9. TRICARE Your Military Health Plan
Health Net Federal Services, Inc.
Beneficiary Education
Seminar
Hello and welcome to your Beneficiary Education Briefing on TRICARE and Health Net Federal Services. Health Net is your regional contractor in the TRICARE North region. You will hear a lot more about Health Net later on in this briefing session. The purpose of this briefing is to provide you with all the information, tools, and resources you need to accomplish the following:
#1) To become an educated beneficiary of one of the most important benefits the uniformed services offers to you, your health care benefit and
#2) To understand how to select the plan option which is best for you, how to access care and service, and who to contact for questions and concerns when you need assistance.
BR400801BEN0504C 1 1

10. What is TRICARE? DoD’s integrated health care delivery system
Provides health benefits and services to active duty and retired members of the uniformed services, their families, and survivors worldwide
Available to Army, Navy, Air Force, Marine Corps, Coast Guard, the U.S. Public Health Service (USPHS), and the National Oceanic and Atmospheric Administration (NOAA)
TRICARE is the Department of Defense’s integrated health care delivery system, which provides health benefits and services to active duty and retired members of the uniformed services, their families and survivors worldwide.
The Uniformed Services includes the:
U.S Army
U.S. Air Force
U.S. Navy
U.S. Marine Corps
U.S Coast Guard
U.S. Public Health Service, and
National Oceanic & Atmospheric Administration.
TRICARE combines your current access to military hospitals and clinics—the core of our nation’s Military Health System—with resources from a network of civilian health care providers. This unique health system supports readiness, ensures the health of our forces, and cares for them when ill or injured, anywhere around the globe.
BR400801BEN0504C 4 4

11. New TRICARE Regions 11 Health Net Federal Services 1-877-874-2273
TriWest Healthcare Alliance
TRICARE North Region—includes Connecticut, Delaware, the District of Columbia, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Vermont, Virginia, North Carolina, Illinois, Indiana, Kentucky, Michigan, Missouri (St. Louis area), Ohio, Tennessee (Ft. Campbell area), and Wisconsin. Contact Health Net Federal Services at TRICARE ( ),
TRICARE West Region—includes Alaska, Arizona, California, Colorado, Hawaii, Idaho, Iowa (excluding Rock Island Arsenal), Kansas, Minnesota, Missouri (except the St. Louis area), Montana, Nebraska, Nevada, New Mexico, North Dakota, Oregon, South Dakota, Texas (the southwestern corner including El Paso), Utah, Washington, and Wyoming. Contact TriWest at TRIWEST ( ),
TRICARE South Region—includes Alabama, Florida, Georgia, Mississippi, South Carolina, Tennessee (excluding the Ft. Campbell area), Louisiana, Arkansas, Texas (excluding the El Paso area), Oklahoma, and Louisiana. Contact Humana Military Healthcare Services at ,
Humana Military Healthcare Services
BR400801BEN0504C 11 11

12. Who is eligible for TRICARE?
Active duty service members (ADSMs) and retirees of any of the seven uniformed services
Reserve Component members on active duty for more than 30 consecutive days (under Federal orders), from any of the seven uniformed services
Spouses of active duty, retired, and eligible Reserve Component service members
Who is eligible for TRICARE?
Active duty service members (ADSM) and retirees of any of the seven uniformed services and their spouses
Reserve Component members on active duty for more than 30 consecutive days—under Federal orders, from any of the seven uniformed services and their spouses
Uniformed services includes the Army, Air Force, Navy, Marine Corps, Coast Guard, Public Health Service, or the National Oceanic & Atmospheric Administration.
The Reserve Component includes the Army National Guard, the Army Reserve, the Naval Reserve, the Marine Corps Reserve, the Air National Guard, the Air Force Reserve, and the U.S. Coast Guard Reserve
BR400801BEN0504C 27 27

