans Health: 1-866-773-0404
TRICARE For Life Website: www.TRICARE4u.com
TRICARE East Region Contractor

Humana Military: 1-800-444-5445
Humana Military Website: HumanaMilitary.com
www.tricare-east.com
TRICARE West Region Contractor

Health Net Federal Services, LLC: 1-844-866-WEST (1-844-866-9378)
Health Net Federal Services, LLC Website: www.tricare-west.com
Medicare: 1-800-MEDICARE (1-800-633-4227)
Social Security Administration: 1-800-772-1213
An Important Note About TRICARE Program Information

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 the TRICARE For Life contractor or your 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.health.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 sponsor’s or family member’s 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
Most TRICARE plans meet the Affordable Care Act requirement for minimum essential coverage. You’ll get an Internal Revenue Service
Form 1095 from your pay center each January listing the coverage you had during the previous tax year. You can find other health care
coverage options at www.healthcare.gov.
Use this page as a guide for the most important resources available to you. TRICARE WEBSITE: WWW.TRICARE.MIL
Important Contact Information

TRICARE FOR LIFE CONTRACTOR
Wisconsin Physicians Service (WPS)—Military and Veterans Health administers the TRICARE For Life (TFL) benefit and
should be your primary contact for TRICARE-related customer service needs in the U.S. or U.S. territories (American Samoa,
Guam, the Northern Mariana Islands, Puerto Rico and the U.S. Virgin Islands). International SOS Government Services, Inc.
(International SOS) administers the TFL benefit overseas.
GENERAL CONTACT INFORMATION GRIEVANCES
Phone: 1-866-773-0404 Email: [email protected]

Online: www.TRICARE4u.com WPS/TRICARE For Life
ATTN: Grievances
Written Correspondence:
P.O. Box 8974
WPS/TRICARE For Life
Madison, WI 53708
P.O. Box 7889
Madison, WI 53707
CLAIMS
WPS/TRICARE For Life (stateside) TRICARE Overseas Program

P.O. Box 7890 (Latin America and Canada)
Madison, WI 53707 P.O. Box 7985
Madison, WI 53707 USA
TRICARE Overseas Program (Eurasia-Africa) TRICARE Overseas Program (Pacific)
P.O. Box 8976 P.O. Box 7985
Madison, WI 53708 USA Madison, WI 53707 USA
DEFENSE ENROLLMENT ELIGIBILITY REPORTING SYSTEM (DEERS)

You have several options for updating and verifying DEERS information:
In person Visit a local ID card office. Find an office near you at

(add a family member or update www.dmdc.osd.mil/rsl. Call to verify location and
contact information) business hours.
Phone or fax 1-800-538-9552 (phone)
(update contact information) 1-866-363-2883 (TDD/TTY)
1-800-336-4416 (fax)
Online (update contact information) milConnect: https://milconnect.dmdc.osd.mil
Mail (update contact information) Defense Manpower Data Center Support Office
400 Gigling Road
Seaside, CA 93955
TRICARE REGIONAL CONTRACTORS
Regional contractors provide health care services and support in the TRICARE regions. They can help TFL beneficiaries with
prior authorizations, but they do not provide referrals for TFL beneficiaries. You may go to www.medicare.gov for help in
locating providers, hospitals, home health agencies or suppliers of durable medical equipment in your area. See the following
table for contact information for the two U.S. regional contractors. If you are overseas, your TRICARE Overseas Program (TOP)
contractor is International SOS. Contact your TOP Regional Call Center listed below or visit www.tricare-overseas.com.
Regional Contractors (Stateside) TOP Regional Call Centers (Overseas)

TRICARE East Region TRICARE Eurasia-Africa
Humana Military +44-20-8762-8384 (overseas)
1-800-444-5445 1-877-678-1207 (stateside)
HumanaMilitary.com [email protected]
TRICARE Latin America and Canada
TRICARE West Region
+1-215-942-8393 (overseas)
Health Net Federal Services, LLC 1-877-451-8659 (stateside)
1-844-866-WEST (1-844-866-9378) [email protected]
www.tricare-west.com
TRICARE Pacific
Singapore: +65-6339-2676 (overseas)
1-877-678-1208 (stateside)
[email protected]
Sydney: +61-2-9273-2710 (overseas)
1-877-678-1209 (stateside)
[email protected]
OTHER CONTACT INFORMATION

FOR MORE INFORMATION RESOURCE NUMBERS WEBSITES
Medicare 1-800-633-4227 www.medicare.gov
Social Security Administration 1-800-772-1213 www.ssa.gov
TRICARE Pharmacy Program 1-877-363-1303 www.tricare.mil/pharmacy
www.express-scripts.com/TRICARE
TRICARE Dental Program 1-844-653-4061 (CONUS) www.uccitdp.com
1-844-653-4060 (OCONUS)
711 (TDD/TTY)
Federal Employees Dental and See website www.tricare.mil/fedvip

Vision Insurance Program www.benefeds.com
Customer Service See website www.tricare.mil/bcacdcao
Community Directory
(find a Beneficiary Counseling and
Assistance Coordinator or a Debt
Collection Assistance Officer)
Find a military hospital or clinic See website www.tricare.mil/mtf
Get benefit correspondence See website https://milconnect.dmdc.osd.mil
by email
Welcome to
TRICARE For Life
LEARN HOW TRICARE AND MEDICARE
WORK TOGETHER
TRICARE For Life is Medicare-wraparound coverage for TRICARE

beneficiaries who have Medicare Part A and Medicare Part B,
regardless of age or where you live.
TRICARE For Life (TFL) provides comprehensive health care coverage. You
have the freedom to seek care from any Medicare-participating or Medicare
non-participating provider, or military hospital or clinic if space is available.
Medicare-participating providers file your claims with Medicare. After paying its
portion, Medicare automatically forwards the claim to TRICARE for processing
(unless you have other health insurance [OHI]). TRICARE pays after Medicare
and OHI for TRICARE-covered health care services. See “Finding a Provider” in
the Getting Care section of this handbook for information about provider types.
This handbook will help you make the most of your TFL coverage. You will find
information about eligibility requirements, getting care and claims. This handbook
also provides details about your pharmacy and dental coverage options.
Table of Contents
1. How TRICARE For Life Works.......................................................................4

Eligibility............................................................................................................................... 4
Understanding Medicare....................................................................................................... 5
Frequently Asked Questions: Medicare.................................................................................. 8
How TRICARE For Life Works with Medicare........................................................................... 9
Figure 1.1 TRICARE For Life Out-of-Pocket Costs............................................... 9
Frequently Asked Questions: How TRICARE For Life Works................................................... 12
2. Getting Care.............................................................................................13
Finding a Provider............................................................................................................... 13
Figure 2.1 Military Hospital and Clinic Appointment Priorities......................14
Urgent Care........................................................................................................................ 15
Mental Health Care............................................................................................................. 16
Prior Authorization for Care................................................................................................. 16
3. TRICARE For Life Coverage........................................................................ 17

Medical Coverage............................................................................................................... 17
Dental Coverage................................................................................................................. 17
Vision Coverage.................................................................................................................. 18
Frequently Asked Questions: TRICARE For Life Coverage...................................................... 18
4. Pharmacy................................................................................................. 19
Prescription Drug Coverage................................................................................................. 19
Filling Prescriptions............................................................................................................. 19
Figure 4.1 TRICARE Pharmacy Home Delivery Registration Methods ......... 21
Pharmacy Policy..................................................................................................................22
Pharmacy Claims................................................................................................................ 24
5. Claims...................................................................................................... 26
Health Care Claims in the U.S.
and U.S. Territories............................................................................................................. 26
Health Care Claims Overseas.............................................................................................. 27
Appealing a Claim or Prior Authorization Denial................................................................... 27
Third-Party Liability............................................................................................................. 27
Explanation of Benefits....................................................................................................... 28
Debt Collection
Assistance Officers............................................................................................................. 28
6. Life Changes: Keep Your DEERS Information Up To Date.............................29

Using MILConnect To Update Information in DEERS.............................................................29
Getting Married or Divorced................................................................................................30
Figure 6.1 Eligibility Situations for Former Spouses........................................30
Children.............................................................................................................................. 31
Moving................................................................................................................................32
Survivor Coverage...............................................................................................................32
Suspension of Social Security Disability Insurance..............................................................32
7. For Information and Assistance.................................................................33

