Your SlideShare is downloading. ×
Tricare for life_handbook_2011_smaller_lo_res
Upcoming SlideShare
Loading in...5
×

Thanks for flagging this SlideShare!

Oops! An error has occurred.

×
Saving this for later? Get the SlideShare app to save on your phone or tablet. Read anywhere, anytime – even offline.
Text the download link to your phone
Standard text messaging rates apply

Tricare for life_handbook_2011_smaller_lo_res

464
views

Published on


0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total Views
464
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
3
Comments
0
Likes
0
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
No notes for slide

Transcript

  • 1. TRICARE ®For Life Handbook
  • 2. September 2011Important InformationMedicare: 1-800-MEDICARE (1-800-633-4227)Social Security Administration: 1-800-772-1213TRICARE National Web site: www.tricare.milTRICARE For Life ContractorWisconsin Physicians Service: 1-866-773-0404TRICARE For Life Web site: www.TRICARE4u.comTRICARE North Region ContractorHealth Net Federal Services, LLC: 1-877-TRICARE (1-877-874-2273)Health Net Web site: www.hnfs.comTRICARE South Region ContractorHumana Military Healthcare Services, Inc.: 1-800-444-5445Humana Military Web site: www.humana-military.comTRICARE West Region ContractorTriWest Healthcare Alliance: 1-888-TRIWEST (1-888-874-9378)TriWest Web site: www.triwest.comAn Important Note About TRICARE Program ChangesAt the time of printing, this information is current. It is important to remember thatTRICARE policies and benefits are governed by public law and federal regulations. Changesto TRICARE programs are continually made as public law and/or federal regulations areamended. For the most recent information, contact your regional contractor or localTRICARE Service Center. More information regarding TRICARE, including the HealthInsurance Portability and Accountability Act (HIPAA) Notice of Privacy Practices, can befound online at www.tricare.mil.
  • 3. Important Contact InformationUse this page as a guide for the most important resources available to you.TRICARE’s Web Site: www.tricare.milTRICARE’s official Web site is your first stop for the most up-to-date information about yourbenefit. Go to www.tricare.mil for information about eligibility and TRICARE-covered services;answers to frequently asked questions; information on your TRICARE pharmacy benefit; todownload claims forms and instructions; to locate a TRICARE Service Center or militarytreatment facility; to find a TRICARE Debt Collection Assistance Officer; and to answer questionsabout survivor coverage, loss of eligibility, and program option information, among other things.Subscribe to TRICARE For Life (TFL) program updates at www.tricare.mil/subscriptions. General Contact Claims Information Phone: 1-866-773-0404 WPS/TRICARE For Life (U.S.) TRICARE Overseas (Eurasia-Africa) Web: www.TRICARE4u.com P.O. Box 7890 P.O. Box 8976 Madison, WI 53707-7890 Madison, WI 53708-8976 USA Written Correspondence: TRICARE Overseas WPS/TRICARE For Life (Latin America and Canada) Grievances P.O. Box 7889 P.O. Box 7985 Madison, WI 53707-7880 E-mail: reportit@wpsic.com Madison, WI 53707-7985 USA TRICARE Overseas * TRICARE Overseas Grievances TRICARE Overseas (Pacific) P.O. Box 7992 P.O. Box 7992 P.O. Box 7985 Madison, WI 53707-7992 Madison, WI 53707-7992 Madison, WI 53707-7985 USA* Use this address for overseas appeals and grievances as well as general inquiries.Defense Enrollment Eligibility Reporting System (DEERS)DEERS is a database of uniformed service members (sponsors), family members, and othersworldwide who are entitled under law to military benefits, including TRICARE. Sponsors arerequired to keep DEERS updated, including their residential and mailing address for themselvesand eligible dependents.You have several options for updating and verifying DEERS information: In Person Phone Visit a local identification card-issuing facility. 1-800-538-9552 Find a facility near you at www.dmdc.osd.mil/rsl. 1-866-363-2883 (TTY/TDD) Call to verify location and business hours. Online Fax DEERS Web site: www.dmdc.osd.mil/appj/address/ 1-831-655-8317 Beneficiary Web Enrollment Web site: Mail www.dmdc.osd.mil/appj/bwe/ Defense Manpower Data Center Support Office 400 Gigling Road Seaside, CA 93955-6771
  • 4. TRICARE Regional ContractorsRegional contractors provide health care services and support in the TRICARE regions and canhelp TFL beneficiaries with prior authorizations, but do not provide referrals for TFL beneficiaries.Wisconsin Physicians Service administers the TFL program and should be your primarycontact for TRICARE-related customer service needs in the United States or U.S. territories(American Samoa, Guam, the Northern Mariana Islands, Puerto Rico, and the U.S. VirginIslands). Go to www.medicare.gov and click on “Facilities & Doctors” for help findingproviders. Overseas, contact your TRICARE Overseas Program (TOP) Regional Call Center.Regional Contractors (Stateside)TRICARE North Region TRICARE South Region TRICARE West Region Health Net Federal Services, LLC Humana Military Healthcare TriWest Healthcare Alliance 1-877-TRICARE (1-877-874-2273) Services, Inc. 1-888-TRIWEST (1-888-874-9378) www.hnfs.com 1-800-444-5445 www.triwest.com www.humana-military.comRegional Contractor (Overseas)TRICARE Eurasia-Africa TRICARE Latin America TRICARE Pacific and Canada TOP Regional Call Center TOP Regional Call Center TOP Regional Call Centers +44-20-8762-8384 (overseas) +1-215-942-8393 (overseas) Singapore: +65-6339-2676 (overseas) 1-877-678-1207 (stateside) 1-877-451-8659 (stateside) 1-877-678-1208 (stateside) tricarelon@internationalsos.com tricarephl@internationalsos.com sin.tricare@internationalsos.com Sydney: +61-2-9273-2710 (overseas) 1-877-678-1209 (stateside) sydtricare@internationalsos.comOther Contact InformationFor More Information Resource Numbers Web Sites Medicare 1-800-633-4227 www.medicare.gov Social Security Administration 1-800-772-1213 www.ssa.gov TRICARE Pharmacy Program 1-877-363-1303 www.tricare.mil/pharmacy www.express-scripts.com/TRICARE Prescription Drug Formulary Search 1-877-363-1303 www.pec.ha.osd.mil TRICARE Dental Program 1-800-866-8499 www.TRICAREdentalprogram.com TRICARE Retiree Dental Program 1-888-838-8737 www.trdp.org Office of Personnel Management 1-888-767-6738 www.opm.gov/forms 1-800-582-3337 www.opm.gov/insure/ltc Find a Debt Collection See Web site www.tricare.mil/bcacdcao Assistance Officer Find a Beneficiary Counseling and See Web site www.tricare.mil/bcacdcao Assistance Coordinator Find a military treatment facility See Web site www.tricare.mil/mtf Toll-free overseas contact information See chart above www.tricare-overseas.com
  • 5. Welcome to TRICARE For LifeTRICARE For Life (TFL) is the Medicare- processing (unless you have other healthwraparound coverage for TRICARE insurance [OHI]). TRICARE pays afterbeneficiaries who have Medicare Part A and Medicare and OHI for covered healthPart B, regardless of age or place of residence. care services.TFL provides comprehensive health care This handbook will help you make thecoverage. You have the freedom to seek most of your TFL coverage. You will findcare from any Medicare-participating or information about eligibility requirements,nonparticipating provider, or military getting care, and claims. This handbooktreatment facilities on a space-available also provides details about your pharmacybasis. Medicare-participating providers and dental coverage options.file your claims with Medicare. Afterpaying its portion, Medicare automaticallyforwards the claim to TRICARE for 1
  • 6. Table of Contents1. How TRICARE For Life Works ............................................................ 4 Eligibility ......................................................................................................................4 Understanding Medicare ..............................................................................................4 Frequently Asked Questions: Medicare ........................................................................6 How TRICARE For Life Works with Medicare...........................................................7 Frequently Asked Questions: How TRICARE For Life Works ..................................102. Getting Care ..................................................................................... 12 Finding a Provider ......................................................................................................12 Emergency Care .........................................................................................................13 Urgent Care ................................................................................................................13 Behavioral Health Care ..............................................................................................14 Prior Authorization for Care .......................................................................................143. TRICARE For Life Coverage .............................................................. 15 TRICARE Medical Coverage .....................................................................................15 Dental Coverage .........................................................................................................15 Frequently Asked Questions: TRICARE For Life Coverage ......................................164. Pharmacy .......................................................................................... 17 Prescription Drug Coverage .......................................................................................17 Filling Prescriptions ...................................................................................................17 Pharmacy Policy .........................................................................................................19 Pharmacy Claims .......................................................................................................215. Claims ............................................................................................... 23 Health Care Claims ....................................................................................................23 Appealing a Claim or Authorization Denial...............................................................23 Third-Party Liability ..................................................................................................24 Explanation of Benefits ...............................................................................................24 Debt Collection Assistance Officers ...........................................................................24 2
  • 7. 6. Life Changes: Update Your DEERS Record ..................................... 25 Getting Married or Divorced .....................................................................................25 Children ......................................................................................................................26 Moving .......................................................................................................................27 Survivor Coverage ......................................................................................................27 Loss of Eligibility .......................................................................................................27 Suspension of Social Security Disability Insurance ...................................................287. For Information and Assistance ..................................................... 29 Beneficiary Counseling and Assistance Coordinators ................................................29 Your Right to Appeal a Decision ................................................................................29 Filing a Grievance ......................................................................................................318. Glossary ............................................................................................ 329. List of Figures .................................................................................. 3810. Index ................................................................................................. 39See the inside back cover of this handbook for “TRICARE Expectations for Beneficiaries.” 3
