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TRICARE Prime Handbook
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Getting Started
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Your Primary Care Manager
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When you enrolled in TRICARE Prime, you selected or were assigned a primary care manager (PCM). Your PCM provides your routine health care and coordinates referrals for specialty care that he or she cannot provide. Your PCM may be an MTF provider or a civilian TRICARE network provider within a Prime service area (PSA).
A PSA is a geographic area where TRICARE Prime benefits are offered. It’s typically a geographic area around an MTF and specific areas with a significant concentration of uniformed service personnel and retirees and their families. A PSA must also have a substantial medical community to support most or all TRICARE Prime enrolled beneficiary medical needs.
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On-Call Providers
PCMs are required to provide access to care 24 hours a day, seven days a week. To cover all hours, your PCM may designate an oncall provider who will act on their behalf to support your health care needs. Therefore, the information, instructions, care, or care coordination you receive from the oncall provider should be treated as if it was coming from your PCM. |
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Changing Your Primary Care Manager
You may change your PCM at any time provided the new PCM is accepting new patients and your request complies with local MTF guidelines. Once you have selected a new PCM from your regional contractor’s provider directory (viewable online at each contractor’s Web site), complete a TRICARE Prime Enrollment and PCM Change Form with the new PCM’s name and address.
You only need to complete the portion of the form related to the PCM change. The change will become effective once the application is received and processed by your regional contractor. You may also call your regional contractor to change your PCM. Once your PCM change is processed, you will be mailed a confirmation letter with the new PCM name and telephone number.
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Enrollment Card
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You and each enrolled family member will receive his or her own TRICARE Prime enrollment card. Included with the card is a letter identifying your PCM’s name and telephone number. Write your PCM’s name and telephone number on your card. TRICARE network providers may require you to show the enrollment card as well as your uniformed services identification (ID) or Common Access Card (CAC) at the time of service. Your TRICARE Prime enrollment effective date is printed on this card. |
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The TRICARE Prime enrollment card does not verify your eligibility for TRICARE. Only your DEERS record can verify eligibility. |
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Disenrollment
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Enrollment in TRICARE Prime is continuous and you do not have to re-enroll every year to maintain coverage. Certain events will, however, cause you to be disenrolled from TRICARE Prime.
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Sponsor Status Change
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Any change in the sponsor’s status (e.g., retirement or National Guard and Reserve member deactivation) will cause you to be disenrolled automatically from TRICARE Prime. If you will remain eligible for TRICARE Prime (after the status change), you should submit a new enrollment application to Humana Military before the status change occurs to avoid a lapse in coverage. |
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Non-Payment of Enrollment Fees
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If you are required to pay enrollment fees and you do not pay them when due, you will be disenrolled from TRICARE Prime. When disenrolled for non-payment, you are subject to a 12-month lockout during which you will not be permitted to re-enroll in TRICARE Prime. To avoid missing an appointment, learn about automatic payment options in the TRICARE: Summary of Beneficiary Costs flyer or contact Humana Military. |
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Becoming Medicare-Eligible at Age 65
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When you become entitled to premium-free Medicare Part A at age 65, you automatically lose eligibility for TRICARE Prime and become eligible for TRICARE For Life (TFL) if you have Medicare Part B coverage. Visit www.tricare.mil/tfl for more information about TFL.
Note: If you are not entitled to premium-free Medicare Part A when you become age 65, you remain eligible for TRICARE Prime, Standard, and Extra, and you are not required to have Medicare Part B coverage. You must present a Social Security Administration Letter of Disallowance to an ID card-issuing facility to retain TRICARE coverage.
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Voluntary Disenrollment
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If you choose to disenroll from TRICARE Prime before the annual enrollment renewal date, you are subject to a 12-month lockout,* during which you will not be permitted to re-enroll in TRICARE Prime. You must contact Humana Military to initiate a voluntary disenrollment.
Active duty service members must enroll in either TRICARE Prime or TRICARE Prime Remote. Voluntary disenrollment is not an option.
* The 12-month lockout provision does not apply to active duty family members of sponsors grade E-1 through E-4.
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Loss of Eligibility
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If you lose your TRICARE eligibility as shown in DEERS, your TRICARE Prime coverage will end automatically. If you believe you are still eligible for TRICARE, you will need to update your DEERS record to re-establish your eligibility. Once DEERS is updated, you must re-enroll in TRICARE Prime, or you will be covered under TRICARE Standard and TRICARE Extra.
If your DEERS record is correct and you have lost eligibility, you may qualify for transitional health care. See the Life Events, “Separating from the Service” section for details about transitional health care options. You will receive a certificate of creditable coverage when TRICARE eligibility is lost. See the Life Events, “Loss of Eligibility” section for more information about the certificate of creditable coverage.
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