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 MTF. This includes specialty care, if available at the 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. If no network providers are available for a specific specialty, TRICARE sometimes approves care with an out-of-network provider at no cost to the family.

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 most care that is not provided by their primary care manager (PCM). If a family uses the MTF and referrals for specialty care, there are usually no deductibles, no cost shares, and no co-pays. 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 are not required to have a PCM, but may use civilian providers as their PCM. While you can choose in-network or out-ofnetwork providers, out-of-network providers have a higher cost share. Families on TRICARE Select do not need referrals for specialty care through a specialty MD, but they do need a referral and authorization for ABA services. No referral is needed to use an approved urgent care clinic, and no POS deductibles or cost shares apply when urgent care is provided by a TRICARE network provider or a TRICARE-authorized (network or non-network) Urgent Care Center (UCC) or Convenience Clinic (CC).

The program does have deductibles, cost shares, and co-pays. For active duty and retired family members, there is a catastrophic cap on how much a family has to pay in a year. Once the family hits that cap, their care (including prescription drugs) is largely free for the family for the remainder of the calendar year. These costs are subject to change, so check TRICARE’s website for the most recent cost sheets related to your plan.

If you are on either of the TRICARE plans, you do not need a referral or authorization for outpatient, office-based mental health services, except for psychoanalysis. Any services other than office-based outpatient do require a referral. However, you may need prior authorization from your regional contractor for certain services.

The current TRICARE Cost sheet can be found here.

You may occasionally need to find other, non-military, service providers for your child. 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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