  • 8. How TRICARE For Life WorksEligibility Insurance]” on the following page for information about the MedicareTRICARE For Life (TFL) is available to Part B special enrollment period forTRICARE beneficiaries, regardless of age ADSMs and ADFMs.)and place of residence, if you have MedicarePart A and Medicare Part B. You are eligible Note: Regardless of age, ADFMs who havefor TFL on the first date that you have both Medicare Part A may enroll in TRICAREMedicare Part A and Medicare Part B. Prime if they live in a TRICARE Prime Service Area (PSA). The TRICARE PrimeTRICARE Eligibility Requirements enrollment fee is waived for retiree familyWhen you are entitled to premium-free members with Medicare Part B coverage.Medicare Part A: Understanding Medicare• Medicare Part B coverage is required to remain TRICARE-eligible if you are a: TFL is managed by the Department of • Retired service member (including Defense. Medicare is managed by the retired National Guard and Reserve Centers for Medicare and Medicaid members drawing retirement pay) Services (CMS). The two agencies work • Family member of a retired together to coordinate benefits. service member Medicare is a federal entitlement health • Medal of Honor recipient or eligible insurance program for people: family member • Age 65 or older • Survivor of a deceased sponsor • Under age 65 with certain disabilities • Qualifying former spouse • Any age with end-stage renal• Medicare Part B coverage is not required disease (ESRD) to remain TRICARE-eligible if: Medicare Part A (Hospital Insurance) • You are an active duty service member (ADSM) or active duty family member Medicare Part A covers inpatient hospital (ADFM) (ADSMs and ADFMs remain care, hospice care, inpatient skilled nursing eligible for TRICARE Prime and facility care, and some home health care. TRICARE Standard and TRICARE The Social Security Administration (SSA) Extra options while the sponsor is on determines your entitlement to Medicare active duty. However, when the sponsor Part A based on your work history or your retires, you must have Medicare Part B spouse’s work history. You are eligible for to remain TRICARE-eligible. See premium-free Medicare Part A at age 65 if “Medicare Part B [Medical you or your spouse has 40 quarters or 10 years of Social Security-covered employment. 4
  • 9. HOW TRICARE FOR LIFE WORKS SECTION 1If, when you turn 65, you are not eligible for Note: If you have ESRD, sign up forpremium-free Medicare Part A under your Medicare Part A and Part B as soonown Social Security number (SSN), you as you are eligible to avoid a break inmust file for benefits under your spouse’s TRICARE coverage and the Medicare(this includes divorced or deceased spouses) Part B late-enrollment premium surcharge.SSN, if he or she is 62 or older. If your spouse Medicare Entitlement Based onis not yet 62, you should enroll in Medicare a DisabilityPart B at age 65 to avoid paying a surcharge If you receive disability benefits from thefor late enrollment, and you should file for SSA, you are entitled to Medicare in thePart A benefits under your spouse’s record 25th month of receiving disability payments.when he or she turns 62. The CMS will notify you of your MedicareMedicare Part B (Medical Insurance) entitlement date.Medicare Part B covers provider services, If you return to work and your Socialoutpatient care, preventive care, home health Security disability payments are suspended,care, and durable medical equipment. your Medicare entitlement continues for upMedicare Part B has a monthly premium, to eight years and six months. When yourwhich may change annually and varies based disability payments are suspended, youon income. If you sign up after your initial will receive a bill every three months forenrollment period for Medicare Part B, your Medicare Part B premiums. Youyou may have to pay a monthly premium must continue to pay your Medicaresurcharge for as long as you have Medicare Part B premiums to remain eligible forPart B. The surcharge is 10 percent for each TRICARE coverage.12-month period that you were eligible forMedicare Part B but did not enroll. Medicare Entitlement Based on Age The Medicare entitlement age is 65. If youMedicare allows ADSMs and ADFMs who already receive benefits from the SSA orare entitled to Medicare based on age or the Railroad Retirement Board, you willdisability (does not apply to those with ESRD) automatically receive Part A and be enrolledto delay Part B enrollment and sign up in Part B at age 65.during a special enrollment period, whichwaives the late enrollment surcharge. The If you are age 65 or older and do not receivespecial enrollment period for ADSMs and Social Security or Railroad RetirementADFMs is available any time the sponsor Board benefits, you must apply for Medicareis on active duty or within eight months benefits. Your Medicare initial enrollmentfollowing either (1) the sponsor’s retirement period is a seven-month period.or (2) the end of TRICARE coverage, • If your birthday falls on the first of thewhichever comes first. To avoid a break in month, your initial enrollment periodcoverage, ADSMs and ADFMs must sign up begins four months before the month youfor Medicare Part B before sponsors retire. 5
  • 10. turn 65. Enroll no later than two months Frequently Asked Questions: before the month you turn 65 to avoid a Medicare break in TRICARE coverage. You are eligible for Medicare coverage on the first I will be 65 soon and will become entitled day of the month before you turn 65. to Medicare. I work full time and have employer group health plan coverage,• If your birthday falls on any day other and I don’t plan on retiring for a few more than the first of the month, your initial years. Medicare says I can delay my Part B enrollment period begins three months enrollment if I have employer group health before the month you turn 65. Enroll no plan coverage. How does this affect my later than one month before your birth TRICARE benefit? month to avoid a break in TRICARE coverage. You are eligible for Medicare Medicare allows individuals with group on the first day of the month you turn 65. health plan coverage based on current employment to delay Part B enrollment andEnroll in Medicare Part B when first sign up during a special enrollment period,eligible to avoid a break in TRICARE which waives the late-enrollment premiumcoverage. If you sign up after your initial surcharge. If you or your spouse still worksenrollment period, you may have to pay a and has group health plan coverage throughpremium surcharge for as long as you have current employment, you may sign up forPart B. The Medicare Part B surcharge is Medicare Part B during the special enrollment10 percent for each 12-month period that you period, which is available within the eightwere eligible to enroll in Part B but did not. months following either (1) retirementYour Part B premiums are automatically or (2) the end of the group health plantaken out of your Social Security or coverage, whichever comes first.Railroad Retirement Board checks. If you If you are entitled to premium-free Medicareare not receiving these types of payments, Part A, you must also have Part B to remainMedicare bills you every three months for TRICARE-eligible, even if you have groupPart B premiums. health plan coverage based on current employment. Sign up for Part B before you retire or lose group health plan coverage to ensure your TRICARE coverage under TFL will begin immediately following the end of your group health plan coverage. Your TFL coverage begins on the first day you have both Medicare Part A and Part B coverage. 6
  • 11. HOW TRICARE FOR LIFE WORKS SECTION 1If I am not entitled to premium-free Claim” from SSA. To keep your TRICAREMedicare Part A when I turn 65, can coverage, take the “Notice(s) of Award” orI still use TFL? “Notice(s) of Disapproved Claim” to a uniformed services identification (ID)Because you are not entitled to premium- card-issuing facility to have your Defensefree Medicare Part A, you do not need Enrollment Eligibility Reporting SystemMedicare Part B to keep your TRICARE (DEERS) record updated and receive a newbenefit. You do not transition to TFL. You ID card. This allows you to keep yourmay continue enrollment in TRICARE eligibility for TRICARE Prime or TRICAREPrime if you live in a PSA, or use TRICARE Standard and TRICARE Extra after youStandard and TRICARE Extra. For turn 65. To confirm that your TRICAREinformation about TRICARE program coverage will continue without a break,options, visit the TRICARE Web site at contact Wisconsin Physicians Service (WPS)www.tricare.mil. after you update your DEERS record.If you are not eligible for premium-free Note: A Report of Confidential SocialMedicare Part A under your own SSN Security Benefit Information (SSA-2458)when you turn 65, you must file for benefits from the SSA is not accepted as proof ofunder your spouse’s (this includes divorced non-entitlement to premium-free Part A toor deceased spouses) SSN if he or she is 62 keep TRICARE eligibility.or older. If your spouse is not yet 62, youmust file for benefits under his or her SSN How TRICARE For Life Workswhen he or she turns 62. with MedicareIf you will be eligible under your spouse’s Medicare and TFL work together toSSN in the future, you should sign up minimize your out-of-pocket expenses.for Medicare Part B during your initial However, there are instances when someenrollment period to avoid paying a Part B health care costs may not be covered bypremium surcharge for late enrollment. Medicare and/or TFL.Even if you are not entitled to premium- Health Care Services Covered byfree Medicare Part A, you are eligible for Medicare and TRICAREPart B at age 65. See “Medicare Entitlement When you see a participating orBased on Age” earlier in this section for nonparticipating Medicare provider, youmore information. have no out-of-pocket costs for services covered by both Medicare and TFL. MostIf you sign up for Medicare and are not health care services fall into this category.eligible for premium-free Part A under your After Medicare pays its portion of the claim,or your spouse’s (this includes divorced TFL pays the remaining amount and youor deceased spouses) SSN, you receive a pay nothing.“Notice of Award” or “Notice of Disapproved 7
  • 12. allowable charge) and you are responsible for the remainder of the billed charges. Opt-out providers establish private contracts with patients. Under a private contract, there are no limits on what the provider can charge for health care services. Health Care Services Covered by Medicare but Not by TRICARE When you receive care that is covered by Medicare only (e.g., chiropractic care), Medicare processes the claim as the primary payer. TFL makes no payment, regardless of any action Medicare takes. You areAs the primary payer, Medicare approves responsible for the Medicare deductiblehealth care services for payment. If Medicare and copayments.does not pay because it determines that the Health Care Services Covered bycare is not medically necessary, TFL also does TRICARE but Not by Medicarenot pay. You may appeal Medicare’s decision, When you receive care that is coveredand if Medicare reconsiders and provides only by TFL (e.g. TRICARE-coveredcoverage, TFL also reconsiders coverage. services received overseas), TRICAREIf a health care service is covered by both processes the claim as the primary payer.Medicare and TFL, but Medicare does not You are responsible for the applicable TFLpay because you have used up your Medicare deductible, cost-shares, and remainingbenefit, TFL becomes the primary payer. In billed charges.this case, you are responsible for your TFL TFL claims are normally filed with Medicaredeductible and cost-shares. first; however, when a health care service isIf a health care service is normally covered not covered by Medicare, the claim may beby both Medicare and TFL, but you receive filed directly with WPS, unless you havethe service from a provider who has opted OHI. See the Claims section of thisout of Medicare, the provider cannot bill handbook for additional information.Medicare and, therefore, Medicare will pay Health Care Services Not Coverednothing. When you see an opt-out provider, by Medicare or TRICARETFL will process the claim as the second When you receive care that is not coveredpayer, unless you have other health insurance by Medicare or TFL (e.g., cosmetic surgery),(OHI). TFL pays the amount it would have neither makes a payment on the claim. Youpaid if Medicare had processed the claim are responsible for the entire bill.(normally 20 percent of the TRICARE- 8
