TRICARE For Life HANDBOOK
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TRICARE® For Life
AU G U S T 2 01 8
HANDBOOK
A guide to understanding your program benefitsAUGUST 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 93955TRICARE 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 emailWelcome 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................................................................................................................ 245. 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........................................................................................................ 36How 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
4SECTION 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.
5Medicare 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.
6Your 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.
7FAQs 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
8Medicare 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)
9services 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
10Coordinating 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.
11FAQs 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
12Getting 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
13Military 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
14treat 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.
15MENTAL 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.
16TRICARE 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).
17TRICARE 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,
18Pharmacy
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.
19a 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
20Germany, 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
21PHARMACY 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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