TRICARE Prime, TRICARE Prime Remote (TPR), and TRICARE Prime Remote for Active Duty Family Members (TPRADFM) are managed care options offering the most affordable and comprehensive coverage. While active duty service members (ADSMs) must enroll in a TRICARE Prime option, active duty family members (ADFMs), retirees and their families, and others may choose to enroll in TRICARE Prime or use TRICARE Standard and TRICARE Extra.
When activated for more than 30 consecutive days, National Guard and Reserve members are covered as ADSMs and must enroll in TRICARE Prime or TPR. Members of the National Guard and Reserve who have been issued activation orders become eligible for TRICARE coverage 180 days in advance of their mobilization date and remain eligible until either deactivation prior to mobilization, or until 180 days after deactivation post-mobilization. Their eligible family members are covered as ADFMs and may enroll in TRICARE Prime or TPRADFM or may use TRICARE Standard and TRICARE Extra.
In the South Region, TRICARE Prime, TPR, and TPRADFM require enrollment with Humana Military Healthcare Services, Inc. (Humana Military). TRICARE Prime enrollees receive TRICARE Prime enrollment cards, and both TPR and TPRADFM enrollees receive TPR enrollment cards. These cards include important contact information but are not required to obtain care. Although beneficiaries should expect to present their cards at the time of service, enrollment cards do not verify TRICARE eligibility. See the TRICARE Eligibility section of this handbook for instructions on verifying patient eligibility. Figures 4.1 and 4.2 show examples of the TRICARE Prime and TPR enrollment cards. Figure 4.1 TRICARE Prime Enrollment Card
TRICARE Prime is a managed care option available in TRICARE Prime Service Areas (PSAs). ADSMs who live and work in PSAs must enroll in TRICARE Prime; however, ADFMs and other eligible beneficiaries may enroll in TRICARE Prime or use TRICARE Standard and TRICARE Extra. Each TRICARE Prime enrollee is assigned or may select a primary care manager (PCM). Whenever possible, a PCM located at a military treatment facility (MTF) is assigned, but a TRICARE network PCM may be assigned if an MTF PCM is not available.
TRICARE Prime beneficiaries should always seek nonemergency care from their PCMs, unless using the point-of-service (POS) option. In most cases, a TRICARE Prime enrollee must obtain a referral and/or prior authorization to receive nonemergency care from another provider.
An MTF has the “right of first refusal” for TRICARE Prime referrals within their catchment area for inpatient admissions, specialty appointments, and procedures requiring written prior authorization, provided the MTF is able to deliver the service requested by the beneficiary’s civilian provider. This means TRICARE Prime enrollees must first try to obtain care at MTFs. MTF staff members review the referral to determine if they can provide care within access standards. If the service is not available within access standards, the MTF refers the beneficiary to a TRICARE network provider. Back to Top |
