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TRICAREReserve Select Handbook
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TRICARE Reserve Select Web Site: www.tricare.mil/reserve/reserveselect
Reserve Affairs Web Site: www.defenselink.mil/ra
Guard/Reserve Portal Address: https://www.dmdc.osd.mil/appj/trs/index.jsp
TRICARE National Web Site: www.tricare.mil
TRICARE Mail Order Pharmacy: 1-866-DoD-TMOP (1-866-363-8667)TRICARE Retail Network Pharmacy: 1-866-DoD-TRRX (1-866-363-8779)
TRICARE North Region Contractor
Health Net Federal Services, LLC (Health Net): 1-800-555-2605
Health Net Web Site: www.healthnetfederalservices.com
TRICARE South Region Contractor
Humana Military Healthcare Services, Inc. (Humana Military): 1-800-444-5445
Humana Military Web Site: www.humana-military.com
TRICARE West Region ContractorTriWest Healthcare Alliance, Corp.(TriWest): 1-888-TRIWEST (1-888-874-9378)
TriWest Web Site: www.triwest.com
TRICARE Overseas (TRICARE Europe,TRICARE Latin America and Canada, and TRICARE Pacific)
Overseas Toll-Free Number: 1-888-777-8343
Overseas Web Site: www.tricare.mil/overseas
An Important Note About TRICARE Program Changes
At the time of printing, the information in this handbook is current. It is important to remember that TRICAREpolicies and benefits are governed by public law. Changes to TRICARE programs are continually made as public lawis amended. For the most recent information, contact your regional contractor or local TRICARE Service Center.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.
Important Information
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TRICARE Reserve Select (TRS) is a premium-
based health plan that qualified National Guard
and Reserve members may purchase unless
eligible for coverage under the Federal Employees
Health Benefits program (FEHB). If either the
member or spouse is eligible to purchase the
FEHB then the member and family are not
eligible to purchase TRS.
We use the terms National Guard and Reserve
throughout this handbook to include: Army National Guard
Army Reserve
Navy Reserve
Marine Corps Reserve
Air National Guard
Air Force Reserve
U.S. Coast Guard Reserve
TRS offers coverage similar to TRICARE
Standard and TRICARE Extra, and a monthly
premium will be charged. You will receive
comprehensive coverage with access to
TRICARE-authorized providers. Annual
deductibles, cost-shares, and a catastrophic cap
apply. You may access care from a military
treatment facility (MTF) on a space-available
basis only. You may fill prescriptions through the
MTF, the TRICARE mail-order pharmacy, and
TRICARE retail network and non-network
pharmacies. Costs for prescription medications
vary depending upon the pharmacy option you
choose and the medications availability on the
uniform formulary.
For more information about TRS coverage, visit
www.tricare.mil/reserve/reserveselect. For more
information about the National Guard and Reserve
and the Selected Reserve, visit the Reserve Affairs
Web site at www.defenselink.mil/ra.
Programs Not Available withTRICARE Reserve Select
If you are enrolled in TRS, you may not
participate in the following programs:
Special Supplemental Food Program
TRICARE Extended Care Health Option
(ECHO)
TRICARE Global Remote Overseas (TGRO)
TRICARE Prime
TRICARE Prime Remote (TPR)
TRICARE Prime Remote for Active Duty
Family Members (TPRADFM)
TRICARE Prime Overseas
TRICARE Puerto Rico Prime
TRICARE Reserve Family Demonstration
Project
US Family Health Plan (USFHP)
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TRICARE North Region
The TRICARE North Region includes
Connecticut, Delaware, the District of Columbia,
Illinois, Indiana, Kentucky, Maine, Maryland,
Massachusetts, Michigan, New Hampshire,
New Jersey, New York, North Carolina, Ohio,
Pennsylvania, Rhode Island, Vermont, Virginia,
West Virginia, Wisconsin, and portions of Iowa
(Rock Island Arsenal area), Missouri (St. Louis
area), and Tennessee (Ft. Campbell area).
TRICARE South Region
The TRICARE South Region includes Alabama,
Arkansas, Florida, Georgia, Louisiana,
Mississippi, Oklahoma, South Carolina,
Tennessee (excluding the Ft. Campbell area),
and Texas (excluding the El Paso area).
TRICARE West Region
The TRICARE West Region includes Alaska,
Arizona, California, Colorado, Hawaii, Idaho,
Iowa (excluding Rock Island Arsenal area),
Kansas, Minnesota, Missouri (excluding the St.
Louis area), Montana, Nebraska, Nevada, New
Mexico, North Dakota, Oregon, South Dakota,
Texas (the southwestern corner, including
El Paso), Utah, Washington, and Wyoming.
TRICARE Overseas
TRS is available overseas. The TRICARE overseas
areas include TRICARE Europe, TRICARE Latin
America and Canada (TLAC), and TRICARE
Pacific. The TRICARE South Region contractor,
Humana Military, handles enrollment, billing, and
customer support services for these overseas areas.
2
Regionalcontractor
Health Net Federal Services, LLC(Health Net)
Phone 1-800-555-2605
Web site www.healthnetfederalservices.com
Regionalcontractor
Humana Military HealthcareServices, Inc. (Humana Military)
Phone 1-877-298-3408
Web site www.humana-military.com
Regionalcontractor
TriWest Healthcare Alliance Corp.(TriWest)
Phone 1-888-TRIWEST (1-888-874-9378)
Web site www.triwest.com
Your TRICARE Regional Contractor
We often refer to your regional contractor throughout this handbook and describe differences in each
region. In cases where there are regional differences, refer to the information specific to your region.
Besides offering toll-free customer service telephone lines and Web sites, each regional contractor
operates TRICARE Service Centers throughout the region, typically at or near military installations,
which offer customer service support. The following descriptions of each TRICARE region include
contact information for each regional contractor.
NORTHWEST
SOUTH
Regionalcontractor
Humana Military HealthcareServices, Inc. (Humana Military)
Phone 1-877-298-3408
Web site www.humana-military.com
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TRICARE Europe includes Africa, Europe, and
the Middle East. TLAC includes Canada, the
Caribbean Basin, Central and South America,
Puerto Rico, and the Virgin Islands. TRICARE
Pacific includes Asia, Australia, Guam, India,
Japan, Korea, New Zealand, and remote Western
Pacific countries.
TRICARE Service Centers (TSCs) can provideinformation about locating a provider or
accessing health care in overseas locations.
Contact the TRICARE Area Office in your
overseas area to locate a TSC near you.
The U.S. Department of State provides several
useful resources, including a Web site listing
U.S. Embassies and Consulates. A TRICARE
point of contact is located at each U.S. Embassy
and Consulate. Locate a U.S. Embassy or
Consulate at www.usembassy.gov.
3
TRICARE Europe TLAC TRICARE Pacific
Phone Toll-free: 1-888-777-8343,Option 1
Comm.: 011-49-6302-67-7432
DSN: 496-7432
Toll-free: 1-888-777-8343,Option 3
Comm.: 1-706-787-2424
DSN: 773-2424
Toll-free: 1-888-777-8343,Option 4
Comm.: 011-81-6117-43-2036
DSN: 643-2036
Remote Sites: 011-65-6-338-9277
Fax Comm.: 011-49-6302-67-6374
DSN: 496-6374
1-706-787-3024 Comm.: 011-81-6117-43-2037
DSN: 643-2037
E-mail [email protected] [email protected] [email protected]
Online www.tricare.mil/europe www.tricare.mil/tlac www.tricare.mil/pacific
TRICARE Area Office Contact Information
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1. Getting Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Finding a Provider . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6
TRICARE Reserve Select Wallet Card . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
Emergency Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
Care at a Military Treatment Facility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
Prior Authorization for Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7Getting Care While Traveling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8
Getting Care Overseas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8
2. Covered Services, Limitations, and Exclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Outpatient Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9
Inpatient Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10
Clinical Preventive Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10
Behavioral Health Care Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11
Pharmacy Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14
Maternity Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16
Dental Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16Services or Procedures with Significant Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17
Exclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18
3. Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Health Care Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21
Pharmacy Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22
Overseas Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22
Coordinating Benefits with Other Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23
Third-Party Liability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24
Explanation of Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24
4. Changes to Your TRICARE Reserve Select Coverage . . . . . . . . . . . . . . . . . . . . . . 26
Changes to Your Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26
Coverage for Newborns or Adopted Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26
When TRICARE Reserve Select Coverage Ends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27
TRICARE Reserve Select Survivor Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29
5. Information and Assistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Qualifying for TRICARE Reserve Select . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
Customer Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
Beneficiary Counseling and Assistance Coordinators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
Updating DEERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
Appealing a Decision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31
Filing a Grievance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32
Reporting Suspected Fraud and Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34
4
Table of Contents
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5
6. Acronyms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
7. Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
8. Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Sample Explanation of Benefits Statements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39
9. List of Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
10. Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
For information about your patient rights and responsibilities, see the inside back cover of this
handbook.
