Getting out, military health issues - Navy Times

Tricare Prime

Prime is a Tricare option similar to a health maintenance organization, which has lower out-of-pocket costs but requires enrollees to use network providers and coordinate their care through a Primary Care Manager — a doctor, nurse practitioner or team — who provides treatment and coordinates all aspects of their health care.

Tricare regional managed care support contractors contract with health care providers to supply services at discounted fees. Doctors and other providers agree to join a network and see Tricare Prime patients.

Prime 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 each year. There is a Tricare Prime option available overseas for active-duty troops and their command-sponsored family members. 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 the Tricare Prime travel benefit. Before traveling, coordination is made with the military treatment facility staff if enrolled with a military hospital or clinic, or the Tricare regional office if enrolled in Tricare Prime with a civilian primary care manager.

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 medical care if they follow the Prime rules. They do pay for pharmacy services. 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.