TRICARE For Life HANDBOOK

 
TRICARE For Life HANDBOOK
TRICARE® For Life
AU G U S T 2 01 8

                                                    HANDBOOK

   A guide to understanding your program benefits
AUGUST 201 8

Important Information

                   TRICARE Website:                                                     www.tricare.mil

                   TRICARE For Life Contractor
                   Wisconsin Physicians Service (WPS)—
                   Military and Veterans Health:                                        1-866-773-0404
                   TRICARE For Life Website:                                            www.TRICARE4u.com

                   TRICARE East Region Contractor
                   Humana Military:                                                     1-800-444-5445
                   Humana Military Website:                                             HumanaMilitary.com
                                                                                        www.tricare-east.com

                   TRICARE West Region Contractor
                   Health Net Federal Services, LLC:                                    1-844-866-WEST (1-844-866-9378)
                   Health Net Federal Services, LLC Website:                            www.tricare-west.com

                   Medicare:                                                            1-800-MEDICARE (1-800-633-4227)

                   Social Security Administration:                                      1-800-772-1213

An Important Note About TRICARE Program Information
At the time of publication, this information is current. It is important to remember that TRICARE policies and benefits are governed
by public law and federal regulations. Changes to TRICARE programs are continually made as public law and/or federal regulations
are amended. Military hospital and clinic guidelines and policies may be different than those outlined in this publication. For the
most recent information, contact the TRICARE For Life contractor or your local military hospital or clinic. More information regarding
TRICARE, including the Health Insurance Portability and Accountability Act (HIPAA) Notice of Privacy Practices, can be found online
at www.tricare.mil. See the inside back cover of this handbook for “TRICARE Expectations for Beneficiaries.”

Keep Your DEERS Information Up To Date!
It is essential to keep information in the Defense Enrollment Eligibility Reporting System (DEERS) current for you and your family.
Failure to update DEERS to accurately reflect the sponsor’s or family member’s residential address and/or the ineligibility of a former
dependent could be considered fraud and a basis for administrative, disciplinary and/or other appropriate action.

TRICARE Meets the Minimum Essential Coverage Requirement under the Affordable Care Act
Due to tax law changes, beginning Jan. 1, 2019, you’ll no longer be required to have minimum essential coverage. You’ll still get an
Internal Revenue Service Form 1095 from your pay center each January listing the coverage you had during the previous tax year. The
Affordable Care Act requires that individuals maintain health insurance or other health coverage in 2018 that meets the definition of
minimum essential coverage. Most TRICARE plans meet this requirement.
Use this page as a guide for the most important resources available to you.            TRICARE WEBSITE: WWW.TRICARE.MIL

Important Contact Information
TRICARE FOR LIFE CONTRACTOR
Wisconsin Physicians Service (WPS)—­Military and Veterans Health administers the TRICARE For Life (TFL) benefit and
should be your primary contact for TRICARE-related customer service needs in the U.S. or U.S. territories (American Samoa,
Guam, the Northern Mariana Islands, Puerto Rico and the U.S. Virgin Islands). International SOS Government Services, Inc.
(International SOS) administers the TFL benefit overseas.

  GENERAL CONTACT INFORMATION                                                 GRIEVANCES

  Phone: 1-866-773-0404                                                       Email: reportit@wpsic.com
  Online: www.TRICARE4u.com                                                   WPS/TRICARE For Life
                                                                              ATTN: Grievances
  Written Correspondence:
                                                                              P.O. Box 8974
  WPS/TRICARE For Life
                                                                              Madison, WI 53708
  P.O. Box 7889
  Madison, WI 53707

  CLAIMS

  WPS/TRICARE For Life (stateside)                                            TRICARE Overseas Program
  P.O. Box 7890                                                               (Latin America and Canada)
  Madison, WI 53707                                                           P.O. Box 7985
                                                                              Madison, WI 53707 USA
  TRICARE Overseas Program (Eurasia-Africa)                                   TRICARE Overseas Program (Pacific)
  P.O. Box 8976                                                               P.O. Box 7985
  Madison, WI 53708 USA                                                       Madison, WI 53707 USA

DEFENSE ENROLLMENT ELIGIBILITY REPORTING SYSTEM (DEERS)
You have several options for updating and verifying DEERS information:

  In person                                                Visit a local ID card office. Find an office near you at
  (add a family member or update                           www.dmdc.osd.mil/rsl. Call to verify location and
  contact information)                                     business hours.
  Phone or fax                                             1-800-538-9552 (phone)
  (update contact information)                             1-866-363-2883 (TDD/TTY)
                                                           1-800-336-4416 (fax)
  Online (update contact information)                      milConnect: www.dmdc.osd.mil/milconnect
  Mail (update contact information)                        Defense Manpower Data Center Support Office
                                                           400 Gigling Road
                                                           Seaside, CA 93955
TRICARE REGIONAL CONTRACTORS
Regional contractors provide health care services and support in the TRICARE regions. They can help TFL beneficiaries with
prior authorizations, but they do not provide referrals for TFL beneficiaries. You may go to www.medicare.gov for help in
locating providers, hospitals, home health agencies or suppliers of durable medical equipment in your area. See the following
table for contact information for the two U.S. regional contractors. If you are overseas, your TRICARE Overseas Program (TOP)
contractor is International SOS. Contact your TOP Regional Call Center listed below or visit www.tricare-overseas.com.

Regional Contractors (Stateside)                                 TOP Regional Call Centers (Overseas)
  TRICARE East Region                                               TRICARE Eurasia-Africa
  Humana Military                                                   +44-20-8762-8384 (overseas)
  1-800-444-5445                                                    1-877-678-1207 (stateside)
  HumanaMilitary.com                                                tricarelon@internationalsos.com
  www.tricare-east.com
                                                                    TRICARE Latin America and Canada
  TRICARE West Region
                                                                    +1-215-942-8393 (overseas)
  Health Net Federal Services, LLC                                  1-877-451-8659 (stateside)
  1-844-866-WEST (1-844-866-9378)                                   tricarephl@internationalsos.com
  www.tricare-west.com

                                                                    TRICARE Pacific
                                                                    Singapore: +65-6339-2676 (overseas)
                                                                    1-877-678-1208 (stateside)
                                                                    sin.tricare@internationalsos.com
                                                                    Sydney: +61-2-9273-2710 (overseas)
                                                                    1-877-678-1209 (stateside)
                                                                    sydtricare@internationalsos.com

OTHER CONTACT INFORMATION
  FOR MORE INFORMATION                        RESOURCE NUMBERS                     WEBSITES
  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
  TRICARE Dental Program                      1-844-653-4061 (CONUS)               www.uccitdp.com
                                              1-844-653-4060 (OCONUS)
                                              711 (TDD/TTY)

  TRICARE Retiree Dental Program              1-888-838-8737                       www.trdp.org
  Customer Service                            See website                          www.tricare.mil/bcacdcao
  Community Directory
  (find a Beneficiary Counseling and
  Assistance Coordinator or a Debt
  Collection Assistance Officer)
  Find a military hospital or clinic          See website                          www.tricare.mil/mtf
  Get benefit correspondence                  See website                          www.dmdc.osd.mil/milconnect
  by email
Welcome to
TRICARE For Life

 TRICARE For Life is Medicare-wraparound coverage for TRICARE
 beneficiaries who have Medicare Part A and Medicare Part B,
 regardless of age or where you live.
 TRICARE For Life (TFL) provides comprehensive health care coverage. You
 have the freedom to seek care from any Medicare-participating or Medicare
 non-participating provider, or military hospital or clinic on a space-available
 basis. Medicare-participating providers file your claims with Medicare. After
 paying its portion, Medicare automatically forwards the claim to TRICARE for
 processing (unless you have other health insurance [OHI]). TRICARE pays after
 Medicare and OHI for TRICARE-covered health care services. See “Finding a
 Provider” in the Getting Care section of this handbook for information about
 provider types.