13. Updating DEERS Information
Visit an ID card issuing facility; locate one near you at
Call
Mail changes to:
Defense Manpower Data Center Support Office
Attn: COA
400 Gigling Road
Seaside, CA
Make address changes online at:
You can verify your DEERS information by contacting Health Net, by visiting TRICARE service center, or by contacting the nearest uniformed services personnel office (ID card facility). Sponsors or registered family members may make address changes, however, only the sponsor can add or delete a family member from DEERS, and proper documents are required such as a marriage certificate, divorce decree and/or birth certificate.
Update DEERS Information in one of the following ways:
Visit an ID card issuing facility; locate one near you at
Call
Mail changes to:
Defense Manpower Data Center Support Office
ATTN: COA
400 Gigling Road
Seaside, CA
Make address changes online at:
BR400801BEN0504C 36 36

14. Who is eligible for TRICARE?
Unmarried children (including stepchildren) up to age 21 (or 23 if full-time student) under regular TRICARE
Past age 21—Mental/Physical incapacity
Unmarried children remain eligible even if parents divorce or remarry
Dependent parents and parents-in-law
Eligible for primary care in a military treatment facility
Depends on availability in the MTF.
Unmarried children (including stepchildren) of active duty and retired service members and those of eligible reserve component sponsors.
A child’s eligibility ends at age 21 unless the child is a full-time student (validation of student status required) then eligibility ends at age 23 or when the full-time student status ends. Eligibility may extend past age 21 if the child is incapable of self-support because of a mental or physical incapacity and the condition existed prior to age 21, or if the condition occurred between the ages of 21 and 23 while the child was a full-time student.
Unmarried children remain eligible even if parents divorce or remarry.
Dependent parents and parents-in-law are eligible for care in a military treatment facility on a space available basis. They can also enroll in TRICARE Plus to be assured Primary Care services only.
BR400801BEN0504C 28 28

15. TRICARE Young Adult Eligibility
You May Purchase TYA Coverage If You Are All Of The Following:
A dependent of an eligible uniformed service sponsor *
Unmarried
At least age 21 (or age 23 if enrolled in a full-time course of study at an approved institution of higher learning and if your sponsor provides at least 50 percent of the financial support), but have not yet reached age 26

16. TYA Eligibility
Not eligible to enroll in an employer-sponsored health plan offered by your own employer
Not otherwise eligible for any other TRICARE program coverage
*If you are an adult child of a non-activated member of the Selected Reserve of the Ready Reserve or of the Retired Reserve, your sponsor must be enrolled in TRICARE Reserve Select (TRS) or TRICARE Retired Reserve (TRR) for you to be eligible to purchase TYA coverage

17. Purchasing Coverage
TYA offers open enrollment, so if you qualify, you may purchase coverage at any time.
Download the TYA application from the TRICARE and regional contractor’s websites.
Deliver completed applications to a TRICARE Service Center or mail it to your regional contractor.

18. TRICARE and Other Health Insurance
TRICARE pays after all other health insurance plans except for:
Medicaid
TRICARE supplements
The Indian Health Service
Other programs/plans as identified by TMA
Not required to obtain TRICARE referrals or prior authorization for covered services, except for adjunctive dental care, the PFPWD, and behavioral health care services
However, you must follow the OHI referral and authorization requirements if applicable
TRICARE is the secondary payer to all health benefits and insurance plans, except for Medicaid, TRICARE supplements and the Indian Health Service or other programs/plans as identified by the TRICARE Management Activity (TMA).
TRICARE beneficiaries who have other heath insurance (OHI) are not required to obtain TRICARE referrals or pre-authorizations for covered services, except for adjunctive dental care, the PFPWD, and behavioral health care services. These services continue to require prior authorization even when OHI coverage exists. You must follow the OHI referral and authorization requirements, if applicable.
BR400801BEN0504C
132
132

