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Get to know your TRICARE Prime plan

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TRICARE Health Program

TRICARE Prime is similar to a health maintenance organization, or HMO, plan. This means you get most of your care from an assigned or selected primary care manager (PCM). This PCM refers you to specialists for care that he or she can’t provide and works with your TRICARE regional contractor for referrals and authorizations. Depending on where you live and your sponsor’s status, other TRICARE PrimeA managed care option available in Prime Service Areas in the United States; you have an assigned primary care manager who provides most of your care.TRICARE Prime options include:

TRICARE Prime differs from TRICARE Select, the other TRICARE enrollment health plan. In general, TRICARE Prime offers lower out-of-pocket costs than TRICARE SelectStarting on January 1, 2018, TRICARE Select replaces TRICARE Standard and Extra. TRICARE Select is a self-managed, preferred provider network plan. TRICARE Select is a fee-for-service option in the United States that allows you to get care from any TRICARE-authorized provider.  Enrollment is required to participate. TRICARE Select, but fewer personal choices for providers.

Who can enroll in TRICARE Prime?

If you’re on active duty, you’re automatically enrolled in TRICARE Prime. Active duty family members (ADFMs), retirees, and retiree family members may also enroll in TRICARE Prime. In overseas locations, TOP Prime is available to active duty service members (ADSMs) and their command-sponsored family members.

How do you get care with TRICARE Prime?

Under a TRICARE Prime option, you’ll get most of your routine care from your PCM. If you need specialty care, you’ll generally need to coordinate this with your PCM. Certain services require a referral and prior authorization.

If you see a specialist without a referral from your PCM, you’re using the point-of-service option. With the point-of-service option, non-ADSMs can see any TRICARE-authorized provider without a referral. This means that you’ll pay more money to get non-emergency health care from any TRICARE-authorized provider without a referral. ADSMs can’t use the point-of-service option.

What are the costs with TRICARE Prime?

TRICARE Prime generally has the lowest out-of-pocket costs of all the TRICARE health plans. ADSMs and ADFMs pay no deductible and generally have no costs for TRICARE covered services.

Enrollment Costs

ADSMs, ADFMs, and transitional survivors have no enrollment fees. Retirees, their families, and others pay annual enrollment fees.

Costs for Covered Care

ADSMs pay no out-of-pocket costs for covered health care services from a PCM, or with the appropriate referral and prior authorization. ADFMs pay no out-of-pocket costs for covered health care services from a TRICARE network provider in their enrolled TRICARE region, or with the appropriate referral and prior authorization.

Retirees pay copayments or cost-shares for covered health care services from network providers in their enrolled TRICARE region. Out-of-pocket costs are limited to the catastrophic cap amount for that calendar year. For more cost details, check out the TRICARE Costs and Fees Sheet and TRICARE Prime costs. You can also use the TRICARE Compare Cost Tool to compare current plan costs.

Getting to know your TRICARE Prime plan will help you make informed choices and take command of your health this year. To learn more about your health plan and key features, visit TRICARE Prime and download the TRICARE Plans Overview.

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The Evaluation of the TRICARE Program: Access, Cost, and Quality, Fiscal Year 2014 Report to Congress is provided by the TRICARE Management Activity (TMA)/Office of the Chief Financial Officer (OCFO)—Defense Health Cost Assessment and Program Evaluation (DHCAPE), in the Office of the Assistant Secretary of Defense (Health Affairs) (OASD/HA).This evaluation report presents results trended over at least the most recent three fiscal years, where programs are mature and data permit. MHS cost, quality, and access data are compared with corresponding comparable civilian benchmarks, such as comparing beneficiary-reported access and experience to results from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey sponsored by the Agency for Healthcare Research and Quality (AHRQ), comparing our quality measures to the national expectations and results of the Joint Commission, and comparing healthrisky behavior to Healthy People 2020 objectives.

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