 This handbook will help you make the most of your TFL coverage. You will find
 information about eligibility requirements, getting care and claims. This handbook
 also provides details about your pharmacy and dental coverage options.
Table of Contents

1. How TRICARE For Life Works.......................................................................4
     Eligibility............................................................................................................................... 4
     Understanding Medicare....................................................................................................... 5
              Frequently Asked Questions: Medicare......................................................................... 8
     How TRICARE For Life Works with Medicare........................................................................... 9
              Figure 1.1 TRICARE For Life Out-of-Pocket Costs.......................................................... 9
              Frequently Asked Questions: How TRICARE For Life Works.......................................... 12

2. Getting Care.............................................................................................13
     Finding a Provider............................................................................................................... 13
              Figure 2.1 Military Hospital and Clinic Appointment Priorities..................................... 14
     Emergency Care.................................................................................................................. 14
     Urgent Care........................................................................................................................ 15
     Mental Health Care............................................................................................................. 16
     Prior Authorization for Care................................................................................................. 16

3. TRICARE For Life Coverage........................................................................ 17
     Medical Coverage............................................................................................................... 17
     Dental Coverage................................................................................................................. 17
              Frequently Asked Questions: TRICARE For Life Coverage............................................ 18

4. Pharmacy................................................................................................. 19
     Prescription Drug Coverage................................................................................................. 19
     Filling Prescriptions............................................................................................................. 19
              Figure 4.1 TRICARE Pharmacy Home Delivery Registration Methods .......................... 21
     Pharmacy Policy..................................................................................................................22
     Pharmacy Claims................................................................................................................ 24
5. Claims...................................................................................................... 26
      Health Care Claims in the U.S. and U.S. Territories.............................................................. 26
      Health Care Claims Overseas.............................................................................................. 27
      Appealing a Claim or Prior Authorization Denial................................................................... 27
      Third-Party Liability............................................................................................................. 27
      Explanation of Benefits....................................................................................................... 28
      Debt Collection Assistance Officers.................................................................................... 28

6. Life Changes: Keep Your DEERS Information Up To Date.............................29
      Using milConnect to Update Information in DEERS..............................................................29
      Getting Married or Divorced................................................................................................30
              Figure 6.1 Eligibility Situations for Former Spouses....................................................30
      Children.............................................................................................................................. 31
      Moving................................................................................................................................32
      Survivor Coverage...............................................................................................................32
      Suspension of Social Security Disability Insurance..............................................................32

7. For Information and Assistance.................................................................33
      Beneficiary Counseling and Assistance Coordinators...........................................................33
      Your Right to Appeal a Decision..........................................................................................33
              Figure 7.1 TRICARE For Life Appeals Requirements.....................................................34
      Filing a Grievance...............................................................................................................35

8. Index........................................................................................................ 36
How TRICARE For Life Works

ELIGIBILITY
TRICARE For Life (TFL) is available to                 while the sponsor is on active duty.
TRICARE beneficiaries, regardless of age               However, when the sponsor retires,
or where you live, if you have Medicare                you must have Medicare Part B
Part A and Medicare Part B. You are eligible           to remain TRICARE-eligible. See
for TFL on the first date you have both                “Medicare Part B (Medical Insurance)”
Medicare Part A and Medicare Part B.                   later in this section for information
                                                       about the Medicare Part B special
                                                       enrollment period for ADSMs
TRICARE Eligibility Requirements
                                                       and ADFMs.)
When you are entitled to premium-free
                                                     ■ You are enrolled in TRICARE Reserve
Medicare Part A:
                                                       Select (TRS), TRICARE Retired
•   Medicare Part B coverage is required to            Reserve (TRR), TRICARE Young
    remain TRICARE-eligible if you are a(n):           Adult (TYA), or the US Family Health
                                                       Plan (USFHP) (While you are not
    ■ Retired service member (including
                                                       required to have Medicare Part B to
      retired National Guard and Reserve
                                                       remain eligible for TRS, TRR, TYA, or
      members drawing retirement pay)
                                                       USFHP, you are strongly encouraged
    ■ Family member of a retired                       to sign up for Medicare Part B when
      service member                                   first eligible to avoid paying a late-
                                                       enrollment premium surcharge.)
    ■ Medal of Honor recipient or eligible
      family member
                                                   Note: Regardless of age, ADFMs who have
    ■ Survivor of a deceased sponsor               Medicare Part A may enroll in TRICARE
                                                   Prime if they live in a Prime Service
    ■ Eligible former spouse
                                                   Area (PSA), or with a drive-time waiver,
•   Medicare Part B coverage is not required       within 100 miles of an available primary
    to remain TRICARE-eligible if:                 care manager. A PSA is a geographic area
                                                   where TRICARE Prime is offered. It is
    ■ You are an active duty service member
                                                   typically an area near a military hospital
      (ADSM) or active duty family member
                                                   or clinic. The TRICARE Prime enrollment
      (ADFM) (ADSMs remain eligible for
                                                   fee is waived for any TRICARE Prime
      TRICARE Prime or TRICARE Prime
                                                   beneficiary who has Medicare Part B,
      Remote. ADFMs remain eligible for
                                                   regardless of age. For more information,
      TRICARE Prime, TRICARE Prime
                                                   visit www.tricare.mil/prime.
      Remote or TRICARE Select options

                                               4
SECTION 1
                                                                                                     How TRICARE For Life Works
UNDERSTANDING MEDICARE                              spouses) work history. You are eligible for
                                                    premium-free Medicare Part A at age 65 if
TFL is managed by the Department of
                                                    you or your spouse has 40 quarters or 10 years
Defense. Medicare is managed by the
                                                    of Social Security-covered employment.
Centers for Medicare & Medicaid Services
(CMS). The two agencies work together to
                                                    If you are not entitled to premium-free
coordinate benefits.
                                                    Medicare Part A when you turn 65 under
                                                    your own Social Security number (SSN),
Medicare is a federal entitlement health
                                                    you must file for benefits under your
insurance program for people:
                                                    spouse’s (this includes divorced or deceased
•   Age 65 or older                                 spouses) SSN if he or she is 62 or older. If
                                                    your spouse is not yet 62, and you anticipate
•   Under age 65 with certain disabilities
                                                    that he or she will be eligible for premium-
•   Any age with end-stage renal                    free Medicare Part A at age 65, you should
    disease (ESRD)                                  sign up for Medicare Part B when first
                                                    eligible at age 65 to avoid paying a late-
                                                    enrollment premium surcharge. You should
Medicare Part A (Hospital Insurance)
                                                    then file for Part A benefits under your
Medicare Part A covers inpatient hospital           spouse’s record two months before he or she
care, hospice care, inpatient skilled nursing       turns 62.
facility care and some home health care.
The Social Security Administration (SSA)            Note: If neither spouse will be eligible for
determines your entitlement to Medicare             premium-free Medicare Part A, neither
Part A based on your work history or your           will need Medicare Part B to remain
spouse’s (this includes divorced or deceased        TRICARE-eligible.