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Finding a Provider
With TRICARE Reserve Select (TRS) you may
receive care from any TRICARE-authorized
provider without a referral. Some services will
require prior authorization (discussed later inthis section). Figure 1.1 describes the different
types of providers.
You may use either a TRICARE network provider
or a non-network, TRICARE-authorized provider
at any time. For example, if an orthopedic surgeon
and a physical therapist are treating you, one could
be a TRICARE network provider and the other
could be a non-network, TRICARE-authorized
provider. Ask if your health care provider(s) is a
TRICARE network provider. Visits to a TRICAREnetwork provider will cost you less out of pocket,
and the provider will file claims on your behalf.
With a non-network, TRICARE-authorized
provider, youll pay more out of pocket and may
have to file your own claims.
To find a TRICARE network provider or a
non-network, TRICARE-authorized provider,visit the provider locator at
www.tricare.mil/ProviderDirectory. The
regional contractors also have TRICARE
network provider directories on their Web sites,
which you may use to locate providers in each
region. If you do not have Internet access, call
your regional contractor for assistance locating
a provider.
Note: For information about finding a provider
overseas, see Getting Care Overseas later inthis section.
6
TRICARE Provider Types Figure 1.1
Getting Care
TRICARE-Authorized Providers
TRICARE-authorized providers are those who meet TRICAREs licensing and certification requirements andhave been certified by TRICARE to provide care to TRICARE beneficiaries. These include doctors, hospitals,ancillary providers (such as laboratories and radiology centers), and pharmacies. If you see a provider who isnot TRICARE-authorized, you are responsible for the full cost of care.
There are two types of TRICARE-authorized providers: Network and Non-network.
Network Providers Non-Network Providers
Have a signed agreement with yourregional contractor to provide care.
Agree to handle claims for you.
Using a network provider is yourbest option.
Do not have a signed agreement with your regional contractor.
There are two types of non-network providers: Participating andNonparticipating.
Participating Nonparticipating
May choose to participate on aclaim-by-claim basis
Have agreed (when participating)to file claims for you, to acceptpayment directly from TRICARE,and to accept the TRICARE-allowable charge, (less anyapplicable patient cost-shares paidby you) as payment in full for theirservices.
Using a participating provider isyour best option if seeing a non-network provider.
Have not agreed to accept theTRICARE-allowable charge or fileyour claims.
Have the legal right to charge youup to 15% above the TRICARE-allowable charge for services. Youare responsible for paying thisamount in addition to anyapplicable patient cost-share.
If you visit a nonparticipatingprovider, you may have to pay theprovider first and file a claim withTRICARE for reimbursement.
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TRICARE Reserve SelectWallet Card
You and each covered family member should
receive (or may already have received) a TRS
wallet card when your TRS enrollment is
processed through the Defense Enrollment
Eligibility Reporting System (DEERS). TRS
wallet cards contain key phone numbers andother information to assist you with your health
care coverage. If your doctor, hospital, pharmacist,
durable medical equipment supplier, or other
provider asks to see your insurance card, you
may present this card.
If you do not receive your TRS wallet card
within four to six weeks of submitting your TRS
Requestform, contact your regional contractor
for assistance.
Emergency Care
TRICARE defines an emergency as a medical,
maternity, or psychiatric condition that would lead
a prudent layperson (someone with average
knowledge of health and medicine) to believe that
a serious medical condition exists; that the absence
of medical attention would result in a threat to
the patients life, limb, or sight; that the patientrequires immediate medical treatment; or that the
patient has painful symptoms requiring immediate
attention to relieve suffering.
If you require emergency care, call 911 or go to
the nearest emergency room. If you are admitted,
you may need to obtain authorization (depending
on the type of care) by contacting your regional
contractor.
Care at a Military TreatmentFacility
A military treatment facility (MTF) is a military
hospital or clinic, usually located on or near a
military installation. You may receive care at
an MTF on a space-available basis only. MTF
appointments are limited, and you will be
assigned the lowest priority for receiving MTF
care. To locate an MTF, access the MTF Locator
at www.tricare.mil/mtf.
Prior Authorization for Care
You may access care from any TRICARE-
authorized provider you choose whenever you
need it. Referrals are not required, but some
services will require prior authorization.
A prior authorization is a review of the requested
health care service to determine if it is medically
necessary at the requested level of care. Prior
authorizations must be obtained prior to services
being rendered or within 24 hours of an admission.
Some providers may call the regional contractor to
obtain prior authorization for you. If you have
questions about your authorization requirements,
call your regional contractor or visit their Web site
for assistance before seeking care.
7
TRS Wallet Card (front)
TRS Wallet Card (back)
Figure 1.2
Figure 1.3
SA
MPLE
TRICARE Reserve Select
TRS Member: John Q. Sample
Effective Date: 01 Jan 2000
Covered Person: Susie Q. Sample
www.tricare.mil
The TRS identification number is the TRSmembers Social Security Number.
TRICARE: The Worlds Best Health Care
for the Worlds Best Military
SAMPLE
This card is not a guarantee of coverage. Coverage under TRS is separate from
any medical coverage indicated on the military identification card. TRS benefits
are available from TRICARE-authorized providers and TRICARE Network
providers. Pre-certification is required for inpatient mental health and selected
regionally-determined procedures.
TRICARE Regional Contractor xxx-xxx-xxxxxxx.xxxx.xxx
TRICARE Retail Pharmacy
xxx-xxx-xxxx
TRICARE Mail Order Pharmacy
xxx-xxx-xxxx
http://xxxxx/xxxxx/xxxxx/xxxxx.xxx
In EMERGENCYdial 911 or go to the nearest
emergency medical facility.
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The following services* require prior
authorization in all three TRICARE regions:
Adjunctive dental services
Extended Care Health Option (ECHO) services
Home health services
Hospice care
Nonemergency inpatient admissions for
substance use disorders and behavioral health
Outpatient behavioral health care beyond
the eighth visit each fiscal year (October 1
September 30)
Transplantsall solid organ and stem cell
* This list is not intended to be all-inclusive.
Each regional contractor has additional prior
authorization requirements. Visit your regional
contractors Web site or call their toll-free
number to learn about your regions
requirements, as they may change periodically.
Note: For overseas prior authorization
information, see Getting Care Overseas later
in this section.
Getting Care While Traveling
While you are traveling, you may visit any
TRICARE network provider or any non-network,TRICARE-authorized provider. You may be
required to pay non-network providers directly
and file your claim with your regional contractor
for reimbursement (See the Claims section of this
handbook.). You should file the claim with the
contractor in your home region, not in the region
in which you received the care. You will find
claim forms at www.tricare.mil/claims. In
the right-hand navigation column, look for
Downloads. Then click on TRICARE Claim
Form (DD Form 2642).
Getting Care Overseas
You may receive care from any qualified
host-nation provider without a referral. We
recommend that you contact your TRICARE
Service Center (TSC), TRICARE Area Office
(TAO), or the nearest U.S. Embassy Health Unit
for assistance in locating a provider. Locate a
U.S. Embassy or Consulate by visitingwww.usembassy.gov.
Prior Authorization RequirementsOverseas
Since authorization requirements may vary by
overseas area, contact the nearest overseas TAO
for assistance before seeking care. See Figure
3.2, Overseas Claims Addresses, in the Claims
section of this handbook for TAO contact
information.
8
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9
TRICARE Reserve Select (TRS) covers most care that is medically necessary and considered proven.
