TRICARE Prime

Regular Army: Active Duty

Benefit Fact Sheet

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Summary:

TRICARE Prime is a managed-care health insurance option available to all eligible military beneficiaries that are not entitled to Medicare (are age 65 or older) in Prime Service Areas of the North, South, and West Regions of TRICARE.

Eligibility:

Active duty Soldiers and authorized Family members are eligible for TRICARE Prime coverage.

TRICARE benefits information changes frequently so be sure to check http://www.tricare.mil/Welcome/Plans/Prime.aspx for updates.

Active duty Soldiers are required to enroll in one of the applicable TRICARE plans; the type of plan is dependent on where they live and work. Registration in DEERS (Defense Eligibility Enrollment System) is necessary to utilize TRICARE benefits. (NOTE: Anyone can change their information in DEERS but only the military sponsor can add or delete Family members.)

Newborn babies and newly adopted Children are covered under Prime for the first 60 days. After 60 days, they must be properly registered in Defense Enrollment Eligibility Reporting System (DEERS) and formally enrolled in Prime in order to receive Prime coverage by submitting DD Form 2876. If on day 61 the Child is not enrolled in TRICARE Prime, he or she will be covered under TRICARE Standard and TRICARE Extra.

TRICARE covers eligible Children until age 21. For TRICARE coverage beyond the age of 21, college students must be enrolled full-time at an accredited institution of higher education and the sponsor must provide more than 50 percent of the student's financial support up to the age of 23.

The National Defense Authorization Act (NDAA) FY 2011 gave the DoD the authority to expand benefits to qualified dependents that lose TRICARE eligibility and are under the age of 26. Young adults can purchase TRICARE Young Adult and pay monthly premiums.

Un-remarried former Spouses of eligible Soldiers may be eligible for Prime; however, the individual must first establish his/her eligibility for health care coverage by verifying registration in DEERS under his/her own social security number. Completing DD Form 2876 is required to enroll in TRICARE Prime under the former Spouse's SSN; otherwise, the former Spouse will be covered under TRICARE Standard and TRICARE Extra. The former Spouse must have been married to the same member or former member for at least 20 years, and at least 20 of those years must have been creditable in determining the member's eligibility for retirement pay with coverage beginning after the date of divorce, dissolution or annulment OR the former Spouse must have been married for at least 20 years, and at least 15 - but less than 20 - of those married years must have been creditable in determining the member's eligibility for retirement with coverage for only one year from the date of the divorce, dissolution, or annulment.

When an active duty sponsor dies, surviving Spouses remain eligible for TRICARE health care benefits as active duty Family members for a three-year period. At the end of the three-year period, TRICARE eligibility continues, but the survivor's status changes to that of retiree Family member. It is important for the survivor to update personal information and to keep supporting documents current in DEERS. Surviving Children whose sponsor died on or after October 7, 2001, remain eligible for TRICARE benefits. Unlike Spouses, eligibility will not change after three years, and Children remain covered until eligibility ends due to the age limits or another reason (e.g. marriage).

Benefit Highlights:

TRICARE Prime enrollees receive most of their health care at a military treatment facility (MTF) and their care is coordinated by a primary care manager (PCM). Prime enrollees agree to seek treatment first from their PCM (usually at the MTF) before seeking routine treatment elsewhere. (Emergency care should be sought at the nearest emergency room or health care facility.)

When a beneficiary enrolls in Prime at a MTF, he/she will be assigned a PCM who will coordinate care, maintain health records, and make referrals to specialists, if necessary. If specialty care is needed, or if the MTF cannot provide the treatment the beneficiary needs, the PCM may refer the patient to a "preferred" or "in-network" provider (doctor, nurse practitioner, lab, etc.) managed by the regional TRICARE contractor.

Active duty Service members (including activated Guard/Reserve members) and their Families pay no enrollment fees and no out-of-pocket costs for any type of care as long as care is received from the primary care manager or with a referral.

All others pay annual enrollment fees and network copayments. Beginning October 1, 2012, there was a modest increase in TRICARE Prime enrollment fees. The fee increase applies only to new enrollees whose TRICARE Prime applications are received on or after October 1, 2012.

Annual Fees

$273.84/year for individuals
$547.68/year for Families

Quarterly Fees

$68.46/quarter for individuals
$136.92/quarter for Families

Monthly Fees

$22.82/month for individuals
$45.64/month for Families

The TRICARE Prime fee you pay depending on the date of enrollment:

When You Enrolled

Your Prime Enrollment Fee

Before October 1, 2011

Individual: $230/year
Family: $460/year

Between October 1, 2011 and October 1, 2012

Individual: $260 per year
Family: $520 per year

Between October 1, 2012 and October 1, 2013

Individual: $269.28/year
Family: $538.56/year

On or after October 1, 2013

Individual: $273.84/year
Family: $547.68/year

The only beneficiaries who are exempt from the enrollment fee increases each year are those classified as either:

  • survivors of active duty deceased sponsors
  • medically-retired uniformed Service members and their dependents

MTF Appointment Priorities: Active duty Soldiers and Service members have first priority for making an appointment at the MTF. Next are active duty Family members who are enrolled in Prime, then all other Prime enrollees, followed by all other beneficiaries who are not enrolled in Prime.