                                                5
Medicare Part B (Medical Insurance)                period, which waives the late-enrollment
                                                   premium surcharge. The special enrollment
Medicare Part B covers provider services,
                                                   period for ADSMs and ADFMs is available
outpatient care, home health care, durable
                                                   anytime the sponsor is on active duty
medical equipment and some preventive
                                                   or within eight months following either
services. Medicare Part B has a monthly
                                                   (1) the month your sponsor retires (2) the
premium, which may change yearly and
                                                   month TRICARE coverage ends, whichever
varies based on income. If you sign up
                                                   comes first. To avoid a break in TRICARE
after your initial enrollment period for
                                                   coverage, ADSMs and ADFMs must sign up
Medicare Part B, you may have to pay a late-
                                                   for Medicare Part B before their sponsor’s
enrollment premium surcharge (10 percent
                                                   active duty status ends.
for each 12-month period that you were
eligible to enroll in Medicare Part B but
                                                   Note: ADSMs and ADFMs with ESRD do
did not) for as long as you have Medicare
                                                   not have a special enrollment period and
Part B. For specific information about your
                                                   should enroll in Medicare Part A and Part B
Part B premium and/or surcharge amount,
                                                   when first eligible.
call SSA at 1-800-772-1213.

Medicare allows ADSMs and ADFMs                    USFHP and Medicare Entitlement
who are entitled to Medicare based on
                                                   If you are a USFHP beneficiary under age
age or disability (does not apply to those
                                                   65 and entitled to premium-free Medicare
with ESRD) to delay Part B enrollment
                                                   Part A, you are strongly encouraged to
and sign up during a special enrollment
                                                   have Medicare Part B (except for disabled
                                                   ADFMs). If you are enrolled in USFHP and
                                                   entitled to Medicare based on disability or
                                                   age, you are not required to have Medicare
                                                   Part B. As of Oct. 1, 2012, Medicare-eligible
                                                   beneficiaries age 65 and older can no longer
                                                   enroll in USFHP. Anyone whose enrollment
                                                   was effective Oct. 1, 2012, or later and
                                                   becomes Medicare-eligible based on age, is
                                                   disenrolled from USFHP and transferred
                                                   to TFL.

                                                   Medicare Entitlement Based on
                                                   a Disability
                                                   If you receive Social Security disability
                                                   benefits, you are entitled to Medicare in
                                                   the 25th month of receiving disability
                                                   payments. CMS will notify you of your
                                                   Medicare entitlement date.

                                               6
Your Medicare initial enrollment period is a
If you return to work and your Social
                                                      seven-month period.
Security disability payments are suspended,
your Medicare entitlement continues for               •   If your birthday falls on the first of the

                                                                                                         SECTION 1
up to eight years and six months. When                    month, your initial enrollment period
your disability payments are suspended,                   begins four months before the month you
you will get a bill every three months                    turn 65. Enroll no later than two months

                                                                                                        How TRICARE For Life Works
for your Medicare Part B premiums.                        before the month you turn 65 to avoid
You must continue to pay your Medicare                    a break in TRICARE coverage. You are
Part B premiums to remain eligible for                    eligible for Medicare coverage on the first
TRICARE coverage.                                         day of the month before you turn 65.
                                                      •   If your birthday falls on any day other
Medicare Entitlement Based on ESRD                        than the first of the month, your initial
                                                          enrollment period begins three months
If you are eligible for Medicare benefits based
                                                          before the month you turn 65. Enroll no
on ESRD, enroll in Medicare Part A and
                                                          later than one month before your birth
Part B when you are first eligible to remain
                                                          month to avoid a break in TRICARE
TRICARE-eligible. ADSMs and ADFMs
                                                          coverage. You are eligible for Medicare
with ESRD do not have a special enrollment
                                                          on the first day of the month you turn 65.
period and should enroll in Part B when first
eligible to avoid the Part B late-enrollment
                                                      Enroll in Medicare Part B when first
premium surcharge.
                                                      eligible to avoid a break in TRICARE
                                                      coverage. If you sign up after your initial
Medicare Entitlement Based on                         enrollment period, you may have to pay
Lou Gehrig’s Disease                                  a late-enrollment premium surcharge for
                                                      as long as you have Part B. The Medicare
If you have Lou Gehrig’s disease (also
                                                      Part B surcharge is 10 percent for each
called amyotrophic lateral sclerosis or ALS),
                                                      12-month period that you were eligible
you automatically get Medicare Part A and
                                                      to enroll in Part B but did not.
Part B the month your disability begins.
                                                      Your Part B premiums are automatically
Medicare Entitlement Based on Age                     taken out of your Social Security or
                                                      U.S. Railroad Retirement Board monthly
The Medicare entitlement age is 65. If you
                                                      payments. If you do not get these types of
already get retirement benefits from the
                                                      payments, Medicare bills you every three
SSA or the U.S. Railroad Retirement Board,
                                                      months for Part B premiums.
you are automatically entitled to Medicare
Part A and Part B the month you turn 65 or
                                                      Note: If you live in Puerto Rico and already
the month prior if your birthday falls on the
                                                      get SSA or U.S. Railroad Retirement Board
first of the month.
                                                      benefits, you automatically get Medicare
                                                      Part A; however, you must sign up for Part B.
If you do not receive Social Security or U.S.
Railroad Retirement Board benefits before
age 65, you must apply for Medicare benefits.