However, there are special rules or limits on certain types of care, while other types of care are not
covered at all. This section is not intended to be all-inclusive. Check with your regional contractor
for additional information.
Outpatient Services
Figure 2.1 provides coverage details for covered outpatient services. This chart is not intended to be
all-inclusive.
Covered Services, Limitations, and Exclusions
Service Description
Ambulance Services Covers emergency transfers to or from a beneficiarys home, accident scene, or otherlocation to a hospital; transfers between hospitals; ambulance transfers from ahospital-based emergency room to a hospital more capable of providing the requiredcare; and transfers between a hospital or skilled nursing facility and another hospital-
based or freestanding outpatient therapeutic or diagnostic department/facility.Excludes ambulance service used instead of taxi service when the patients conditionwould have permitted use of regular private transportation; transport or transfer of apatient primarily for the purpose of having the patient nearer to home, family, friends,or personal physician; and medicabs or ambicabs that function primarily as publicpassenger conveyances transporting patients to and from their medical appointments.
Ancillary Services Covers certain diagnostic radiology and ultrasound; diagnostic nuclear medicine;pathology and laboratory services; and cardiovascular studies.
Durable MedicalEquipment (DME)
Generally covered if medically necessary and appropriate, and if prescribed by aphysician for the specific use of the beneficiary. Duplicate items of DME that areessential to provide a fail-safe, in-home, life-support system are covered. In this case,duplicate means an item that meets the definition of DME and serves the same
purpose but may not be an exact duplicate of the original DME item. For example, aportable oxygen concentrator may be covered as a backup for a stationary oxygengenerator.
Emergency Services Emergency services are covered for medical, maternity, or psychiatric conditions thatwould lead a prudent layperson (someone with average knowledge of health andmedicine) to believe that a serious medical condition exists; that the absence ofmedical attention would result in a threat to the patients life, limb, or sight; that thepatient may be a danger to self or others and requires immediate medical treatment;or that the patient has painful symptoms requiring immediate attention to relievesuffering.
Home Health Care Covers part-time or intermittent skilled nursing services and home health services;physical, speech, and occupational therapy; medical social services; and routine andnon-routine medical services. All care must be provided by a participating home
health care agency and be authorized in advance by the regional contractor.Individual ProviderServices
Covers office visits; outpatient office-based medical and surgical care; consultation,diagnosis, and treatment by a specialist; allergy tests and treatment; osteopathicmanipulation; rehabilitation services (e.g., physical therapy, speech pathologyservices, and occupational therapy); and medical supplies used within the office.
Laboratory andX-Ray Services
Generally covered if prescribed by a physician. (Some exceptions apply, e.g., chemo-sensitivity assays and bone density X-ray studies for routine osteoporosis screeningare not covered.)
Prosthetic Devices andMedical Supplies
Generally covered if prescribed by a physician and if directly related to a medicalcondition. Prosthetic devices must be FDA approved.
Outpatient Services: Coverage Details Figure 2.1
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10
Inpatient Services
Figure 2.2 provides coverage details for covered inpatient services. This chart is not intended to be
all-inclusive.
Clinical Preventive Services
Figure 2.3 provides coverage details for covered clinical preventive services. This chart is not intendedto be all-inclusive.
Service Description
Hospitalization Covers semiprivate room (and when medically necessary, special care units), generalnursing, and hospital service. Includes inpatient physical and surgical services; meals(including special diets); drugs and medications while an inpatient; operating andrecovery room; anesthesia; laboratory tests; X-rays and other radiology services;necessary medical supplies and appliances; and blood and blood products.
Skilled NursingFacility (SNF) Care
Covers semiprivate room; regular nursing services; meals, including special diets;physical, occupational, and speech therapy; drugs furnished by the facility; and necessarymedical supplies and appliances. Unlike Medicare, TRICARE covers an unlimitednumber of days as medically necessary.
Service Description
Health Promotionand DiseasePreventionExaminations
Office visits may be covered for the following services (subject to age and other criteria):
Cancer screening examinations and services (breast cancer, cancer of femalereproductive organs, colorectal cancer, and prostate cancer)
Infectious diseases (Hepatitis B screening, human immunodeficiency virus [HIV]testing) and preventive therapy when at-risk (tetanus, animal bite, Rh immune globulin,and exposure to certain infectious diseases, including tuberculosis)
Genetic testing and counseling for certain clinical indications during pregnancy
Other: routine chest X-rays and electrocardiograms required for admission when apatient is scheduled to receive general anesthesia on an inpatient or outpatient basis
Immunizations Covered for age-appropriate dose of vaccines, including influenza, as recommended by theCenters for Disease Control and Prevention (CDC). Coverage for human papillomavirus(HPV) vaccine provided for initial administration for girls age 11-12, or if not previouslyadministered, for girls age 13-26.
Other HealthPromotion andDisease PreventionServices
The following services may be covered if provided in connection with a visit forimmunizations, Pap smears, mammograms, or examinations for colon and prostate cancer:
Cancer screening (testicular, skin, oral cavity and pharyngeal, and thyroid)
Infectious disease (tuberculosis screening, Rubella antibodies)
Cardiovascular disease (cholesterol screening, blood pressure screening)
Body measurements (height and weight)
Vision screening
Audiology screening (only allowed under well-child services)
Counseling services expected of good clinical practice that are included with theappropriate office visit at no additional charge (dietary assessment and nutrition;physical activity and exercise; cancer surveillance; safe sexual practices; tobacco,alcohol, and substance abuse; promoting dental health; accident and injury prevention;and stress, bereavement, and suicide risk assessment)
Inpatient Services: Coverage Details Figure 2.2
Clinical Preventive Services: Coverage Details Figure 2.3
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Behavioral Health Care Services
You may receive your first eight behavioral
health outpatient visits per fiscal year
(October 1September 30) without prior
authorization from your regional contractor.
After the first eight visits, prior authorization is
required. Remember to obtain care only fromTRICARE network providers or non-network,
TRICARE-authorized providers. The following
types of behavioral health providers may be
authorized providers under TRICARE:
Psychiatrists
Clinical psychologists
Clinical psychiatric nurse specialists
Clinical social workers
Certified marriage and family therapists with a
TRICARE participation agreement
Pastoral counselorswith physician referral
and supervision
Mental health counselorswith physician
referral and supervision
If you are unsure which type of provider would
best meet your needs, contact your regional
contractor for assistance.
Figure 2.4 on the following page provides
coverage details for covered behavioral health
care services. This chart is not intended to be
all-inclusive. For additional information aboutcovered and non-covered behavioral health care
services and how to access care, contact your
regional contractor.
Service Description
Pap Smear Covered as either a diagnostic or routine preventive procedure. The humanpapillomavirus (HPV) Pap test is not covered as a routine screening Pap smear.
School Physicals Covered for children ages 511 if required in connection with school enrollment.
Note: Annual school sports physicals are not covered.
Well-Child Care Covered from birth to age 6; includes office visits, immunizations, and vision screening.
Clinical Preventive Services: Coverage Details (continued)
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Behavioral Health Care Services: Coverage Details Figure 2.4
* The fiscal year is October 1September 30.
Service Description
Acute InpatientPsychiatric Care
Acute inpatient psychiatric care may be covered on an emergency or nonemergencybasis. Prior authorization from your regional contractor is required for allnonemergency inpatient admissions. In emergency situations, authorization isrequired for continued stay.
Limitations
Patients age 19 and older are limited to 30 days per fiscal year.*
Patients age 18 and younger are limited to 45 days per fiscal year.*
Inpatient admissions for substance use disorder detoxification and rehabilitationcount toward the 30- or 45-day limit.
MedicationManagement
If you are taking prescription medications for a behavioral health condition, you mustbe under the care of a provider who is authorized to prescribe those medications. Yourprovider will manage the dosage and duration of your prescription to ensure you arereceiving the best care possible.
PsychiatricPartial Hospitalization
Psychiatric partial hospitalization provides interdisciplinary therapeutic services atleast three hours per day, five days a week, in any combination of day, evening, night,and weekend treatment programs.
Prior authorization from your regional contractor is required.
Facility must be TRICARE-authorized.
Psychiatric partial hospitalization programs must agree to participate in TRICARE.