Beneficiary Counseling and Assistance Coordinators...........................................................33
Your Right To Appeal a Decision..........................................................................................33
Figure 7.1 TRICARE For Life Appeals Requirements........................................34
Filing a Grievance...............................................................................................................35
8. Index........................................................................................................ 36
How TRICARE For Life Works
ELIGIBILITY
TRICARE For Life (TFL) is available to while the sponsor is on active duty.
TRICARE beneficiaries, regardless of age However, when the sponsor retires,
or where you live, if you have Medicare you must have Medicare Part B
Part A and Medicare Part B. You are eligible to remain TRICARE-eligible. See
for TFL on the first date you have both “Medicare Part B (Medical Insurance)”
Medicare Part A and Medicare Part B. later in this section for information
about the Medicare Part B special
enrollment period for ADSMs
TRICARE Eligibility Requirements
and ADFMs.)
When you are entitled to premium-free
■ You are enrolled in TRICARE Reserve
Medicare Part A:
Select (TRS), TRICARE Retired
• Medicare Part B coverage is required to Reserve (TRR), TRICARE Young
remain TRICARE-eligible if you are a(n): Adult (TYA), or the US Family Health
Plan (USFHP) (While you are not
■ Retired service member (including
required to have Medicare Part B to
retired National Guard and Reserve
remain eligible for TRS, TRR, TYA, or
members drawing retirement pay)
USFHP, you are strongly encouraged
■ Family member of a retired to sign up for Medicare Part B when
service member first eligible to avoid paying a late-
enrollment premium surcharge.)
■ Medal of Honor recipient or eligible
family member
Note: Regardless of age, ADFMs who have
■ Survivor of a deceased sponsor Medicare Part A may enroll in TRICARE
Prime if they live in a Prime Service
■ Eligible former spouse
Area (PSA), or with a drive-time waiver,
• Medicare Part B coverage is not required within 100 miles of an available primary
to remain TRICARE-eligible if: care manager. A PSA is a geographic area
where TRICARE Prime is offered. It is
■ You are an active duty service member
typically an area near a military hospital
(ADSM) or active duty family member
or clinic. The TRICARE Prime enrollment
(ADFM) (ADSMs remain eligible for
fee is waived for any TRICARE Prime
TRICARE Prime or TRICARE Prime
beneficiary who has Medicare Part B,
Remote. ADFMs remain eligible for
regardless of age. For more information,
TRICARE Prime, TRICARE Prime
visit www.tricare.mil/prime.
Remote or TRICARE Select options
4
SECTION 1
UNDERSTANDING MEDICARE spouses) work history. You are eligible for
premium-free Medicare Part A at age 65 if
TFL is managed by the Department of
you or your spouse has 40 quarters or 10 years
Defense. Medicare is managed by the
of Social Security-covered employment.
Centers for Medicare & Medicaid Services
(CMS). The two agencies work together to
If you are not entitled to premium-free
coordinate benefits.
Medicare Part A when you turn 65 under
your own Social Security number (SSN),
Medicare is a federal entitlement health
you must file for benefits under your
insurance program for people:
spouse’s (this includes divorced or deceased
• Age 65 or older spouses) SSN if he or she is 62 or older. If
your spouse is not yet 62, and you anticipate
• Under age 65 with certain disabilities that he or she will be eligible for premium-
• Any age with end-stage renal free Medicare Part A at age 65, you should
disease (ESRD) sign up for Medicare Part B when first
eligible at age 65 to avoid paying a late-
enrollment premium surcharge. You should
Medicare Part A (Hospital Insurance)
then file for Part A benefits under your
Medicare Part A covers inpatient hospital spouse’s record two months before he or she
care, hospice care, inpatient skilled nursing turns 62.
facility care and some home health care.
The Social Security Administration (SSA) Note: If neither spouse will be eligible for
determines your entitlement to Medicare premium-free Medicare Part A, neither
Part A based on your work history or your will need Medicare Part B to remain
spouse’s (this includes divorced or deceased TRICARE-eligible.
5
Medicare Part B (Medical Insurance) period, which waives the late-enrollment
premium surcharge. The special enrollment
Medicare Part B covers provider services,
period for ADSMs and ADFMs is available
outpatient care, home health care, durable
anytime the sponsor is on active duty
medical equipment and some preventive
or within eight months following either
services. Medicare Part B has a monthly
(1) the month your sponsor retires (2) the
premium, which may change yearly and
month TRICARE coverage ends, whichever
varies based on income. If you sign up
comes first. To avoid a break in TRICARE
after your initial enrollment period for
coverage, ADSMs and ADFMs must sign up
Medicare Part B, you may have to pay a late-
for Medicare Part B before their sponsor’s
enrollment premium surcharge (10 percent
active duty status ends.
for each 12-month period that you were
eligible to enroll in Medicare Part B but
Note: ADSMs and ADFMs with ESRD do
did not) for as long as you have Medicare
not have a special enrollment period and
Part B. For specific information about your
should enroll in Medicare Part A and Part B
Part B premium and/or surcharge amount,
when first eligible.
call SSA at 1-800-772-1213.
Medicare allows ADSMs and ADFMs USFHP and Medicare Entitlement

who are entitled to Medicare based on
If you are a USFHP beneficiary under age
age or disability (does not apply to those
65 and entitled to premium-free Medicare
with ESRD) to delay Part B enrollment
Part A, you are strongly encouraged to
and sign up during a special enrollment
have Medicare Part B (except for disabled
ADFMs). If you are enrolled in USFHP and
entitled to Medicare based on disability or
age, you are not required to have Medicare
Part B. As of Oct. 1, 2012, Medicare-eligible
beneficiaries age 65 and older can no longer
enroll in USFHP. Anyone whose enrollment
was effective Oct. 1, 2012, or later and
becomes Medicare-eligible based on age, is
disenrolled from USFHP and transferred
to TFL.
Medicare Entitlement Based on

a Disability
If you receive Social Security disability
benefits, you are entitled to Medicare in
the 25th month of receiving disability
payments. CMS will notify you of your
Medicare entitlement date.
6
Your Medicare initial enrollment period is a
If you return to work and your Social
seven-month period.
Security disability payments are suspended,
your Medicare entitlement continues for • If your birthday falls on the first of the
SECTION 1
up to eight years and six months. When month, your initial enrollment period
your disability payments are suspended, begins four months before the month you
you will get a bill every three months turn 65. Enroll no later than two months

for your Medicare Part B premiums. before the month you turn 65 to avoid
You must continue to pay your Medicare a break in TRICARE coverage. You are
Part B premiums to remain eligible for eligible for Medicare coverage on the first
TRICARE coverage. day of the month before you turn 65.
• If your birthday falls on any day other
Medicare Entitlement Based on ESRD than the first of the month, your initial
enrollment period begins three months
If you are eligible for Medicare benefits based
before the month you turn 65. Enroll no
on ESRD, enroll in Medicare Part A and
later than one month before your birth
Part B when you are first eligible to remain
month to avoid a break in TRICARE
TRICARE-eligible. ADSMs and ADFMs
coverage. You are eligible for Medicare
with ESRD do not have a special enrollment
on the first day of the month you turn 65.
period and should enroll in Part B when first
eligible to avoid the Part B late-enrollment
Enroll in Medicare Part B when first
premium surcharge.
eligible to avoid a break in TRICARE
coverage. If you sign up after your initial
Medicare Entitlement Based on enrollment period, you may have to pay
Lou Gehrig’s Disease a late-enrollment premium surcharge for
as long as you have Part B. The Medicare
If you have Lou Gehrig’s disease (also
Part B surcharge is 10 percent for each
called amyotrophic lateral sclerosis or ALS),
12-month period that you were eligible
you automatically get Medicare Part A and
to enroll in Part B but did not.
Part B the month your disability begins.
Your Part B premiums are automatically
Medicare Entitlement Based on Age taken out of your Social Security or
U.S. Railroad Retirement Board monthly
The Medicare entitlement age is 65. If you
payments. If you do not get these types of
already get retirement benefits from the
payments, Medicare bills you every three
SSA or the U.S. Railroad Retirement Board,
months for Part B premiums.
you are automatically entitled to Medicare
Part A and Part B the month you turn 65 or
Note: If you live in Puerto Rico and already
the month prior if your birthday falls on the
get SSA or U.S. Railroad Retirement Board
first of the month.
benefits, you automatically get Medicare
Part A; however, you must sign up for Part B.
If you do not receive Social Security or U.S.
Railroad Retirement Board benefits before
age 65, you must apply for Medicare benefits.
7
FAQs Frequently Asked Questions:
Medicare
I will be 65 soon and will sponsored coverage to ensure are not eligible for premium-free
become entitled to Medicare. your TRICARE coverage under Medicare Part A, you are eligible
I work full time and have TFL begins immediately following for Medicare Part B at age 65.
employer-sponsored group the end of your employer- See “Medicare Entitlement
health plan coverage, and I sponsored coverage. Your TFL Based on Age” earlier in this
don’t plan on retiring for a few coverage begins on the first day section for more information.
you have both Medicare Part A
more years. Medicare says I If you sign up for Medicare and
and Part B coverage.
can delay my Part B enrollment are not eligible for premium-
if I have employer-sponsored free Part A under your or your
coverage. How does this affect If I am not entitled to premium- spouse’s (this includes divorced
my TRICARE benefit? free Medicare Part A when I turn or deceased spouses) SSN, you
65, can I still use TFL? will get a “Notice of Award” or
If you are entitled to premium- “Notice of Disapproved Claim”
free Medicare Part A, you must Because you are not entitled to from SSA. To keep your TRICARE
also have Part B to remain premium-free Medicare Part A, coverage, take the “Notice(s)
TRICARE-eligible, even if you you do not need Medicare of Award” or “Notice(s) of
have employer-sponsored Part B to keep your TRICARE Disapproved Claim” to a
coverage. Medicare allows benefit. You do not transition uniformed services ID card
individuals with employer- to TFL. You may continue office to have your Defense
sponsored coverage to delay enrollment in TRICARE Prime Enrollment Eligibility Reporting
Part B enrollment and sign up if you live in a PSA, or if System (DEERS) record updated
during a special enrollment qualified, you may enroll in and get a new ID card. This
period, which waives the late- TRICARE Select. For information allows you to keep your eligibility
enrollment premium surcharge. about TRICARE program options, for TRICARE Prime or TRICARE
If you or your spouse still works visit www.tricare.mil. Select after you turn 65.
and has employer-sponsored If you are not eligible for premium-
coverage, you may sign up Note: Uniformed services
free Medicare Part A under your ID card offices will not accept
for Medicare Part B during a own SSN when you turn 65,
special enrollment period, which an SSA Report of Confidential
you must file for benefits under Social Security Benefit
is available anytime you or your your spouse’s (this includes
spouse is currently working and Information form (SSA-2458)
divorced or deceased spouses) as proof of ineligibility for
covered by employer-sponsored SSN if he or she is 62 or older.
coverage, or within the eight premium-free Part A to keep
If your spouse is not yet 62, your TRICARE eligibility.
months following either (1) loss you must file for benefits under
of employment or (2) loss of his or her SSN two months
group health plan coverage, before he or she turns 62.
whichever comes first.
If you will be eligible under
If you choose to delay your spouse’s SSN in the
enrollment in Medicare future, you should sign up for
Part B and rely solely on your Medicare Part B during your
employer-sponsored coverage, initial enrollment period to avoid
sign up for Part B before paying a Part B late-enrollment
you retire or lose employer- premium surcharge. Even if you
8
Medicare Entitlement Based on an When you see a Medicare participating or
Asbestos-Related Disease Medicare non-participating provider, you
have no out-of-pocket costs for services
If you have been diagnosed with an asbestos-
covered by both Medicare and TFL. Most
SECTION 1
related disease (for example, mesothelioma)
health care services fall into this category.
and lived in Lincoln County, Montana, for
After Medicare pays its portion of the claim,
a total of at least six months during a period
TFL pays the remaining amount and you

ending 10 years or more before the diagnosis,
pay nothing.
you are eligible for Medicare. Your Medicare
coverage is effective the month after you
As the primary payer, Medicare approves
sign up.
health care services for payment. If Medicare
does not pay because it determines that the
HOW TRICARE FOR LIFE WORKS care is not medically necessary, TFL also does
WITH MEDICARE not pay. You may appeal Medicare’s decision
and, if Medicare reconsiders and provides
Medicare and TFL work together to
coverage, TFL also reconsiders coverage.
minimize your out-of-pocket expenses.
However, there are instances when some
If a health care service is covered by both
health care costs may not be covered by
Medicare and TFL, but Medicare does
Medicare and/or TFL.
not pay because you have used up your
Medicare benefit, TFL becomes the primary
Health Care Services Covered by payer. In this case, you are responsible for
Medicare and TRICARE your TFL deductible and cost-shares.
Figure 1.1 TRICARE For Life Out-of-Pocket Costs
TYPE OF SERVICE MEDICARE PAYS TRICARE PAYS YOU PAY
Covered by Medicare- Remaining amount Nothing