                                                  7
FAQs       Frequently Asked Questions:
            Medicare
I will be 65 soon and will          sponsored coverage to ensure           are not eligible for premium-free
become entitled to Medicare.        your TRICARE coverage under            Medicare Part A, you are eligible
I work full time and have           TFL begins immediately following       for Medicare Part B at age 65.
employer-sponsored group            the end of your employer-              See “Medicare Entitlement
health plan coverage, and I         sponsored coverage. Your TFL           Based on Age” earlier in this
don’t plan on retiring for a few    coverage begins on the first day       section for more information.
                                    you have both Medicare Part A
more years. Medicare says I                                                If you sign up for Medicare and
                                    and Part B coverage.
can delay my Part B enrollment                                             are not eligible for premium-
if I have employer-sponsored                                               free Part A under your or your
coverage. How does this affect      If I am not entitled to premium-       spouse’s (this includes divorced
my TRICARE benefit?                 free Medicare Part A when I turn       or deceased spouses) SSN, you
                                    65, can I still use TFL?               will get a “Notice of Award” or
If you are entitled to premium-                                            “Notice of Disapproved Claim”
free Medicare Part A, you must      Because you are not entitled to        from SSA. To keep your TRICARE
also have Part B to remain          premium-free Medicare Part A,          coverage, take the “Notice(s)
TRICARE-eligible, even if you       you do not need Medicare               of Award” or “Notice(s) of
have employer-sponsored             Part B to keep your TRICARE            Disapproved Claim” to a
coverage. Medicare allows           benefit. You do not transition         uniformed services ID card
individuals with employer-          to TFL. You may continue               office to have your Defense
sponsored coverage to delay         enrollment in TRICARE Prime            Enrollment Eligibility Reporting
Part B enrollment and sign up       if you live in a PSA, or if            System (DEERS) record updated
during a special enrollment         qualified, you may enroll in           and get a new ID card. This
period, which waives the late-      TRICARE Select. For information        allows you to keep your eligibility
enrollment premium surcharge.       about TRICARE program options,         for TRICARE Prime or TRICARE
If you or your spouse still works   visit www.tricare.mil.                 Select after you turn 65.
and has employer-sponsored          If you are not eligible for premium-
coverage, you may sign up                                                  Note: Uniformed services
                                    free Medicare Part A under your        ID card offices will not accept
for Medicare Part B during a        own SSN when you turn 65,
special enrollment period, which                                           an SSA Report of Confidential
                                    you must file for benefits under       Social Security Benefit
is available anytime you or your    your spouse’s (this includes
spouse is currently working and                                            Information form (SSA-2458)
                                    divorced or deceased spouses)          as proof of ineligibility for
covered by employer-sponsored       SSN if he or she is 62 or older.
coverage, or within the eight                                              premium-free Part A to keep
                                    If your spouse is not yet 62,          your TRICARE eligibility.
months following either (1) loss    you must file for benefits under
of employment or (2) loss of        his or her SSN two months
group health plan coverage,         before he or she turns 62.
whichever comes first.
                                    If you will be eligible under
If you choose to delay              your spouse’s SSN in the
enrollment in Medicare              future, you should sign up for
Part B and rely solely on your      Medicare Part B during your
employer-sponsored coverage,        initial enrollment period to avoid
sign up for Part B before           paying a Part B late-enrollment
you retire or lose employer-        premium surcharge. Even if you

                                                     8
Medicare Entitlement Based on an                     When you see a Medicare participating or
Asbestos-Related Disease                             Medicare non-participating provider, you
                                                     have no out-of-pocket costs for services
If you have been diagnosed with an asbestos-
                                                     covered by both Medicare and TFL. Most

                                                                                                       SECTION 1
related disease (for example, mesothelioma)
                                                     health care services fall into this category.
and lived in Lincoln County, Montana, for
                                                     After Medicare pays its portion of the claim,
a total of at least six months during a period
                                                     TFL pays the remaining amount and you

                                                                                                      How TRICARE For Life Works
ending 10 years or more before the diagnosis,
                                                     pay nothing.
you are eligible for Medicare. Your Medicare
coverage is effective the month after you
                                                     As the primary payer, Medicare approves
sign up.
                                                     health care services for payment. If Medicare
                                                     does not pay because it determines that the
HOW TRICARE FOR LIFE WORKS                           care is not medically necessary, TFL also does
WITH MEDICARE                                        not pay. You may appeal Medicare’s decision
                                                     and, if Medicare reconsiders and provides
Medicare and TFL work together to
                                                     coverage, TFL also reconsiders coverage.
minimize your out-of-pocket expenses.
However, there are instances when some
                                                     If a health care service is covered by both
health care costs may not be covered by
                                                     Medicare and TFL, but Medicare does
Medicare and/or TFL.
                                                     not pay because you have used up your
                                                     Medicare benefit, TFL becomes the primary
Health Care Services Covered by                      payer. In this case, you are responsible for
Medicare and TRICARE                                 your TFL deductible and cost-shares.

Figure 1.1 TRICARE For Life Out-of-Pocket Costs

 TYPE OF SERVICE          MEDICARE PAYS              TRICARE PAYS           YOU PAY

 Covered by               Medicare-                  TRICARE-allowable      Nothing
 TRICARE and              authorized amount          amount
 Medicare

 Covered by               Medicare-                  Nothing                Medicare
 Medicare only            authorized amount                                 deductible and
                                                                            cost-share

 Covered by               Nothing                    TRICARE-allowable      TRICARE deductible
 TRICARE only                                        amount                 and cost-share

 Not covered              Nothing                    Nothing                Billed charges
 by TRICARE                                                                 (which may exceed
 or Medicare                                                                the Medicare or
                                                                            TRICARE-allowable
                                                                            amount)

                                                 9
services received overseas), TRICARE
If a health care service is normally covered
                                                        processes the claim as the primary payer.
by both Medicare and TFL, but you get the
                                                        You are responsible for the applicable TFL
service from a provider who has opted out of
                                                        deductible, cost-shares and remaining billed
Medicare, the provider cannot bill Medicare
                                                        charges. Outside the U.S. and U.S. territories
and Medicare pays nothing. When you
                                                        (American Samoa, Guam, the Northern
see an opt-out provider, TFL processes the
                                                        Mariana Islands, Puerto Rico and the
claim as the second payer, unless you have
                                                        U.S. Virgin Islands), there may be no
other health insurance (OHI). TFL pays
                                                        limit to the amount that nonparticipating
the amount it would have paid if Medicare
                                                        non-network providers may bill. You are
had processed the claim (normally TFL
                                                        responsible for paying any amount that
pays 20 percent of the TRICARE-allowable
                                                        exceeds the TRICARE-allowable charge,
charge) and you are responsible for the
                                                        in addition to your deductible and cost-
remainder of the billed charges.
                                                        shares. Visit www.tricare.mil/overseas for
                                                        more information.
Similarly, U.S. Department of Veterans Affairs
(VA) providers cannot bill Medicare and
                                                        TFL claims are normally filed with
Medicare pays nothing. When you see a VA
                                                        Medicare first; however, when a health care
provider for health care not related to service-
                                                        service is not covered by Medicare, your
connected injuries or illnesses, TFL processes
                                                        provider may file the claim directly with
the claim as the second payer. TFL pays up to
                                                        Wisconsin Physicians Service (WPS)—
20 percent of the TRICARE-allowable charge.
                                                        Military and Veterans Health, unless you
                                                        have OHI. See the Claims section of this
Opt-out providers establish private contracts
                                                        handbook for more information.
with patients. Under a private contract,
there are no limits on what the provider can
charge for health care services.                        Medical Services Not Covered by
                                                        Medicare or TRICARE
Medical Services Covered by Medicare                    When you get care that is not covered
but Not by TRICARE                                      by Medicare or TFL (for example, most
                                                        cosmetic surgery), neither makes a payment
When you get care that is covered by
                                                        on the claim. You are responsible for the
Medicare only (for example, chiropractic
                                                        entire bill.
care), Medicare processes the claim as the
primary payer. TFL pays nothing, regardless
                                                        For more information on covered
of any action Medicare takes. You are
                                                        services, visit www.medicare.gov or
responsible for the Medicare deductible
                                                        www.tricare.mil/coveredservices or
and cost-shares.
                                                        contact WPS.