TRICARE has access standards in place to help ensure timely health care. These include:

  • The wait time for an urgent care appointment should not exceed 24 hours (one day).
  • The wait time for routine appointment should not exceed one week (seven days)
  • The wait time for a specialty care appointment or wellness visit should not exceed four weeks (28 days).
  • The travel time for routine appointment should not exceed 30 minutes
  • The travel time for specialty care appointment should not exceed one hour.

TRICARE Prime Remote: TRICARE Prime is not available in all locations. Active duty Soldiers and their Families who are on remote assignment, typically 50 miles from a MTF, may utilize the TRICARE Prime Remote (TPR) program. TPR is specific to geographic location, and eligibility is based on residence and/or work address Zip Code. Eligibility for TPR requires that the Service member both live and work 50 miles from the nearest MTF or one hour's drive from the nearest MTF. To determine if a Soldier or Family member is eligible for TPR, enter the ZIP Codes in the following link: http://www.tricare.mil/Welcome/Plans/TPR.aspx

TRICARE Overseas: TRICARE Prime is available for active duty and Families overseas. The TRICARE Overseas Program delivers the Prime benefit to active duty Soldiers and Families in the three overseas areas: Eurasia-Africa, the Pacific, and Latin America/Canada. The TRICARE Prime Remote Overseas program delivers the Prime benefit to active duty Soldiers and Families stationed in designated "remote" locations overseas. More information regarding the TRICARE Overseas Program may be found at:

 http://www.tricare.mil/Welcome/Plans/TPO.aspx

  http://www.tricare.mil/Welcome/Plans/TPRO.aspx

Enrolling in Prime: For active duty Soldiers, Prime coverage is automatic, however the active duty Soldier must fill out an enrollment form and submit it to the regional TRICARE contractor. For active duty Family members who desire to participate in Prime, enrollment is required. One enrollment form must be submitted per person. Enrollment forms may be downloaded from the following TRICARE website: http://www.tricare.mil/Welcome/Plans/Prime.aspx

Alternatively, enrollment may be completed online via the Beneficiary Web Enrollment Web site: https://www.dmdc.osd.mil/appj/bwe/indexAction.do  

Disenrolling in Prime: Active duty Soldiers are required to be enrolled in Prime, however Family members may choose to disenroll from TRICARE Prime at any time. If they choose to disenroll before the annual enrollment renewal date, they may be subject to a one-year lockout. The lockout provision does not apply to Family members whose sponsor is E-1 through E-4.

Any change in status (e.g., from active duty to retired or a reservist demobilizing) will cause automatic disenrollment from TRICARE Prime. When the member changes status, and remains TRICARE eligible, he/she must re-enroll in Prime immediately to maintain coverage. Active duty Family members are required to disenroll from the TRICARE Overseas Program (TOP) Prime within 60 days of departure if they no longer live in a TOP Prime area.

Transferring Enrollment in Prime: Active duty Soldiers and Family members scheduled for a permanent change of station (PCS) move will remain enrolled in Prime for a maximum of 60 days from the date they leave their current TRICARE region (in the U.S. or overseas). To avoid Prime coverage interruptions, enrollees need to transfer their enrollment to the new regional contractor (U.S.) or MTF (overseas) and select a new PCM. Before the move, enrollees should let their current TRICARE Service Center (TSC) know they are moving. Upon arrival at the next duty station, enrollees should stop by a TSC in the new region or overseas area as soon as possible to fill out needed paperwork.

Additional Information:

For more information, please visit the official TRICARE webpages maintained by the Office of the Assistant Secretary of Defense (Health Affairs) and the TRICARE Management Activity:

TRICARE Prime Home Page:  http://www.tricare.mil/Welcome/Plans/Prime.aspx

TRICARE Home: http://www.tricare.mil/

TRICARE Region North: http://www.tricare.mil/Welcome/About/Regions/North.aspx

TRICARE Region South: http://www.tricare.mil/Welcome/About/Regions/South.aspx

TRICARE Region West: http://www.tricare.mil/Welcome/About/Regions/West.aspx

TRICARE Overseas Region: http://www.tricare.mil/Welcome/About/Regions/Overseas.aspx  

TRICARE DEERS Information:  http://www.tricare.mil/Welcome/Eligibility/DEERS

TRICARE Prime Fact Sheet: http://www.tricare.mil/~/media/Files/TRICARE/Publications/FactSheets/Prime_FS.pdf

TRICARE Prime and TRICARE Prime Remote Handbook:  www.tricare.mil/~/media/Files/TRICARE/Publications/Handbooks/TP_TPR_HBK.pdf

Document Review Date: 7 March 2014