TRICARE and authorized amount
Medicare
Covered by Medicare- Nothing Medicare

Medicare only authorized amount deductible and
cost-share
Covered by Nothing TRICARE-allowable TRICARE deductible

TRICARE only amount and cost-share
Not covered Nothing Nothing Billed charges

by TRICARE (which may exceed
or Medicare the Medicare or
TRICARE-allowable
amount)
9
services received overseas), TRICARE
If a health care service is normally covered
processes the claim as the primary payer.
by both Medicare and TFL, but you get the
You are responsible for the applicable TFL
service from a provider who has opted out of
deductible, cost-shares and remaining billed
Medicare, the provider cannot bill Medicare
charges. Outside the U.S. and U.S. territories
and Medicare pays nothing. When you
(American Samoa, Guam, the Northern
see an opt-out provider, TFL processes the
Mariana Islands, Puerto Rico and the
claim as the second payer, unless you have
U.S. Virgin Islands), there may be no
other health insurance (OHI). TFL pays
limit to the amount that nonparticipating
the amount it would have paid if Medicare
non-network providers may bill. You are
had processed the claim (normally TFL
responsible for paying any amount that
pays 20 percent of the TRICARE-allowable
exceeds the TRICARE-allowable charge,
charge) and you are responsible for the
in addition to your deductible and cost-
remainder of the billed charges.
shares. Visit www.tricare.mil/overseas for
more information.
Similarly, U.S. Department of Veterans Affairs
(VA) providers cannot bill Medicare and
TFL claims are normally filed with
Medicare pays nothing. When you see a VA
Medicare first; however, when a health care
provider for health care not related to service-
service is not covered by Medicare, your
connected injuries or illnesses, TFL processes
provider may file the claim directly with
the claim as the second payer. TFL pays up to
Wisconsin Physicians Service (WPS)—
20 percent of the TRICARE-allowable charge.
Military and Veterans Health, unless you
have OHI. See the Claims section of this
Opt-out providers establish private contracts
handbook for more information.
with patients. Under a private contract,
there are no limits on what the provider can
charge for health care services. Medical Services Not Covered by
Medicare or TRICARE
Medical Services Covered by Medicare When you get care that is not covered
but Not by TRICARE by Medicare or TFL (for example, most
cosmetic surgery), neither makes a payment
When you get care that is covered by
on the claim. You are responsible for the
Medicare only (for example, chiropractic
entire bill.
care), Medicare processes the claim as the
primary payer. TFL pays nothing, regardless
For more information on covered
of any action Medicare takes. You are
services, visit www.medicare.gov or
responsible for the Medicare deductible
www.tricare.mil/coveredservices or
and cost-shares.
contact WPS.
Medical Services Covered by TRICARE See Figure 1.1 on the previous page for TFL
but Not by Medicare out-of-pocket costs.
When you get care that is covered only
by TFL (for example, TRICARE-covered
10
Coordinating TRICARE For Life with TFL works exactly as it does in the U.S.
Other Health Insurance Unless you have OHI, TFL is the second
payer after Medicare for most health care
How Medicare coordinates with OHI depends services. Your provider files the claim with
SECTION 1
on whether or not the OHI is based on current Medicare first. Medicare pays its portion
employment. In either case, TFL pays last. and automatically forwards the claim to
WPS for processing.

OHI Not Based on Current Employment
Medicare does not provide coverage outside
If you have OHI that is not based on your the U.S., U.S. territories or aboard ships
or a family member’s current employment, outside U.S. territorial waters. Therefore,
Medicare pays first, your OHI pays second TFL is your primary payer for health care
and TFL pays last. received in all other overseas locations,
unless you have OHI.
Other Health Insurance Based
on Current Employment Eligible TFL beneficiaries may receive
covered services and supplies from a
Generally, if you have an employer-sponsored network provider or any authorized-
health plan based on current employment, TRICARE provider. You will be subject to
that health plan pays first, Medicare pays the applicable catastrophic cap, deductibles
second and TFL pays last. If there are fewer and cost-shares. If a TFL beneficiary
than 20 employees in the employer-sponsored receives covered services from a network
plan, Medicare pays first, your OHI pays provider, the beneficiary’s out-of-pocket
second and TFL pays last. costs will generally be lower. Prior
authorization may be required (except for
When your OHI processes the claim after emergency care). When seeking care from a
Medicare, you need to submit a claim to civilian provider, area- or country-specific
WPS for any remaining balance. See the requirements may also apply. For TFL
Claims section of this handbook for deductibles and cost-shares, visit
more information. www.tricare.mil/tflcosts.
Note: TRICARE pays after most insurance For requirements about getting care in the
plans with the exception of Medicaid, Philippines, see “Overseas Providers” in the
TRICARE supplements, the Indian Health Getting Care section of this handbook.
Service and other programs and plans as
identified by the Defense Health Agency. You should be prepared to pay upfront
for services and submit a claim to the
TRICARE Overseas Program (TOP) claims
How TRICARE For Life Works Overseas
processor. Claims for care received overseas
TRICARE is the only payer overseas. are submitted directly to the TOP claims-
Medicare provides coverage in the U.S. processing address for the area where you
and U.S. territories. Medicare also covers received care and must include proof of
health care services received aboard ships payment. See the Claims section of this
in U.S. territorial waters. In these locations, handbook for more information.
11
Does TFL pay for the Medicare Suspension Confirmation Medicare for assistance with
Part B premium and deductible? form (RI 79-9). Eligible former finding Medicare providers.
spouses who have not
The Medicare Part B monthly You may be able to sign up
remarried can get the form
premium is your responsibility. for TRICARE Plus. TRICARE
from the employing offices or
TFL covers the Medicare Plus is a program that allows
retirement system maintaining
Part B deductible as long beneficiaries who normally
their enrollments.
as the health care service are only able to get military
is covered by both Medicare hospital and clinic care (if
and TRICARE. Is a referral or TRICARE prior space is available) to enroll and
authorization required for health get primary care appointments
care services? at the military hospital or clinic.
Using TFL seems so easy. TRICARE Plus offers the same
Should I cancel my Medicare A referral or TRICARE prior primary care access standards
supplement, Medicare authorization is not required as beneficiaries enrolled
Advantage Plan or OHI? under TFL when Medicare is the in a TRICARE Prime option.
primary payer. However, when Beneficiaries should contact
Carefully evaluate your health TFL becomes the primary payer,
insurance needs to determine their local military hospitals or
TRICARE prior authorization clinics to determine if TRICARE
if you should continue requirements apply.
Medicare supplements, Plus is available and whether
Medicare Advantage Plans they may participate in it.
or OHI. You may contact I was enrolled in TRICARE Prime® Enrollment in TRICARE Plus at
your local State Health at a military hospital. I received one military hospital or clinic
Insurance Assistance Program a letter from the military hospital does not automatically extend
for free health insurance telling me I am no longer eligible TRICARE Plus enrollment to
counseling and assistance. for enrollment in TRICARE Prime. another military hospital or
For more information, visit What does that mean? clinic. The military hospital or
https://shipnpr.acl.gov. clinic is not responsible for
Once you become entitled to
Note: If you drop your OHI any costs when a beneficiary
premium-free Medicare Part A
coverage, you must notify WPS. enrolled in TRICARE Plus
because you are age 65, you
seeks care outside the military
are eligible for TFL when you
hospital or clinic.
I am a TFL beneficiary and a also have Medicare Part B.
retired federal employee. Can I You are no longer eligible for
enrollment in TRICARE Prime,
suspend my Federal Employees
unless you have an active
Health Benefits (FEHB) Program
duty sponsor.
coverage to use TFL?
You may continue to seek care
Yes. You may suspend your at a military hospital or clinic if
FEHB coverage and premium space is available, but will likely
payments at any time. Visit need to seek care from civilian
www.opm.gov/forms to get a Medicare providers. Contact
Health Benefits Cancellation/
12
Getting Care
FINDING A PROVIDER opt-out provider, TFL pays the amount it

