24 Feb TRICARE Prime
TRICARE Prime is the most popular healthcare plan used by active-duty military families. It is the cheapest plan available, requiring less money out-of-pocket than other TRICARE plans. Like a civilian HMO, the plan requires you to use certain providers—in particular, that most of your family’s treatment will be given at military facilities and through your TRICARE plan’s Preferred Provider Network, or “PPN”.
TRICARE Prime Coverage Summary
With TRICARE Prime, your Primary Care Manager, or “PCM”, typically consists of the doctors and medical staff at military treatment facilities, or “MTFs”. Your PCM is the first person you contact for any sort of medical treatment, and must make any referrals to any other providers, including specialists and even if they are part of your Prime PPN. Additionally, enrollment in TRICARE Prime must be for a minimum of one year.
Included in your TRICARE Prime plan: In exchange for the limited choice of providers, there is no enrollment fee for active-duty servicemembers or their families, no fee for visiting a military treatment facility, and no fee incurred when the beneficiary is referred to a civilian provider, and no annual deductible for in-network care.
Not included in your TRICARE Prime plan: There is a minimal enrollment fee for retired servicemembers and their families. All Prime beneficiaries will only be charged a maximum of $1000 per year in out-of-pocket expenses.
If you wish to see a civilian TRICARE-authorized provider, you may do so using the Point-of-Service, or “POS”, feature available as part of your TRICARE Prime coverage. You can see any TRICARE provider, in- or out-of-network, but you will pay a $300 deductible as an individual or a $600 deductible as a family, plus 50 percent cost-share, plus up to 15 percent in excess charges. Please note that these charges do not count toward your $1000 out-of-pocket maximum.
TRICARE Prime Eligibility
- Active duty service members and their families
- Retired service members and their families*
- Activated Guard/Reserve members and their families
- Non-activated Guard/Reserve members and their families who qualify for care under the Transitional Assistance Management Program
- Retired Guard/Reserve members at age 60 and their families*
- Medal of Honor recipients and their families
- Qualified former spouses
*Only available for retirees who are not eligible for TRICARE for Life
TRICARE Prime Vision Coverage
One of the many exclusive benefits offered only through TRICARE Prime is vision coverage. All Prime beneficiaries over the age of three receive a comprehensive eye exam biannually. (Vision screening is also covered at birth and six months of age for children and annually for diabetic patients.) The exam can be performed by any TRICARE in-network provider without consulting your PCM for a referral or authorization, or any out-of-network provider with a referral or authorization from your PCM. As with other Point of Service treatments, if you get an eye exam out-of-network without authorization or a referral, you will be subject to the associated costs.
TRICARE Prime Travel Expenses Reimbursements
Travel Reimbursement is another exclusive benefit available to TRICARE Prime members. Any “reasonable” travel costs incurred in traveling more than 100 miles away from home for a PCM referral regarding medically necessary specialist treatment can be submitted to TRICARE for reimbursement.
Please note that this benefit is not available to active-duty servicemembers/sponsors, only to their family member beneficiaries.