TRICARE Prime is a managed care option offering the most affordable and comprehensive coverage. TRICARE Prime is available in TRICARE Prime service areas (PSAs)—areas near an MTF and where Humana Military has established TRICARE Prime networks. While ADSMs must enroll in TRICARE Prime where available, ADFMs, retired service members and their family members, survivors, certain former spouses, and other eligible beneficiaries may choose to enroll in TRICARE Prime or remain covered by TRICARE Standard and TRICARE Extra.
Active duty service members (ADSMs), including National Guard and Reserve members called to active duty for more than 30 consecutive days, must enroll in TRICARE Prime or TRICARE Prime Remote.
Here are some general features of the TRICARE Prime option:
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Enrollment required
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Enhanced benefits and services
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Priority access for care at MTFs
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Most care received from an assigned PCM (or approved TRICARE-authorized provider if enrolled in TPR/TPRADFM and network providers are not available)
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PCM referrals required for specialty care
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No claims to file (in most cases)
Prime Access Standards
The TRICARE Prime access standards are another advantage to enrolling in TRICARE Prime. The following access standards apply:
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The wait time for an urgent care appointment will not exceed 24 hours (one day).
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The wait time for a routine appointment will not exceed one week (seven days).
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The wait time for a specialty care appointment or wellness visit will not exceed four weeks (28 days).
Additionally, you should have access to a PCM whose office is within 30 minutes of your home. Specialty care travel time should not exceed one hour under normal circumstances, unless a longer time is necessary because of the absence of providers in the area.
Beginning February 20, 2009, if the Military Treatment Facility (MTF) is an available choice for enrollment, those beneficiaries requesting enrollment to that MTF must sign the Access to Care waiver section of the enrollment form. When this section is signed, the beneficiary is acknowledging that their drive time to primary care may exceed 30 minutes and drive time to specialty care may exceed 60 minutes. View the
Access to Care section for more information.
Split Enrollment
Split enrollment allows families living in separate TRICARE regions to enroll in TRICARE Prime together. To use split enrollment, you may submit the enrollment form to either contractor where the family members live. If one or more of the family members live in the South region, Humana Military will coordinate the enrollment and enrollment fee as appropriate with the other region. The region where the enrollment fee payment is made is determined by the sponsor’s TRICARE Prime enrollment location. If the sponsor is not enrolled, the region where payment is made is determined by the next eldest TRICARE Prime family member enrolled. An enrollment fee left unpaid causes the entire family to be disenrolled.
Key points to remember with split enrollment:
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Families with college students, children living with a custodial parent or guardian, or families
otherwise separated can enroll together in separate regions.
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Active duty families are not required to pay enrollment fees, but they can still enroll in
separate regions.
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Retiree families have only one enrollment fee.There is no limit to the number of family
members that can enroll.
Point-of-Service Option
You are required to obtain all care from your PCM or through referrals from your PCM to specialists within the TRICARE provider network, when available. However, the point of service (POS) option allows you to receive nonemergency health care services from any TRICARE-authorized provider without requesting a referral from your PCM. Using the POS option results in higher out-of-pocket costs.
The POS option does not apply to the following:
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Active duty service members
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Newborns or adopted children in their first 60 days
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Emergency care
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Preventive care services from a network provider
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First eight behavioral health outpatient visits from a network provider
- If you have other health insurance
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