would have paid (normally up to 20 percent
You may get health care services from
of the allowable charge) if Medicare had
Medicare participating and Medicare non-
processed the claim, and you are responsible
participating providers, as well as from
for paying the remainder of the billed
providers who have opted out of Medicare.
charges. In cases where access to medical
If TRICARE For Life (TFL) is the primary
care is limited (underserved areas), TFL may
payer, you must visit TRICARE-authorized
waive the second-payer status for Medicare
providers and facilities. You will have
opt-out providers and pay the claim as the
SECTION 2
significant out-of-pocket expenses when
primary payer.
you get care from opt-out providers, or
when seeing a U.S. Department of Veterans
Affairs (VA) provider for health care not Veterans Affairs Providers
Getting Care
related to a service-connected injury or
VA providers cannot bill Medicare and
illness. Costs vary according to the type of
Medicare cannot pay for services received
provider you see (for example, opt-out or VA).
from VA. If you are eligible for both TFL
and VA benefits, you will have significant
Medicare Participating Providers out-of-pocket expenses when seeing a
VA provider for health care not related
Medicare participating providers agree to
to a service-connected injury or illness.
accept the Medicare allowed amount as
If you get care at a VA facility, you may
payment in full.
be responsible for 80 percent of the bill.
By law, TRICARE can only pay up to 20
Medicare Non-participating Providers percent of the TRICARE-allowable amount
for these services. When using your TFL
Medicare non-participating providers do
benefit, your least expensive options are to
not accept the Medicare allowed amount
see a Medicare participating or Medicare
as payment in full. They may charge up
non-participating provider.
to 15 percent above the Medicare allowed
amount, a cost that is covered by TFL.
If you want to seek care from a VA provider,
check with Wisconsin Physicians Service
Opt-Out Providers (WPS)—Military and Veterans Health
by calling 1-866-773-0404 to confirm
Providers who opt out of Medicare enter into
coverage details and determine what is
private contracts with patients and are not
covered by TRICARE.
allowed to bill Medicare. Therefore, Medicare
does not pay for health care services you get
from opt-out providers. When you see an
13
Military Hospitals and Clinics Philippine locations are encouraged to
see a TRICARE-preferred provider. Visit
A military hospital or clinic is usually www.tricare-overseas.com/philippines.htm
located on or near a military base. You may for more information.
get care at a military hospital or clinic if
space is available. See Figure 2.1 for military
When seeking care from a civilian provider,
hospital and clinic appointment priorities.
be prepared to pay upfront for services and
submit a claim to the TRICARE Overseas
Figure 2.1 Military Hospital and Program (TOP) claims processor. Outside
Clinic Appointment Priorities the U.S. and U.S. territories (American
Samoa, Guam, the Northern Mariana
1 Active duty service members Islands, Puerto Rico and the U.S. Virgin
Islands), there may be no limit to the
2 Active duty family members
amount that nonparticipating non-network
(ADFMs) enrolled in TRICARE Prime
providers may bill, and you are responsible
3 Retired service members, their for paying any amount that exceeds the
families and all others enrolled in TRICARE-allowable charge, in addition to
TRICARE Prime or TRICARE Plus your deductible and cost-shares.
(primary care)
For information on overseas proof-of-
4 ADFMs not enrolled in
TRICARE Prime payment requirements for submitting
claims, see “Health Care Claims Overseas”
TRICARE Reserve Select members in the Claims section of this handbook.
and their families
5 Retired service members and their For more information about getting care
families, TRICARE Retired Reserve overseas, call your TOP Regional Call
members and their families, Center or visit www.tricare-overseas.com.
beneficiaries enrolled in TRICARE
Plus (specialty care) and all others EMERGENCY CARE
not enrolled in TRICARE Prime
TRICARE defines an emergency as a
medical, maternity or psychiatric condition
that would lead a “prudent layperson”
Overseas Providers (someone with average knowledge of health
and medicine) to believe that a serious
With TFL overseas, you may generally use
medical condition exists; that the absence of
any purchased care sector provider, also
immediate medical attention would result in
called a civilian provider, and get care
a threat to life, limb or sight; when a person
at military hospitals and clinics if space
has severe, painful symptoms requiring
is available, except in the Philippines,
immediate attention to relieve suffering; or
where you are required to see a certified
when a person is at immediate risk to self
provider for care. Additionally, TOP Select
or others. The TRICARE health care benefit
beneficiaries who reside in the Philippines
covers adjunctive dental care (for example,
and who seek care within designated
dental care that is medically necessary to
14
treat a covered medical—not a dental— care from the nearest emergency care
condition). The TRICARE health care facility. You can contact the TOP
benefit does not cover non-adjunctive dental Regional Call Center for your area or visit
care, which refers to any routine, preventive, www.tricare-overseas.com for assistance
restorative, prosthodontic, periodontal, or in finding a civilian provider. Contact the
emergency dental care that is not related TOP Regional Call Center within 24 hours if
to a medical condition. Eligible TRICARE you are admitted to coordinate follow-on care.
beneficiaries may receive non-adjunctive
dental services if enrolled in the TRICARE
URGENT CARE
Dental Program or the Federal Employees
Dental and Vision Insurance Program. Urgent care services are medically
necessary services required for an
If you need emergency care in the U.S. or
illness or injury that would not result in
U.S. territories, call 911 or go to the nearest
further disability or death if not treated
emergency room. Make sure you present
SECTION 2
immediately, but does require professional
your Medicare card so your claim is filed
attention within 24 hours. You could
with Medicare.
require urgent care for conditions such as
a sprain or rising fever, as both of these
Getting Care
If traveling or living overseas, first
conditions have the potential to develop
attempt to seek care from the nearest
into an emergency if treatment is delayed
military hospital or clinic. If a military
longer than 24 hours.
hospital or clinic is not available, seek
If it’s after hours or you’re not sure if

you need to see a health care provider,
contact the Military Health System
(MHS) Nurse Advice Line 24/7. Visit
www.mhsnurseadviceline.com to chat
with a nurse or to find country-specific
numbers. In the U.S., call 1-800-TRICARE
(1-800-874-2273), option 1. You can talk to
a registered nurse who can:
• Answer your urgent care questions
• Answer your pediatric care questions
(pediatric nurses are available) • Help you schedule appointments at
military hospitals or clinics, if available
• Help you determine whether you need Note: The MHS Nurse Advice Line is not
to see a health care provider
intended for emergencies and is not a
• Help you find the closest urgent care substitute for emergency treatment. If you
center or emergency room think you may have a medical emergency, call
911 or go to the nearest emergency room.
15
MENTAL HEALTH CARE For requests for authorization, providers
should fill out the specific request form
Medicare helps cover visits with the following
and submit it for review. Authorization
types of health care providers:
request forms and instructions on how
• A psychiatrist or other doctor to submit forms are available online at
www.TRICARE4u.com.
• Clinical psychologist
• Clinical social worker If you have questions about prior
authorization requirements, contact WPS.
• Clinical nurse specialist See the Important Contact Information
• Nurse practitioner section at the beginning of this handbook
for the WPS website and toll-free number.
• Physician’s assistant
The following services require prior
Medicare only covers these visits when they
authorization:
are provided by health care providers who
accept Medicare payment. To help lower your • Adjunctive dental services (dental
costs, ask your health care providers if they care that is medically necessary in
accept assignment, which means they accept the treatment of an otherwise covered
the Medicare-approved amount as payment in medical—not dental—condition)*
full, before you schedule an appointment.
• Extended Care Health Option services
(active duty family members only)
For more information on Medicare’s
mental health care coverage, visit • Home health care services
www.medicare.gov.
• Home infusion therapy
PRIOR AUTHORIZATION FOR CARE
• Hospice care
When TFL becomes the primary payer
• Transplants—all solid organ and stem cell
(for example, if your Medicare benefits • Some prescription medications
run out), TRICARE prior authorization (for example, brand-name medications
requirements apply. or those with quantity limitations)
Prior authorization is a review of the Note: This list is not all-inclusive.

requested health care service to determine For details about prior authorization
if it is medically necessary at the requested requirements, contact WPS.
level of care. If you have a prior authorization
* For more information on TRICARE dental
from a TRICARE regional contractor coverage, see “Dental Coverage” in the TRICARE
(Health Net Federal Services, LLC; Humana For Life Coverage section of this handbook.
Military; or International SOS Government
Services, Inc.) that covers the dates on your
claim, WPS honors that prior authorization
and no TFL prior authorization is required.
16
TRICARE For Life Coverage
Examples of services that are generally not

reimbursable by TFL or Medicare include:
• Acupuncture
• Experimental or investigational services
(in most cases)
• Eye exams (routine)
• Hearing aids*
Note: This list is not all-inclusive.
MEDICAL COVERAGE * If you are a retired sponsor, you may be eligible
for the Retiree-At-Cost Hearing Aid Program
TRICARE For Life (TFL) and Medicare and should call a participating military hospital
cover proven, medically necessary and or clinic. Visit www.militaryaudiology.org for
appropriate care. TFL has special rules and more information.
limitations for certain types of care, and
some types of care are not covered at all.
DENTAL COVERAGE
TRICARE policies are very specific about
which services are covered and which are You may qualify for one of two voluntary
SECTION 3
not. It is in your best interest to take an dental care programs: the TRICARE
active role in verifying coverage. Dental Program (TDP) or the Federal
Employees Dental and Vision Insurance
Note: Medicare also has limits on the Program (FEDVIP).

amount of care it covers and, in some cases,
TFL may cover these health care services
TRICARE Dental Program
after your Medicare benefits run out.
The TDP provides worldwide dental
To determine if Medicare covers a specific coverage for eligible family members of
service or benefit, visit www.medicare.gov active duty service members, survivors,
or call 1-800-633-4227. To determine if certain National Guard and Reserve
TFL covers the service or benefit, visit the members and their families, and Individual
TRICARE website at www.tricare.mil or Ready Reserve members and their families.
call Wisconsin Physicians Service—Military Former spouses and remarried surviving
and Veterans Health at 1-866-773-0404. spouses do not qualify to purchase coverage.
See Figure 1.1 in the How TRICARE For For more information about the TDP, visit
Life Works section of this handbook for more www.uccitdp.com or call United Concordia
information on your out-of-pocket costs. Companies, Inc. at 1-844-653-4061 (CONUS)
or 1-844-653-4060 (OCONUS).
17
Federal Employees Dental and Vision Former spouses and remarried surviving
Insurance Program spouses don’t qualify to purchase dental
coverage. However, if enrolled in a
FEDVIP, offered by the U.S. Office of
TRICARE health plan, they may qualifty to
Personnel Management, is available to
purchase vision coverage. For information
retired service members and their eligible
about FEDVIP, visit www.benefeds.com.
family members, including certain retired
National Guard and Reserve members and
their family members. VISION COVERAGE
You and other eligible family members
FEDVIP is also available to certain
enrolled in a TRICARE health plan may
surviving family members of deceased
qualify to purchase vision coverage through
active duty sponsors, Medal of Honor
FEDVIP. For information about FEDVIP,
recipients, and their immediate family
visit www.benefeds.com.
members and survivors.

Does TFL cover long-term care? occupational and speech TFL is the primary payer for SNF
therapy; drugs furnished by the care beyond Medicare’s 100-day
No. Long-term care (or custodial
facility; and necessary medical limit as long as the patient
care) is not a covered benefit.
supplies and appliances. Skilled continues to require skilled
However, you may qualify
nursing care is typically provided nursing services and no other
to purchase long-term care
in a skilled nursing facility (SNF). health insurance is involved. SNF
insurance through commercial
care requires prior authorization
insurance programs or through For TFL and Medicare to cover
on day 101, when TRICARE is
the Federal Long Term Care SNF admission, you must have
the primary payer. TFL covers
Insurance Program. had a medical condition that
an unlimited number of days as
was treated in a hospital for at
For more information about medically necessary.
least three consecutive days,
the Federal Long Term Care
and you must be admitted to Note: SNF care is only covered
Insurance Program, visit
a Medicare-certified, TRICARE- in the U.S. and U.S. territories
www.opm.gov/insure/ltc or
participating SNF within 30 days (American Samoa, Guam,
call 1-800-582-3337.
of discharge from the hospital the Northern Mariana
(with some exceptions for Islands, Puerto Rico and
Does TRICARE cover skilled medical reasons). Your health the U.S. Virgin Islands).
nursing care? care provider’s plan of care
must demonstrate your need
TFL covers skilled nursing
for skilled nursing services.
services; meals (including
special diets); physical,
18
Pharmacy
SECTION 4 Pharmacy
PRESCRIPTION DRUG COVERAGE FILLING PRESCRIPTIONS
TRICARE offers comprehensive
prescription drug coverage and
Military Pharmacies
several options for filling your covered Military pharmacies are usually located
prescriptions. To fill a prescription, you within military hospitals and clinics. At
need a prescription and a valid uniformed a military pharmacy, you may get up to
services ID card or Common Access Card. a 90-day supply of most medications at
Your options for filling your prescriptions no cost. Most military pharmacies accept
depend on the type of drug your provider prescriptions from both civilian and
prescribes. For more information, visit military providers, regardless of whether
www.express-scripts.com/TRICARE or not you are enrolled at the military
or call 1-877-363-1303. The TRICARE hospital or clinic.
pharmacy benefit is administered by
Express Scripts, Inc. (Express Scripts). Electronic prescribing (e-prescribing) is
accepted at many military pharmacies
When traveling overseas, be prepared to pay in the U.S., Puerto Rico and Guam. This
upfront for medications and file a claim to allows your civilian providers to send
get money back for non-military hospital prescriptions electronically to military
or clinic and non-network pharmacy pharmacies near you. E-prescribing from
services. TRICARE For Life recommends
that you fill all of your prescriptions before
traveling overseas.
If you live or travel in the Philippines,