19. TRICARE Standard Fee-for-service option No enrollment required
Seek care from any TRICARE-authorized provider
Responsible for annual deductibles and
cost-shares—highest out-of-pocket expense
May have to pay provider then file claim for reimbursement
May seek care in an MTF on a space-available basis
Active duty service members are not eligible for TRICARE Standard
When using TRICARE Standard, you may seek treatment in a military hospital or clinic, but only on a space-available basis In many areas, space-available appointments are becoming increasingly difficult to obtain.
TRICARE Standard offers the freedom for you to seek care from any TRICARE-authorized provider. After meeting an annual deductible, you may see any TRICARE-authorized civilian provider and the government will pay part of the cost and you will be responsible for part of the cost for covered benefits. A deductible is the amount of money you are responsible for paying each year before the government will begin to pay.
You don’t have to enroll in TRICARE Standard; in most cases, you simply select your doctor at time of need, pay for services, and submit the paperwork to TRICARE for reimbursement for covered services.
BR400801BEN0504C 66 66

20. TRICARE Standard Costs
Annual deductible
Active duty E-4 and below: $50 individual/$100 for family
Active duty E-5 and above: $150 individual/$300 for family
Retirees and families: $150 individual/$300 for family
Cost-shares after deductible has been met
Active duty family members: 20% of allowed charges
Retirees and their family members: 25% of allowed charges
May be responsible for up to 15% above the TRICARE allowable charge for services if providers do not participate in TRICARE
With TRICARE Standard, each fiscal year (which begins on October 1 and ends on September 30) you must first pay a deductible if you receive care from civilian providers.
For grades E-4 and below the deductible is:$50 individual/ $100 for family
The amount paid toward your deductible is listed on the Explanation of Benefits (EOB) statement. You receive this statement in the mail each time a claim is processed.
If the provider accepts assignment, he or she will bill TRICARE for you and will accept the TRICARE maximum allowable charge as full payment. If the provider does not participate in TRICARE, you may have to pay the provider first and file the claim for reimbursement. You may also be responsible for paying up to 15% above the TRICARE allowable amount for covered services.
BR400801BEN0504C 67 67

21. TRICARE Extra vs. Standard
Any TRICARE network provider
Active duty family member: 15% of negotiated rate
Retirees: 20% of negotiated rate
Providers will file claims for you
Not responsible for additional charges for covered benefits
Standard
Any TRICARE-authorized provider
Active duty family member: 20% of allowable charge
Retirees: 25% of allowable charge
May have to file claims
Nonparticipating providers may charge up to 15% above allowable charge for services
In comparing the two plans, the similarities are same deductible, no enrollment, and no monthly or annual premiums. TRICARE Standard differs from Extra as follows:
Active duty family member: Pay 20% after meeting deductible
May have to pay up to 15% above the TRICARE allowable charge if provider does not participate in TRICARE
The differences with TRICARE Extra are that you select providers in the TRICARE network, the cost-share is 5% lower than Standard, and you are not responsible for additional charges for covered benefits.
Both options allow for care at the MTF on a space-available basis.
BR400801BEN0504C 69 69

22. Supplemental Insurance
Health benefit plans that are specifically designed to supplement TRICARE Standard benefits.
An extensive list of military associations is available at under the Community tab.

23. TRICARE Prime Managed care option Enrollment required
Fewer out-of-pocket costs
Select (or are assigned) a primary care manager (PCM)
Care received at MTFs and in the civilian preferred provider network
Guaranteed access standards
No claims to file
TRICARE Prime is a managed care option similar to a civilian health maintenance organization. TRICARE Prime offers fewer out-of-pocket costs than any other TRICARE option, with no deductibles to meet and low or no cost-shares. TRICARE Prime enrollees receive most of their care from a military treatment facility (MTF), augmented by the TRICARE contractor's Preferred Provider Network.
TRICARE Prime has certain access standards that dictate your waiting time for appointments. Enrollment is required and TRICARE Prime enrollees are assigned a primary care manager (PCM). Let’s start by talking about enrollment first.
BR400801BEN0504C 47 47

