Tricare Reserve Select Handbook

8/7/2019 Tricare Reserve Select Handbook

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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 Reserve Select


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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.

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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.

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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.

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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.

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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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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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11

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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12

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)



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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.


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)



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3. Register by mail. Download the registration

form at www.tricare.mil/pharmacy and mail

it to:


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.

15


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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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17

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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19

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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21

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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22

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.


of service. To file a pharmacy claim, obtain and


(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.


of service or within one year of the date of an

inpatient discharge. To file a claim, obtain and


(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)

23

TRICARE Europe TRICARE Latin America and Canada TRICARE Pacific

WPSOverseas ClaimsP.O. Box 8976Madison, WI 53708-8976



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


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


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.

24


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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

25


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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

26

Changes to Your TRICARE ReserveSelect Coverage


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27

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

Documents

Tricare Reserve Select Handbook