you are required to use a certified
pharmacy. For more information, visit
www.tricare-overseas.com/philippines.htm.
Over-the-counter (OTC) drugs are not

covered overseas (except in U.S. territories).
This includes drugs that are considered
OTC in the U.S., even when they require a
prescription in a foreign country.
Note: You do not need a Medicare Part D

prescription drug plan to keep your
TRICARE prescription drug coverage.
19
a health care provider to a pharmacy have questions about your prescriptions,
reduces medication errors and offers more pharmacists are available 24/7 to speak
convenience. You can ask your provider to confidentially with you.
look for your local military pharmacy in the
e-prescribing database/network. For faster processing of your mail-order
prescriptions, register before placing
Non-formulary medications are generally not your first order. Once you are registered,
available at military pharmacies. To check your provider can send prescriptions
the availability of a particular drug, contact electronically or by phone. Express Scripts
the nearest military pharmacy. sends your medications directly to your
home within about 14 days of receiving
your prescription. Register for TRICARE
TRICARE Pharmacy Home Delivery
Pharmacy Home Delivery using any of the
There is no cost for TRICARE Pharmacy options listed in Figure 4.1 on the next page.
Home Delivery for active duty service
members. Copayments apply for all covered Note: Overseas beneficiaries must have
medications (up to a 90-day supply). an APO/FPO address or be assigned to
Additionally, prescriptions are delivered to a U.S. Embassy or Consulate and have a
you with free standard shipping, and refills prescription from a U.S.-licensed provider to
can be easily ordered online, by phone or use home delivery. Refrigerated medications
by mail. Home delivery also provides you cannot be shipped to APO/FPO addresses.
with convenient notifications about your Beneficiaries living in Germany cannot use
order status, refill reminders and assistance the home delivery option due to country-
in renewing expired prescriptions. If you specific legal restrictions. If you live in
20
Germany, fill prescriptions at military or Northern Mariana Islands, Puerto Rico and
overseas pharmacies. the U.S. Virgin Islands. Currently, there are
no TRICARE retail network pharmacies in
If you have prescription drug coverage American Samoa.
SECTION 4 Pharmacy
through other health insurance (OHI),
you can use TRICARE Pharmacy Home Visit www.express-scripts.com/TRICARE
Delivery only if the medication is not or call 1-877-363-1303 for customer service,
covered under your OHI or if you exceed including finding the nearest TRICARE
the OHI’s coverage limit. retail network pharmacy.
TRICARE Retail Network Pharmacies Non-Network Pharmacies

Another option for filling your prescriptions When visiting non-network pharmacies,
is through TRICARE retail network you pay the full price of your medication
pharmacies. To fill prescriptions (one upfront and file a claim to get money
copayment per 30-day supply), present your back. Claims are subject to deductibles,
prescription and uniformed services ID card out-of-network cost-shares and TRICARE-
to the pharmacist. required copayments. All deductibles must
be met before you can get money back. For
This option allows you to fill your details about filing a claim, see the Claims
prescriptions at TRICARE retail network section of this handbook.
pharmacies throughout the U.S. without
having to submit a claim. You have access to
TRICARE retail network pharmacies in the
U.S. and the U.S. territories of Guam, the
Figure 4.1 TRICARE Pharmacy Home Delivery Registration Methods
Visit www.express-scripts.com/TRICARE.
ONLINE
Call 1-877-363-1303 or 1-877-540-6261 (TDD/TTY).

PHONE
Download the registration form from www.express-scripts.com/TRICARE,

and mail it to:
Express Scripts, Inc.
MAIL
P.O. Box 52150
Phoenix, AZ 85072
21
PHARMACY POLICY same safe, effective treatment as brand-
name drugs. It is DoD policy to generally
Quantity Limits use generic formulary medications instead
of brand-name medications whenever
TRICARE has established quantity limits possible. A brand-name drug with a generic
on certain medications, which means the equivalent generally may be dispensed only
Department of Defense (DoD) pays for a after the prescribing provider completes a
specified, limited amount of medication each clinical assessment indicating the brand-
time you fill a prescription. Quantity limits name drug is medically necessary and after
are often applied to ensure medications are Express Scripts grants approval. Prescribers
safely and appropriately used. may call 1-866-684-4488 to submit a request
for a brand-name drug to be dispensed
Exceptions to established quantity limits instead of a generic, or a completed form
may be made if the prescribing provider may be faxed to 1-866-684-4477. Find the
can justify medical necessity, or in cases of Brand over Generic Prior Authorization
natural disasters, as approved by TRICARE. Request Form by searching for the brand-
name drug at www.express-scripts.com/
tricareformulary. If a generic-equivalent
Prior Authorization
drug does not exist or is not on the
Some drugs require prior authorization formulary, the brand-name drug is
from Express Scripts. Medications requiring dispensed at the brand-name copayment.
prior authorization may include, but are If you fill a prescription for a brand-name
not limited to, prescription drugs specified drug that is not considered medically
by the DoD Pharmacy and Therapeutics necessary and when a generic equivalent is
(P&T) Committee, brand-name medications available, you are responsible for paying the
with generic equivalents, medications entire cost of the prescription.
with age limitations and medications
prescribed for quantities exceeding
Non-Formulary Drugs
normal limits. Search for your drug at
www.express-scripts.com/tricareformulary The DoD P&T Committee may recommend
to see if it is covered under TRICARE, that certain drugs be placed in the non-
requires prior authorization or has quantity formulary category. These medications
limits. You may also call 1-877-363-1303 for include any drug in a therapeutic class
information about your drug. determined to be less clinically effective
or less cost-effective than other drugs
in the same class. Non-formulary drugs
Generic Formulary and Brand-Name
are available through the TRICARE
Formulary Drugs Pharmacy Program at an additional cost.
Generic drugs are medications approved You may be able to fill non-formulary
by the U.S. Food and Drug Administration prescriptions at formulary costs if your
that are clinically equivalent to brand-name provider can establish medical necessity by
medications. Generic drugs provide the completing and submitting the appropriate
22
SECTION 4 Pharmacy
TRICARE pharmacy medical-necessity If your compound drug does not pass the
form for the non-formulary medication. initial screening, you have three options:
For forms and medical-necessity criteria,
call Express Scripts at 1-877-363-1303 or 1. Your pharmacist may be able to use a
search for the non-formulary medication at different, approved ingredient.
www.express-scripts.com/tricareformulary. 2. Your health care provider may prescribe
a different drug.
Note: Some non-formulary drugs are only
covered through home delivery. Check with 3. Your health care provider may request
Express Scripts before filling prescriptions a prior authorization. If the prior
for non-formulary drugs at a TRICARE authorization is denied, you can appeal
retail network pharmacy. that decision.
For information on how to save money For more information, visit

and make the most of your pharmacy www.tricare.mil/compounddrugs.
benefit, visit www.tricare.mil/pharmacy
or www.express-scripts.com/TRICARE.
Specialty Medication Care Management
Specialty medications are usually high-
Non-Covered Drugs
cost; self-administered; injectable, oral or
Non-covered drugs are excluded from infused drugs that treat serious chronic
TRICARE coverage. If your drug falls into conditions (for example, multiple sclerosis,
the non-covered category, you’ll have to pay rheumatoid arthritis or hepatitis C). These
the full cost of the drug. drugs typically require special storage and
handling and are not readily available at
your local pharmacy. Specialty medications
Compound Drugs
may also have side effects that require
Compound drugs are made by a pharmacist pharmacist and/or nurse monitoring.
mixing multiple ingredients together to
create a prescription drug that is specific to The Specialty Medication Care Management
a beneficiary’s needs. TRICARE screens all program is in place to improve your health
prescriptions for compound drugs to ensure through continuous health evaluation,
each ingredient of the drug is safe, effective ongoing monitoring, assessment of
and covered by TRICARE.
23
educational needs and medication-use medications, and are able to provide these
management. This program provides: specialty medications to beneficiaries. Visit
www.express-scripts.com/TRICARE/
• Access to proactive, clinically based pharmacy to find a pharmacy in the
services for specific diseases and is
specialty network.
designed to help you get the most benefit
from your medication
PHARMACY CLAIMS
• Monthly refill reminder calls
You do not need to file pharmacy claims for
• Scheduled deliveries to specified locations prescriptions filled at military pharmacies,
• Specialty consultation with a nurse through TRICARE Pharmacy Home
or pharmacist at any point during Delivery or at TRICARE retail network
your therapy pharmacies. However, if you fill a prescription
at a non-network pharmacy in the U.S. or
These services are provided to you at U.S. territories (American Samoa, Guam, the
no additional cost when you get your Northern Mariana Islands, Puerto Rico and
medications through TRICARE Pharmacy the U.S. Virgin Islands), you must pay the
Home Delivery. Participation is voluntary. full price of your prescription upfront and
file a claim to get money back.
If you or your provider orders a specialty
medication from TRICARE Pharmacy Currently, there are no TRICARE retail
Home Delivery, Express Scripts sends you network pharmacies in American Samoa.
additional information about the Specialty
Medication Care Management program and To file a claim:
how to get started.
1. Download the TRICARE DoD/
CHAMPUS Medical Claim—Patient’s
With specific mailing instructions from you
Request for Medical Payment
or your provider, TRICARE Pharmacy Home
form (DD Form 2642) by visiting
Delivery ships your specialty medication
www.tricare.mil/pharmacyclaims.
to your home. For your convenience and
safety, TRICARE Pharmacy Home Delivery 2. Complete the form and attach the
contacts you to arrange delivery before the required paperwork as described on
medication is shipped. the form.
3. Mail the form and paperwork to:
Certain specialty medications may only
be available through home delivery or
retail pharmacies in the specialty network.
TRICARE Claims
The specialty network is a select network of P.O. Box 52132
retail specialty pharmacies in the TRICARE Phoenix, AZ 85072
retail pharmacy network. These pharmacies
have expertise in medication management
for conditions that require specialty
24
Prescription claims require the following Pharmacy Claims Appeals
information for each drug:
If you disagree with the determination on
• Patient’s name your pharmacy claim (if your claim is denied),
SECTION 4 Pharmacy
you or your appointed representative has the
• Drug name, strength, date filled, days’ right to request a reconsideration. The request
supply, quantity dispensed and price
(or appeal) for reconsideration must be in
• National Drug Code, if available writing, signed, and postmarked or received
by Express Scripts within 90 calendar days
• Prescription number from the date of the decision, and must
• Name and address of the pharmacy include a copy of the claim decision.
• Name and address of the Your signed, written request must state the
prescribing provider
specific matter you disagree with and must
• Shipping invoice from OHI mail order be sent to the following address:
pharmacy, if applicable
• Explanation of benefits from OHI, P.O. Box 60903
if applicable Phoenix, AZ 85082
If you have OHI with pharmacy benefits,