Limitations
Limited to 60 treatment days (whether a full- or partial-day treatment) in a fiscalyear.* These 60 days are not offset by or counted toward the 30- or 45-day inpatientlimit.
Psychological Testingand Assessment
Covered when medically or psychologically necessary and provided in conjunctionwith otherwise-covered psychotherapy. Psychological tests are considered to bediagnostic services and are not counted against the limit of two psychotherapy visitsper week.
Limitations
Testing and assessment is generally limited to six hours in a fiscal year.
Exclusions
Psychological testing is not covered for the following circumstances:
Academic placement
Job placement
Child custody disputes
General screening in the absence of specific symptoms
Teacher or parental referrals
Diagnosing specific learning disorders or learning disabilities
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Service Description
Psychotherapy Prior authorization is required after the first eight behavioral health outpatient visits perbeneficiary, per fiscal year.* Covered psychotherapy includes:
Individual, conjoint, family, or group sessions
Collateral visits
Play therapy (a form of individual therapy used with children)
Psychoanalysis (prior authorization from your regional contractor required)
Limitations
Outpatient psychotherapy is limited to a maximum of two sessions per week in anycombination of individual, family, collateral, or group sessions, and is not covered whenthe patient is an inpatient in an institution.
Inpatient psychotherapy is limited to five sessions per week in any combination ofindividual, family, collateral, or group sessions. The duration and frequency of care isdependent upon medical necessity.
ResidentialTreatment Center(RTC) Care
RTC care provides extended care for children and adolescents with psychological disordersthat require continued treatment in a therapeutic environment.
Unless therapeutically contraindicated, the family and/or guardian must actively
participate in the continuing care of the patient either through direct involvement at thefacility or geographically distant family therapy.
Facility must be TRICARE-authorized.
Prior authorization from your regional contractor is required.
RTC care is considered elective and will not be covered for emergencies.
Admission primarily for substance use rehabilitation is not authorized.
Care must be recommended and directed by a psychiatrist or clinical psychologist.
Limitations
Limited to 150 days per fiscal year* (may be waived if determined to be medically orpsychologically necessary)
Note: No qualified RTCs were available in overseas locations at time of printing.
Behavioral Health Care Services: Coverage Details (continued)
* The fiscal year is October 1September 30.
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Pharmacy Services
TRICARE offers comprehensive prescription drug
coverage and several options for filling your
prescriptions. To have a prescription filled, youll
need a written prescription. If your pharmacist asks
for your insurance card, you should provide your
TRS wallet card. Visit www.tricare.mil/pharmacy
for pharmacy cost information.
Military Treatment Facility Pharmacy
Prescriptions may be filled (up to a 90-day
supply for most medications) at an MTF
pharmacy at no cost as long as the medication
is on the MTF formulary. You should contact
the MTF pharmacy to find out what is on the
formulary and for specific details about filling
prescriptions there.
TRICARE Mail Order Pharmacy
The mail-order pharmacy is your least expensive
option when not using the MTF. You may receive
up to a 90-day supply for most medications
delivered to your home for a small copayment.
Refills may be requested by mail, phone, or
online. Registering for the mail-order pharmacy
is easy:
1. Register online. Go to
www.tricare.mil/pharmacy and click onFilling Prescriptions. Then select How to
Register in the left-hand navigation column.
Complete the online registration form and
follow the instructions for submission.
2. Register by phone. Call 1-866-363-8667 (in
the United States). If overseas, call
1-866-ASK-4PEC (1-866-275-4732).
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Service Description
Treatment forSubstance UseDisorders
A substance use disorder includes alcohol or drug abuse or dependence. TRICARE maycover services for the treatment of substance use disorders, including detoxification,rehabilitation, and outpatient group and family therapy. Emergency and inpatient hospitalservices are considered medically necessary only when the patients condition is such thatthe personnel and facilities of a hospital are required.
Note: All treatment for substance use disorders requires prior authorization from your
regional contractor.Coverage and Limitations
Benefit periodOnly three substance use disorder treatment benefit periods in a lifetimeare covered (waiver possible in accordance with policy criteria). A benefit period beginswith the first date of covered treatment and ends 365 days later, regardless of the totalservices actually used within the benefit period. Emergency and inpatient hospital servicesfor detoxification, stabilization, and treatment of medical complications of substance usedisorders do not count for purposes of establishing the beginning of a benefit period.
DetoxificationIf chemical detoxification is needed but does not require the personnelor facilities of a general hospital setting, detoxification services are covered in addition torehabilitative care. In a diagnosis-related group (DRG)-exempt facility, detoxificationservices are limited to seven days per year, unless the limit is waived.
RehabilitationRehabilitation (residential or partial) is limited to 21 days per year orone inpatient stay in a facility subject to the DRG-based reimbursement system, perbenefit period; you are limited to three benefit periods in your lifetime. All inpatient stayscount toward the 30- or 45-day inpatient limit.
Outpatient CareMust be provided by an approved substance use disorder facility in agroup setting. Coverage is limited to 60 visits per fiscal year.* Individual outpatient carefor substance use disorder is not covered.
Family TherapyOutpatient family therapy is covered beginning with the completion ofrehabilitative care. You are covered for up to 15 visits in a benefit period.
Behavioral Health Care Services: Coverage Details (continued)
* The fiscal year is October 1September 30.
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3. Register by mail. Download the registration
form at www.tricare.mil/pharmacy and mail
it to:
TRICARE Mail Order Pharmacy
P.O. Box 52150
Phoenix, AZ 85072-9954
Include the written prescription and the appropriate
copayment when you mail your registration.
For faster processing of your mail-order
prescription, you may register before placing
your first order. Once you are registered, your
provider can fax or call in your prescriptions.
You can convert maintenance prescriptions
(prescriptions you take on a regular basis)
that you have filled at a TRICARE Retail Network
Pharmacy to the TRICARE Mail Order Pharmacy
via the Member Choice Center (MCC). To convert
online, go to www.tricare.mil/pharmacy and
click on "Filling Prescriptions." Then select
"Convert Retail Prescriptions" in the left-hand
navigation column and follow the instructions
to convert online. To convert by phone, call
1-877-363-1433. A trained MCC Patient Care
Advocate will walk you through the process and
convert your medication(s) to home delivery.
Your medications will be sent directly to your
home within approximately 14 days after your
prescription is received. If you have prescription
drug coverage from another health insurance
plan, you can use the mail-order pharmacy if the
medication is not covered under the other plan or
if you exceed the dollar limit of coverage under
the other plan.
TRICARE Retail Network Pharmacy
You may have prescriptions filled (up to a 30-
day supply) at any pharmacy in the TRICAREretail network for a small copayment. For more
information or to locate a TRICARE retail
network pharmacy, call 1-866-DoD-TRRX
(1-866-363-8779) or visit
www.tricare.mil/pharmacy.
Note: Retail network pharmacies are available in
the United States, American Samoa, Guam, the
Northern Mariana Islands, Puerto Rico, and the
U.S. Virgin Islands.
Non-Network Pharmacy
Filling prescriptions at a non-network pharmacy is
the most expensive option. You may have to pay
for the total amount first and then file a claim to
receive a partial reimbursement from TRICARE
after your deductible is met. (For more information
about pharmacy claims, see the Claims section of
this handbook.)
Quantity Limits and PriorAuthorization
TRICARE has established quantity limits on
certain medications, which means that the
Department of Defense (DoD) will only pay for
a specified amount (a 30-, 60-, or 90-day supply)
of medication. Quantity limits are applied to
ensure the medications are safely and
appropriately used. Exceptions to established
quantity limits may be made if the prescribingprovider is able to justify medical necessity.
Some drugs require prior authorization. For a
general list of prescription drugs that are covered
under TRICARE, and for drugs that require prior
authorization or have quantity limits, visit
www.tricare.mil/pharmacy and click on
Medications. Then, from the left-hand
navigation bar, select Prior Authorization. If
you dont have Internet access, you can call
toll-free 1-866-DoD-TRRX (1-866-363-8779)or 1-866-DoD-TMOP (1-866-363-8667).
Generic Drug Use Policy
It is DoD policy to use generic medications, instead
of brand-name medications, whenever possible.
Brand-name drugs that have a generic equivalent
may be dispensed only if the prescribing physician
is able to justify medical necessity for use of the
brand-name drug in place of the generic equivalent.