  • 13. HOW TRICARE FOR LIFE WORKS SECTION 1For more information on covered When your OHI processes the claim afterservices, visit www.medicare.gov Medicare, you need to submit a claim toor www.tricare.mil or contact WPS. WPS for any remaining balance. See the Claims section of this handbook forSee Figure 1.1 for TFL out-of-pocket costs. additional information.Coordinating TRICARE For Life with Note: TRICARE pays after most insuranceOther Health Insurance plans with the exception of Medicaid,How Medicare coordinates with OHI TRICARE supplements, the Indian Healthdepends on whether or not the OHI is Service, and other programs and plans asbased on current employment. In either identified by the TRICARE Managementcase, TFL is the last payer. Activity.OHI Not Based on Current Employment How TRICARE For Life Works OverseasIf you have OHI that is not based on your Medicare provides coverage in the Unitedor a family member’s current employment, States and U.S. territories, which are:Medicare pays first, the OHI pays second, • American Samoaand TFL pays last. • GuamOHI Based on Current Employment • Northern Mariana IslandsGenerally, if you have an employer- • Puerto Ricosponsored health plan based on current • U.S. Virgin Islandsemployment, that health plan pays first,Medicare pays second, and TFL pays last. Medicare also covers health care servicesIf there are fewer than 20 employees in the received onboard ships in U.S. territorialemployer-sponsored plan, Medicare pays waters. In these locations, TFL worksfirst, the employer plan pays second, and exactly as it does in the United States.TFL pays last.TRICARE For Life Out-of-Pocket Costs Figure 1.1 Type of Service Medicare Pays TRICARE Pays You Pay Covered by TRICARE Medicare-authorized Remaining amount Nothing and Medicare amount Covered by Medicare Medicare-authorized Nothing Medicare deductible only amount and cost-share Covered by TRICARE Nothing TRICARE-allowable TRICARE deductible only amount and cost-share Not Covered by Nothing Nothing Billed charges (which TRICARE or Medicare may exceed the Medicare amount or balance billing cap) 9
  • 14. Unless you have OHI, TFL is the second processing address for the region wherepayer after Medicare for most health care you received care. See the Claims sectionservices. Your provider files the claim of this handbook for more information.with Medicare first. Medicare pays its Frequently Asked Questions:portion and automatically forwards the How TRICARE For Life Worksclaim to WPS for processing. Does TFL pay for the Medicare Part BMedicare does not provide coverage outside premium and deductible?of the United States, U.S. territories, andships in territorial waters. Therefore, TFL is The Part B monthly premium is youryour primary payer for health care received responsibility. TFL covers the Medicarein all other overseas locations, unless you Part B deductible as long as the healthhave OHI. TFL provides the same coverage care service is covered by both Medicareas TRICARE Standard and has the same and TRICARE.cost-shares and deductibles for beneficiarieswho live or travel overseas. When seeking Using TFL seems so easy. Should I cancelcare from a host nation provider, region- my Medicare supplement, Medicareor country-specific requirements may also Advantage Plan, or other OHI?apply. You should be prepared to pay up frontfor services and submit a claim to the You should carefully evaluate your healthoverseas claims processor. Claims for care insurance needs to determine if youreceived overseas are submitted directly to should continue any OHI plans, Medicarethe TRICARE Overseas Program claims- supplements, and Medicare Advantage 10
  • 15. HOW TRICARE FOR LIFE WORKS SECTION 1Plans. You may contact your local State Once you become entitled to premium-freeHealth Insurance Assistance Program for Medicare Part A because you are age 65,free health insurance counseling and you are eligible for TFL when you alsoassistance. have Medicare Part B. You are no longer eligible for enrollment in TRICARE Prime,Note: If you drop your OHI coverage, you unless you have an active duty sponsor.must notify WPS. You may continue to seek care at an MTFI am a TFL beneficiary and a retired on a space-available basis, but will likelyfederal employee. Can I suspend my need to seek care from civilian MedicareFederal Employees Health Benefits providers. When you visit civilian Medicare(FEHB) coverage to use TFL? providers, you have no out-of-pocket costs for services covered by both Medicare andYes. You may suspend your FEHB coverage TRICARE. Contact Medicare for assistanceand premium payments at any time. Visit with finding Medicare-certified providers.www.opm.gov/forms or call the Officeof Personnel Management Retirement You may be able to sign up for TRICAREInformation Office at 1-888-767-6738 to Plus. TRICARE Plus is a program thatget a Health Benefits Election Form allows beneficiaries who normally are only(SF 2809). Eligible unremarried former able to get MTF care on a space-availablespouses can get the form from the basis to enroll and receive primary careemploying offices or retirement system appointments at the MTF within themaintaining their enrollments. same primary care access standards as beneficiaries enrolled in a TRICAREIs a referral or TRICARE prior Prime option. Beneficiaries should contactauthorization required for health their local MTFs to determine if they maycare services? participate in TRICARE Plus.A referral or TRICARE prior authorization Enrollment in TRICARE Plus at one MTFis not required under TFL when Medicare does not automatically extend TRICAREis the primary payer. However, when TFL Plus enrollment to another MTF. The MTFbecomes the primary payer, TRICARE is not responsible for any costs when aauthorization requirements apply as they TRICARE Plus enrollee is referred outsidewould for a TRICARE Standard beneficiary. the MTF for additional civilian care.I was enrolled in TRICARE Prime ata military treatment facility (MTF).I received a letter from the MTFtelling me I was no longer eligible forenrollment in TRICARE Prime. Whatdoes that mean? 11
  • 16. Getting CareFinding a Provider of the billed charges. In cases where access to medical care is limited (i.e., underservedYou may receive health care services from areas), TFL may waive the second-payerMedicare-participating and nonparticipating status for Medicare opt-out providers andproviders, as well as from providers who pay the claim as the primary payer.have opted out of Medicare. If TRICAREFor Life (TFL) is the primary payer, you Veterans Affairs Providersmust visit TRICARE-authorized providers Medicare cannot pay for services receivedand facilities. You will incur higher out- from VA. Therefore, TRICARE is theof-pocket costs when you obtain care from primary payer for VA claims and you willopt-out providers or Veterans Affairs (VA) be responsible for the TRICARE annualproviders. Costs vary according to the type deductible and cost-shares. Alternatively,of provider you see (i.e., participating, you may choose to use your VA benefit.nonparticipating, opt-out, VA). Military Treatment FacilitiesMedicare-Participating Providers A military treatment facility (MTF) is aMedicare-participating providers agree to military hospital or clinic usually locatedaccept the Medicare-approved amount as on or near a military base. You may receivepayment in full. care at an MTF on a space-available basis. See Figure 2.1 for MTF appointmentMedicare Nonparticipating Providers priorities.Nonparticipating providers do not acceptthe Medicare-approved amount as payment MTF Appointment Priorities Figure 2.1in full. They may charge up to 115 percent 1 Active duty service membersof the Medicare-approved amount. TFL pays 2 Active duty family members (ADFMs) enrolled in TRICARE Primeup to the 115-percent limiting charge. 3 Retired service members, their families,Opt-Out Providers and all others enrolled in TRICARE Prime or TRICARE PlusProviders who opt out of Medicare enterinto private contracts with patients and are 4 ADFMs not enrolled in TRICARE Prime TRICARE Reserve Select members andnot allowed to bill Medicare. Therefore, their familiesMedicare does not pay for health care 5 Retired service members, their families,services you receive from opt-out providers. TRICARE Retired Reserve members and their families, and all others not enrolledWhen you see an opt-out provider, TFL in TRICARE Primepays the amount it would have paid ifMedicare had processed the claim (normally20 percent of the allowable charge) andyou are responsible for paying the remainder 12
  • 17. immediate medical attention would result in a threat to life, limb, or sight; when a person has severe, painful symptoms requiring immediate attention to relieve suffering; or when a person is at immediate risk to self or others. The TRICARE health care benefit covers adjunctive dental care (i.e., dental care that is medically necessary to treat a covered medical-not dental- condition). The TRICARE health care GETTING CARE SECTION 2 benefit does not cover non-adjunctive dental care, which refers to any routine, preventive, restorative, prosthodontic, periodontic, or emergency dental care that is not related to a medical condition. Eligible TRICARE beneficiaries may receive non-adjunctive dental services if enrolled in the TRICARE Dental Program or theOverseas Providers TRICARE Retiree Dental Program.With TFL overseas, you may generally useany host nation provider and receive care If you need emergency care, call 911 or goat MTFs on a space-available basis, unless to the nearest emergency room. Make sureregion- or country-specific requirements you present your Medicare card so that yourapply. When seeking care from a host claim is filed with Medicare.nation provider, you should be preparedto pay up front for services and submit a If traveling or living overseas, first attemptclaim to the overseas claims processor. to seek care from the nearest MTF. If anFor more information about getting care MTF is not available, seek care from theoverseas, call your TRICARE Overseas nearest emergency room. You can contactProgram (TOP) Regional Call Center or the TOP Regional Call Center for yourvisit www.tricare-overseas.com. region for assistance in finding a host nation provider.Emergency Care Note: Most dental conditions that may beTRICARE defines an emergency as a considered emergencies are not coveredmedical, maternity, or psychiatric condition under Medicare or TFL.that would lead a “prudent layperson”(someone with average knowledge of health Urgent Careand medicine) to believe that a serious Urgent care services are medically necessarymedical condition exists; that the absence of services required for an illness or injury that 13