Medical Services Covered by TRICARE                     See Figure 1.1 on the previous page for TFL
but Not by Medicare                                     out-of-pocket costs.
When you get care that is covered only
by TFL (for example, TRICARE-covered

                                                   10
Coordinating TRICARE For Life with                     TFL works exactly as it does in the U.S.
Other Health Insurance                                 Unless you have OHI, TFL is the second
                                                       payer after Medicare for most health care
How Medicare coordinates with OHI depends              services. Your provider files the claim with

                                                                                                       SECTION 1
on whether or not the OHI is based on current          Medicare first. Medicare pays its portion
employment. In either case, TFL pays last.             and automatically forwards the claim to
                                                       WPS for processing.

                                                                                                      How TRICARE For Life Works
OHI Not Based on Current Employment
                                                       Medicare does not provide coverage outside
If you have OHI that is not based on your              the U.S., U.S. territories or aboard ships
or a family member’s current employment,               outside U.S. territorial waters. Therefore,
Medicare pays first, your OHI pays second              TFL is your primary payer for health care
and TFL pays last.                                     received in all other overseas locations,
                                                       unless you have OHI.
Other Health Insurance Based
on Current Employment                                  Eligible TFL beneficiaries may receive
                                                       covered services and supplies from a
Generally, if you have an employer-sponsored           network provider or any authorized-
health plan based on current employment,               TRICARE provider. You will be subject to
that health plan pays first, Medicare pays             the applicable catastrophic cap, deductibles
second and TFL pays last. If there are fewer           and cost-shares. If a TFL beneficiary
than 20 employees in the employer-sponsored            receives covered services from a network
plan, Medicare pays first, your OHI pays               provider, the beneficiary’s out-of-pocket
second and TFL pays last.                              costs will generally be lower. Prior
                                                       authorization may be required (except for
When your OHI processes the claim after                emergency care). When seeking care from a
Medicare, you need to submit a claim to                civilian provider, area- or country-specific
WPS for any remaining balance. See the                 requirements may also apply. For TFL
Claims section of this handbook for                    deductibles and cost-shares, visit
more information.                                      www.tricare.mil/tflcosts.

Note: TRICARE pays after most insurance                For requirements about getting care in the
plans with the exception of Medicaid,                  Philippines, see “Overseas Providers” in the
TRICARE supplements, the Indian Health                 Getting Care section of this handbook.
Service and other programs and plans as
identified by the Defense Health Agency.               You should be prepared to pay upfront
                                                       for services and submit a claim to the
                                                       TRICARE Overseas Program (TOP) claims
How TRICARE For Life Works Overseas
                                                       processor. Claims for care received overseas
TRICARE is the only payer overseas.                    are submitted directly to the TOP claims-
Medicare provides coverage in the U.S.                 processing address for the area where you
and U.S. territories. Medicare also covers             received care and must include proof of
health care services received aboard ships             payment. See the Claims section of this
in U.S. territorial waters. In these locations,        handbook for more information.

                                                  11
FAQs       Frequently Asked Questions:
            How TRICARE For Life Works
Does TFL pay for the Medicare     Suspension Confirmation               for assistance with finding
Part B premium and deductible?    form (RI 79-9). Eligible former       Medicare providers.
                                  spouses who have not
The Medicare Part B monthly                                             You may be able to sign up
                                  remarried can get the form
premium is your responsibility.                                         for TRICARE Plus. TRICARE
                                  from the employing offices or
TFL covers the Medicare                                                 Plus is a program that allows
                                  retirement system maintaining
Part B deductible as long                                               beneficiaries who normally
                                  their enrollments.
as the health care service                                              are only able to get military
is covered by both Medicare                                             hospital and clinic care on
and TRICARE.                      Is a referral or TRICARE prior        a space-available basis to
                                  authorization required for health     enroll and get primary care
                                  care services?                        appointments at the military
Using TFL seems so easy.                                                hospital or clinic. TRICARE
Should I cancel my Medicare       A referral or TRICARE prior           Plus offers the same primary
supplement, Medicare              authorization is not required         care access standards as
Advantage Plan or OHI?            under TFL when Medicare is the        beneficiaries enrolled in
                                  primary payer. However, when          a TRICARE Prime option.
Carefully evaluate your health    TFL becomes the primary payer,
insurance needs to determine                                            Beneficiaries should contact
                                  TRICARE prior authorization           their local military hospitals or
if you should continue            requirements apply.
Medicare supplements,                                                   clinics to determine if TRICARE
Medicare Advantage Plans                                                Plus is available and whether
or OHI. You may contact           I was enrolled in TRICARE Prime®      they may participate in it.
your local State Health           at a military hospital. I received    Enrollment in TRICARE Plus at
Insurance Assistance Program      a letter from the military hospital   one military hospital or clinic
for free health insurance         telling me I am no longer eligible    does not automatically extend
counseling and assistance.        for enrollment in TRICARE Prime.      TRICARE Plus enrollment to
For more information, visit       What does that mean?                  another military hospital or
https://shipnpr.acl.gov.                                                clinic. The military hospital or
                                  Once you become entitled to
Note: If you drop your OHI                                              clinic is not responsible for
                                  premium-free Medicare Part A
coverage, you must notify WPS.                                          any costs when a beneficiary
                                  because you are age 65, you
                                                                        enrolled in TRICARE Plus
                                  are eligible for TFL when you
                                                                        seeks care outside the military
I am a TFL beneficiary and a      also have Medicare Part B.
                                                                        hospital or clinic.
retired federal employee. Can I   You are no longer eligible for
                                  enrollment in TRICARE Prime,
suspend my Federal Employees
                                  unless you have an active
Health Benefits (FEHB) Program
                                  duty sponsor.
coverage to use TFL?
                                  You may continue to seek care
Yes. You may suspend your         at a military hospital or clinic
FEHB coverage and premium         on a space-available basis,
payments at any time. Visit       but will likely need to seek
www.opm.gov/forms to get a        care from civilian Medicare
Health Benefits Cancellation/     providers. Contact Medicare

                                                  12
Getting Care

FINDING A PROVIDER                                    opt-out provider, TFL pays the amount it
                                                      would have paid (normally up to 20 percent
You may get health care services from
                                                      of the allowable charge) if Medicare had
Medicare participating and Medicare non-
                                                      processed the claim, and you are responsible
participating providers, as well as from
                                                      for paying the remainder of the billed
providers who have opted out of Medicare.
                                                      charges. In cases where access to medical
If TRICARE For Life (TFL) is the primary
                                                      care is limited (underserved areas), TFL may
payer, you must visit TRICARE-authorized
                                                      waive the second-payer status for Medicare
providers and facilities. You will have
                                                      opt-out providers and pay the claim as the

                                                                                                     SECTION 2
significant out-of-pocket expenses when
                                                      primary payer.
you get care from opt-out providers, or
when seeing a U.S. Department of Veterans
Affairs (VA) provider for health care not             Veterans Affairs Providers