If a generic equivalent does not exist, the brand-
name drug will be dispensed at the brand-namecopayment. If you insist on having a prescription
filled with a brand-name drug that is not considered
medically necessary, and when a generic equivalent
is available, you will be responsible for paying the
entire cost of the prescription out of pocket.
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Non-Formulary Drugs
Any drug determined to be not as clinically
effective or not as cost-effective as other drugs in
its therapeutic class may be recommended for
placement in the non-formulary classification.
Non-formulary drugs are available to beneficiaries
from the mail-order or retail pharmacies at a
higher cost. You may be able to have non-
formulary prescriptions filled at the formulary
costs if your provider can establish medical
necessity. Note: Non-formulary drugs are
generally not available at MTFs.
To learn more about medications and common
drug interactions, to check for generic equivalents,
or to determine if a drug is classified as a
non-formulary medication, visit the online
TRICARE Formulary Search Tool at
www.tricareformularysearch.org. For
information on how to save money and make
the most of your pharmacy benefit, visit
www.tricare.mil/pharmacy, or call
1-877-DoD-MEDS (1-877-363-6337) and
select option seven for pharmacy details.
Maternity Services
Prenatal care is important, and we strongly
recommend that those who are pregnant, and
those who anticipate becoming pregnant, seek
appropriate medical care. TRS covers maternity
care, including prenatal care, delivery, and
postpartum care. Medically necessary hospital
and professional services (prenatal and
postnatal) are covered, in addition to any other
services deemed medically necessary. Newborns
are covered separately.
Maternity Ultrasounds
TRICARE covers maternity ultrasounds when
medically necessary. Some situations that are
covered include:
Estimating gestational age
Evaluating fetal growth
Conducting a biophysical evaluation for fetal
well-being
Evaluating a suspected ectopic pregnancy
Defining the cause of vaginal bleeding
Diagnosing or evaluating multiple gestations
Confirming cardiac activity
Evaluating maternal pelvic masses or uterine
abnormalities
Evaluating suspected hydatidiform mole
Evaluating the fetuss condition in late
registrants for prenatal care
A physician is not obligated to perform
ultrasonography on a patient who is low risk and
has no medical indications constituting medical
necessity.
Some providers may offer patients routine
ultrasound screening as part of the scope of care
after 1620 weeks of gestation. TRICARE does
not cover routine ultrasound screening. Only
maternity ultrasounds with a valid medical
indication that constitutes medical necessity arecovered by TRICARE. Refer to your regional
contractors Web site for additional details on
maternity ultrasound coverage.
If your TRS coverage ends during your
pregnancy, TRICARE will not cover any
remaining maternity costs unless your family
qualifies for other TRICARE health coverage or
has enrolled in the Continued Health Care
Benefit Program. See When TRICARE Reserve
Select Coverage Ends in the Changes to YourTRICARE Reserve Select Coverage section of
this handbook.
For procedures on how to add your newborn to
your TRS coverage, refer to Coverage for
Newborns or Adopted Children in the Changes
to Your TRICARE Reserve Select Coverage
section of this handbook.
Dental Services
The TRICARE Dental Program (TDP) is separate
from other TRICARE programs and is not
contingent upon enrollment in TRS. For more
information about the TDP, visit the United
Concordia Companies, Inc., Web site at
www.TRICAREdentalprogram.com or call
toll-free 1-800-866-8499for general information.
To enroll, call 1-888-622-2256. If you are overseas,
call toll-free at 1-888-418-0466or 1-717-975-5017.
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Services or Procedures with Significant Limitations
Figure 2.5 is a list of medical, surgical, and behavioral health care services that may not be covered
unless exceptional circumstances exist. This list is not intended to be all-inclusive. Check your
regional contractor's Web site for additional information.
Services or Procedures with Significant Limitations Figure 2.5
Service Description
Abortions Abortions are only covered when the life of the mother would be endangered if thepregnancy were carried to term. The attending physician must certify in writing thatthe abortion was performed because a life-threatening condition existed. Medicaldocumentation must be provided. MTFs may not be able to provide such servicesbased upon limited capabilities.
Breast Pumps Heavy-duty, hospital-grade electric breast pumps (including services and suppliesrelated to the use of the pump) for mothers of premature infants are covered. Anelectric breast pump is covered while the premature infant remains hospitalized duringthe immediate postpartum period. Hospital-grade electric breast pumps may also becovered after the premature infant is discharged from the hospital with a physician-documented medical reason. This documentation is also required for premature infantsdelivered in non-hospital settings. Breast pumps of any type, when used for reasons
of personal convenience, are excluded even if prescribed by a physician.Cardiac andPulmonaryRehabilitation
Both are covered only for certain indications. Phase III cardiac rehabilitation forlifetime maintenance performed at home or in medically unsupervised settings isexcluded.
Chiropractic Care Coverage is limited to ADSMs and is only available at specific MTFs under theChiropractic Care Program. This program is not available under TRS.
Cosmetic, Plastic,or ReconstructiveSurgery
Only covered when used to restore function, correct a serious birth defect, restore bodyform after a serious injury, improve appearance of a severe disfigurement, or after amedically necessary mastectomy.
Cranial OrthoticDevice or MoldingHelmet
Cranial orthotic devices are excluded for treatment of nonsynostic positionalplagiocephaly.
Dental Care andDental X-Rays
Both are covered only for adjunctive dental care (i.e., dental care that is medicallynecessary in the treatment of an otherwise covered medicalnot dentalcondition).
Education andTraining
Outpatient diabetic self-management and training programs are covered when theservices are provided by a TRICARE-authorized individual provider who also meetsnational standards for diabetes self-management education programs recognized by theAmerican Diabetes Association (ADA). The providers Certificate of Recognitionfrom the ADA must accompany the claim for reimbursement.
Eyeglasses orContact Lenses
Contact lenses and/or eyeglasses are covered only for:
Treatment of infantile glaucoma
Corneal or scleral lenses for treatment of keratoconus
Scleral lenses to retain moisture when normal tearing is not present or is inadequate
Corneal or scleral lenses to reduce corneal irregularities other than astigmatism
Intraocular lenses, contact lenses, or eyeglasses for loss of human lens functionresulting from intraocular surgery, ocular injury, or congenital absence
Note: Adjustments, cleaning, and repairs for eyeglasses are not covered.
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Exclusions
In general, TRICARE excludes services and
supplies that are not medically or psychologically
necessary for the diagnosis or treatment of a
covered illness (including behavioral health
disorders) or injury, or for the diagnosis and
treatment of pregnancy or well-baby care. All
services and supplies (including inpatient
institutional costs) related to a non-coveredcondition or treatment, or provided by an
unauthorized provider, are excluded.
The following specific services are excluded
under any circumstance. This list is not
intended to be all-inclusive. Check your regional
contractors Web site for additional information.
Acupuncture
Alterations to living spaces
Artificial insemination, including in-vitro
fertilization, gamete intrafallopian transfer, and
all other such reproductive technologies
Autopsy services or postmortem examinations
Birth control/contraceptives (non-prescription)
Bone marrow transplants for treatment of
ovarian cancer
Camps (e.g., weight loss)
Care or supplies furnished or prescribed by animmediate family member
Charges that providers may apply to missed or
rescheduled appointments
Counseling services that are not medically
necessary in the treatment of a diagnosed
medical condition. For example, educational
counseling, vocational counseling, and
counseling for socioeconomic purposes, stress
management, or life-style modification.
Service Description
Food, Food Substitutesor Supplements, orVitamins
Covered when used as the primary source of nutrition for enteral, parenteral, or oralnutritional therapy. Intraperitoneal nutrition (IPN) therapy is covered for malnutritionas a result of end-stage renal disease.
Gastric Bypass Gastric bypass, gastric stapling, or gastroplastyto include vertical bandedgastroplastyis covered when one of the following conditions is met:
1. The patient is 100 pounds over the ideal weight for height and bone structure andhas one of these associated medical conditions: diabetes mellitus, hypertension,cholecystitis, narcolepsy, Pickwickian syndrome (and other severe respiratorydiseases), hypothalamic disorders, or severe arthritis of the weight-bearing joints.