  • 18. would not result in further disability or death Prior authorization is a review ofif not treated immediately, but does require the requested health care service toprofessional attention within 24 hours. You determine if it is medically necessary atcould require urgent care for conditions such the requested level of care. If you have anas a sprain, sore throat, or rising temperature, authorization from a TRICARE regionalas each of these has the potential to develop contractor (Health Net Federal Services,into an emergency if treatment is delayed LLC; Humana Military Healthcarelonger than 24 hours. Services, Inc.; TriWest Healthcare Alliance; or International SOS Assistance, Inc.)Behavioral Health Care that covers the dates on your claim, Wisconsin Physicians Service (WPS) willMedicare helps cover visits with the honor those authorizations and no TFLfollowing types of health care providers: authorization is required. The TRICARE• A psychiatrist or other doctor For Life Authorization Request form is• Clinical psychologist available on the WPS Web site. Providers• Clinical social worker should fill out the TRICARE For Life• Clinical nurse specialist Authorization Request form and submit it to the fax number provided in the top right• Nurse practitioner corner of the form.• Physician’s assistant If you have questions about authorizationMedicare only covers these visits when requirements, contact WPS.they are provided by health care providerswho accept Medicare payment. To pay even The following services require priorless, you should also ask your health care authorization:providers if they accept assignment, which • Adjunctive dental servicesmeans they accept the Medicare-approved • All outpatient behavioral health careamount as payment in full, before you after the first eight sessions in a fiscalschedule an appointment. year (October 1–September 30) fromFor more information on Medicare’s an authorized, independent behavioralbehavioral health care coverage, visit health providerwww.medicare.gov. • Dental anesthesia and institutional care • Hospice carePrior Authorization for Care • Inpatient behavioral health care servicesWhen TFL becomes the primary payer • Organ and stem cell transplants(e.g., if your Medicare benefits are • Partial hospitalizationexhausted), TRICARE prior authorization • Psychoanalysisrequirements apply. Note: This list is not all-inclusive. 14
  • 19. TRICARE For Life CoverageTRICARE Medical Coverage • Eye examinations (routine) • Hearing aids*TRICARE For Life (TFL) and Medicare Note: This list is not all-inclusive.cover proven, medically necessary, andappropriate care. TFL has special rules and * Retired sponsors may be eligible for the Retiree-limitations for certain types of care, and At-Cost Hearing Aid Program. If you are a retired service member and you need a hearingsome types of care are not covered at all. aid, you should call a participating militaryTRICARE policies are very specific about treatment facility. For more information, visit GETTING CARE SECTION 2which services are covered and which are www.militaryaudiology.org/rachap/state.html.not. It is in your best interest to take an Dental Coverageactive role in verifying coverage. TRICARE offers two voluntary dentalNote: Medicare also has limits on the insurance programs, the TRICARE Dentalamount of care it covers and, in some Program (TDP) and the TRICARE Retireecases, TFL may cover these health care Dental Program (TRDP).services after your Medicare benefits havebeen exhausted. TRICARE Dental Program The TDP provides worldwide dentalTo determine if Medicare covers a specific coverage for family members of allservice or benefit, visit www.medicare.gov TRICARE FOR LIFE COVERAGE SECTION 3 active duty service members and Nationalor call 1-800-633-4227. To determine if Guard and Reserve members and theirTFL covers the service or benefit, visit the families. For information about the TDP,TRICARE Web site at www.tricare.mil visit the TRICARE dental Web site ator contact Wisconsin Physicians Service www.tricare.mil/dental.(WPS) at 1-866-773-0404. See Figure 1.1in the How TRICARE For Life Works TRICARE Retiree Dental Programsection of this handbook for more The TRDP is available to retired serviceinformation on your out-of-pocket costs. members and their eligible family members, including retired National Guard andExamples of services that are generally Reserve members who are entitled tonot reimbursable by either program include: retirement pay but do not begin receiving• Acupuncture it until age 60, their eligible family members,• Experimental or investigational services certain surviving family members of (in most cases) deceased active duty sponsors, and Medal of Honor recipients and their immediate family members and survivors. For information about the TRDP, including 15
  • 20. possible restrictions, visit the TRDP Web exceptions for medical reasons). Yoursite at www.trdp.org or call Delta Dental® doctor’s plan of care must demonstrateof California toll-free at 1-888-838-8737. your need for skilled nursing services.Frequently Asked Questions: Note: TFL is the primary payer for SNFTRICARE For Life Coverage care beyond Medicare’s 100-day limit as long as the patient continues to requireDoes TFL cover long-term care? skilled nursing services and no other health insurance is involved. SNF careNo. Long-term care (or custodial care) requires prior authorization on day 101,is not a covered benefit. However, you when TRICARE is the primary payer.may qualify to purchase long-term care TFL covers an unlimited number of daysinsurance through commercial insurance as medically necessary.programs or through the Federal LongTerm Care Insurance Program. For moreinformation about the Federal LongTerm Care Insurance Program, visitwww.opm.gov/insure/ltc or call1-800-582-3337.Does TRICARE cover skillednursing care?TFL covers reasonable and necessary skillednursing care and rehabilitative therapies,including semiprivate rooms; regular nursingservices; meals (including special diets);physical, occupational, and speech therapy;drugs furnished by the facility; and necessarymedical supplies and appliances. Skillednursing care is typically provided in askilled nursing facility (SNF).For TFL and Medicare to cover SNFadmission, you must have had a medicalcondition that was treated in a hospital forat least three consecutive days, and youmust be admitted to a Medicare-certified,TRICARE-participating SNF within 30 daysof discharge from the hospital (with some 16
  • 21. PharmacyPrescription Drug Coverage military providers, regardless of whether or not you are enrolled at the MTF.TRICARE offers several options forfilling your prescriptions. TRICARE Non-formulary medications are generallycovers proven, medically necessary, and not available at MTF pharmacies. To checkappropriate prescription medication. To fill the availability of a particular drug, contacta prescription, you need the prescription the nearest MTF pharmacy.and a valid uniformed services TRICARE Pharmacy Home Deliveryidentification (ID) card or a CommonAccess Card. When traveling overseas, TRICARE Pharmacy Home Delivery isbe prepared to pay up front for medications your least expensive option when not usingand file a claim for reimbursement for an MTF pharmacy. Additionally,non-military treatment facility (MTF) prescriptions are delivered to you throughand non-network pharmacy services. free standard shipping, and refills can beTRICARE For Life recommends that easily ordered online, by phone, or by mail.you fill all of your prescriptions before TRICARE Pharmacy Home Deliverytraveling overseas. also provides you with refill reminders, convenient notifications about your orderIn certain overseas locations, region- status, and assistance with renewingspecific or country-specific requirements expired prescriptions. If you have questions TRICARE FOR LIFE COVERAGE SECTION 3may require using a TRICARE-approved about your prescriptions, pharmacists arepharmacy. For more information, contact available 24 hours a day, seven days ayour TRICARE Overseas Program week to talk confidentially with you.(TOP) Regional Call Center or visitwww.tricare-overseas.com. For faster processing of your mail-order prescriptions, register before placingNote: You do not need a Medicare Part D your first order. Once you are registered,prescription drug plan to keep your your provider can fax or call in yourTRICARE prescription drug coverage. prescriptions. Express Scripts, Inc. (Express Scripts) sends your medicationsFilling Prescriptions directly to your home within about 14 PHARMACY SECTION 4Military Treatment Facility Pharmacy days of receiving your prescription.An MTF pharmacy is the least expensive Note: Overseas beneficiaries must haveoption for filling prescriptions. At an an APO/FPO or embassy address to useMTF pharmacy, you may receive up to TRICARE Pharmacy Home Delivery,a 90-day supply of most medications at and the prescription must be from ano cost. Most MTF pharmacies accept U.S.-licensed provider.prescriptions written by both civilian and 17
  • 22. If you have prescription drug coverage This option allows you to fill prescriptionsthrough other health insurance (OHI), at TRICARE network pharmacies withoutyou can use TRICARE Pharmacy Home submitting claims. You have access toDelivery only if the medication is not approximately 60,000 retail networkcovered under your OHI or if you exceed pharmacies in the United States and U.S.the OHI’s coverage limit. Register for territories (American Samoa,* Guam, theTRICARE Pharmacy Home Delivery Northern Mariana Islands, Puerto Rico,using any of the options in Figure 4.1. and the U.S. Virgin Islands). TRICARE retail network pharmacies are only locatedMember Choice Center in the United States and U.S. territories.The Member Choice Center makes it easy * Currently, there are no TRICARE retailto reduce your out-of-pocket costs by network pharmacies in American Samoa.transferring your current maintenancemedication prescriptions to TRICARE Visit www.express-scripts.com/TRICAREPharmacy Home Delivery. or call 1-877-363-1303 for customer service, including finding the nearest TRICARENote: To use the Member Choice Center, you retail network pharmacy.must have a maintenance prescription froma retail pharmacy or MTF. The Member Non-Network PharmaciesChoice Center contacts your provider to get When visiting non-network pharmacies,new written prescriptions for home delivery. you pay the full price of your medication up front and file a claim for reimbursement.TRICARE Retail Network Pharmacies Reimbursements are subject to deductibles,Another option for filling your prescriptions out-of-network cost-shares, and TRICARE-is through TRICARE retail network required copayments. All deductibles mustpharmacies. You may fill prescriptions (one be met before any reimbursement can becopayment per 30-day supply) when you made. For details about filing a claim, seepresent your written prescription and the Claims section of this handbook.uniformed services ID card to the pharmacist.TRICARE Pharmacy Home Delivery Registration Methods Figure 4.1 Online Visit www.express-scripts.com/TRICARE Phone Call 1-877-363-1433 (Member Choice Center) or 1-877-540-6261 (TDD/TTY) Mail Download the registration form from www.express-scripts.com/TRICARE, and mail it to: Express Scripts, Inc. P.O. Box 52150 Phoenix, AZ 85072-9954 18