Additional documentation in support of the
see “Coordinating TRICARE For Life
appeal may be submitted; however, because
with Other Health Insurance” in the
the request for reconsideration must be
How TRICARE For Life Works section
postmarked or received within 90 calendar
of this handbook. Call Express Scripts at
days of the date of the decision, do not delay
1-877-363-1303 with questions about filing
the request for reconsideration for the sake
pharmacy claims.
of additional documentation. If additional
documentation will be submitted at a later
Pharmacy Claims Overseas date, the letter requesting reconsideration
must state that additional documentation
Overseas, you may fill prescriptions at
will be submitted and specify the expected
military pharmacies or through home
date of submission. Upon receiving your
delivery, if available. Otherwise, you
request, all TRICARE claims related to the
will need to fill prescriptions at overseas
entire course of treatment are reviewed.
pharmacies by paying the full cost upfront
and filing a claim with the TRICARE
Overseas Program claims processor to get
money back. You must submit proof of
payment with all overseas pharmacy claims,
including an itemized bill or invoice. For
more information about how to file claims
for prescriptions filled overseas, visit
www.tricare.mil/pharmacyclaims.
25
Claims
HEALTH CARE CLAIMS IN THE U.S. Attach a readable copy of the provider’s bill
AND U.S. TERRITORIES to the claim form, making sure it contains
the following:
In most cases, your provider files your
health care claims with Medicare first. • Patient’s name
Medicare pays its portion, and unless
you have other health insurance (OHI),
• Sponsor’s Social Security number (SSN)
or Department of Defense Benefits
forwards the claim to TRICARE For Life
Number (DBN) (Eligible former spouses
(TFL) for processing.
should use their own SSNs or DBNs, not
their sponsors’.)
However, when TFL is the primary payer
(for example, if Medicare does not cover • Provider’s name and address (If more
the health care service), your provider may than one provider’s name is on the
be required to file your claim directly with bill, circle the name of the person who
Wisconsin Physicians Service (WPS)— provided the service for which the claim
Military and Veterans Health. If you have is filed.)
OHI, you must file the claim with your
OHI before filing with TFL.
• Date and place of each service
• Description of each service or
You are responsible for making sure supply furnished
your claims are filed within one year of
either the date of service or the date of
• Charge for each service
an inpatient discharge. To file a claim • Diagnosis (If the diagnosis is not on the
with TFL, fill out a TRICARE DoD/ bill, complete block 8a on the form.)
CHAMPUS Medical Claim—Patient’s
Request for Medical Payment form For care received in the U.S. or U.S. territories
(DD Form 2642). You can download (American Samoa, Guam, the Northern
forms and instructions from TRICARE Mariana Islands, Puerto Rico and the
at www.tricare.mil/claims or the WPS U.S. Virgin Islands), claims must be filed
website at www.TRICARE4u.com. within one year of either the date of service
or the date of an inpatient discharge. Send
When filing a claim with TFL, include claims to the WPS/TRICARE For Life
your Medicare Summary Notice and OHI mailing address provided in the Important
explanation of benefits (EOB), if applicable. Contact Information section at the beginning
of this handbook.
26
SECTION 5 Claims
HEALTH CARE CLAIMS OVERSEAS APPEALING A CLAIM OR PRIOR
AUTHORIZATION DENIAL
TFL is the primary payer for care overseas
unless you have OHI and Medicare pays You may appeal decisions regarding claims
nothing. You are required to submit proof payments or prior authorization denials
of payment with all claims for care received of requested services. Medicare and TFL
overseas. Proof of payment may include a have separate appeals processes. Medicare-
credit card receipt, canceled check, credit related appeals should be submitted to
card statement or invoice from the provider Medicare. You should only submit appeals
that clearly states payment was received. For to WPS if TFL is the primary payer.
more information, contact your TRICARE
Overseas Program Regional Call Center
THIRD-PARTY LIABILITY
and choose option 2 for claims assistance or
visit www.tricare.mil/proofofpayment. If TRICARE is the primary payer, the
Federal Medical Care Recovery Act allows
Unlike other TRICARE beneficiaries, TRICARE to get money back for treatment
TFL beneficiaries should file claims in the costs if you are injured in an accident
overseas areas where they received care. caused by someone else. The Statement
of Personal Injury—Possible Third Party
Claims for care you get outside the U.S. and Liability form (DD Form 2527) is sent to
U.S. territories must be filed within three you if a claim appears to have third-party
years of either the date of service or the liability involvement. Within 35 calendar
date of an inpatient discharge. Send claims days, you must complete and sign this form
to the appropriate TRICARE Overseas and follow the directions for returning
Program mailing address provided in the it to the appropriate claims processor.
Important Contact Information section at Visit www.tricare.mil/claims and click
the beginning of this handbook. on “Third-Party Liability” to download
DD Form 2527.
27
EXPLANATION OF BENEFITS DEBT COLLECTION
ASSISTANCE OFFICERS
A TRICARE EOB is not a bill. It is an
itemized statement that shows the action TRICARE Debt Collection Assistance
TRICARE has taken on your claims. An Officers (DCAOs) are located at military
EOB is for your information and files. hospitals and clinics and TRICARE
Regional Offices to help resolve your
After reviewing the EOB, you have the TRICARE health care collection-related
right to appeal certain decisions regarding issues. Contact a DCAO if you received a
your claims and must do so in writing negative credit rating or were contacted by
within 90 days of the date of the EOB a collection agency due to an issue related
notice. You should keep EOB statements to your TFL claim.
with your health insurance records for
future reference. When you visit a DCAO, you must bring
or submit documentation associated with
For more information about appeals, a collection action or adverse credit rating,
visit www.TRICARE4u.com or see the including debt collection letters, EOB
For Information and Assistance section of statements and medical and/or dental bills
this handbook. from providers. The more information you
provide, the faster the cause of the problem
can be determined. The DCAO researches
your claim, provides you with a written
resolution of your collection problem and
informs the collection agency that action is
being taken to resolve the issue.
DCAOs cannot provide legal advice or repair

your credit rating, but they can help by
providing documentation for the collection
or credit-reporting agency to explain the
circumstances relating to the debt.
Visit the Customer Service Community

Directory at www.tricare.mil/bcacdcao
to find a DCAO near you.
TRICARE DCAOs can only assist you with

TFL-related issues. Contact Medicare for
assistance with Medicare-related issues.
28
Life Changes: Keep Your DEERS
Information Up To Date
TRICARE For Life (TFL) continues to USING MILCONNECT TO UPDATE

provide health care coverage for you and INFORMATION IN DEERS
your family as your life changes. However,
Active duty service members, retirees
you need to take specific actions to make
and eligible family members can use the
sure you remain TRICARE-eligible. It is
milConnect website to see health care
essential that you keep information in the
eligibility and personnel information,
Defense Enrollment Eligibility Reporting
uniformed services ID cards and
System (DEERS) current for you and your
information on other benefits, including
family. DEERS is a computerized database
Servicemembers’ Group Life Insurance.
of uniformed service members (active duty
and retired), their family members and
You can also use milConnect to sign up
others who are eligible for military benefits,
for benefit notifications. When benefit
including TRICARE. Proper and current
changes occur, you will get an email
DEERS registration is key to getting timely,
directing you to log on to milConnect
effective TFL benefits.
at https://milconnect.dmdc.osd.mil.
Note: Your Social Security number (SSN)
You can log on to milConnect’s secure
SECTION 6 Life Changes: Keep Your DEERS

and the SSNs of each of your covered family
site using a Common Access Card (CAC),
members should be included in DEERS for
Defense Finance and Accounting Service
TRICARE coverage to be reflected accurately.
myPay PIN or Department of Defense (DoD)
Self-Service Logon (DS Logon). You may
Maintaining your DEERS information is
visit a Veterans Affairs Regional Office to
your responsibility. It is essential to verify
complete an in-person proofing process
your information in DEERS anytime you
to request a DS Logon, or you may go
have a life-changing event. You have several
online for a remote-proofing process. Visit
options for updating and verifying DEERS
https://myaccess.dmdc.osd.mil for more
information. See the Important Contact
information. If you need a new ID card, you
Information section at the beginning of
can visit a uniformed services ID card office
this handbook.
and request a DS Logon at the same time.
Note: Only sponsors (or a sponsor-
appointed individual with valid power
of attorney) can add a family member in
DEERS. Family members age 18 and older
may update their own contact information.
29
GETTING MARRIED OR DIVORCED Divorce
Sponsors must update DEERS in the event
Marriage of a divorce. The sponsor needs to provide
a copy of the divorce decree, dissolution
It is extremely important for sponsors to
or annulment.
register new spouses in DEERS to ensure
their TRICARE eligibility and coverage
are reflected accurately. To register a new Former Spouse Coverage
spouse in DEERS, the sponsor needs to
Certain former spouses are eligible to
provide a copy of the marriage certificate
continue TFL coverage as long as they:
to the nearest uniformed services ID card
office. The new spouse is also required to • Do not remarry (If a former spouse
show two forms of ID (for example, any remarries, the loss of benefits remains
combination of Social Security card, driver’s applicable even if the remarriage ends in
license, birth certificate, current uniformed death or divorce, unless the new spouse is
services ID card or CAC). Once your spouse a sponsor.)
is registered in DEERS, he or she gets a
uniformed services ID card and may use
• Are not covered by employer-sponsored
health plans
TRICARE. Your spouse must show his or
her ID card to get care.
Figure 6.1 Eligibility Situations for Former Spouses
1 • The former spouse must have been married to the same service member or
former member for at least 20 years, and at least 20 of those years must have
been creditable in determining the member’s eligibility for retirement pay.
• If this requirement is met, the former spouse is eligible for TRICARE coverage
after the date of the divorce, dissolution or annulment.1 Eligibility continues as
long as the preceding requirements continue to be met and the former spouse
does not remarry.
2 • The former spouse must have been married to the same service member or
former member for at least 20 years, and at least 15—but less than 20—of
those married years must have been creditable in determining the member’s
eligibility for retirement pay.
• If this requirement is met, the former spouse is eligible for TRICARE coverage for
only one year from the date of the divorce, dissolution or annulment.1
1. For divorce decrees, dissolutions or annulments on or before September 29, 1988, check DEERS for
eligibility information.
30
• Are not also former spouses of North To extend coverage beyond your child’s
Atlantic Treaty Organization or Partners 21st birthday, contact your local ID card
for Peace nation members office to verify what documentation
is needed.
• Meet the requirements of one of the two
situations described in Figure 6.1 on the
At age 21 (or 23), adult children may qualify
previous page
to purchase TRICARE Young Adult (TYA)
coverage until reaching age 26, and later,
Former spouses who are TFL-eligible
Continued Health Care Benefit Program
must change their personal information
(CHCBP) coverage. For more information
in DEERS, so their name and SSN or DoD
on TYA, visit www.tricare.mil/tya.
Benefits Number (DBN), are listed for the
For more information on CHCBP, visit
primary contact information. The former
www.tricare.mil/chcbp.
spouse’s TRICARE eligibility is shown in
DEERS under his or her own SSN or DBN,
Note: Children with disabilities may
not the sponsor’s.
remain TRICARE-eligible beyond the
normal age limits. Check with your
Former spouses who are not eligible for
sponsor’s service for eligibility criteria.
TRICARE may not continue seeking health
care services under the TRICARE benefit.
If an ineligible former spouse continues to
do so, the former spouse and/or the sponsor
may have to pay TRICARE for those services.
CHILDREN
SECTION 6 Life Changes: Keep Your DEERS