2. The patient is 200 percent or more of the ideal weight for height and bonestructure. An associated medical condition is not required for this category.
3. The patient has had an intestinal bypass or other surgery for obesity and, becauseof complications, requires a second surgery (a takedown).
General AnesthesiaServices andInstitutional Costsfor Non-AdjunctiveDental Treatment
Covered when medically necessary to safeguard a patients life or in conjunctionwith non-adjunctive dental treatment (dental care not related to a medical condition)for patients with developmental, mental, or physical disabilities and for patients age5 or under.
Genetic Testing Covered when medically proven and appropriate, and when the results of the test willinfluence the medical management of the patient. Routine genetic testing is not covered.
Laser/LASIK/RefractiveCorneal Surgery
Covered only to relieve astigmatism following a corneal transplant.
Private Hospital Rooms Not covered unless ordered for medical reasons or a semiprivate room is not available.Hospitals that are subject to the TRICARE diagnosis-related group (DRG) paymentsystem may provide the patient with a private room, but will only receive the standardDRG amount. The hospital may bill the patient for the extra charges if the patientrequests a private room.
Shoes, Shoe Inserts,Shoe Modifications,
and Arch Supports
Shoe and shoe inserts are covered only in very limited circumstances. Orthopedicshoes may be covered when a permanent part of a brace. For individuals with diabetes,
extra-depth shoes with inserts or custom-molded shoes with inserts may be covered.
Services or Procedures with Significant Limitations (continued)
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Custodial care
Diagnostic admissions
Domiciliary care
Dyslexia treatment
Electrolysis
Elevators or chair lifts
Exercise equipment, spas, whirlpools, hot tubs,
swimming pools, health club memberships, orother such charges or items
Experimental or unproven procedures
Foot care (routine) except if required as a result
of a diagnosed systemic medical disease affecting
the lower limbs, such as severe diabetes
General exercise programs, even if
recommended by a physician and regardless of
whether rendered by an authorized provider
Inpatient stays:
For rest or rest cures
To control or detain a runaway child,
whether or not admission is to an authorized
institution
To perform diagnostic tests, examinations,
and procedures that could have been and are
performed routinely on an outpatient basis
In hospitals or other authorized institutions
above the appropriate level required to
provide necessary medical care
Learning disability services
Megavitamins and orthomolecular psychiatric
therapy
Mind expansion and elective psychotherapy
Naturopaths
Non-surgical treatment of obesity or morbid
obesity
Personal, comfort, or convenience items, such
as beauty and barber services, radio, television,
and telephone
Postpartum inpatient stay of a mother forpurposes of staying with the newborn infant
(usually primarily for the purpose of
breastfeeding the infant) when the infant (but
not the mother) requires the extended stay; or
continued inpatient stay of a newborn infant
primarily for purposes of remaining with the
mother when the mother (but not the newborn
infant) requires extended postpartum inpatient
stay
Preventive care, such as routine annual or
employment-requested physical examinations;
routine screening procedures; immunizations;
except as provided in the Clinical Preventive
Services list (See Clinical Preventive
Services earlier in this section.)
Psychiatric treatment for sexual dysfunction
Services and supplies:
Provided under a scientific or medical study,
grant, or research program
Furnished or prescribed by an immediate
family member
For which the beneficiary has no legal
obligation to pay or for which no charge
would be made if the beneficiary or sponsor
were not eligible under TRICARE
Furnished without charge (e.g., cannot file
claims for services provided free-of-charge)
For the treatment of obesity, except aspreviously outlined in Services or
Procedures with Significant Limitations,
earlier in this section. Diets, weight loss
counseling, weight loss medications, wiring
of the jaw, or similar procedures are
excluded
Inpatient stays, directed or agreed to by a
court or other governmental agency (unless
medically necessary)
Required as a result of occupational disease
or injury for which any benefits are payableunder a workers compensation or similar
law, whether such benefits have been applied
for or paid, except if benefits provided under
these laws are exhausted
That are (or are eligible to be) fully payable
under another medical insurance or program,
either private or governmental, such as
coverage through employment or Medicare
(In such instances, TRICARE is the
secondary payer for any remaining charges.)
Sex changes or sexual inadequacy treatment.However, treatment of ambiguous genitalia
which has been documented to be present at
birth is covered.
Smoking cessation services and supplies
Sterilization reversal surgery
Surgery performed primarily for psychological
reasons (such as psychogenic)
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Therapeutic absences from an inpatient facility,
except when such absences are specifically
included in a treatment plan approved by
TRICARE
Transportation except by ambulance
Travel, even if prescribed by a physician, to
obtain medical care
X-ray, laboratory, and pathological services
and machine diagnostic tests not related to a
specific illness or injury or a definitive set of
symptoms, except for cancer-screening
mammography, cancer screening, Pap tests,
and other tests allowed under the clinical
preventive services benefit.
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Health Care Claims
In order for TRICARE to pay any provider, that
provider must be an authorized TRICARE
provider. As noted in Figure 1.1 in the Getting Care
section of this handbook, if the provider is alsoparticipating, the provider will file claims for you.
All network providers are both TRICARE-
authorized providers and participating TRICARE
providers. If you see a TRICARE network provider
or a non-network, participating provider, your
provider will submit claims on your behalf. If you
see a non-network, non-participating provider, you
may be required to submit your own health care
claims. You will be reimbursed for TRICARE-
covered services at the TRICARE-allowable
charge, less any copayments, cost-shares, ordeductibles. Claims should be submitted to the
claims processor in the region where you live.
Note: You should ask any non-network provider if
they are participating and authorized by TRICARE.
If providers are not participating, you may incur
charges up to 15 percent above the TRICARE-
allowable charge for covered services. If providers
are not authorized by TRICARE, they will not be
paid for services rendered. If a provider would like
to become a TRICARE-authorized provider, theregional contractor can assist them.
Claims must be filed within one year of the date
of service or within one year of the date of an
inpatient discharge. To file a claim, obtain and
fill out a Patients Request for Medical Payment
(DD Form 2642). You can download forms and
instructions from the TRICARE Web site at
www.tricare.mil/claims or from your regional
contractors Web site. You also can get forms and
instructions at a TRICARE Service Center (TSC)or a military treatment facility (MTF). If you
have claims questions, call your regional
contractor.
When filing a claim, attach a readable copy of
the providers bill to the claim form, making sure
it contains the following:
Social Security number of the sponsor (the
National Guard or Reserve member)
Beneficiary (patient) name
Providers name and address (If more than one
providers name is on the bill, circle the name
of the person who treated you.)
Date and place of each service
Description of each service or supply furnished
Charge for each service
Diagnosis (If the diagnosis is not on the bill,
be sure to complete block 8a on the form.)
Be sure to complete all 12 blocks of the form
correctly and sign it. Note: Providers submit
inpatient facility claims.
You may be required to pay up front for services if
you see a non-network, TRICARE-authorized
provider who chooses not to participate on the
claim. In this case, TRICARE will reimburse you
directly for the TRICARE-allowable charge minus
any applicable deductible and cost-share.
Remember that nonparticipating providers can
charge you up to 15 percent above the TRICARE-
allowable charge for services in addition to your
cost-share and/or deductible. TRICARE does not
reimburse you for this charge, and you will have to
pay the charge out of pocket.
If you receive care while traveling, file
TRICARE claims based on where you live, not
where you received care.
Claims
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Send claims to the address listed for your region
in Figure 3.1. Keep a copy of your paperwork for
your records.
For claims processing information, call your
regional contractor, visit your regional
contractors Web site, or visit the TRICARE Web
site at www.tricare.mil/claims.
Pharmacy Claims
You may have to submit your own pharmacy
claims if you fill prescriptions at a non-network
pharmacy or if you have other health insurance
(OHI). (See Coordinating Benefits with
Other Coverage later in this section.) Before
reimbursement is granted for non-network
pharmacy claims, you must meet an annualTRICARE deductible.