  • 23. Pharmacy Policy be dispensed only after the prescribing physician completes a clinical assessmentQuantity Limits indicating the brand-name drug is medicallyTRICARE has established quantity limits necessary and after Express Scriptson certain medications, which means the grants approval. Prescribers may callDepartment of Defense (DoD) pays for a 1-866-684-4488 to submit a request forspecified, limited amount of medication a brand-name drug to be dispensed ineach time you fill a prescription. Quantity lieu of a generic, or a completed formlimits are often applied to ensure medications may be faxed to: 1-866-684-4477. Theare safely and appropriately used. Brand over Generic Prior Authorization Request Form may be found atExceptions to established quantity limits www.pec.ha.osd.mil/forms_criteria.php.may be made if the prescribing provider If a generic-equivalent drug does not exist,can justify medical necessity, or in cases of the brand-name drug is dispensed at thenatural disasters, as approved by TRICARE. brand-name copayment.Prior Authorization If you fill a prescription with a brand-nameSome drugs require prior authorization from drug that is not considered medicallyExpress Scripts. Medications requiring necessary and when a generic equivalentprior authorization may include, but are is available, you are responsible for payingnot limited to, prescription drugs specified the entire cost of the prescription.by the DoD Pharmacy and Therapeutics(P&T) Committee, brand-name medications Non-Formulary Drugswith generic equivalents, medications The DoD P&T Committee may recommendwith age limitations, and medications to the director of TRICARE Managementprescribed for quantities exceeding normal Activity that certain drugs be placed inlimits. If you do not have Internet access, the third, “non-formulary” tier. Thesecall 1-877-363-1303 to inquire about a medications include any drug in aspecific drug. therapeutic class determined to be less relatively clinically effective or cost-Generic Drug-Use Policy effective than other drugs in the sameGeneric drugs are medications approved class. For an additional cost, third-tierby the U.S. Food and Drug Administration drugs are available through TRICARE PHARMACY SECTION 4and are clinically equivalent to brand-name Pharmacy Home Delivery or retail networkmedications. Generic drugs provide the same pharmacies. You may be able to fill non-safe, effective treatment as brand-name formulary prescriptions at formularydrugs. It is DoD policy to use generic costs if your provider can establishmedications instead of brand-name medical necessity by completing andmedications whenever possible. A brand- submitting the appropriate TRICAREname drug with a generic equivalent may pharmacy medical-necessity form for 19
  • 24. the non-formulary medication. Call These services are provided to you at noExpress Scripts at 1-877-363-1303 or visit additional cost when you receive yourwww.pec.ha.osd.mil/forms_criteria.php medications through TRICARE Pharmacyfor forms and medical-necessity criteria. Home Delivery. Participation is voluntary.For information on how to save money and If you or your provider orders a specialtymake the most of your pharmacy benefit, medication from TRICARE Pharmacyvisit www.tricare.mil/pharmacy or Home Delivery, Express Scripts sends youwww.express-scripts.com/TRICARE. additional information about the Specialty Medication Care Management program andSpecialty Medication how to get started.Care ManagementSpecialty medications are usually high-cost; Using TRICARE Pharmacy Home Deliveryself-administered; injectable, oral, or infused to fill specialty medication prescriptionsdrugs that treat serious chronic conditions provides you with access to the Specialty(e.g., multiple sclerosis, rheumatoid arthritis, Medication Care Management programhepatitis C). These drugs typically require benefits previously described. With specificspecial storage and handling and are not mailing instructions from you or yourreadily available at your local pharmacy. provider, TRICARE Pharmacy HomeSpecialty medications may also have side Delivery ships your specialty medicationeffects that require pharmacist and/or to your home. For your convenience andnurse monitoring. safety, TRICARE Pharmacy Home Delivery contacts you to arrange delivery before theThe Specialty Medication Care Management medication is shipped.program is structured to improve yourhealth through continuous health evaluation, Note: Some specialty medications may notongoing monitoring, assessment of be available through TRICARE Pharmacyeducational needs, and medication-use Home Delivery because the medication’smanagement. This program provides: manufacturer limits the drug’s distribution• Access to proactive, clinically based to specific pharmacies. If you submit a services for specific diseases and is prescription for a limited-distribution designed to help you get the most benefit medication, TRICARE Pharmacy Home from your medication Delivery either forwards your prescription• Monthly refill reminder calls to a pharmacy of your choice that can fill it or provides you with instructions about• Scheduled deliveries to specified locations where to send the prescription to have• Specialty consultation with a nurse it filled. or pharmacist at any point during your therapy 20
  • 25. Pharmacy Claims Prescription claims require the following information for each drug:You do not need to file pharmacy claims • Patient’s namefor prescriptions filled at MTF pharmacies, • Prescription name, strength, date filled,through TRICARE Pharmacy Home days’ supply, quantity dispensed, and priceDelivery, or at TRICARE retail networkpharmacies. However, if you fill a prescription • National Drug Code, if availableat a non-network pharmacy in the United • Prescription numberStates or U.S. territories (American Samoa,* • Name and address of the pharmacyGuam, the Northern Mariana Islands, • Name and address of thePuerto Rico, and the U.S. Virgin Islands), prescribing physicianyou must pay the full price of yourprescription up front and file a claim Contact Express Scripts at 1-877-363-1303for reimbursement. with questions about filing pharmacy claims.If you live in the Philippines, you are Pharmacy Claims Appealsrequired to visit an approved pharmacy. If you disagree with the determinationAn approved pharmacy has been verified on your pharmacy claim (i.e., if yourto meet required TOP contract standards claim is denied), you or your appointedand is allowed to invoice TRICARE for representative has the right to request aTRICARE beneficiary claims. reconsideration. The request (or appeal)* Currently, there are no TRICARE retail for reconsideration must be in writing, network pharmacies in American Samoa. signed and postmarked or received by Express Scripts within 90 calendar daysTo file a claim: from the date of the decision and must1. Download TRICARE DoD/CHAMPUS include a copy of the claim decision. Medical Claim Patient’s Request for Medical Payment form (DD Form 2642) Your signed, written request must state the at www.tricare.mil/claims. specific matter you disagree with and must be sent to the following address no later than2. Complete the form and attach the 90 days from the date of the notice: required paperwork as described on the form. Express Scripts, Inc. PHARMACY SECTION 43. Mail the form and paperwork to: P.O. Box 60903 Phoenix, AZ 85082-0903 Express Scripts, Inc. TRICARE Claims P.O. Box 66518 St. Louis, MO 63166-6518 21
  • 26. Additional documentation in support of the documentation will be submitted at a laterappeal may be submitted; however, because date, the letter requesting reconsiderationthe request for reconsideration must be must state that additional documentation willpostmarked or received within 90 calendar be submitted and specify the expected datedays of the date of the decision, do not delay of submission. Upon receiving your request,the request for reconsideration for the sake all TRICARE claims related to the entireof additional documentation. If additional course of treatment are reviewed. 22
  • 27. CLAIMS SECTION 5ClaimsHealth Care Claims Attach a readable copy of the provider’s bill to the claim form, making sure itIn most cases, your provider files your health contains the following:care claims with Medicare first. Medicare • Patient’s namepays its portion and, unless you have other • Sponsor’s Social Security number (SSN)health insurance (OHI), forwards the claim (Eligible former spouses should use theirto TRICARE For Life (TFL) for processing. SSNs, not their sponsors’.)However, when TFL is the primary payer • Provider’s name and address (If more than(e.g., if Medicare does not cover the health one provider’s name is on the bill, circlecare service), your provider may be required the name of the person who provided theto file your claim directly with Wisconsin service for which the claim is filed.)Physicians Service (WPS)/TFL (WPS). • Date and place of each serviceIf you have OHI, you must file the claim • Description of each service orwith your OHI before filing with TFL. supply furnishedYou are responsible for making sure • Charge for each serviceyour claims are filed within one year of • Diagnosis (If the diagnosis is not oneither the date of service or the date of the bill, be sure to complete block 8aan inpatient discharge. To file a claim on the form.)with TFL, fill out a TRICARE DoD/CHAMPUS Medical Claim—Patient’s Unlike other TRICARE beneficiaries, TFLRequest for Medical Payment form beneficiaries should file claims in the regions(DD Form 2642). You can download where they received care. Send claims to theforms and instructions from TRICARE appropriate mailing address provided in theat www.tricare.mil/claims or the WPS beginning of this handbook.Web site at www.TRICARE4u.com. You Appealing a Claim orcan also obtain forms and instructions Authorization Denialat a TRICARE Service Center (TSC) ora military treatment facility (MTF). Fill You may appeal authorization denials ofout the form completely and sign it. Visit requested services or decisions regarding PHARMACY SECTION 4www.tricare.mil/contactus to locate a claims payments. Medicare and TFL haveTSC or MTF. separate appeals processes. Medicare- related appeals should be submitted toWhen filing a claim with TFL, include Medicare. You should only submit appealsyour Medicare Summary Notice and OHI to WPS if TFL is the primary payer.explanation of benefits (EOB), if applicable. 23
  • 28. Third-Party Liability TRICARE Regional Offices to help resolve your TRICARE health care collection-If TRICARE is the primary payer, the related issues. Contact a DCAO if youFederal Medical Care Recovery Act allows received a negative credit rating or wereTRICARE to be reimbursed for treatment contacted by a collection agency due to ancosts if you are injured in an accident caused issue related to your TFL claim.by someone else. The Statement of PersonalInjury—Possible Third-Party Liability When you visit a TRICARE DCAO forform (DD Form 2527) is sent to you if a assistance, you must take or submitclaim appears to have third-party liability documentation associated with a collectioninvolvement. Within 35 calendar days, action or adverse credit rating, includingyou must complete and sign this form debt collection letters, EOBs, and medicaland follow the directions for returning it and/or dental bills from providers. The moreto the appropriate claims processor. Visit information you provide, the faster the causewww.tricare.mil/claims to download of the problem can be determined. TheDD Form 2527. DCAO researches your claim, provides you with a written resolution of your collectionExplanation of Benefits problem, and informs the collection agency that action is being taken to resolve the issue.A TRICARE EOB is not a bill. It is anitemized statement that shows the action DCAOs cannot provide legal advice orTRICARE has taken on your claims. An repair your credit rating, but they canEOB is for your information and files. help by providing documentation for the collection or credit-reporting agency toAfter reviewing the EOB, you have the explain the circumstances relating to theright to appeal certain decisions regarding debt. Visit the DCAO directory onlineyour claims and must do so in writing at www.tricare.mil/bcacdcao to find awithin 90 days of the date of the EOB TRICARE DCAO near you.notice. You should keep EOBs with yourhealth insurance records for future reference. TRICARE DCAOs can only assist you with TFL-related issues. Contact Medicare forFor more information about appeals, visit assistance with Medicare-related issues.www.TRICARE4u.com or see the ForInformation and Assistance section ofthis handbook.Debt CollectionAssistance OfficersTRICARE Debt Collection AssistanceOfficers (DCAOs) are located at MTFs and 24
