Figure 3.2 and the following information are some additional features of the TRICARE Prime options that you should take into consideration.
Enrollment in Non-Prime Service Areas
If enrolled in TPR or TPRADFM (available only to ADSMs and ADFMs), you will choose a network PCM in a non-Prime service area, when available. If a network provider is not available, you may choose any approved TRICARE-authorized, non-network provider as your PCM.
All other beneficiaries (retirees, their families, or others) residing in a non-Prime service area who want to enroll in TRICARE Prime must choose a PCM within a PSA, even if a network provider is available outside of the PSA. When you select a PCM outside of the PSA, you are agreeing to waive your TRICARE Prime access standards and travel longer distances to receive care from a network provider. All other beneficiaries cannot enroll in Prime outside of a PSA. Note: If you live within 100 miles of an MTF, you may be able to waive your access standards to enroll in TRICARE Prime at the MTF.
TRICARE Prime Split Enrollment Feature
Split enrollment allows families living in separate TRICARE regions to enroll in TRICARE Prime together. To use split enrollment, you must notify each family member’s regional contractor of the split enrollment status. 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. The regional contractors will coordinate enrollment fees and send the statements to the designated payer. 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.
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There is no limit to the number of family members that can enroll.
Note: While split enrollment is not available with TPR and TPRADFM, family members residing in separate locations may enroll in TRICARE Prime, if it is available where they reside.
TRICARE 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.
TRICARE Prime Travel Entitlement
If you are referred by your PCM for specialty care at a location more than 100 miles (one way) from your PCM, you may be eligible to have your reasonable travel expenses reimbursed by TRICARE. You must have a valid referral and travel orders from a TRICARE representative at the MTF where you are enrolled or from the TRICARE regional office (TRO) if your PCM is a TRICARE network provider.
Note: The above only applies to enrollees in Continental United States locations.
TRICARE Prime 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
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If you have other health insurance
TRICARE Prime Enrollment Portability
Enrollment portability allows you to easily transfer your TRICARE Prime coverage to another TRICARE region, if TRICARE Prime is offered at your new location. We recommend that you transfer your enrollment if you will be staying at your new location for at least 30 days (even if the relocation is only temporary). Retirees, their family members, survivors, and former spouses may transfer enrollment twice during an enrollment year, as long as the second transfer is back to the original region of enrollment. There are no limitations on the number of transfers for ADSMs and ADFMs.
If you move within the same region, you are not affected by enrollment portability (if the move is to an area that offers TRICARE Prime) and are only required to fill out a TRICARE Prime Enrollment Application and PCM Change Form to update your address and designate your new PCM.
Note: ADSMs and ADFMs moving to or from a designated TPR ZIP code area can transfer between TRICARE Prime and TPR/TPRADFM.
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