Getting out, military health issues - Navy Times

Tricare Prime

Prime is the military’s health maintenance organization, which has lower out-of-pocket costs but places restrictions on an individual’s choice of providers and facilities. Since the wars in Iraq and Afghanistan, there is less available space for retirees to enroll in Prime at many military facilities.

Users see a primary care provider — a doctor, nurse practitioner or team — who renders treatment and coordinates all aspects of their health care.

Prime is the only Tricare option that requires enrollment. There is no enrollment fee for active-duty members or their families, but retirees pay $230 for an individual or $460 for a family to enroll. Prime is not available to retirees overseas.

Individuals enrolled in Prime at military hospitals and clinics get higher priority for health care services than those not enrolled. Enrolled active-duty dependents have priority just behind service members. Enrolled retirees and their families are seen next, followed by active-duty dependents not enrolled in Prime.

Patients referred to a specialist more than 100 miles from their primary care facility can have their travel expenses reimbursed under Prime.

Prime limits out-of-pocket expenses; it has no deductibles, and co-payments for health care visits are lower than for the other programs.

Co-pays for civilian doctor visits are $12 for enrolled retirees and their dependents. Active-duty dependents don’t pay for civilian care, if they follow the Prime rules. The catastrophic cap — the ceiling on how much a family must pay annually for covered health care services — is $1,000 for active-duty families and $3,000 for retirees’ families, provided they follow the rules.

Costs rise substantially if an individual goes outside the Tricare network without authorization from the primary care provider. In such instances, deductibles are $300 for an individual or $600 for a family. After the deductible is met, Tricare will pay only 50 percent of what it establishes as a reasonable charge.