                                                                                                     Getting Care
related to a service-connected injury or
                                                      VA providers cannot bill Medicare and
illness. Costs vary according to the type of
                                                      Medicare cannot pay for services received
provider you see (for example, opt-out or VA).
                                                      from VA. If you are eligible for both TFL
                                                      and VA benefits, you will have significant
Medicare Participating Providers                      out-of-pocket expenses when seeing a
                                                      VA provider for health care not related
Medicare participating providers agree to
                                                      to a service-connected injury or illness.
accept the Medicare allowed amount as
                                                      If you get care at a VA facility, you may
payment in full.
                                                      be responsible for 80 percent of the bill.
                                                      By law, TRICARE can only pay up to 20
Medicare Non-participating Providers                  percent of the TRICARE-allowable amount
                                                      for these services. When using your TFL
Medicare non-participating providers do
                                                      benefit, your least expensive options are to
not accept the Medicare allowed amount
                                                      see a Medicare participating or Medicare
as payment in full. They may charge up
                                                      non-participating provider.
to 15 percent above the Medicare allowed
amount, a cost that is covered by TFL.
                                                      If you want to seek care from a VA provider,
                                                      check with Wisconsin Physicians Service
Opt-Out Providers                                     (WPS)—Military and Veterans Health
                                                      by calling 1-866-773-0404 to confirm
Providers who opt out of Medicare enter into
                                                      coverage details and determine what is
private contracts with patients and are not
                                                      covered by TRICARE.
allowed to bill Medicare. Therefore, Medicare
does not pay for health care services you get
from opt-out providers. When you see an

                                                 13
Military Hospitals and Clinics                          Philippine locations are encouraged to
                                                        see a TRICARE-preferred provider. Visit
A military hospital or clinic is usually located        www.tricare-overseas.com/philippines.htm
on or near a military base. You may get care            for more information.
at a military hospital or clinic on a space-
available basis. See Figure 2.1 for military
                                                        When seeking care from a civilian provider,
hospital and clinic appointment priorities.
                                                        be prepared to pay upfront for services and
                                                        submit a claim to the TRICARE Overseas
Figure 2.1 Military Hospital and                        Program (TOP) claims processor. Outside
Clinic Appointment Priorities                           the U.S. and U.S. territories (American
                                                        Samoa, Guam, the Northern Mariana
 1      Active duty service members                     Islands, Puerto Rico and the U.S. Virgin
                                                        Islands), there may be no limit to the
 2      Active duty family members
                                                        amount that nonparticipating non-network
        (ADFMs) enrolled in TRICARE Prime
                                                        providers may bill, and you are responsible
 3      Retired service members, their                  for paying any amount that exceeds the
        families and all others enrolled in             TRICARE-allowable charge, in addition to
        TRICARE Prime or TRICARE Plus                   your deductible and cost-shares.
        (primary care)
                                                        For information on overseas proof-of-
 4      ADFMs not enrolled in
        TRICARE Prime                                   payment requirements for submitting
                                                        claims, see “Health Care Claims Overseas”
        TRICARE Reserve Select members                  in the Claims section of this handbook.
        and their families

 5      Retired service members and their               For more information about getting care
        families, TRICARE Retired Reserve               overseas, call your TOP Regional Call
        members and their families,                     Center or visit www.tricare-overseas.com.
        beneficiaries enrolled in TRICARE
        Plus (specialty care) and all others            EMERGENCY CARE
        not enrolled in TRICARE Prime
                                                        TRICARE defines an emergency as a
                                                        medical, maternity or psychiatric condition
                                                        that would lead a “prudent layperson”
Overseas Providers                                      (someone with average knowledge of health
                                                        and medicine) to believe that a serious
With TFL overseas, you may generally use
                                                        medical condition exists; that the absence of
any purchased care sector provider, also
                                                        immediate medical attention would result in
called a civilian provider, and get care at
                                                        a threat to life, limb or sight; when a person
military hospitals and clinics on a space-
                                                        has severe, painful symptoms requiring
available basis, except in the Philippines,
                                                        immediate attention to relieve suffering; or
where you are required to see a certified
                                                        when a person is at immediate risk to self
provider for care. Additionally, TOP Select
                                                        or others. The TRICARE health care benefit
beneficiaries who reside in the Philippines
                                                        covers adjunctive dental care (for example,
and who seek care within designated
                                                        dental care that is medically necessary to
                                                   14
treat a covered medical—not a dental—                   care from the nearest emergency care
condition). The TRICARE health care                     facility. You can contact the TOP
benefit does not cover non-adjunctive dental            Regional Call Center for your area or visit
care, which refers to any routine, preventive,          www.tricare-overseas.com for assistance
restorative, prosthodontic, preiodontal, or             in finding a civilian provider. Contact the
emergency dental care that is not related               TOP Regional Call Center within 24 hours if
to a medical condition. Eligible TRICARE                you are admitted to coordinate follow-on care.
beneficiaries may receive non-adjunctive
dental services if enrolled in the TRICARE
                                                        URGENT CARE
Dental Program or the TRICARE Retiree
Dental Program.                                         Urgent care services are medically
                                                        necessary services required for an
If you need emergency care in the U.S. or
                                                        illness or injury that would not result in
U.S. territories, call 911 or go to the nearest
                                                        further disability or death if not treated
emergency room. Make sure you present

                                                                                                         SECTION 2
                                                        immediately, but does require professional
your Medicare card so your claim is filed
                                                        attention within 24 hours. You could
with Medicare.
                                                        require urgent care for conditions such as
                                                        a sprain or rising fever, as both of these

                                                                                                         Getting Care
If traveling or living overseas, first
                                                        conditions have the potential to develop
attempt to seek care from the nearest
                                                        into an emergency if treatment is delayed
military hospital or clinic. If a military
                                                        longer than 24 hours.
hospital or clinic is not available, seek

    If it’s after hours or you’re not sure if
    you need to see a health care provider,
    contact the Military Health System
    (MHS) Nurse Advice Line 24/7. Visit
    www.mhsnurseadviceline.com to chat
    with a nurse or to find country-specific
    numbers. In the U.S., call 1-800-TRICARE
    (1-800-874-2273), option 1. You can talk to
    a registered nurse who can:
    •   Answer your urgent care questions
    •   Answer your pediatric care questions
        (pediatric nurses are available)               •   Help you schedule appointments at
                                                           military hospitals or clinics, if available
    •   Help you determine whether you need
                                                       Note: The MHS Nurse Advice Line is not
        to see a health care provider
                                                       intended for emergencies and is not a
    •   Help you find the closest urgent care          substitute for emergency treatment. If you
        center or emergency room                       think you may have a medical emergency, call
                                                       911 or go to the nearest emergency room.