  • 29. CLAIMS SECTION 5Life Changes: Update Your DEERS RecordTRICARE For Life (TFL) continues to have a life-changing event. You haveprovide health care coverage for you and your several options for updating and verifyingfamily as your life changes. However, you DEERS information. See “Importantneed to take specific actions to make sure Contact Information” at the beginning ofyou remain TRICARE-eligible. It is essential this handbook.that you keep information in the DefenseEnrollment Eligibility Reporting System Note: Only sponsors (or those appointed(DEERS) current for you and your family. power of attorney) can add or delete a family LIFE CHANGES: UPDATE YOUR DEERS RECORD SECTION 6DEERS is a computerized database of member. Family members age 18 and olderuniformed service members (active duty may update their own contact information.and retired), their family members, and Getting Married or Divorcedothers who are eligible for military benefits,including TRICARE. Proper and current MarriageDEERS registration is key to receiving It is extremely important for sponsors totimely, effective TFL benefits. register new spouses in DEERS to ensure they are eligible for TRICARE programs,Maintaining your TRICARE eligibility is including TFL. To register a new spouse inyour responsibility. It is essential to verify DEERS, the sponsor needs to provide a copyyour information in DEERS any time you of the marriage certificate to the nearest uniformed services identification (ID) card-issuing facility. The new spouse is also required to show two forms of ID (e.g., any combination of Social Security card, driver’s license, birth certificate, current military ID card, or Common Access Card). Once your spouse is registered in DEERS, he or she receives a uniformed services ID card and is eligible for TFL. Your spouse must show his or her ID card to access care. Divorce Sponsors must update DEERS in the event of a divorce. The sponsor needs to provide a copy of the divorce decree, dissolution, or annulment. 25
  • 30. Former Spouse Coverage ChildrenCertain former spouses are eligible tocontinue TFL coverage as long as they: Your dependent’s coverage does not change because you are entitled to TFL. Any• Do not remarry (If a former spouse children who retain eligibility under the remarries, the loss of benefits remains sponsor remain TRICARE-eligible until applicable even if the remarriage ends reaching age 21 (or age 23 if enrolled in in death or divorce.) a full-time course of study at an approved• Are not covered by employer-sponsored institution of higher learning, and if the health plans sponsor provides over 50 percent of• Are not also former spouses of North the financial support), as long as his or Atlantic Treaty Organization or “Partners her DEERS information is current. To for Peace” nation members extend coverage beyond your child’s 21st• Meet the requirements of one of the two birthday, contact DEERS to verify what situations described in Figure 6.1 documentation is needed.Former spouses who are TFL-eligible must At age 21 (or 23), children may be eligiblechange their personal information in DEERS for the TRICARE Young Adult (TYA)so their names and Social Security numbers program, and later for the Continued(SSNs) are listed for the primary contact Health Care Benefit Program (CHCBP).information. The former spouse’s TRICARE For more information on TYA, visiteligibility is shown in DEERS under his or www.tricare.mil/tya. For more informationher SSN, not the sponsor’s. on CHCBP, visit www.tricare.mil/chcbp.Eligibility Requirements for Former Spouses Figure 6.1 1 • The former spouse must have been married to the same military member or former member for at least 20 years, and at least 20 of those years must have been creditable in determining the member’s eligibility for retirement pay. • The former spouse is eligible for TRICARE coverage after the date of the divorce, dissolution, or annulment.1 • Eligibility continues as long as the preceding requirements continue to be met and the former spouse does not remarry. 2 • The former spouse must have been married to the same military member or former member for at least 20 years, and at least 15—but less than 20—of those married years must have been creditable in determining the member’s eligibility for retirement pay. • The former spouse is eligible for TRICARE coverage for only one year from the date of the divorce.1. For divorce decrees, annulments, or dissolutions on or before September 29, 1988, contact DEERS for eligibility verification. 26
  • 31. Note: Children with disabilities may remain benefits will eventually change. If you haveTRICARE-eligible beyond the normal age any questions, visit www.tricare.mil/deers.limits. Contact the DEERS support office Loss of Eligibilityfor eligibility criteria.Moving Upon loss of TRICARE eligibility, each family member automatically receives aWhether you are moving across the street certificate of creditable coverage. Theor overseas, moving with TFL is easy. All certificate of creditable coverage is ayou need to do is update your personal document that serves as evidence of priorinformation in DEERS, find a provider who health care coverage under TRICARE, so LIFE CHANGES: UPDATE YOUR DEERS RECORD SECTION 6is Medicare-certified (in the United States that you cannot be excluded from a newand U.S. territories) and TRICARE- health plan for preexisting conditions.authorized, and continue to receive care Certificates may be issued in thewhen you need it. See “Finding a Provider” following circumstances:in the Getting Care section of this handbook. • Upon the sponsor’s separation from activeSurvivor Coverage duty, a certificate is issued to the sponsor listing all eligible family members.If your TFL sponsor dies, you remain • Upon the loss of eligibility for a dependentTRICARE-eligible and will continue to child (age 21, or age 23 if enrolled in areceive TFL benefits as long as your DEERS full-time course of study at an approvedinformation is up to date and you are either institution of higher learning, and if theof the following: sponsor provides over 50 percent of the• A surviving spouse and do not remarry financial support), a certificate is issued (If you remarry, TRICARE eligibility to the dependent child. cannot be regained later, even if you • Upon loss of coverage after divorce, a divorce or your new spouse dies.) certificate is issued to the former spouse• An unmarried child under age 21 (or age once information is updated in DEERS. 23 if enrolled in a full-time course of study at an approved institution of higher Certificates automatically reflect the most learning, and if the sponsor provided over recent period of continuous coverage under 50 percent of the financial support) TRICARE. Certificates issued upon a beneficiary request reflect each period ofNote: Children with disabilities may remain continuous TRICARE coverage that endedeligible beyond normal age limits. Check within the 24 months prior to the date ofDEERS for eligibility criteria. loss of eligibility. Each certificate identifies the name of the sponsor or family memberUpon the death of your sponsor, you will it is issued for, the dates TRICAREreceive a letter from DEERS telling you coverage began and ended, and theabout your program options and how your certificate issue date. 27
  • 32. Send written requests for certificates Suspension of Social Securityof creditable coverage to the Defense Disability InsuranceManpower Data Center Support Office at: Medicare coverage may continue up to Defense Manpower Data Center eight years and six months following Support Office suspension of Social Security Disability ATTN: Certificate of Insurance payments. When Social Security Creditable Coverage Disability Insurance payments are suspended 400 Gigling Road because you have returned to work, you Seaside, CA 93955-6771 will receive quarterly bills for the Medicare Part B premium. As long as you remainThe request must include: entitled to premium-free Medicare Part• Sponsor’s name and SSN A, you must pay the Part B premium to• Name of person the certificate is maintain your TRICARE coverage. requested for• Reason for the request• Name of person and address the certificate should be sent to• Requester’s signatureCertificates cannot be requested by phone.If there is an urgent need for a certificateof creditable coverage, fax your requestto 1-831-655-8317 and/or request that thecertificate be faxed to a particular number. 28
  • 33. For Information and AssistanceBeneficiary Counseling and read the back of your Medicare SummaryAssistance Coordinators notice or contact Medicare.TRICARE Beneficiary Counseling and TRICARE For Life Appeals RequirementsAssistance Coordinators (BCACs) can helpyou with TRICARE For Life (TFL) You may appeal a TFL denial of a requestedquestions and concerns, and they can advise authorization of services even if no care wasyou about obtaining health care. BCACs provided and no claim was submitted. There LIFE CHANGES: UPDATE YOUR DEERS RECORD SECTION 6are located at military treatment facilities are some things you may not appeal. Forand TRICARE Regional Offices. To locate example, when TFL is the primary payer,a BCAC, visit the online directory at you may not appeal the denial of care fromwww.tricare.mil/bcacdcao. a provider who is not TRICARE-authorized.Your Right to Appeal a Decision When services are denied based on medical necessity or a benefit decision, you areIf you believe a service or claim was automatically notified in writing. Thedenied improperly, in whole or in part, notification includes an explanation of whatyou (or another appropriate party) may was denied or why a payment was reducedfile an appeal. An appeal must involve and the reasoning behind the decision.an appealable issue. For example, you FOR INFORMATION AND ASSISTANCE SECTION 7have the right to appeal Medicare or TFL Filing TRICARE For Life Appealsdecisions regarding claims payments. TFL appeals must be filed with WPS within 90 days from the date that appearsMedicare and TFL have separate claims on the explanation of benefits or denialprocesses. For most services, Medicare is notification letter. If you are not satisfiedyour primary payer. If you want to appeal with a decision rendered on an appeal,a Medicare decision, you must contact there may be further levels of appealMedicare. Contact Wisconsin Physicians available to you. Your TFL appeal mustService (WPS) to appeal TFL decisions. meet the requirements listed in Figure 7.1. For specific information about filing aMedicare Denials TFL appeal, contact WPS.Any services or supplies denied payment byMedicare and appealable under Medicare Prior authorization denial appeals may beare not considered for coverage by TFL. either expedited or non-expedited, dependingHowever, if a Medicare appeal results in on the urgency of the situation. You or ansome payment by Medicare, TRICARE appointed representative must file for anconsiders coverage as the second payer. expedited review of a prior authorizationFor more information on Medicare appeals, denial within three calendar days of receipt 29
  • 34. of the initial denial. A non-expedited denial A description of the issue or concernreview must be filed no later than 90 days must include:after receipt of the initial denial. • The specific issue in dispute • A copy of the previous denialAppeals should contain the following: determination notice• Beneficiary’s name, address, and • Any appropriate supporting documents telephone number• Sponsor’s Social Security number (SSN)• Beneficiary’s date of birth• Beneficiary’s or appealing party’s signatureTRICARE For Life Appeals Requirements Figure 7.1 1 An appropriate appealing party must submit the appeal. Proper appealing parties include: • You, the beneficiary • A person appointed, in writing, by you to represent you for the purpose of the appeal • An attorney filing on your behalf • Non-network participating providers If a party other than those listed above submits the appeal, you must complete and sign the Appointment of Representative and Authorization to Disclose Information form, which is available on the Wisconsin Physicians Service Web site at www.TRICARE4u.com. Appeals submitted without this form will not be processed. Note: Network providers are not appropriate appealing parties, unless appointed, in writing, by you. 2 The appeal must be submitted in writing. 3 The issue in dispute must be an appealable issue. The following are not appealable issues: • Allowable charges • Eligibility • Denial of services from an unauthorized provider • Denial of treatment plan when an alternative treatment plan is selected 4 An appeal must be filed within 90 days of the date on the explanation of benefits or denial notification letter. 5 There must be an amount in dispute to file an appeal. In cases involving an appeal of a denial of an authorization in advance of receiving the actual services, the amount in dispute is deemed to be the estimated TRICARE-allowable charge for the services requested. There is no minimum amount to request a reconsideration. 30