Your dependents’ coverage does not
change because you are entitled to TFL.
Any children who retain eligibility under
the sponsor remain TRICARE-eligible
until reaching age 21 (or age 23 if enrolled
full-time at an approved college and if the
sponsor provides over 50 percent of the
financial support), as long as his or her
DEERS information is current.
31
MOVING
Whether you are moving across the
street or overseas, TFL moves with you.
Just update your personal information in
DEERS, find a provider who is a Medicare
participating or Medicare non-participating
provider (in the U.S. and U.S. territories),*
and continue to get care when you need it.
See “Finding a Provider” in the Getting Care
section of this handbook.
* The U.S. territories include American Samoa,
Guam, the Northern Mariana Islands, Puerto
Rico and the U.S. Virgin Islands.
SURVIVOR COVERAGE
If your TFL sponsor dies, you remain
TRICARE-eligible and will continue to get SUSPENSION OF SOCIAL SECURITY
TRICARE benefits as long as your DEERS DISABILITY INSURANCE
information is up to date and you are either
Medicare coverage may continue up to eight
of the following:
years and six months following suspension
• A surviving spouse who has not of Social Security Disability Insurance
remarried (If you remarry, TRICARE payments. When Social Security Disability
eligibility cannot be regained later, even Insurance payments are suspended because
if you divorce or your new spouse dies.) you have returned to work, you will get
quarterly bills for the Medicare Part B
• A surviving unmarried child under premium. As long as you remain entitled to
age 21 (or age 23 if enrolled full-time
premium-free Medicare Part A, you must
at an approved college and if the
pay the Part B premium to maintain your
sponsor provided over 50 percent of
TRICARE coverage.
the financial support)
Note: Children with disabilities may remain

TRICARE-eligible beyond normal age
limits. Check with your sponsor’s service
for eligibility criteria.
32
For Information and Assistance
SECTION 7
BENEFICIARY COUNSELING AND However, if a Medicare appeal results in

ASSISTANCE COORDINATORS some payment by Medicare, TRICARE
considers coverage as the second payer.
TRICARE Beneficiary Counseling and
Assistance Coordinators (BCACs) can For more information on Medicare appeals,
help you with TRICARE For Life (TFL) read the back of your Medicare Summary
questions and concerns, and they can Notice or contact Medicare.
advise you about getting health care.
BCACs are located at military hospitals
TRICARE For Life Appeals Requirements
and clinics and TRICARE Regional
Offices. To locate a BCAC, visit the You may appeal a TFL denial of a requested
Customer Service Community Directory prior authorization of services even if
at www.tricare.mil/bcacdcao. no care was provided and no claim was
submitted. There are some things you may
not appeal. For example, when TFL is the
YOUR RIGHT TO APPEAL A DECISION
primary payer, you may not appeal the
If you believe a service or claim was denial of care from a provider who is not
denied improperly, in whole or in part, TRICARE-authorized.
you (or another appropriate party) may
file an appeal. An appeal must involve an When services are denied based on medical
appealable issue. For example, you have the necessity or a benefit decision, you are
right to appeal Medicare or TFL decisions automatically notified in writing. The
about claims payments. notification includes an explanation of what
was denied or why a payment was reduced
Medicare and TFL have separate claims and the reasoning behind the decision.
processes. For most services, Medicare is
your primary payer. To appeal a Medicare
Filing TRICARE For Life Appeals
decision, follow the instructions on your
Medicare Summary Notice. Contact TFL appeals must be filed with WPS within
Wisconsin Physicians Service (WPS)— 90 days from the date that appears on the
Military and Veterans Health to appeal explanation of benefits or denial notification
TFL decisions. letter. If you are not satisfied with a decision
on an appeal, there may be further levels
of appeal available to you. Your TFL
Medicare Denials
appeal must meet the requirements listed
Any services or supplies denied payment by in Figure 7.1 on the following page. For
Medicare and appealable under Medicare specific information about filing a TFL
are not considered for coverage by TFL. appeal, contact WPS.
33
Prior authorization denial appeals may be Appeals should contain the following:
either expedited or non-expedited, depending
on the urgency of the situation. You or an
• Beneficiary’s name, address and
phone number
appointed representative must file for an
expedited review of a prior authorization • Sponsor’s Social Security number (SSN)
denial within three calendar days of receipt or Department of Defense Benefits
of the initial denial. A non-expedited denial Number (DBN)
review must be filed no later than 90 days
after receipt of the initial denial.
• Beneficiary’s date of birth
• Beneficiary’s or appealing
party’s signature
Figure 7.1 TRICARE For Life Appeals Requirements
1 An appropriate appealing party must submit the appeal. Proper appealing parties include:
• You, the beneficiary
• Participating non-network providers
If a party other than those listed above submits the appeal, you will generally be
required to complete and sign an appointment of representative form, which is
available on your regional contractor’s website. Appeals submitted without this form
will not be processed, except in the following cases:
• A custodial parent submits an appeal on behalf of a minor beneficiary
• An attorney files an appeal without specific appointment by the proper appealing party
Note: Network providers are not appropriate appealing parties, but may be appointed
as representatives, in writing, by you.
2 The appeal must be submitted in writing.
3 The issue in dispute must be an appealable issue. The following are not appealable issues:
• Allowable charges
• Eligibility
• Denial of services from an unauthorized provider
• Denial of treatment plan when an alternative treatment plan is selected
4 An appeal must be filed within 90 days of the date on the explanation of benefits or
denial notification letter.
5 There must be an amount in dispute to file an appeal. In cases involving an appeal of

a denial of prior authorization in advance of receiving the actual services, the amount
in dispute is deemed to be the estimated TRICARE-allowable charge for the services
requested. There is no minimum amount to request a reconsideration.
34
A description of the issue or concern • The performance of any part of the
must include: health care delivery system
• The specific issue in dispute • Practices related to patient safety
SECTION 7
• A copy of the previous denial When filing a grievance, include the
determination notice
following information:
• Any appropriate supporting documents

• Beneficiary’s name, address and
phone number
FILING A GRIEVANCE
• Sponsor’s SSN or DBN
A grievance is a written complaint or
concern about a non-appealable issue
• Beneficiary’s date of birth
regarding a perceived failure by any • Beneficiary’s signature
member of the TFL health care delivery
team, including TRICARE-authorized A description of the issue or concern
providers or military providers, to provide must include the following:
appropriate and timely health care services,
access or quality, or to deliver the proper
• Date and time of the event
level of care or service. • Name(s) of the provider(s) and/or
person(s) involved
The TFL grievance process provides the
opportunity to report, in writing, any
• Address of the event
concern or complaint regarding health • Nature of the concern or complaint
care quality or service. Any TFL civilian or
military provider; TFL beneficiary; sponsor;
• Details describing the event or issue
or parent, guardian or other representative • Any appropriate supporting documents
of an eligible dependent child may file
a grievance. WPS is responsible for the See the Important Contact Information
investigation and resolution of all grievances. section at the beginning of this handbook
for grievance contact information
Grievances are generally resolved within at WPS. Contact Medicare to file
60 days of receipt. Following resolution, Medicare-related grievances.
the party that submitted the grievance is
notified of the review completion.
Grievances may include such issues as:

• The quality of health care or services (for
example, accessibility, appropriateness,
level, continuity or timeliness of care)
• The demeanor or behavior of providers
and their staff members
35
Index
A Covered services, 9, 10
Custodial care, 18
Accident, 27
Cruise ship, 11
Active duty family member (ADFM), 4, 6, 7, 14, 16
Customer Service Community Directory, 28, 33
Active duty service member (ADSM), 4, 6, 7,
14, 17, 20, 29
D
Active duty sponsor, 12, 18
Acupuncture, 17 Debt Collection Assistance Officer (DCAO), 28
Age limitations, 22, 31, 32 Deductible, 9–12, 14, 21
Allowable charge, 10, 13, 14, 34 Defense Enrollment Eligibility Reporting System
Amyotrophic lateral sclerosis (ALS), 7 (DEERS), 8, 29–32
Appeal, 9, 23, 25, 27, 28, 33, 34 Defense Manpower Data Center Support Office, 29
Appointment, 12, 14–16, 34 Dental care, 1, 15–18, 28
Asbestos-related disease, 7 Dependent child, 35
Authorization, 12, 16, 18, 22, 23, 27, 33, 34 Disability, 5–7, 15, 31, 32
Divorce, 5, 8, 30, 32
B Durable medical equipment, 6
Beneficiary Counseling and Assistance
E
Coordinator (BCAC), 28, 33
Bill, 6, 7, 9, 10, 13, 14, 25, 26, 28, 32 Eligibility, 1, 4–8, 12, 13, 17, 18, 26, 29–32,
Brand-name drug, 16, 20, 22 34, 35
Brand-name formulary drug, 22 Emergency, 15
End-stage renal disease (ESRD), 5–7
C Enrollment, 4, 6–8, 12, 14, 19, 29, 31, 32
Enrollment surcharge, 4–8
Centers for Medicare and Medicaid Services, 5, 6
Explanation of benefits (EOB), 25, 26, 28, 33, 34
Charge, 9, 10, 13, 14, 26, 34
Express Scripts, Inc. (Express Scripts), 19–25
Children, 31, 32, 35
Eye examinations, 17
Claim, 1, 8–11, 13–16, 19, 21, 24–28, 33
Common Access Card (CAC), 19, 29, 30
F
Compound drugs, 23
Continued Health Care Benefit Program Federal Employees Dental and Vision Insurance
(CHCBP), 31 Program (FEDVIP), 15, 17, 18
Copayment, 20–22 Federal Employees Health Benefits (FEHB), 12
Cost-share, 9–11, 14, 21 Former spouse, 4, 12, 17, 18, 26, 30, 31
36
G Military Health System Nurse Advice Line, 15
Military hospital or clinic, 1, 4, 12, 14, 15, 17,
Generic drug, 20, 22
19, 28, 33
Generic equivalent, 22
Moving, 32
Grievance, 35
Guardian, 35
N
H National Guard and Reserve, 4, 17, 18
Network pharmacy, 21, 23, 24
Health Net Federal Services, LLC (Health Net), 16
Network provider, 34
Hearing aids, 17
Non-covered drugs, 23
Home health care, 5, 6, 16
Non-formulary drugs, 22, 23
Hospice care, 5, 16
Non-network pharmacy, 19, 21, 24
Hospital, 1, 4, 5, 12, 14, 15, 17–19, 28, 33
Nonparticipating non-network provider, 10, 14
Humana Military, 16
SECTION 8 Index
O
I
Occupational therapy, 18
ID card, 8, 19, 21, 29–31
Other health insurance (OHI), 1, 9–12, 18, 21,
Indian Health Service, 11
25–27
Out-of-pocket costs, 9, 10, 13, 17
L
Outpatient care, 6
Limitations, 16, 17, 22 Overseas, 10, 11, 14, 15, 17, 19–21, 25, 27, 32
Long-term care, 18 Over-the-counter (OTC) drugs, 19
Lou Gehrig’s disease, 7
P
M
Participating non-network provider, 34
Marriage, 30 Payment, 6, 7, 9–13, 16, 24–27, 32, 33
Medicaid, 5, 11 Personnel Management, U.S. Office of, 18
Medical equipment, 6 Pharmacy, 1, 19–25
Medicare Part A, 1, 4–8, 12, 32 Philippines, 11, 14, 19
Medicare Part B, 1, 4–8, 12, 32 Physical therapy, 18
Medicare Part D, 19 Premium, 4–8, 12, 32
Medicare non-participating provider, 1, 13, 14, Prescription, 16, 19–25
32 Preventive care, 6
Medicare participating provider, 1, 13, 14, 32 Prime Service Area (PSA), 4, 8
Medication, 16, 19–24 Prior authorization, 12, 16, 18, 22, 23, 27, 33, 34
Mental health care, 16 Program options, 8
Mesothelioma, 7
37
TRICARE-allowable charge, 10, 14, 34
TRICARE-authorized provider, 11, 13, 32, 33, 35
Q
U
Quantity limits, 16, 22
Uniformed services identification (ID) card, 8,
19, 21, 29, 30
R
United Concordia Companies, Inc. (United
Referral, 12 Concordia), 17
Regional contractor, 16, 34 Urgent care, 15
Retail network pharmacy, 21, 23, 24 US Family Health Plan (USFHP), 4, 6
Retired, 4, 7, 8, 12, 14, 17, 18, 29, 30 U.S. Territories, 10, 11, 14, 15, 18, 19, 21, 24,
26, 27, 32
S
Skilled nursing care, 18 V
Skilled nursing facility (SNF), 5, 18 Veterans Affairs, 10, 13, 14, 29
Social Security Administration (SSA), 5–8 Vision care, 18
Social Security number (SSN), 5, 8, 26, 29, 31,
34, 35 W
Space-available care, 1, 12, 14
Wisconsin Physicians Service (WPS), 10–12, 14,
Specialty Medication Care Management, 23, 24
16, 17, 26, 27, 33, 35
Specialty medication, 23, 24
Speech therapy, 18
Spouse, 4, 5, 8, 12, 17, 18, 26, 30–32
Survivor, 4, 17, 18, 32
T
Third-party liability, 27
Transplants, 16
Travel, 11, 15, 19
TRICARE Dental Program (TDP), 15, 17
TRICARE Overseas Program (TOP), 11, 14–16,
25, 27
TRICARE Pharmacy Home Delivery, 20, 21, 24
TRICARE Plus, 12, 14
TRICARE Prime, 4, 8, 12, 14
TRICARE Regional Offices, 28, 33
TRICARE Select, 4, 8
TRICARE supplement, 11
TRICARE Young Adult, 31
38
TRICARE Expectations
for Beneficiaries
According to the Department of Defense (DoD), confidentiality of your health care information
as a TRICARE beneficiary, you should expect to protected to the extent permitted by law. You
have the following abilities and support: also should expect to have the ability to
review, copy and request amendments to your
• Get information: You should expect to get medical records.
accurate, easy-to-understand information from
written materials, presentations and TRICARE • Complaints and appeals: You should expect
representatives to help you make informed a fair and efficient process for resolving
decisions about TRICARE programs, medical differences with health plans, health care
professionals and facilities. providers and institutions that serve you.
• Choose providers and plans: You should

expect a choice of health care providers that Additionally, DoD has the following expectations
is sufficient to ensure access to appropriate of you as a TRICARE beneficiary:
high-quality health care.
• Maximize your health: You should maximize
• Emergency care: You should expect to access healthy habits such as exercising, not using
medically necessary and appropriate emergency tobacco and maintaining a healthy diet.
health care services as is reasonably available
when and where the need arises. • Make smart health care decisions: You should
be involved in health care decisions, which
• Participate in treatment: You should expect means working with providers to provide
to receive and review information about the relevant information, clearly communicate
diagnosis, treatment and progress of your wants and needs and develop and carry out
conditions, and to fully participate in all agreed-upon treatment plans.
decisions related to your health care, or to be
represented by family members or other duly • Be knowledgeable about TRICARE: You should
appointed representatives. be knowledgeable about TRICARE coverage
and program options.
• Respect and nondiscrimination: You should
expect to receive considerate, respectful care • You also should:
from all members of the health care system ■■ Show respect for other patients and health
without discrimination based on race, color, care workers.
national origin or any other basis recognized ■■ Make a good-faith effort to meet financial
in applicable law or regulations. obligations.
• Confidentiality of health information: You ■■ Use the disputed claims process when
should expect to communicate with health there is a disagreement.
care providers in confidence and to have the
TRICARE is a registered trademark of the Department of Defense, Defense Health Agency. All rights reserved.
Regional Contractors (Stateside) TOP Regional Call Centers (Overseas)
TRICARE For Life TRICARE Eurasia-Africa

Wisconsin Physicians Service— +44-20-8762-8384 (overseas)
Military and Veterans Health 1-877-678-1207 (stateside)
www.TRICARE4u.com [email protected]
1-866-773-0404
TRICARE Latin America and Canada
TRICARE East Region +1-215-942-8393 (overseas)
Humana Military 1-877-451-8659 (stateside)
HumanaMilitary.com [email protected]
1-800-444-5445 TRICARE Pacific
Singapore: +65-6339-2676 (overseas)
TRICARE West Region 1-877-678-1208 (stateside)
Health Net Federal Services, LLC [email protected]
www.tricare-west.com
Sydney: +61-2-9273-2710 (overseas)
1-844-866-WEST (1-844-866-9378)
HA6973BET02203
1-877-678-1209 (stateside)
[email protected]
www.tricare.mil

TFL HBK

Uploaded by

Copyright:

Available Formats

TFL HBK

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

TFL HBK

Uploaded by

Copyright:

Available Formats

TRICARE® For Life

Learn how TRICARE and Medicare work together

TRICARE Website: www.tricare.mil

TRICARE For Life Contractor

TRICARE East Region Contractor

TRICARE West Region Contractor

Medicare: 1-800-MEDICARE (1-800-633-4227)

Social Security Administration: 1-800-772-1213

An Important Note About TRICARE Program Information

Keep Your DEERS Information Up To Date!

Important Contact Information

GENERAL CONTACT INFORMATION GRIEVANCES

Phone: 1-866-773-0404 Email: [email protected]

WPS/TRICARE For Life (stateside) TRICARE Overseas Program

DEFENSE ENROLLMENT ELIGIBILITY REPORTING SYSTEM (DEERS)

In person Visit a local ID card office. Find an office near you at

Regional Contractors (Stateside) TOP Regional Call Centers (Overseas)

OTHER CONTACT INFORMATION

Federal Employees Dental and See website www.tricare.mil/fedvip

TRICARE For Life is Medicare-wraparound coverage for TRICARE

1. How TRICARE For Life Works.......................................................................4

3. TRICARE For Life Coverage........................................................................ 17

6. Life Changes: Keep Your DEERS Information Up To Date.............................29

7. For Information and Assistance.................................................................33

Medicare allows ADSMs and ADFMs USFHP and Medicare Entitlement

Medicare Entitlement Based on

How TRICARE For Life Works

How TRICARE For Life Works

Figure 1.1 TRICARE For Life Out-of-Pocket Costs

TYPE OF SERVICE MEDICARE PAYS TRICARE PAYS YOU PAY

Covered by Medicare- Remaining amount Nothing

Covered by Medicare- Nothing Medicare

Covered by Nothing TRICARE-allowable TRICARE deductible

Not covered Nothing Nothing Billed charges

How TRICARE For Life Works

FINDING A PROVIDER opt-out provider, TFL pays the amount it

If it’s after hours or you’re not sure if

Prior authorization is a review of the Note: This list is not all-inclusive.

Examples of services that are generally not

TRICARE For Life Coverage

FAQs Frequently Asked Questions:

If you live or travel in the Philippines,

Over-the-counter (OTC) drugs are not

Note: You do not need a Medicare Part D

TRICARE Retail Network Pharmacies Non-Network Pharmacies

Figure 4.1 TRICARE Pharmacy Home Delivery Registration Methods

Call 1-877-363-1303 or 1-877-540-6261 (TDD/TTY).

Download the registration form from www.express-scripts.com/TRICARE,

For information on how to save money For more information, visit

If you have OHI with pharmacy benefits,

DCAOs cannot provide legal advice or repair

Visit the Customer Service Community

TRICARE DCAOs can only assist you with

TRICARE For Life (TFL) continues to USING MILCONNECT TO UPDATE

SECTION 6 Life Changes: Keep Your DEERS

Figure 6.1 Eligibility Situations for Former Spouses

SECTION 6 Life Changes: Keep Your DEERS

Note: Children with disabilities may remain