Benefit Fact Sheet
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.
DFAS will provide IRS Form 1095-C to all U.S. military members, and IRS Form 1095-B to all Retirees, Annuitants, former Spouses and all other individuals having TRICARE coverage during all or any portion of tax year 2022. An IRS Form 1095 documents you (and your Family members, if applicable) have the minimum essential coverage. These forms will document the information that DFAS will provide to the IRS on yourself and your authorized Family members. According to the IRS, these forms are not required to prepare or file income tax returns but will be available via myPay no later than January 31, 2023.
Retired Army National Guard 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 Select.
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, their 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, their Spouse maintains regular TRICARE eligibility until they (Spouse) become 65 years old if they become eligible for Medicare coverage, otherwise TRICARE eligibility continues.
Newborn babies and newly adopted Children are covered under Prime for the first 90 days (stateside) or 120 days (overseas). After 90 days (stateside) and 120 days (overseas) , 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 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 their eligibility for health care coverage by verifying registration in DEERS under their 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 Select. 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.
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 an MTF, they 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.
If you have TRICARE Prime, you must pay enrollment fees, unless you are:
An active duty Service member (including activated Guard/Reserve members)
All others pay annual enrollment fees and network copayments. The fee increase applies only to new enrollees whose TRICARE Prime applications are received on or after January 1, 2023.
If you are a survivor or medically-retired Service Member, your enrollment fee will stay the same as long as you keep TRICARE Prime.
Please visit https://tricare.mil/Costs/Compare to find your TRICARE costs, including copayments, enrollment fees, and payment options effective January 1, 2023.
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: https://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 https://tricare.mil/costs for fees and payment options. Enrollment forms may be downloaded from the following TRICARE website: https://tricare.mil/Plans/Enroll/Prime.aspx
Alternatively, enrollment may be completed online via the Beneficiary Web Enrollment Web site: https://milconnect.dmdc.osd.mil/milconnect/
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.
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: https://tricare.mil/Plans/HealthPlans/Prime.aspx
TRICARE Home: https://tricare.mil/
TRICARE Regions: https://www.tricare.mil/About/Regions
TRICARE Region West: https://www.tricare-west.com/content/hnfs/home/tw.html
TRICARE Region East: https://www.humanamilitary.com/
TRICARE Overseas Region: http://www.tricare-overseas.com/
TRICARE DEERS Information: https://tricare.mil/DEERS
TRICARE Plans Overview: https://www.tricare.mil/-/media/Files/TRICARE/Publications/Misc/Plans_Overview.ashx