Understanding Military Medical Benefits and TRICARE

Military Medicine: Depending upon their status, active duty members, retired members, members of the Guard/Reserves, family members, and certain veterans receive free or government subsidized medical and dental care. For the most part, this care falls under an overall program known as TRICARE. 

Beginning in 1988, the military offered service families a choice of ways in which they might use their military health care benefits. Five years of successful operation and high levels of patient satisfaction convinced Defense Department officials that they should extend and improve the concepts of military medicine reform initiative (called CRI - Champus Reform Initiative), as a uniform program nationwide. The new program, known as TRICARE, is now fully in place.

In FY 1996, the TRICARE/CHAMPUS budget was more than $3.5 billion, and more than 20 million claims were received. Today, nearly 5.5 million people are eligible for TRICARE benefits.

Types of TRICARE

When TRICARE was first instituted, there were only three types. Over the past few years, more TRICARE health plan options have been established. Visit the TRICARE website for complete details on all TRICARE plans:

• TRICARE Prime
• TRICARE Prime Remote
• TRICARE Prime Overseas
• TRICARE Prime Remote Overseas
• TRICARE Standard and Extra
• TRICARE Standard Overseas
• TRICARE For Life
• TRICARE Reserve Select
• TRICARE Retired Reserve
• TRICARE Young Adult
• US Family Health Plan

TRICARE Prime

This option is similar to an HMO in concept. It requires that one specifically enroll in the program (active duty members are enrolled automatically). Individuals enrolled in TRICARE Prime are assigned to a primary care provider (PCP), which is usually the local military medical facility (base hospital).

In order to receive specialist care, enrollees must be referred by their PCP. Under this program, there is no enrollment fee or cost-sharing for active duty members and family members of active duty.

For retirees (under age 65) and family members of retirees (under age 65), there is an enrollment fee for TRICARE Prime that increases each year. One can get the forms to enroll in TRICARE Prime online.

A brand new option under TRICARE Prime is the Point of Service (POS) enrollment option. Normally under TRICARE Prime, you must be referred by the PCP in order to receive any reimbursement for medical care received from anyone other than the PCP. But, if you elect the POS option at time of enrollment, you can use TRICARE Prime and still use the TRICARE Standard or TRICARE Extra options described below.

TRICARE Standard and Extra

This program gives more flexibility than TRICARE Prime, but could result in addition costs. You do not need to enroll in advance to use TRICARE Extra. Under this program, you see any Authorized TRICARE Provider, present your ID Card and receive medical care.

• The TRICARE Authorized Providers have a contract with the military to limit costs to designated amounts. Under TRICARE Extra, active duty family members pay an annual deducible (the year begins every October):
• See link for costs updates - TRICARE COSTS

For retirees and retiree family members (under age 65), the program costs a little more, though the annual deductible is the same. Visit the TRICARE Standard and Extra Costs webpage for all cost details.

Under TRICARE Extra, the medical provider fills out the TRICARE Claim Forms for you, and they receive direct payment from TRICARE for their portion. You simply pay them your portion of the costs.

TRICARE for Life

Until recently, when a retiree or retiree family member reached the age of 65, they were no longer eligible for TRICARE. Instead, they were expected to receive medical care under the provisions of Medicare. This changed in 2001 with the introduction of TRICARE for Life (TFL). Again, there is no need to enroll in advance (except one must be enrolled in Medicare Part B). Additionally, the only charges for this program are the monthly Medicare Part B premiums. Under this program, you see an authorized Medicare Provider and present your ID Card. TRICARE then becomes the second payer and picks up any costs that Medicare doesn't cover.

Although Medicare doesn’t cover services provided outside of the continental United States, retirees residing in foreign countries can still take advantage of TFL because TRICARE becomes the primary source of health benefits for them.

Like those living in the United States, to be eligible overseas retirees must be enrolled in Medicare Part B. TRICARE for Life will provide the same level of coverage afforded retirees under 65 and they will be responsible for the same TRICARE cost shares and deductibles as the under 65 retirees. Since a great number of retirees living overseas did not enroll in Part B because Medicare didn’t cover medical care received in foreign countries, some of the military related organizations are pushing for a waiver of the Part B penalty which entails a 10 percent penalty for each year the individual was eligible for Part B but didn’t enroll. However, there is currently nothing in the works that indicates such a waiver is coming.

Pharmacy Benefits with TRICARE

There are several ways to fill prescription medications through TRICARE:

Military Pharmacies

You may have prescriptions filled (up to a 90-day supply for most medications) at a military treatment facility (MTF) pharmacy free of charge. Please be aware that not all medications are available at MTF pharmacies. Each facility is required to make available the medications listed in the basic core formally (BCF). The MTF, through their local Pharmacy & Therapeutics Committee, may add additional medications to their local formally based on the scope of care at that MTF.

TRICARE Mail Order Pharmacy (TMOP)

You can order medications online or through the mail. You can receive up to a 90 day supply (for most medications). Generic formulary costs are $0, while the brand name formulary is $20. Non-formulary cost is $49 unless you have a medical necessity.

Network Pharmacies

You may receive up to a 30-day supply of prescription medication from a pharmacy within the TRICARE Pharmacy Network. The cost for generic formulary is $10, and the cost for brand name formulary is $24. Non-formulary is $50 unless you have medical necessity.

Non-network Pharmacies

The costs for non-network pharmacies are based on where you are, who you are and in some cases, what plan you're using. You may need to pay up front and file a claim for reimbursement.

The costs will generally be higher, however, for non-active duty beneficiaries. Active duty service members will receive full reimbursement. For complete details and costs for beneficiaries, visit the TRICARE prescription costs web page.

Active Duty/Reserve Dental Care

• Dental care for active duty, of course, is free through the Military Dental Clinic. TRICARE does, however, offer optional dental plans for family members of active duty and members of the Guard/Reserves and their family members. These programs require a monthly premium. The programs pay the total cost of some dental care, plus cost-share for other dental care.
• See current rates for dental
• Three different dental programs

VA Medical Care

I run into folks all the time who think that any military retiree or any veteran can get free medical care from the Veterans Administration. Not true. To receive medical care from the VA, you must be a Veteran (over 180 days of military service), have an honorable discharge and have either a service-connected illness, injury or disability, or you must fall into a certain range of poverty.

More information about VA Medical Care is available on the VA's Web Site.