                                                  15
MENTAL HEALTH CARE                                      For requests for authorization, providers
                                                        should fill out the specific request form
Medicare helps cover visits with the following
                                                        and submit it for review. Authorization
types of health care providers:
                                                        request forms and instructions on how
•   A psychiatrist or other doctor                      to submit forms are available online at
                                                        www.TRICARE4u.com.
•   Clinical psychologist
•   Clinical social worker                              If you have questions about prior
                                                        authorization requirements, contact WPS.
•   Clinical nurse specialist
                                                        See the Important Contact Information
•   Nurse practitioner                                  section at the beginning of this handbook
                                                        for the WPS website and toll-free number.
•   Physician’s assistant
                                                        The following services require prior
Medicare only covers these visits when they
                                                        authorization:
are provided by health care providers who
accept Medicare payment. To help lower your             •   Adjunctive dental services (dental
costs, ask your health care providers if they               care that is medically necessary in
accept assignment, which means they accept                  the treatment of an otherwise covered
the Medicare-approved amount as payment in                  medical—not dental—condition)*
full, before you schedule an appointment.
                                                        •   Extended Care Health Option services
                                                            (active duty family members only)
For more information on Medicare’s
mental health care coverage, visit                      •   Home health care services
www.medicare.gov.
                                                        •   Home infusion therapy

PRIOR AUTHORIZATION FOR CARE
                                                        •   Hospice care

When TFL becomes the primary payer
                                                        •   Transplants—all solid organ and stem cell
(for example, if your Medicare benefits                 •   Some prescription medications
run out), TRICARE prior authorization                       (for example, brand-name medications
requirements apply.                                         or those with quantity limitations)

Prior authorization is a review of the                  Note: This list is not all-inclusive.
requested health care service to determine              For details about prior authorization
if it is medically necessary at the requested           requirements, contact WPS.
level of care. If you have a prior authorization
                                                        * For more information on TRICARE dental
from a TRICARE regional contractor                        coverage, see “Dental Coverage” in the TRICARE
(Health Net Federal Services, LLC; Humana                 For Life Coverage section of this handbook.
Military; or International SOS Government
Services, Inc.) that covers the dates on your
claim, WPS honors that prior authorization
and no TFL prior authorization is required.

                                                   16
TRICARE For Life Coverage

                                                    Examples of services that are generally not
                                                    reimbursable by TFL or Medicare include:
                                                    •   Acupuncture
                                                    •   Experimental or investigational services
                                                        (in most cases)
                                                    •   Eye exams (routine)
                                                    •   Hearing aids*

                                                    Note: This list is not all-inclusive.
MEDICAL COVERAGE                                    * If you are a retired sponsor, you may be eligible
                                                      for the Retiree-At-Cost Hearing Aid Program
TRICARE For Life (TFL) and Medicare                   and should call a participating military hospital
cover proven, medically necessary and                 or clinic. Visit www.militaryaudiology.org for
appropriate care. TFL has special rules and           more information.
limitations for certain types of care, and
some types of care are not covered at all.
                                                    DENTAL COVERAGE
TRICARE policies are very specific about
which services are covered and which are            TRICARE offers two voluntary dental

                                                                                                           SECTION 3
not. It is in your best interest to take an         insurance programs, the TRICARE Dental
active role in verifying coverage.                  Program (TDP) and the TRICARE Retiree
                                                    Dental Program (TRDP).
Note: Medicare also has limits on the

                                                                                                          TRICARE For Life Coverage
amount of care it covers and, in some cases,
                                                    TRICARE Dental Program
TFL may cover these health care services
after your Medicare benefits run out.               The TDP provides worldwide dental
                                                    coverage for eligible family members of
To determine if Medicare covers a specific          active duty service members, survivors,
service or benefit, visit www.medicare.gov          certain National Guard and Reserve
or call 1-800-633-4227. To determine if             members and their families, and Individual
TFL covers the service or benefit, visit the        Ready Reserve members and their families.
TRICARE website at www.tricare.mil or               Former spouses and remarried surviving
call Wisconsin Physicians Service—Military          spouses do not qualify to purchase coverage.
and Veterans Health at 1-866-773-0404.              For more information about the TDP, visit
See Figure 1.1 in the How TRICARE For               www.uccitdp.com or call United Concordia
Life Works section of this handbook for more        Companies, Inc. at 1-844-653-4061 (CONUS)
information on your out-of-pocket costs.            or 1-844-653-4060 (OCONUS).

                                               17
TRICARE Retiree Dental Program                     Medal of Honor recipients and their
                                                        immediate family members and survivors.
     The TRDP is available to retired service           Former spouses and remarried surviving
     members and their eligible family members,         spouses do not qualify to purchase
     including certain retired National Guard           coverage. For information about the
     and Reserve members and their family               TRDP, including possible restrictions,
     members. The TRDP is also available                visit www.trdp.org or call Delta Dental
     to certain surviving family members                of California at 1-888-838-8737.
     of deceased active duty sponsors, and

 FAQs       Frequently Asked Questions:
            TRICARE For Life Coverage
Does TFL cover long-term care?     occupational and speech                TFL is the primary payer for SNF
                                   therapy; drugs furnished by the        care beyond Medicare’s 100-day
No. Long-term care (or custodial
                                   facility; and necessary medical        limit as long as the patient
care) is not a covered benefit.
                                   supplies and appliances. Skilled       continues to require skilled
However, you may qualify
                                   nursing care is typically provided     nursing services and no other
to purchase long-term care
                                   in a skilled nursing facility (SNF).   health insurance is involved. SNF
insurance through commercial
                                                                          care requires prior authorization
insurance programs or through      For TFL and Medicare to cover
                                                                          on day 101, when TRICARE is
the Federal Long Term Care         SNF admission, you must have
                                                                          the primary payer. TFL covers
Insurance Program.                 had a medical condition that
                                                                          an unlimited number of days as
                                   was treated in a hospital for at
For more information about                                                medically necessary.
                                   least three consecutive days,
the Federal Long Term Care
                                   and you must be admitted to            Note: SNF care is only covered
Insurance Program, visit
                                   a Medicare-certified, TRICARE-         in the U.S. and U.S. territories
www.opm.gov/insure/ltc or
                                   participating SNF within 30 days       (American Samoa, Guam,
call 1-800-582-3337.
                                   of discharge from the hospital         the Northern Mariana
                                   (with some exceptions for              Islands, Puerto Rico and
Does TRICARE cover skilled         medical reasons). Your health          the U.S. Virgin Islands).
nursing care?                      care provider’s plan of care
                                   must demonstrate your need
TFL covers skilled nursing
                                   for skilled nursing services.
services; meals (including
special diets); physical,

                                                   18
Pharmacy

                                                                                                  SECTION 4
PRESCRIPTION DRUG COVERAGE                            FILLING PRESCRIPTIONS

                                                                                                  Pharmacy
TRICARE offers comprehensive
prescription drug coverage and several
                                                      Military Pharmacies
options for filling your prescriptions. To            Military pharmacies are usually located
fill a prescription, you need a prescription          within military hospitals and clinics. At
and a valid uniformed services ID card                a military pharmacy, you may get up to
or Common Access Card. Your options                   a 90-day supply of most medications at
for filling your prescriptions depend                 no cost. Most military pharmacies accept
on the type of drug your provider                     prescriptions from both civilian and
prescribes. For more information, visit               military providers, regardless of whether
www.express-scripts.com/TRICARE                       or not you are enrolled at the military
or call 1-877-363-1303. The TRICARE                   hospital or clinic.
pharmacy benefit is administered by
Express Scripts, Inc. (Express Scripts).              Electronic prescribing (e-prescribing) is
                                                      accepted at many military pharmacies
When traveling overseas, be prepared to pay           in the U.S., Puerto Rico and Guam. This
upfront for medications and file a claim to           allows your civilian providers to send
get money back for non-military hospital              prescriptions electronically to military
or clinic and non-network pharmacy                    pharmacies near you. E-prescribing from
services. TRICARE For Life recommends
that you fill all of your prescriptions before
traveling overseas.

