TRICARE Plans

TRICARE Plans

The TRICARE health plan and special program options that are available depend on who you are and where you live. In addition to consolidating the regions, TRICARE also changed its plan options.  The TRICARE website offers the best tool for comparing plans here. As of 2018, families will need to enroll in the plan of their choice during the Open Enrollment period in November-December every year.  As is common with many health plans, participants will then be locked into the plan they choose for the following calendar year. Once the plan is in effect, it can only be changed if there is a qualifying, life changing event (such as marriage, birth, or relocation).

Since details regarding specific plans and eligibility may change often, you should consult the TRICARE website for more details on different options, especially for Retiree and Reserve options. A primer on the two plans available for active duty families is provided below.

If you need to find non-military healthcare providers or specialists to assist your child, see the Resources section for information on the search process.

The following are some of those most frequently used in integrated intervention approaches.

Active Duty family members on TRICARE Prime will receive their primary care at their assigned Military Treatment Facility (MTF).  If specialty care is involved, the family will receive it, if available, at their assigned MTF or at an MTF within an hour’s drive.  If specialty care is not available through the MTF or within the one-hour travel radius, the MTF will refer the family to local network providers for the needed care. If there are no network providers available for a specific specialty, TRICARE will sometimes approve care with an out-of-network provider at no cost.

TRICARE Prime is the only option for active-duty service members. This restriction does not apply to families and dependents.

TRICARE Prime families need referrals and authorization for all care that is not done by their Primary Care Manager. For TRICARE Prime, if a family uses the MTF and referrals for specialty care, there are no deductibles, no cost shares and no copays. If families choose to see an out-of-network, but participating provider without a referral and authorization, they will be charged a Point of Service fee.

Families on Prime are eligible for reimbursement for travel if the provider is outside of a certain radius. Families who are stationed over 50 miles from an MTF are eligible for TRICARE Prime Remote, which allows families to use approved civilian providers with no out of pocket costs. TRICARE Prime families no longer need a referral to use an approved urgent care clinic.

Active Duty family members on TRICARE Select will use civilian providers as their Primary Care Managers. TRICARE Select families can choose In Network or Out of Network providers but Out of Network providers have a higher cost share.  Families on TRICARE Select do not need referrals for specialty care through a specialty MD. Families on TRICARE Select still need a referral and authorization for therapy services (this includes physical, occupational, speech and ABA therapy). The program does have deductibles, cost shares, and copays.  For Active Duty and Retired family members, there is a catastrophic cap of how much a family has to pay in a year.  Once the family hits that cap, their care (including prescription drugs) is free for the remainder of the calendar year. The cap is currently set at $1,000 a year for AD family members and $3,000 a year for most retired families, but is subject to change from year to year. TRICARE Select families do not need a referral to use an approved urgent care clinic.

The current TRICARE Cost sheet can be found here.

You may occasionally need to find other, non-military, service providers for your child. Finding Other Providers. This appendix from OAR’s Life Journey Through Autism: A Guide for Military Families serves as a starting point in searching for providers.

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