Claims must be filed within one year of the date
of service. To file a pharmacy claim, obtain and
fill out a Patients Request for Medical Payment
(DD Form 2642). Prescription claims require the
following information for each drug:
Name of the patient
Name, strength, date filled, days supply,
quantity dispensed, and price of each drug
National Drug Code (NDC), if available
Prescription number of each drug
Name and address of the pharmacy
Name and address of the prescribing physician
You can download forms and instructions at
www.tricare.mil/claims. Click on TRICARE
Claim Form (DD Form 2642) under Downloads
in the right-hand navigation column. Call
1-866-DoD-TRRX (1-866-363-8779) with
questions about filing a pharmacy claim.
Overseas Claims
TRICARE Reserve Select (TRS) claims for
services received overseas are processed under
the TRICARE South Region contract. Wisconsin
Physicians Service (WPS) has been subcontracted
by Humana Military to provide claims processing
services for all overseas TRICARE areas. For
information and assistance in filing claims for
services received overseas, visit
www.TRICARE4u.com.
Claims must be filed within one year of the date
of service or within one year of the date of an
inpatient discharge. To file a claim, obtain and
fill out a Patients Request for Medical Payment
(DD Form 2642). You can download forms at
www.tricare.mil/claims or from your local TSC
and a TRICARE Point of Contact (POC).
When you fill out patient information and claim
forms, be sure to use your overseas APO or FPOmailing address and attach photocopies of fully
itemized bills from the provider showing the cost
for each service or supply provided. Using a
Continental United States (CONUS) address will
result in payment problems.
Regional Claims Processing Information Figure 3.1
TRICARE North Region TRICARE South Region TRICARE West Region
Send claims to:
Health Net Federal Services, LLCc/o PGBA, LLC/TRICAREP.O. Box 870140Surfside Beach, SC 29587-9740
www.healthnetfederalservices.comwww.myTRICARE.com
Send claims to:
TRICARE South RegionClaims DepartmentP.O. Box 7031Camden, SC 29020-7031
www.humana-military.comwww.myTRICARE.com
Send claims to:
West Region ClaimsP.O. Box 77028Madison, WI 53707-1028
www.triwest.com
www.TRICARE4u.com
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Send claims to the address listed for youroverseas region in Figure 3.2. Keep a copy of
your paperwork for your records.
TRICARE Point of Contact Program
The TRICARE Overseas Program (TOP) POC
Program is a liaison service that assists
beneficiaries and host-nation providers in remote
locations in filing medical and TRICARE Dental
Program claims. This ensures timely overseas
claims filing and payment, and continued
beneficiary access to quality host-nation health
care. To locate a POC near you, contact the
TRICARE Area Office or an overseas dental
treatment facility in your area.
Coordinating Benefits withOther Coverage
Line-of-Duty Care
TRICARE Reserve Select (TRS) does not cover
care associated with a line-of-duty injury, illness,
or disease. Line-of-duty conditions are covered
100 percent by the Department of Defense under
line-of-duty procedures separate from TRS.
Therefore, TRS deductibles and cost-shares do
not apply to care for line-of-duty conditions.
National Guard and Reserve members who have
a line-of-duty condition must have the
appropriate paperwork to receive care under line-
of-duty procedures. Any necessary care for line-
of-duty conditions must be coordinated through
your unit or Reserve Center. You will be directed
to a nearby MTF or to a TRICARE-authorized
provider for care. For more information about
obtaining line-of-duty care, contact your unit or
Reserve Center.
Other Health Insurance
TRS is the secondary payer after all health benefits
and insurance plans, except for Medicaid,
TRICARE supplements, the Indian Health Service,
and other programs or plans as identified by theTRICARE Management Activity.
If you have other health insurance (OHI), youll
need to follow the OHIs rules for filing claims
and file the claim with them first. If there is an
amount your OHI does not cover, you can file
the claim with TRICARE for reimbursement. It
is important to follow the requirements of your
OHI. If your OHI denies a claim for failure to
follow their rules, such as obtaining care without
authorization or using a non-network provider,TRICARE may also deny your claim.
Keep your regional contractor and health care
providers informed about your OHI so that they
can coordinate your benefits and help ensure that
there is no delay or denial in the payment of
your claims.
How TRICARE Calculates Paymentwith OHI
TRICARE regulations require coordination
of benefits with OHI coverage. Due to these
regulations, TRICARE does not always pay the
OHI copayment or the balance remaining after
the OHI pays. However, your liability is usually
eliminated. Payment calculations differ by
provider status as follows.
TRICARE Network Individual/GroupProviders and Most Inpatient Facilities
If your OHI pays more than the TRICARE-allowed amount, then no TRICARE payment is
authorized. The charge is considered paid in full,
and the provider may not bill you. Otherwise,
TRICARE pays the lesser of:
The allowed amount minus the OHI payment
The amount TRICARE would have paid
without OHI
The beneficiarys liability
(OHI copayment/deductible)
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TRICARE Europe TRICARE Latin America and Canada TRICARE Pacific
WPSOverseas ClaimsP.O. Box 8976Madison, WI 53708-8976
WPSOverseas ClaimsP.O. Box 7985Madison, WI 53707-7985
WPSOverseas ClaimsP.O. Box 7985Madison, WI 53707-7985
Overseas Claims Addresses Figure 3.2
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Non-Network Individual/Group ProvidersWho Accept TRICARE Assignment(Participating)
TRICARE pays the lesser of:
The billed amount minus the OHI payment
The amount TRICARE would have paid
without OHI
The beneficiarys liability(OHI copayment/deductible)
Non-Network Individual/Group ProvidersWho Do Not Accept TRICARE Assignment(Nonparticipating)
Nonparticipating providers may only bill you up
to 15 percent above the TRICARE-allowable
charge. If your OHI paid more than 115 percent
of the TRICARE-allowable charge, then no
TRICARE payment is authorized, the charge is
considered paid in full, and the provider may not
bill you. Otherwise, TRICARE pays the lesser
of:
115 percent of the allowed amount minus the
OHI payment
The amount TRICARE would have paid
without OHI
The beneficiarys liability (OHI
copayment/deductible)
Staff Model HMOs, Group HMOs, andOther Capitated OHI Plan Providers
If you are enrolled in one of these OHI plans,
the provider/group either works directly for the
HMO or is paid a monthly or annual amount
rather than a fee for each service performed. In
these plans you may only receive a copayment
receipt, and an itemized bill or explanation of
benefits (EOB) may not be available.
In these cases, you can submit a Patients
Request for Medical Payment(DD Form 2642)
with a copy of your HMO copayment receipt.
For processing, the copayment is considered the
billed amount. Deductibles and cost-shares are
applied, and you may only receive partial
reimbursement of your HMO copayment.
Pharmacy Claims
When using OHI, the OHI is the first payer for
pharmacy coverage. You may then be eligible for
full or partial reimbursement from TRICARE for
out-of-pocket costs, including copayments. If
you have OHI, you should use a retail pharmacy
under your private insurer that is also in the
TRICARE retail pharmacy network to avoid
paying the TRICARE non-network deductible.
You may not use TRICAREs mail-order
pharmacy if you have OHI prescription drug
coverage, unless the medication is not covered
under the other plan, or unless you exceed the
dollar limit of coverage under the other plan.
When you have OHI, the rules of that insurer
apply. You should call 1-866-DoD-TRRX
(1-866-363-8779) for specific instructions about
filing pharmacy claims if you have OHI.
Third-Party Liability
The Federal Medical Care Recovery Act allows
TRICARE to be reimbursed for its costs of
treatment if you are injured in an accident that
was caused by someone else. The Statement of
Personal Injury Third Party Liability (DD Form
2527) form will be sent to you if a claim appears
to have third-party liability involvement. Within
35 calendar days you must complete and sign
this form and follow the directions for returningit to the appropriate claims processor. You can
download the DD Form 2527 at
www.tricare.mil/claims or from your regional
contractors Web site.
Explanation of Benefits
An EOB is not a bill. It is an itemized statement
that shows what action TRICARE has taken on
your claims. An EOB is for your information andfiles.
After reviewing the EOB, you have the right to
appeal certain decisions regarding your claims and
must do so in writing within 90 days of the date of
the EOB notice. (For more information about
appeals, see the Information and Assistance section
of this handbook.) You should keep EOBs with
your health insurance records for reference.