  • 35. Filing a Grievance When filing a grievance, include the following information:A grievance is a written complaint or • Beneficiary’s name, address, andconcern about a non-appealable issue telephone numberregarding a perceived failure by any • Sponsor’s SSNmember of the TFL health care deliveryteam, including TRICARE-authorized • Beneficiary’s date of birthproviders or military providers, to provide • Beneficiary’s signatureappropriate and timely health care services,access, or quality, or to deliver the proper A description of the issue or concern mustlevel of care or service. include the following: • Date and time of the eventThe TFL grievance process provides • Name(s) of the provider(s) and/orthe opportunity to report, in writing, any person(s) involvedconcern or complaint regarding health • Address of the eventcare quality or service. Any TFL civilianor military provider; TFL beneficiary; • Nature of the concern or complaintsponsor; or parent, guardian, or other • Details describing the event or issuerepresentative of an eligible dependent • Any appropriate supporting documentschild may file a grievance. WPS isresponsible for the investigation and Contact Medicare to file Medicare-relatedresolution of all grievances. grievances. FOR INFORMATION AND ASSISTANCE SECTION 7Grievances are generally resolved within60 days of receipt. Following resolution,the party that submitted the grievance isnotified of the review completion.Grievances may include such issues as:• The quality of health care or services (e.g., accessibility, appropriateness, level, continuity, timeliness of care)• The demeanor or behavior of providers and their staff members• The performance of any part of the health care delivery system• Practices related to patient safety 31
  • 36. GlossaryAdjunctive Dental Services/Care and out-of-pocket costs are dependent onDental care that is medically necessary your eligibility as a TRICARE beneficiaryin the treatment of an otherwise covered and may vary according to the programmedical—not dental—condition. Adjunctive option you are using. Contact your regionalcare includes oral examination and diagnosis contractor for more information.at the request of a physician and requires Debt Collection Assistanceprior authorization. Where adjunctive dental Officer (DCAO)care involves a medical (not dental) DCAOs are persons at military treatmentemergency (such as facial injuries resulting facilities and TRICARE Regional Officesfrom an accident), the requirement for prior who help TRICARE beneficiaries resolveauthorization is waived. This is not dental health care collection-related issues.coverage, which can be purchased separately Beneficiaries should contact a DCAO ifunder an applicable dental plan. they received a negative credit rating orBeneficiary Counseling and Assistance were contacted by a collection agency dueCoordinator (BCAC) to an issue related to TRICARE services.BCACs are persons at military treatment Explanation of Benefits (EOB)facilities and TRICARE Regional Officeswho are available to answer questions, An EOB is a statement sent to a beneficiaryhelp solve health care-related problems, showing that a claim was processed. Itand assist beneficiaries in obtaining includes the amount paid to the provider.medical care through TRICARE. Visit If denied, an explanation of denialwww.tricare.mil/bcacdcao to locate is provided.a BCAC. Formulary Drugs and Non-Formulary DrugsCost-share In 2005, the Department of Defense (DoD)A cost-share is the percentage or portion established a uniform formulary, which is aof costs that the beneficiary will pay for list of covered drugs consisting of genericinpatient or outpatient care. and brand-name drugs. This formularyCovered Service also contains a third tier of medicationsTRICARE covers most inpatient and that are designated as “non-formulary.”outpatient care that is medically necessary Prescriptions for non-formulary drugsand considered proven. However, there can be dispensed, but at a higher costare special rules or limits on certain types to beneficiaries, unless the provider canof care, while other types of care are not establish medical necessity.covered at all. Some services or treatmentsrequire prior authorization. Your coverage 32
  • 37. Since 2005, there have been multiple Medically Necessary Caretherapeutic classes of medications Medical or behavioral health care servicesreviewed by the DoD Pharmacy and and/or supplies necessary to prevent,Therapeutics (P&T) Committee for diagnose, or treat an illness, injury, bodilyclassification of pharmaceuticals into the malfunction, or other covered condition asthree-tier structure. A therapeutic “class” assessed or diagnosed by an authorizedis a grouping of medications used for the provider, and which have been proven to besame medical condition. The uniform safe and effective in accordance withformulary is available worldwide at applicable requirements.DoD’s three points of pharmacy service(military treatment facilities, retail Medicare Enrollment Period: Age 65network pharmacies, and TRICARE The day of the month you were bornPharmacy Home Delivery). determines when you become Medicare- eligible and when you should visit aThe DoD P&T Committee is charged Social Security office to sign up forwith reviewing and recommending Medicare Part A and Part B. By followingmedications to be moved to the third the guidance provided, you can ensuretier of the uniform formulary. These continuous TRICARE coverage and avoidrecommendations are presented to paying monthly late-enrollment premiumthe Beneficiary Advisory Panel for surcharges.comment during a public meeting. Therecommendations and comments are then If you were born on the first day ofpresented to the Director, TRICARE the month:Management Activity for approval. The • You become eligible for Medicare on theDoD P&T Committee meets quarterly to first day of the month before you turn 65.review medications in selected therapeutic • Sign up for Medicare between two andclasses for relative clinical and cost- four months before the month you turn 65.effectiveness. The committee also considers • Your Part A, Part B, and TRICARE Forsafety and patient tolerability. Life (TFL) coverage will begin on theAt the end of the process, the prescription first day of the month before you turn 65.will be either classified as formulary or If you were born after the first day ofnon-formulary, and placed into one of the GLOSSARY SECTION 8 the month:three cost tiers: • You become eligible for Medicare on the• Tier 1: Formulary–Generic first day of the month you turn 65.• Tier 2: Formulary–Brand Name • Sign up for Medicare between one and• Tier 3: Non-Formulary three months before the month you turn 65. 33
  • 38. • Your Part A, Part B, and TFL coverage Medicare Enrollment Period: End-Stage will begin on the first day of the month Renal Disease (ESRD) you turn 65. If you are eligible for premium-free Medicare Part A due to ESRD, you canIf you live in the United States or its enroll in Medicare Part B by visiting yourterritories (American Samoa, Guam, local Social Security office or by callingthe Northern Mariana Islands, Puerto the Social Security Administration atRico, and the U.S. Virgin Islands) and 1-800-772-1213. TTY users should callyou already receive Social Security 1-800-325-0778.or Railroad Retirement Board (RRB)benefits, you will automatically receive Medicare Enrollment Period: General Enrollment PeriodMedicare Part A and Part B when youbecome eligible due to age. If you live in If beneficiaries do not sign up for MedicarePuerto Rico and you get benefits from Part B when first eligible, they may be ableSocial Security or the RRB, you will to sign up during the General Enrollmentautomatically get Part A. However, you Period. This period runs from January 1will need to sign up for Part B. If you through March 31 of each year. During thislive outside the United States and its time, beneficiaries can sign up for Medicareterritories, you must apply for Medicare Part B at the local Social Security office.even if you already receive benefits from If you get benefits from the RailroadSocial Security or the RRB. Go to the Retirement Board (RRB), call your localclosest U.S. Embassy, Federal Benefits RRB office or 1-877-772-5772. YourUnit. Call ahead to verify the documents Medicare Part B coverage will start onyou will need to bring. July 1 of the year you sign up.Medicare Enrollment Period: Medicare Enrollment Period:Amyotrophic Lateral Sclerosis (ALS) MesotheliomaIf you have ALS (also called Lou Gehrig’s Beneficiaries who have been diagnoseddisease), you automatically get Part A and with an asbestos-related disease and livedPart B the month your disability benefits in Lincoln County, Montana, for a total ofbegin. at least six months during a period ending 10 years or more before the diagnosis,Medicare Enrollment Period: Disability are eligible for Medicare. Your MedicareYou are entitled to Medicare Part A and coverage will be effective the month afterMedicare Part B beginning the 25th month you sign up.of receiving Social Security disability Medicare Enrollment Period: Penaltypayments. The Centers for Medicare and for Late EnrollmentMedicaid Services will notify you of your If you do not sign up for Medicare whenMedicare entitlement start date. first eligible, the cost of Medicare Part B 34
  • 39. will go up 10 percent for each full Military Treatment Facility (MTF)12-month period that you could have had An MTF is a medical facility (e.g.,Medicare Part B but did not purchase it, hospital, clinic) owned and operatedexcept in special cases. You will have by the uniformed services and usuallyto pay this penalty as long as you have located on or near a military base. VisitMedicare Part B. www.tricare.mil/mtf to locate an MTF.Medicare Nonparticipating Provider Negotiated RateNonparticipating providers do not The negotiated rate is the rate TRICAREaccept the Medicare-approved amount network providers and TRICAREas payment in full. They may charge up participating non-network providers haveto 115 percent of the Medicare-approved agreed to accept for covered services.amount. TRICARE For Life pays upto the 115 percent limiting charge for Other Health Insurance (OHI)covered services. OHI is any non-TRICARE health insurance that is not considered aMedicare Opt-Out Provider supplement. This insurance may beProviders who opt out of Medicare enter acquired through an employer. Underinto private contracts with patients. Medicare federal law, TRICARE is the last payerdoes not pay for health care services received after all health benefits and insurancefrom opt-out providers. For covered services, plans, except for Medicaid, TRICARETRICARE pays the amount that TRICARE supplements, the Indian Health Service,would have paid had Medicare processed and other programs or plans as identifiedthe claim (normally 20 percent of the by the TRICARE Management Activity.allowable charge). In cases where accessto medical care is limited (i.e., underserved Prime Service Area (PSA)areas), TRICARE may waive the second- A PSA is an area around a military treatmentpayer status for services rendered by facility and in other predetermined areas,Medicare opt-out providers and pay the as defined by ZIP codes, where TRICAREclaim as the primary payer. Prime is offered.Medicare Participating Provider Prior AuthorizationA Medicare participating provider is a Prior authorization is the process of GLOSSARY SECTION 8physician, hospital, skilled nursing facility, reviewing certain medical, surgical, andhome health agency, hospice, or other behavioral health care services to ensurehealth care provider that has agreed to medical necessity and appropriateness ofaccept the Medicare-approved amount care before services are rendered or withinas payment in full. 24 hours of an emergency admission. A TRICARE prior authorization is not required under TRICARE For Life when 35
