TRICARE Prime
Quick Definition
Managed care option with assigned PCM and lowest costs.
Video Explanation
Full Definition
TRICARE Prime is a managed care option similar to a civilian HMO (Health Maintenance Organization). It offers the most comprehensive coverage and lowest out-of-pocket costs in exchange for less flexibility in choosing providers.
Key features of TRICARE Prime: • Assigned Primary Care Manager (PCM) • Referrals required for specialty care • Enrollment in Prime Service Area (PSA) required • Lowest copays and cost-shares • No deductibles • Point-of-service option available (higher costs)
Who can enroll: • Active duty family members (ADFMs) • Retirees and their families • Must live in a Prime Service Area • Must enroll during eligible period
Costs (2024) • Active Duty Family: $0 enrollment fee • Retirees (Group A): $350 individual / $700 family annually • Civilian provider copays: $0-$34 depending on service and status • Most care at MTF or from assigned PCM: $0
Benefits of Prime: • Predictable, low costs • Coordinated care through PCM • Preventive care at no cost • Most comprehensive benefit package • Priority enrollment to MTFs
Limitations: • Must get referrals for specialists • Limited provider choice (assigned PCM) • Only available in PSAs • Must use network providers
Best for: Beneficiaries who want the lowest costs, don't mind assigned providers, prefer coordinated care, and live near a military installation or in a PSA with adequate network coverage.
TRICARE Prime requires more structure but delivers the most comprehensive care at the lowest cost, making it ideal for families with regular healthcare needs or those seeking maximum financial protection.
Related Questions
What is TRICARE?
TRICARE is the healthcare program for uniformed service members, retirees, and their families worldwide.
What is the difference between TRICARE Prime and TRICARE Select?
TRICARE Prime is a managed care option with a primary care manager and lower costs. TRICARE Select offers more flexibility to choose providers with higher out-of-pocket expenses.
How do I enroll in TRICARE?
Ensure you're registered in DEERS, then choose your plan during open enrollment or within 90 days of a qualifying life event.
Can my adult children get TRICARE coverage?
Yes, through TRICARE Young Adult (TYA) for qualified dependents ages 21-26 who are not eligible for employer health coverage.
How does TRICARE work when stationed overseas?
TRICARE Overseas Program (TOP) provides coverage for service members and families stationed outside the US through military facilities and civilian providers.
What TRICARE options are available for Reserve and National Guard members?
Reserve and Guard members have TRICARE Reserve Select when not activated, and regular TRICARE when on active duty orders over 30 days.
Does TRICARE cover mental health services?
Yes, TRICARE covers mental health services including therapy, counseling, and psychiatric care with the same cost-shares as medical services.
How does TRICARE cover pregnancy and maternity care?
TRICARE covers comprehensive maternity care including prenatal visits, delivery, postpartum care, and newborn care at no or low cost.
Can I change my TRICARE plan and when?
You can change TRICARE plans during annual Open Enrollment (late fall) or within 90 days of a Qualifying Life Event.
How does TRICARE cover emergency room visits and urgent care?
TRICARE covers emergency care worldwide without prior authorization. Visit nearest ER for emergencies; urgent care for non-emergencies.
What preventive care services does TRICARE cover?
TRICARE covers comprehensive preventive care at no cost including annual checkups, vaccines, cancer screenings, and wellness visits.
What's the difference between a referral and prior authorization?
Referrals allow you to see specialists (Prime requirement). Prior authorization is approval needed before certain services regardless of plan.
Do surviving family members keep TRICARE after a service member dies?
Yes, surviving family members retain TRICARE coverage indefinitely if the sponsor died on active duty or after retirement with 20+ years of service.
How does TRICARE cover autism spectrum disorder?
TRICARE covers autism diagnosis, ABA therapy, speech therapy, occupational therapy, and medication through the Comprehensive Autism Care Demonstration.
What is TRICARE Young Adult and who qualifies?
TRICARE Young Adult extends coverage to unmarried adult children aged 21-26 who aren't eligible for employer-sponsored insurance.
What TRICARE benefits do Medal of Honor recipients receive?
Medal of Honor recipients receive TRICARE Prime with no enrollment fees and priority access to military healthcare regardless of discharge status.
How do I switch between TRICARE Prime and Select?
You can switch plans during the annual Open Season (Nov-Dec) or after a Qualifying Life Event like PCS, birth, or marriage.
How does TRICARE work for dual-military couples?
In dual-military couples, each spouse is their own sponsor for TRICARE Prime, and children can be enrolled under either parent's plan.
What are the main differences between all TRICARE plans?
TRICARE offers Prime, Select, For Life, Reserve Select, Retired Reserve, and Young Adult plans with varying costs, networks, and eligibility requirements.
Do I have to pay TRICARE Prime enrollment fees?
Active duty families pay no Prime enrollment fees. Retirees pay annual enrollment fees starting at $179 for individual or $358 for family in 2024.
What is a Primary Care Manager (PCM)?
A PCM is your main doctor in TRICARE Prime who provides routine care, manages your health, and issues referrals for specialty care.
What are the TRICARE Prime copays for common services?
TRICARE Prime copays range from $0 for preventive care to $30 for specialty visits. Active duty members have no copays; families have low copays.
Related Terms
Military Treatment Facility(MTF)
Military hospital or clinic providing healthcare to beneficiaries.
Primary Care Manager(PCM)
Your main doctor who coordinates your healthcare.
Prime Service Area(PSA)
Geographic area where TRICARE Prime is available.
Referral
Authorization from your PCM to see a specialist.
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