If you live or travel in the Philippines,
you are required to use a certified
pharmacy. For more information, visit
www.tricare-overseas.com/philippines.htm.

Over-the-counter (OTC) drugs are not
covered overseas (except in U.S. territories).
This includes drugs that are considered
OTC in the U.S., even when they require a
prescription in a foreign country.

Note: You do not need a Medicare Part D
prescription drug plan to keep your
TRICARE prescription drug coverage.

                                                 19
a health care provider to a pharmacy                  have questions about your prescriptions,
reduces medication errors and offers more             pharmacists are available 24/7 to speak
convenience. You can ask your provider to             confidentially with you.
look for your local military pharmacy in the
e-prescribing database/network.                       For faster processing of your mail-order
                                                      prescriptions, register before placing
Non-formulary medications are generally not           your first order. Once you are registered,
available at military pharmacies. To check            your provider can send prescriptions
the availability of a particular drug, contact        electronically or by phone. Express Scripts
the nearest military pharmacy.                        sends your medications directly to your
                                                      home within about 14 days of receiving
                                                      your prescription. Register for TRICARE
TRICARE Pharmacy Home Delivery
                                                      Pharmacy Home Delivery using any of the
There is no cost for TRICARE Pharmacy                 options listed in Figure 4.1 on the next page.
Home Delivery for active duty service
members. Copayments apply for all covered             Note: Overseas beneficiaries must have
medications (up to a 90-day supply).                  an APO/FPO address or be assigned to
Additionally, prescriptions are delivered to          a U.S. Embassy or Consulate and have a
you with free standard shipping, and refills          prescription from a U.S.-licensed provider to
can be easily ordered online, by phone or             use home delivery. Refrigerated medications
by mail. Home delivery also provides you              cannot be shipped to APO/FPO addresses.
with convenient notifications about your              Beneficiaries living in Germany cannot use
order status, refill reminders and assistance         the home delivery option due to country-
in renewing expired prescriptions. If you             specific legal restrictions. If you live in

                                                 20
Germany, fill prescriptions at military or           Northern Mariana Islands, Puerto Rico and
overseas pharmacies.                                 the U.S. Virgin Islands. Currently, there are
                                                     no TRICARE retail network pharmacies in
If you have prescription drug coverage               American Samoa.

                                                                                                     SECTION 4
through other health insurance (OHI),
you can use TRICARE Pharmacy Home                    Visit www.express-scripts.com/TRICARE
Delivery only if the medication is not               or call 1-877-363-1303 for customer service,

                                                                                                     Pharmacy
covered under your OHI or if you exceed              including finding the nearest TRICARE
the OHI’s coverage limit.                            retail network pharmacy.

TRICARE Retail Network Pharmacies                    Non-Network Pharmacies
Another option for filling your prescriptions        When visiting non-network pharmacies,
is through TRICARE retail network                    you pay the full price of your medication
pharmacies. To fill prescriptions (one               upfront and file a claim to get money
copayment per 30-day supply), present your           back. Claims are subject to deductibles,
prescription and uniformed services ID card          out-of-network cost-shares and TRICARE-
to the pharmacist.                                   required copayments. All deductibles must
                                                     be met before you can get money back. For
This option allows you to fill your                  details about filing a claim, see the Claims
prescriptions at TRICARE retail network              section of this handbook.
pharmacies throughout the U.S. without
having to submit a claim. You have access to
TRICARE retail network pharmacies in the
U.S. and the U.S. territories of Guam, the

Figure 4.1 TRICARE Pharmacy Home Delivery Registration Methods

                Visit www.express-scripts.com/TRICARE.
   ONLINE

                Call 1-877-363-1303 or 1-877-540-6261 (TDD/TTY).
   PHONE

                Download the registration form from www.express-scripts.com/TRICARE,
                and mail it to:
                Express Scripts, Inc.
    MAIL
                P.O. Box 52150
                Phoenix, AZ 85072

                                                21
PHARMACY POLICY                                      name drugs. It is DoD policy to generally
                                                     use generic formulary medications instead
Quantity Limits                                      of brand-name medications whenever
                                                     possible. A brand-name drug with a generic
TRICARE has established quantity limits              equivalent generally may be dispensed only
on certain medications, which means the              after the prescribing provider completes a
Department of Defense (DoD) pays for a               clinical assessment indicating the brand-
specified, limited amount of medication each         name drug is medically necessary and after
time you fill a prescription. Quantity limits        Express Scripts grants approval. Prescribers
are often applied to ensure medications are          may call 1-866-684-4488 to submit a request
safely and appropriately used.                       for a brand-name drug to be dispensed
                                                     instead of a generic, or a completed form
Exceptions to established quantity limits            may be faxed to 1-866-684-4477. Find the
may be made if the prescribing provider              Brand over Generic Prior Authorization
can justify medical necessity, or in cases of        Request Form by searching for the brand-
natural disasters, as approved by TRICARE.           name drug at www.express-scripts.com/
                                                     tricareformulary. If a generic-equivalent
                                                     drug does not exist or is not on the
Prior Authorization
                                                     formulary, the brand-name drug is
Some drugs require prior authorization               dispensed at the brand-name copayment.
from Express Scripts. Medications requiring          If you fill a prescription for a brand-name
prior authorization may include, but are             drug that is not considered medically
not limited to, prescription drugs specified         necessary and when a generic equivalent is
by the DoD Pharmacy and Therapeutics                 available, you are responsible for paying the
(P&T) Committee, brand-name medications              entire cost of the prescription.
with generic equivalents, medications
with age limitations and medications
                                                     Non-Formulary Drugs
prescribed for quantities exceeding
normal limits. Search for your drug at               The DoD P&T Committee may recommend
www.express-scripts.com/tricareformulary             that certain drugs be placed in the third,
to see if it is covered under TRICARE,               non-formulary tier. These medications
requires prior authorization or has quantity         include any drug in a therapeutic class
limits. You may also call 1-877-363-1303 for         determined to be less clinically effective
information about your drug.                         or less cost-effective than other drugs
                                                     in the same class. Third-tier drugs are
                                                     available through the TRICARE Pharmacy
Generic Drug Policy
                                                     Program at an additional cost. You may
Generic drugs are medications approved               be able to fill non-formulary prescriptions
by the U.S. Food and Drug Administration             at formulary costs if your provider can
that are clinically equivalent to brand-name         establish medical necessity by completing
medications. Generic drugs provide the               and submitting the appropriate TRICARE
same safe, effective treatment as brand-             pharmacy medical-necessity form for the

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