  • 40. Medicare is the primary payer. However, of care if you see a provider who is notwhen TRICARE becomes the primary TRICARE-authorized.payer, TRICARE authorization TRICARE Network Providerrequirements apply. Authorizationrequirements are listed in the Getting A TRICARE network provider is aCare section of this handbook. professional or institutional provider who has a contractual relationship with aTRICARE-Allowable Charge TRICARE regional contractor to provideThe TRICARE-allowable charge is the care at a contracted rate. A networkmaximum amount TRICARE pays for provider agrees to file claims for TRICAREservices. beneficiaries. A network provider accepts the negotiated rate as payment in full forTRICARE-Approved Provider Overseas services rendered.An approved provider has been verified tomeet TRICARE Overseas Program (TOP) TRICARE Non-Network Providercontract standards and is allowed to invoice A non-network provider has no contractualTRICARE for TRICARE beneficiary relationship with a TRICARE contractorclaims. Currently, all beneficiaries living but is authorized to provide care toin the Philippines must seek care from TRICARE beneficiaries. There are twoapproved providers. The Department of categories of non-network providers—Defense may expand this requirement participating and nonparticipating.to other locations. Individuals in other TRICARE Nonparticipating Non-locations should check if restrictions on Network Providerapproved providers apply in their area. For A nonparticipating non-network providermore information, call your TOP Regional is a TRICARE-authorized hospital,Call Center. institutional provider, physician, or otherTRICARE-Authorized Provider provider that furnishes medical servicesA TRICARE-authorized provider meets and supplies to TRICARE beneficiaries,TRICARE’s licensing and certification but has not signed a contract and does notrequirements and is certified by TRICARE agree to accept the TRICARE-allowableto provide care to TRICARE beneficiaries. charge or file claims for TRICARE beneficiaries. TRICARE nonparticipatingTRICARE-authorized providers include non-network providers may charge up todoctors, hospitals, ancillary providers 115 percent of the TRICARE-allowable(laboratories and radiology centers), amount in the United States and U.S.and pharmacies. There are two types of territories. There is no limit to the amountauthorized providers—network and non- nonparticipating non-network providersnetwork. When TRICARE is the primary may bill in overseas locations.payer, you are responsible for the full cost 36
  • 41. TRICARE Participating Non-NetworkProviderA participating non-network providermay agree to file claims for TRICAREbeneficiaries, accept payment directlyfrom TRICARE, and accept the TRICARE-allowable charge as payment in full forservices delivered. Non-network providersmay participate on a claim-by-claim basis,and may seek payment of applicablecopayments, cost-shares, and deductiblesfrom the beneficiary.TRICARE SupplementA TRICARE supplement is a health planyou may purchase specifically to supplementyour TRICARE coverage. It pays afterTRICARE. A TRICARE supplement isnot employer-sponsored health insurance. GLOSSARY SECTION 8 37
  • 42. List of FiguresFigure 1.1 TRICARE For Life Out-of-Pocket Costs ...................................................... 9Figure 2.1 MTF Appointment Priorities ....................................................................... 12Figure 4.1 TRICARE Pharmacy Home Delivery Registration Methods .......................18Figure 6.1 Eligibility Requirements for Former Spouses ............................................. 26Figure 7.1 TRICARE for Life Appeals Requirements ................................................. 30 38
  • 43. LIST OF FIGURES SECTION 9IndexA Delta Dental® of CaliforniaAccident, 24, 32 (Delta Dental), 16Active duty family member (ADFM), Dental care, 13–14, 32 4–5, 12 Dependent child, 27, 31Active duty service member (ADSM), Disability, 3–5, 13–14, 27–28, 34 4–5, 12, 15, 38–39 Divorce, 3, 5, 7, 25–27Active duty sponsor, 11, 15 Durable medical equipment, 5Acupuncture, 15 EAge limitations, 19, 27 Eligibility, 1–7, 11, 13, 15, 23, 25–27, INDEX SECTION 10Allowable charge, 8, 12, 30, 35–37 30–34Ancillary providers, 36 Emergency, 2, 13–14, 32, 35Appeal, 2–3, 8, 21–24, 29–30 End-stage renal disease (ESRD), 4–5, 34Appointment, 11–12, 14, 30 Enrollment, 4–7, 11–13, 17, 25–27, 33–34Authorization, 2, 11, 14, 16, 19, 23, 29–30, Explanation of benefits (EOB), 2, 23–24, 32, 35–36 29–30, 32B Express Scripts, Inc. (Express Scripts),Behavioral health care, 2, 14, 33, 35 17–21Beneficiary Counseling and Assistance Eye examinations, 15 Coordinator (BCAC), 3, 24, 29, 32 FBill, 5–6, 8, 12, 23–24, 28, 36 Federal Employees Health BenefitsBrand-name drug, 19, 32 (FEHB), 11C Former spouse, 4, 11, 23, 26–27Centers for Medicare and Medicaid G Services, 4, 34 Generic drug, 19Certificate of creditable coverage, 27–28 Generic equivalent, 19Charge, 8–9, 12, 23, 30, 33, 35–37 Grievance, 3, 30–31Children, 3, 26–27, 31 Guardian, 31Claim, 1–2, 7–10, 12–14, 17–18, 21–24, 29, 32, 35–37 HCommon Access Card (CAC), 17, 25 Health Net Federal Services, LLCCopayment, 8, 18–19, 37 (Health Net), 14Cost-share, 8–10, 12, 18, 32, 37 Hearing aids, 15Custodial care, 16 Home health care, 4–5D Hospice care, 4, 14 Hospital, 4, 12, 16, 35–36Debt Collection Assistance Officer Humana Military Healthcare Services, Inc. (DCAO), 2, 24, 32 (Humana Military), 14Deductible, 8–10, 12, 18, 37Defense Enrollment Eligibility Reporting I System (DEERS), 3, 7, 25–27 Identification (ID) card, 7, 17–18, 25Defense Manpower Data Center Support Indian Health Service, 9, 35 Office, 28 39
  • 44. L Prime Service Area (PSA), 4, 7, 35Limitations, 15, 19 Prior authorization, 2, 11, 14, 16, 19, 29,Long-term care, 16 32, 35 Program options, 7, 27, 32M QMarriage, 3, 25–26Medicaid, 4, 9, 34–35 Quantity limits, 19Medical equipment, 5 RMedicare nonparticipating provider, 12, 35 Referral, 11Medicare Part A, 1, 4–7, 11, 28, 33–34 Reimbursement, 17–18, 21, 24Medicare Part B, 4–7, 10–11, 28, 34–35 Renal disease, 4, 34Medicare Part D, 17 Retail network pharmacy, 18–19, 21, 33Medicare participating provider, 35 Retired, 4–6, 11–13, 15, 25–26, 34Medicare-certified provider, 11, 27Medication, 17–20, 32–33 SMember Choice Center, 18 Skilled nursing care, 16Military treatment facility (MTF), Skilled nursing facility (SNF), 4, 16, 35 1, 11–13, 15, 17–18, 21, 23–24, 29, Social Security Administration (SSA), 32–33, 35 4–5, 7, 34Moving, 3, 27, 33 Social Security number (SSN), 5, 7, 23,N 26, 28, 30–31 Specialty Medication Care Management,National Guard and Reserve, 4, 15 20Network pharmacy, 17–19, 21, 33 Specialty medication, 20Network provider, 30, 35–36 Speech therapy, 16Non-formulary drugs, 17, 19–20, 32–33 Spouse, 4–7, 11, 23, 25–27Non-network pharmacy, 17–18, 21 Survivor, 3–4, 15–16, 27Non-network provider, 35–37Nonparticipating provider, 1, 12, 35 TO Third-party liability, 2, 24 Transplants, 14Occupational therapy, 16 Travel, 10, 13, 17Other health insurance (OHI), 1, 8–11, 16, TRICARE Extra, 4, 7 18, 23, 35 TRICARE Management Activity, 9, 19,Out-of-pocket costs, 7, 9, 11–12, 15, 18, 32 33, 35Outpatient care, 5, 32 TRICARE Overseas Program (TOP),P 10, 13–14, 17, 21, 36Participating provider, 30, 35 TRICARE Pharmacy Home Delivery,Payment, 5–6, 8, 11–12, 14, 21, 23, 28–29, 17–21, 33 34–37 TRICARE Plus, 11–12Pharmacy, 1–2, 17–21, 33, 36 TRICARE Prime, 4, 7, 11–12, 35Physical therapy, 16 TRICARE Regional Office, 24, 29, 32Premium, 4–7, 10–11, 28, 33–34 TRICARE Retiree Dental ProgramPrescription, 2, 17–21, 32–33 (TRDP), 13, 15–16Preventive care, 5 TRICARE Service Center (TSC), 23 40
  • 45. TRICARE Standard, 4, 7, 10–11TRICARE supplement, 9, 35, 37TRICARE-allowable charge, 8, 30, 36TRICARE-authorized hospital, 36TRICARE-authorized provider, 12, 31, 36TriWest Healthcare Alliance (TriWest), 14UUniformed services identification (ID) card, 7, 17–18, 25Urgent care, 2, 13–14 INDEX SECTION 10VVeterans Affairs, 12WWisconsin Physicians Service (WPS), 7–11, 14–15, 23, 29–31 41
  • 46. Notes 42
  • 47. TRICARE Expectations for Beneficiaries According to the Department of Defense • Complaints and appeals: You should (DoD), as a TRICARE beneficiary, you expect a fair and efficient process for should expect to have the following abilities resolving differences with health plans, and support: health care providers, and institutions that serve you. • Get information: You should expect to receive accurate, easy-to- Additionally, DoD has the following understand information from written expectations of you as a TRICARE materials, presentations and TRICARE beneficiary: representatives to help you make informed decisions about TRICARE • Maximize your health: You should programs, medical professionals, maximize healthy habits such as and facilities. exercising, not smoking, and maintaining • Choose providers and plans: You a healthy diet. should expect a choice of health care • Make smart health care decisions: providers that is sufficient to ensure You should be involved in health care access to appropriate high-quality decisions, which means working with health care. providers to provide relevant information, • Emergency care: You should expect clearly communicate wants and needs, to access medically necessary and and develop and carry out agreed-upon appropriate emergency health care treatment plans. services as is reasonably available when • Be knowledgeable about TRICARE: and where the need arises. You should be knowledgeable about • Participate in treatment: You should TRICARE coverage and program options. expect to receive and review information • You also should: about the diagnosis, treatment, and • Show respect for other patients and progress of your conditions, and to fully health care workers participate in all decisions related to • Make a good-faith effort to meet your health care, or to be represented financial obligations by family members or other duly appointed representatives. • Use the disputed claims process when there is a disagreement • Respect and nondiscrimination: You should expect to receive considerate, respectful care from all members of the health care system without discrimination based on race, color, national origin, or any other basis recognized in applicable law or regulations. • Confidentiality of health information: You should expect to communicate with health care providers in confidence and to have the confidentiality of your health care information protected to the extent permitted by law. You also should expect to have the ability to review, copy, and request amendments to your medical records. Please provide feedback on this handbook at: www.tricare.mil/evaluations/booklets“TRICARE” is a registered trademark of the TRICARE Management Activity. All rights reserved.
  • 48. TRICARE For LifeTRICARE North RegionHealth Net Federal Services, LLCWisconsin Physicians Servicewww.healthnetfederalservices.comwww.TRICARE4u.com1-877-TRICARE (1-877-874-2273)1-866-773-0404TRICARE South RegionHumana Military Healthcare Services, Inc.TRICARE North Regionwww.humana-military.comHealth Net Federal Services, LLC1-800-444-5445www.hnfs.com1-877-TRICARE (1-877-874-2273)TRICARE West RegionTriWest Healthcare Alliance Corp.www.triwest.comTRICARE South Region1-888-TRIWEST (1-888-874-9378)Humana Military Healthcare Services, Inc.www.humana-military.com1-800-444-5445TRICARE West RegionTriWest Healthcare Alliancewww.triwest.com1-888-TRIWEST (1-888-874-9378) HAXXXBETXXXXXXX HA6471BET09112www.tricare.mil

×