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TRICARE service member learning about behavioral health benefit information

  


Benefits Information

     
TRICARE is the Department of Defense’s worldwide health care program for active duty and retired uniformed services members and their families. TRICARE offers three plans for eligible beneficiaries: Prime, Extra and Standard. TRICARE was designed to make quality healthcare more accessible and easier to use, while lowering costs. No single healthcare plan is exactly right for everybody. That’s why TRICARE offers not just one, but three plan choices.
  • TRICARE Prime is a managed care option similar to a civilian health maintenance organization (HMO). This option requires beneficiaries enroll in the program and seek medical care from a TRICARE network provider. Enrollees are assigned a primary care manager (PCM) who manages their care and provides referrals for specialty care. TRICARE Prime offers less out-of-pocket costs than any other TRICARE option. Active duty members and their families do not pay enrollment fees, annual deductibles or co-payments for care in the TRICARE network. Retired service members and their families pay an annual enrollment fee and minimal co-payments for care in the TRICARE network. Prime offers a "point-of-service" option for care received outside of the TRICARE Prime network. When utilizing this option, a deductible of $300 per individual or $600 per family applies, with a 50% cost share for covered services rendered by a non-network provider.
     
  • TRICARE Extra is a preferred provider option (PPO) in which beneficiaries choose a doctor, hospital, or other medical provider within the TRICARE provider network. Extra is available for all TRICARE-eligible beneficiaries who elect or are not able to enroll in TRICARE Prime. Active duty service members are not eligible for Extra. There is no enrollment required for TRICARE Extra. Beneficiaries are responsible for annual deductibles and cost-shares.
     
  • TRICARE Standard is a fee-for-service option. TRICARE beneficiaries can see an authorized TRICARE provider of their choice. Having this flexibility means that care generally costs more. Standard is available for all TRICARE-eligible beneficiaries who elect or are not able to enroll in TRICARE Prime. Active duty service members are not eligible for Standard. There is no enrollment required for TRICARE Standard. Beneficiaries are responsible for annual deductibles and cost-shares.

      
Active Duty Family Members

  Prime (Prime Card) Extra (Military ID) Standard (Military ID)
Outpatient
E1-E4
E5 and above
Individual/Group
No copayment
No copayment
15% of negotiated rate
15% of negotaited rate
20% of allowable charges
20% of allowable charges
Inpatient
E1-E4
E5 and above
No copayment
No copayment
$20/day ($25 minimum)
$20/day ($25 minimum)
$20/day ($25 minimum)
$20/day ($25 minimum)

   
Retirees and Family Members (non-Medicare reliant)

  Prime (Prime Card) Extra (Military ID) Standard (Military ID)
Outpatient
Individual/Group
$25/$17 copayment/visit
20% of negotiated rate 25% of allowable charges
Inpatient
$40/day 20% of negotiated institutional charges plus 20% of separately billed professional charges $218/day
* Please be aware that mental health and medical cost shares/copayments differ
  • Active duty service members (ADSMs) must receive behavioral health care services at an MTF when available. TRICARE Prime Remote (TPR) ADSMs can receive civilian behavioral health care with a prior authorization. All other ADSMs must have a referral from their PCM and prior authorization from ValueOptions to seek behavioral health care services from a civilian network or non-network provider.
     
  • Retirees and their family members enrolled in Prime will have a medical copayment of $12 for medication management and psychological testing services.
     
  • Call 1-800-700-8646 for assistance in selecting a network mental/behavioral health provider.
     
  • Beneficiaries may see the provider selected for up to eight visits in a fiscal year. If additional visits are required after the initial eight, the provider must contact ValueOptions to obtain authorization.
     
  • All Active Duty Service Members are required to obtain a referral from the Military Treatment Facility (MTF) prior to seeking care in the civilian sector. All other beneficiaries do not need a referral from their Primary Care Manager (PCM) in order to access mental/behavioral health benefits.  
  • Psychological testing is not part of the eight unmanaged visits and therefore, preauthorization is required.
     
  • Preauthorization of all inpatient care is required. However, in an emergency, beneficiaries are directed to go to the nearest emergency room. Ask a family member or someone at the hospital to call ValueOptions within 24 hours to avoid benefit penalties.
     
  • Please call 1-800-700-8646 for information regarding benefits and authorizations.

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Last Update: July 24, 2014