TRICARE Prime

Army Reserve: Retired

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:

Retired Army Reserve Soldiers and Family members who are under age 65 or not otherwise eligible for Medicare are eligible to utilize TRICARE Prime once the Reserve component Soldier completes 20 years of qualifying service, reaches age 60, and starts receiving retired pay. Prime-eligible beneficiaries who choose not to enroll in Prime are covered under TRICARE Standard.

Retirees under age 65 who become entitled to Medicare Part A because of a disability or End Stage Renal Disease (ESRD) and who are enrolled in Medicare Part B receive health care under Medicare and TRICARE for Life (TFL). When the military retiree reaches age 65, his/her health care coverage changes from TRICARE to Medicare and TRICARE for Life (TFL). When a retired sponsor reaches age 65 and becomes eligible for TFL, his or her Spouse maintains regular TRICARE eligibility until he or she (Spouse) becomes 65 years old if he/she becomes eligible for Medicare coverage, otherwise TRICARE eligibility continues.

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.

TRICARE covers eligible Children until age 21. For TRICARE coverage beyond the age of 21, college student 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.

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.

Enrollment Fees: Retired Soldiers and Family members enrolled in TRICARE Prime pay an annual enrollment fee and co-payments. This also applies to those over 65 who are not Medicare-eligible. Current individual and Family enrollment fees may be found on the TRICARE Prime website:
http://www.tricare.mil/Plans/Enroll/Prime.aspx Enrolling in Prime: For retired Soldiers and Family members who desire to participate in Prime, enrollment is required. One enrollment form must be submitted per person. The enrollment fees are applied to the catastrophic cap. Visit www.tricare.mil/costs for fees and payment options. Enrollment forms may be downloaded from the following TRICARE website: http://www.tricare.mil/Plans/Enroll/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: Retired Soldiers and 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. 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.

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/Plans/HealthPlans/Prime.aspx

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

TRICARE Region North: http://www.tricare.mil/TRONorth/default.cfm

TRICARE Region South: http://www.tricare.mil/trosouth/

TRICARE Region West: http://www.tricare.mil/trowest/

TRICARE Overseas Region: http://www.tricare-overseas.com/

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