Military family insurance coverage can be…confusing.
This post breakdowns what you need to know as a military family about TRICARE Prime. If you missed our intro post on what TRICARE is, how to enroll, etc. use this link to read up on the basics before you dive in.
What is TRICARE Prime?
Prime is what the insurance world calls a “managed care option”. This means if you’re a member of this plan, you are assigned to and required to see one of their primary care managers (PCMs) for the majority of your care. There are obviously exceptions, but with Prime, the goal is that majority (if not all) of the time you’re working with the PCM they gave you, which can be both a positive and a negative.
If you require specialty care outside of the practice of the PCM assigned to you, that PCM can make a referral to a specialist. See below for more details on what referrals are and how you go about using them as a spouse.
There are other Prime options, such as Prime Remote, Prime Overseas, and Prime Remote Overseas. Those differ slightly and will be addressed in a post of their own. Today’s focus is all on the general plan that is TRICARE Prime.
Who is eligible?
This is directly from the TRICARE website:
- Active duty members and their families
- Retired service members and their families*
- Activated Guard/Reserve members and their families
- Non-activated Guard/Reserve members and their families who qualify for care under the Transitional Assistance Management Program
- Retired Guard/Reserve members at age 60 and their families*
- Survivors
- Medal of Honor recipients and their families
- Qualified former spouses
*When retired service members and their families become eligible for Medicare based on age, they aren’t eligible to enroll in TRICARE Prime.
What are referrals and how do I use them?
The TRICARE website states, “Referrals are for services that are not considered primary care. An example of a referral is when a PCM sends a patient to see a cardiologist to evaluate a possible heart problem.” These referrals can be for evaluation only or for evaluation and treatment. This referral network is split between TRICARE East and TRICARE West. TRICARE East is handled by Humana and TRICARE West is by Health Network Federal Services (HNFS).
When you go to your doctor on base and they submit a referral these are the entities that will approve your referral and direct you to your specialized care facility, which could be a military hospital or clinic if one is nearby. To find information on your referral you can log in to your TRICARE Online account or go through Humana Military (if you are considered TRICARE East) or HNFS (if you are considered TRICARE West). You should be able to access your profile and find your referrals listed. From there you will have the information of the healthcare provider you will be seeing, their office address, phone number, authorization number, dates of authorization, and expiration date. All referrals should be listed within 72 hours of approval, so if you don’t see yours call Humana/HNFS and seek assistance.
Just because you have an approved referral doesn’t mean you have an appointment, so It’s important you call to book your appointment promptly. If you have a civilian referral note that it will expire if you don’t call to schedule an appointment within 90 days of receiving it. If for some reason you need to change your referral you can always reach out by phone or online portal through your account to Humana/HNFS to do so. If you go to your referred healthcare provider and they believe you need more specialized care, they need to contact Humana/HNFS or else you can go back to your Primary Care Manager to get that referral setup.
What are the biggest pros?
- No out-of-pocket costs for you
- Seeing the same doctor each time I go in for a visit
- Not having to stress about finding a new doctor after a move
What are the biggest cons?
- The referral process can be time-consuming and a pain
- You don’t have the choice of what PCM you see
- Lack of updated providers
- Hard to get appointments quickly
I’m pregnant, is Prime a good fit?
If you’re at a big base with a fairly large hospital, TRICARE Prime might be the option for you. Your healthcare then becomes all in one place, easy to locate and schedule, and also virtually “free” during your visits, with no copays or bills, you don’t even have to pay for prescriptions at the pharmacy, as long as you go on base.
For emergencies, you still go on base, but for urgent care needs, you’re allowed to go anywhere that takes TRICARE, still with no copays. That can be either in your local area where you live or anywhere you visit throughout your pregnancy or otherwise. I believe they just changed the number of urgent care visits you’re allowed from 2 a year to infinite urgent care visits as well.
The downside to Prime while pregnant, and why you might consider TRICARE Select, is you aren’t necessarily able to choose your doctors with Prime. If you do get to choose your doctors, you only get to choose from a limited list of either those available on base. If you don’t have a medical center at your base you could potentially choose from doctors at another medical center on another military base close by (Army, Navy, etc.), or a limited list of doctors in your area that TRICARE can send you if you request it. With Select, although you do get more options to choose from when it comes to your doctors and care, that route usually ends up being more expensive in the long run.
How do I sign-up?
If you haven’t seen our intro post on all things TRICARE, that will have all of your answers. That post does a great job summarizing the enrollment process, linking you to the appropriate websites, and making sure you have everything you need to be squared away in the military’s system to be considered eligible.