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For a sample of the EOB in your region along
with instructions for reading the EOB, see the
following figures in the Appendix section of this
handbook:
North Region: Figure 8.1
South Region: Figure 8.2
West Region: Figure 8.3
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Changes to Your Coverage
When you experience a change in your family
composition certain actions are necessary to
ensure continuous TRICARE Reserve Select
(TRS) coverage for all eligible family members.
Examples of changes in family composition
include:
Marriage
Birth or adoption of child
Placement of a child in the legal custody of the
National Guard or Reserve member by an
order of the court
Divorce or annulment
Death of a spouse or family member
Last family member becomes ineligible
(requires a change from TRS member-and-
family to TRS member-only coverage)
To ensure there is no interruption to your TRS
coverage, first, you must report the change in
family composition as described in Updating
DEERS in the Information and Assistance
section of this handbook.
Second, you must log on to the TRS Web
application at
https://www.dmdc.osd.mil/appj/trs/index.jsp and
follow the prompts for making changes to family
composition. Print the TRS Requestform from the
TRS Web application, sign it, and send it to your
TRICARE regional contractor. This form must be
postmarked or received by your regional contractor
no later than 60 days from the date of the family
change. The effective date of coverage is the datethe family change occurred.
When a change is processed that alters the
premium amount (e.g., a change from member-
only to member-and-family coverage), the
effective date of the premium change will be the
date the family change occurred.
Coverage for Newborns orAdopted Children
TRS coverage for newborns or adopted children
differs depending on the type of coverage the
sponsor (the National Guard or Reserve
Member) has: TRS member-and-family or TRS
member-only.
Adding a Newborn or Adopted Childto Existing Member-and-FamilyCoverage
With TRS member-and-family coverage,
newborns and adopted children are covered
automatically by TRS for 60 days after the birthor adoption. Children can continue TRS with no
break in coverage if the TRS Requestform is
postmarked or received by the TRICARE Service
Center (TSC) or the regional contractor within
60 days of the birth or adoption. Beyond 60
days, the child must be enrolled for claims to be
paid. If the TRS Requestform is not received by
the TSC or the regional contractor or postmarked
within 60 days, any further TRS coverage for the
child is terminated. All pended claims will be
denied, and the member is responsible to pay thetotal amount for all health care the child received.
Note: Since a family plan already exists,
additional premiums will not be required when
enrolling the new child.
Adding a Newborn or Adopted ChildWhen You Have Member-OnlyCoverage
With TRS member-only coverage, newborns or
adopted children are not automatically coveredand claims will not be paid until the newborn or
adopted child is registered in DEERS and a TRS
Requestform is received. If the member wants
coverage retroactive to the date of the birth or
adoption, the request for member-and-family
coverage must be received by the TSC or the
regional contractor or postmarked within 60
days of the birth or adoption. If the TRS
Requestform is not received by the TSC or
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Changes to Your TRICARE ReserveSelect Coverage
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the regional contractor or postmarked within 60
days, all pended claims will be denied, and the
member is responsible to pay the total amount
for all health care the child received.
Note: When the type of plan changes from
memberonly to memberandfamily, there is an
increase in the monthly premium. The sponsor is
responsible for paying the increase in premium,which begins on the date of the birth or adoption.
When TRICARE Reserve SelectCoverage Ends
TRS coverage may be terminated for a number
of reasons. When TRS coverage is terminated,
the regional contractors will initiate your
premium payment refund process within 10 days
of receiving a written TRS termination request.When your TRS coverage is terminated for any
reason, your family members coverage
automatically ends as well.
Loss of Eligibility
Sponsors or family members may lose eligibility
for TRS coverage for the following reasons.
Note: This list is not allinclusive.
Sponsor or family member becomes eligible
for, or covered under, the Federal EmployeesHealth Benefits program
Sponsor leaves the Selected Reserve
Divorce
Child reaches age 21 (or 23 if enrolled as a
fulltime student in college)
Eligibility for Other TRICARECoverage
You may become eligible for other TRICARE
coverage at any time. If you become eligible forother TRICARE coverage for a period of 30 days
or less, TRS coverage will continue unchanged.
If you become eligible for other TRICARE
coverage for a period of more than 30
consecutive days, TRS coverage will terminate.
Other TRICARE coverage may include coverage
before (early eligibility), during (active duty
coverage), and after (Transitional Assistance
Management Program or TAMP) periods of
activation. Any premium amounts already paid
for periods beyond the termination date will be
refunded as described previously. If you, the
National Guard or Reserve member, become
eligible for other TRICARE coverage through a
family member, then you as the sponsor, as well
as any TRSenrolled family members, may
terminate TRS coverage without incurring alockout.
Additionally, if you become eligible for one of
the programs listed below, your TRS coverage
will be terminated.
CHAMPVA
Another federally sponsored health benefits
program, such as the Federal Employees
Health Benefits program.
It is important to note that TRS coverage will
not automatically resume after other
TRICARE coverage ends. If you want to enroll
for TRS coverage at that time, you must follow
the procedures to qualify for and purchase TRS
coverage again, the same as any beneficiary
purchasing new coverage.
Voluntary Termination
You may request to terminate TRS coverage at
any time. If you want to terminate coverage, do
not just stop making payments. You must take
the following action to end your TRS coverage:
Log on to the Guard and Reserve Web Portal at
https://www.dmdc.osd.mil/appj/trs/index.jsp .
Complete the TRS Requestform.
Print, sign, and mail your completed TRS
Requestform to your regional contractor.
A oneyear TRS purchase lockout will applyto members who voluntarily terminate TRS
coverage. A purchase lockout means you will
not be able to purchase TRS coverage for one
year from the effective date of termination. If
you do not take action to terminate coverage and
you simply stop making premium payments,
your coverage terminates. However, you are still
responsible for any premium amounts that were
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due prior to the date you were officially
terminated from TRS.
Termination Due to Non-Payment
Your payment is due no later than the last day of
each month. Your payment will apply to the
following month of coverage. Failure to pay
monthly premiums on time will result in
termination of coverage, but you must still
pay any overdue amounts. (This may result in
up to two months or more of overdue premium
payments.) Termination of coverage due to non-
payment will result in a TRS purchase lockout
for one year or until overdue premiums are paid
in full, whichever is longer.
Note: The government pursues collection action for
overdue and delinquent premiums and may notify
your commander and collect these amounts from
your National Guard or Reserve pay.
Certificate of Creditable Coverage
When your TRS coverage ends, you will receive a
certificate of creditable coverage. The certificate of
creditable coverage is a document that serves as
evidence of prior health care coverage under
TRICARE so that you cannot be excluded from a
new health plan for pre-existing conditions.
The Defense Manpower Data Center SupportOffice (DSO) will issue a certificate of creditable
coverage to sponsors and family members upon
loss of eligibility. Certificates reflect the most
recent period of continuous coverage under
TRICARE.
Certificates issued upon request of a beneficiary
reflect each period of continuous coverage under
TRICARE that ended within the 24 months prior
to the date of loss of eligibility. Each certificate
identifies the name of the sponsor or familymember for whom it is issued, the dates
TRICARE coverage began and ended, and the
certificate issue date.
Send your written requests for a certificate of
creditable coverage to the DSO at:
Defense Manpower Data Center
Support Office
Attn: Certificate of Creditable Coverage
400 Gigling Road
Seaside, CA 93955-6771
The request must include:
Sponsors name and Social Security number
Name of person for whom the certificate is
requested
Reason for the request
Name and address to whom and where the
certificate should be sent
Requesters signature
You cannot request a certificate by phone. Ifthere is an urgent need for a certificate of
creditable coverage, fax your request to the DSO
at 1-831-655-8317 and/or request that the DSO
fax the certificate to a particular number.
For more information, contact the DSO at
1-800-538-9552. For TTY/TDD, dial
1-866-363-2883. You may send questions via
e-mail to the TRICARE Management Activity
Office of HIPAA Electronic Standards at
[email protected] or visitwww.tricare.mil/certificate.
Continued Health Care BenefitProgram
Once your eligibility under TRS ends, you may
be able to apply for temporary, transitional
medical coverage under the Continued Health
Care Benefit Program (CHCBP). CHCBP is a
premium-based health care program and is
similar to, but not part of, TRICARE. If you
qualify, you must enroll yourself and your
eligible family members in C