By TriWest Healthcare Alliance
Of the TRICARE program’s three options—Prime, Extra and Standard—TRICARE Prime has the most advantages in terms of cost, health care services and convenience.
Prime is a versatile health care option that will travel with you and require the least amount of paperwork on your part. Here’s how it works:
Primary Care Manager Prime beneficiaries receive most of their health care from a primary care manager (PCM), who will refer them for any needed specialty care and coordinate any necessary hospitalization.
PCMs are located within a Prime service area (PSA), generally within a 40-mile radius of a military treatment facility (MTF), and are either selected by the beneficiaries or assigned to beneficiaries by the MTF. A PCM may be an MTF provider or a TRICARE civilian network provider. Your family members may select different PCMs from among internists, family practice physicians, pediatricians, physician’s assistants, nurse practitioners or coordinated teams of MTF practitioners.
Care Access Standards
TRICARE Prime guarantees you timely access to health care. A Prime beneficiary should receive emergency care immediately, urgent care within 24 hours, routine appointments within seven days, and specialty referrals, wellness and follow-up care within four weeks.
Prime beneficiaries are entitled to receive primary care within a 30-minute drive of their home, under normal circumstances, and specialty care within an hour’s drive of their home.
Participation in TRICARE Prime requires enrollment, but there is no Prime enrollment fee for family members of active duty service members. Prime enrollment fees for military retirees and their families are $230 per individual or $460 maximum per family. These may be paid annually, quarterly or even monthly if the beneficiary chooses to pay by allotment or electronic funds transfer:
Enrolling and paying your fees in TRICARE Prime is as easy as visiting www.triwest.com, where you can find a Prime enrollment form and a secure site through which you can pay electronically once the completed enrollment form is submitted by mail and processed by TriWest.
Presently, TRICARE Prime requires only an enrollment fee (for non-active duty beneficiaries) and a modest copayment, per visit, for retirees and their family members. It requires no deductibles when you are referred to network health care providers who are outside the MTF. (No TRICARE beneficiary is required to pay a copayment at an MTF.) In most cases, Prime active duty family members do not pay copayments for health care services.
There is a significant cost difference between TRICARE Prime and TRICARE Standard/Extra. Standard and Extra beneficiaries do not have an enrollment fee, but do have to pay an annual deductible and then a percentage of total charges for any care received.
Little or No Claims Filing
As a Prime beneficiary, the only time you may have to file your own claim is if you are referred to a non-network provider who does not accept assignment or will not file a claim. Most of your claims will be filed by your PCM.
If you’re moving to another PSA, your enrollment can be transferred between regions. This is especially convenient for active duty family members making a permanent change of station, retirees moving to a different state, or eligible family members going to college away from home.
Portability allows retirees, their family and former spouses to move twice in a year—as long as the second move brings them back to their original region. They may reenroll in Prime at any time when they return to an area where Prime is available.
To learn more, read the Prime Member Handbook, available online at www.triwest.com or visit www.tricare.osd.mil.