24. Enrolling in TRICARE Prime
Active duty and family members—no enrollment fee
Retirees—$260 for individual/$520 for families
Enroll by 20th of month—effective 1st of the next month
If you enroll after the 20th of the month, your enrollment will begin on the 1st day of the 2nd month after that
Enrollment is continuous
Active duty service members are covered under the TRICARE Prime benefit but are required to complete a TRICARE Prime enrollment application.
To participate in TRICARE Prime, active duty family members, retirees, and their family members must also complete a TRICARE Prime enrollment form. There is no enrollment fee for active duty family members. Retirees and their family members must pay an annual enrollment fee of $230 for an individual or $460 for a family. Payments can be made in annual, quarterly, or monthly installments.
If the TRICARE Prime enrollment form is received by the 20th of the month, coverage is effective the first day of the next month. Enrollment in TRICARE Prime is continuous. During the period of enrollment, TRICARE Prime beneficiaries are required to use only TRICARE Prime. Beneficiaries can choose to disenroll or can be disenrolled due to a move to a non-TRICARE Prime area, a move out of their service area, or nonpayment of enrollment fees. If beneficiaries choose to disenroll from TRICARE Prime, or are disenrolled for nonpayment, they are subject to a 1-year lockout for early disenrollment. The lockout provision does not apply to active duty family members of E-1 through E-4.
BR400801BEN0504C 49 49

25. Referrals
TRICARE Prime beneficiaries will be referred to MTF first when it can provide the specialty services needed. Call TRICARE ( ) for specific information about the MTFs in your TRICARE Prime service area
Specialty care referrals will be approved for a specific length of time and number of visits
Follow the appropriate procedure for specialty referrals to avoid responsibility for charges other than your cost-shares
If you have other health insurance, you must follow the network referrals rules for that carrier
When a TRICARE Prime beneficiary’s PCM is unable to provide a specialized medical service, the PCM must contact Health Net to request a referral. Health Net issues a referral when a TRICARE Prime beneficiary needs specialized medical services from a professional or ancillary provider only if services are not available at the MTF.
The MTF is always the primary source of care for TRICARE beneficiaries. The MTF has first “right of refusal” to provide care for a TRICARE beneficiary. Requests for a referral can be obtained by either submitting a HIPAA-Compliant 278 (electronic transmission) or faxing a referral to Health Net.
In support of delivering high quality health care, Health Net utilizes HealthShare, a Web-based tool, to refer you to hospitals with the most favorable outcomes. You can access the HealthShare tool though the Health Net Web site at
BR400801BEN0504C 60 60

26. TRICARE Comparison Chart
TRICARE Prime/
Prime Remote
TRICARE Standard
TRICARE Extra
Type of Program
Managed Care, HMO-like
Fee-for-service program
Preferred Provider Option
Availability
TRICARE Prime Service Areas/Prime Networks
Throughout U.S. and overseas
Enrollment/ Fees
Required/ ADFM: None Retirees: $260 individual/ $520 family
Not Required/ None
Costs
ADFM: None
Retirees: Civilian co-pays
Deductible and cost shares ADFM: 20%, Retirees: 25%
Deductible and cost shares ADFM: 15%, Retirees: 20%
Provider Choices
MTF’s and Network Providers
TRICARE authorized provider
Space-A at MTF
TRICARE Network Provider
Space-A and MTF
Primary Care Manager (PCM)
All care coordinated through a PCM
No PCM
self-managed care
Referral and Auth Requirements
PCM referrals required for specialty care, some prior-authorization requirements
Self-referred care
Some prior-authorization requirements
Some prior-authorization requirements

