Get to Know Your TRICARE Prime Plan
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 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 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 providerAn authorized provider is any individual, institution/organization, or supplier that is licensed by a state, accredited by national organization, or meets other standards of the medical community, and is certified to provide benefits under TRICARE. There are two types of TRICARE-authorized providers: Network and Non-Network. DS 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.
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.
Last Updated 9/1/2020