27. Catastrophic Cap ADFMs using TRICARE Standard—$1,000 per fiscal year
All other beneficiaries using TRICARE Standard (retirees, family members of retirees, survivors, former spouses)
$3,000 per fiscal year
The catastrophic cap limits your out-of-pocket liability on cost-shares, cost-shares, and deductibles. The catastrophic cap by beneficiary category is as follows:
• ADFMs using TRICARE Standard—$1,000 per fiscal year
• All other beneficiaries using TRICARE Standard (retirees, family members of retirees, survivors, former spouses)—$3,000 per fiscal year
• ADFMs using TRICARE Prime—$1,000 per fiscal year
• All other beneficiaries using TRICARE Prime (retirees, family members of retirees, survivors, former spouses)—$3,000 per enrollment year
BR400801BEN0504C 68 68

28. Enrollment Portability
Transfer TRICARE Prime enrollment from one TRICARE Region to another
Active duty enrollees and their families have unlimited transfers without a break in coverage
Retirees and their families may transfer twice in a single enrollment year as long as second transfer is back to the original enrollment location
Select a new PCM in the new region
Update your new address in DEERS
Enrollment portability allows TRICARE Prime beneficiaries to transfer their enrollment from one TRICARE region to another
Active duty enrollees and their families may move place to place an unlimited number of times without a break in coverage. When a uniformed services family moves to a new TRICARE region, they do not have to change their TRICARE Prime coverage, but they do need to transfer their enrollment to the new regional contractor (Humana or TriWest) and select a new primary care manager (PCM) to avoid expensive point-of-service charges.
When beneficiaries move, they need to update their address in DEERS as soon as possible. 
BR400801BEN0504C 51 51

29. Nonemergency Health Care While Traveling
All routine medical care should be taken care of before you depart or delayed until you return and can see your PCM
For out-of-area urgent/acute care, you must coordinate with your PCM or Health Net for an authorization before seeking care
For out-of-area emergency care, call 911 or go to the nearest emergency room (civilian or military)
TRICARE Prime beneficiaries should remember that all routine medical care should be taken care of before you depart, be delayed until you return and can see your PCM or be delayed until you arrive at your new assignment. For out-of-area urgent/acute care, you must contact your regional contractor for an authorization before seeking care.
For out-of-area emergency care, call 911 or go to the nearest emergency room (civilian or military).
BR400801BEN0504C
103
103

30. Emergency Care Call 911 Visit nearest emergency room
Notify your PCM or Health Net as soon as possible of any emergency admission so that your follow-on care can be coordinated (if enrolled in TRICARE Prime)
A family member can call on your behalf
TRICARE defines an emergency as a condition that would lead a prudent layperson (someone with average knowledge of health and medicine) to believe that a serious medical condition existed or the absence of medical attention would result in a threat to his/her life, limb, or sight and requires immediate medical treatment
TRICARE covers inpatient or outpatient emergency services needed to evaluate or stabilize an emergency medical condition. .
Emergency care does not require an authorization. However, if a beneficiary is admitted as a result of emergency care, the provider should notify Health Net as soon as possible. Inpatient admission notifications are required for all TRICARE beneficiaries.
BR400801BEN0504C
101
101

31. TRICARE Prime Point-of-Service (POS) Option
Freedom to use any TRICARE-authorized provider
In or out of network—no referrals needed
Nonavailability statement is not necessary
Subject to deductibles and cost-shares
Point-of-service option is more costly to the TRICARE Prime enrollee
Does not apply to active duty service members
The Point-of-Service (POS) Option under TRICARE Prime allows enrollees the freedom to seek and receive non-emergent health care services from any TRICARE-authorized civilian provider, in or out of the network, without requesting a referral from their PCM or their regional contractor. When TRICARE Prime enrollees choose to use the POS option, all requirements applicable to TRICARE Standard apply except the requirement for a Nonavailability Statement (NAS). POS claims are subject to outpatient deductibles and cost-shares, and is the most costly TRICARE option to the enrollee. The POS option does not apply to active duty service members.
BR400801BEN0504C 62 62

32. POS Cost-shares and Deductibles
Annual outpatient deductibles are $300 for an individual and $600 for family
50% cost-shares for outpatient and inpatient claims
Excess charges up to 15% over the allowed amount
The annual catastrophic cap does not apply to your out-of-pocket expenses under the POS option
Annual outpatient deductibles are $300 for an individual and $600 for family, 50 percent cost-shares for outpatient and inpatient claims, and excess charges up to 15 percent over the allowed amount. The TRICARE Prime beneficiary's out-of-pocket cost while utilizing POS is accrued against the catastrophic cap. However, there is no cap on POS out-of-pocket expenses. The beneficiary cost-share will remain at 50 percent of the TRICARE allowable charge even after the catastrophic cap has been reached.
BR400801bBEN0504C 63 63

33. TRICARE Dental Active Duty Plan is through MetLife 1-855-638-8371
Retiree Plan is through through Delta Dental or
Fee is based off of your location.

34. TRICARE Pharmacy Coverage
†Non-TRICARE Prime: $25 or 20%
†TRICARE Prime: 50% cost-share
†Non-TRICARE Prime: $12 or 20% †TRICARE Prime: 50% cost-share
Non-network Retail Pharmacy (up to a 30-day supply)
$25
$12 $5
Network Retail
(up to a 30-day supply) $9 $0
TMOP (up to a 90-day supply)
$0*
MTF (up to a 90-day supply)
Non-Formulary
Brand Name
Generic
Type of Pharmacy
Whenever you are eligible for TRICARE, you can take advantage of TRICARE’s world-class pharmacy benefit.
MTF pharmacies will fill a 90-day supply for most written prescriptions from any TRICARE-authorized provider, free of charge. Contact your local MTF for details about filling and refilling prescriptions at its pharmacy.
The TRICARE Mail Order Pharmacy is administered by Express Scripts, Inc. With TMOP, you will mail in your written prescription, along with the appropriate cost-share, to TMOP, and the medications will be sent directly to your mailing address. Providers may fax or phone-in new prescriptions. Prescriptions may be refilled by mail, by phone, or online. Note that controlled substances are always limited to a 30-day supply.  
TRICARE retail network pharmacies are available in the United States (including D.C.) and U.S. Territories, and is administered by Express Scripts. Visit the Express Scripts Web site to locate a network pharmacy.
Filling prescriptions in non-network pharmacies is the most expensive option. Beneficiaries using non-network pharmacies may have to pay the total amount of their prescription first and file a claim to receive partial reimbursement.
Be aware that family members not enrolled in TRICARE Prime are responsible for $9 or 20 percent of the total cost, whichever is greater, after the deductible is met (E1-E-4: $50/person, $100/family; all others, including retirees, pay $150/person, $300/family.) Those enrolled in a TRICARE Prime program are responsible for the higher cost-shares associated with the point-of-service option. That is a 50 percent cost-share after the point-of-service (POS) deductibles ($300 per person/$600 per family) are satisfied.
As always, prescriptions for Service members will be reimbursed at the full amount paid. After satisfying the appropriate deductible, the family member reimbursement will be reduced by the amount of the applicable cost-share.
Overseas active duty family members enrolled in TRICARE Prime (in areas other than Guam, Puerto Rico, or the Virgin Islands) will have no cost-share.
Note: The DoD generic drug policy applies to all prescription medications.
*Not available in the MTF unless medical necessity is established.
†Deductibles apply.
BR413401BET0605W
Reserve Component: Benefits for Reserve Component Family Members 7 7

35. TRICARE For Life
TFL is administered nationally by Wisconsin Physicians service. or
TFL is for all Medicare/TRICARE beneficiaries regardless of age, provided they have Medicare Part A and Medicare Part B.
It’s your responsibility to update DEERS
Put simply, TRICARE pays second after Medicare for most services.

36. Certificate Of Credible Coverage
Shows that you were covered by TRICARE
Request certificates in writing from:
Defense Manpower Data Center Support Office
Attn: Certificate Of Credible coverage
400 Gigling Road
Seaside, CA
For more information call,

37. Thank You For Your Time Today.
QUESTIONS
Thank You For Your Time Today.