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Your Guide to TRICARE Health Plans
What is TRICARE?
TRICARE serves as the health care program provided by the United States Department of Defense for the uniformed services community worldwide. It functions as a government-managed health insurance system, extending coverage to active duty service members, their families, National Guard and Reserve members and their families, retirees and their families, survivors, and certain former spouses.
Serving nearly 9.5 million beneficiaries globally, TRICARE integrates the healthcare resources of the Military Health System (MHS), such as military hospitals and clinics, with networks of civilian healthcare professionals, institutions, pharmacies, and suppliers. The program’s mission is to enhance national security by providing health support for military operations and sustaining the health of all individuals entrusted to its care.
Most TRICARE health plans satisfy the minimum essential coverage requirements mandated by the Affordable Care Act.
Purpose of This Guide
Navigating government healthcare options can often feel complex. This guide provides a clear explanation of three core TRICARE health plan options: TRICARE Prime, TRICARE Select, and TRICARE For Life. The goal is to make this essential information accessible and useful, empowering eligible individuals and families within the military community to understand their choices and make informed decisions about their healthcare coverage.
Understanding TRICARE Basics: Eligibility and Key Terms
Who Can Use TRICARE? General Eligibility
Eligibility for TRICARE is not determined by TRICARE itself, but rather by the sponsor’s specific uniformed service branch. This eligibility status is officially recorded in the Defense Enrollment Eligibility Reporting System (DEERS).
The program broadly covers several categories of individuals:
- Active Duty Service Members (ADSMs) and their families
- National Guard and Reserve members and their families (eligibility often depends on federal order status, such as being activated for more than 30 consecutive days)
- Retired service members and their families
- Retired Reserve members and their families (typically starting at age 60)
- Survivors of deceased service members
- Certain former spouses of service members
- Medal of Honor recipients and their families
- Others who are registered in DEERS as eligible
It is important to note that TRICARE eligibility is tied to specific military affiliations and DEERS registration; it does not automatically extend to all veterans. For family members, eligibility hinges on their relationship to the sponsor (e.g., spouse, child, stepchild) and meeting specific dependency criteria, which might include age limits or student status for children, or specific conditions for former spouses or dependent parents.
Detailed eligibility information specific to various beneficiary categories can be found on the official TRICARE website, including pages for Active Duty Service Members and Families, Retired Service Members and Families, Medicare-Eligible Beneficiaries, and others.
The Importance of DEERS (Defense Enrollment Eligibility Reporting System)
The Defense Enrollment Eligibility Reporting System (DEERS) is the cornerstone of TRICARE eligibility. It is a computerized database containing information on uniformed service members, retirees, and their dependents worldwide. Registration in DEERS is mandatory to receive TRICARE benefits. While sponsors (the service members or retirees) are typically registered automatically, they bear the responsibility of registering their eligible family members.
Maintaining accurate and up-to-date information in DEERS is critical for uninterrupted access to TRICARE benefits. Inaccurate information can lead to problems accessing care or issues with claims processing. Beneficiaries must ensure DEERS reflects current information regarding:
- Address and contact details
- Family status changes (marriage, divorce, birth, adoption, death)
- Sponsor’s status changes (activation, deactivation, retirement, separation)
- Becoming eligible for Medicare
Updates can typically be made online via the milConnect portal, by phone (1-800-538-9552), by fax, or by mail. Adding or removing family members usually requires visiting an ID card office. The milConnect portal also allows eligible users to generate an Eligibility Letter, which serves as proof of current TRICARE coverage. The essential nature of DEERS cannot be overstated; it acts as the gatekeeper for TRICARE access, making administrative diligence a key responsibility for beneficiaries.
Understanding Beneficiary Groups (Group A vs. Group B)
TRICARE beneficiaries are categorized into one of two groups, primarily based on when their sponsor initially joined the uniformed services (through enlistment or appointment):
- Group A: Sponsors whose initial enlistment or appointment occurred before January 1, 2018.
- Group B: Sponsors whose initial enlistment or appointment occurred on or after January 1, 2018.
This distinction is significant because Group A and Group B beneficiaries often have different out-of-pocket costs, including annual enrollment fees, deductibles, copayments, and cost-shares, particularly under TRICARE Prime and TRICARE Select plans. These cost differences primarily affect retirees and their family members, as well as certain active duty family members under TRICARE Select.
It’s also important to note that beneficiaries enrolled in TRICARE Reserve Select (TRS), TRICARE Retired Reserve (TRR), TRICARE Young Adult (TYA), or the Continued Health Care Benefit Program (CHCBP) follow Group B cost structures, regardless of their sponsor’s initial service entry date. Understanding one’s assigned group is essential for accurately predicting healthcare costs under applicable TRICARE plans.
Deep Dive: TRICARE Prime
What is TRICARE Prime?
TRICARE Prime is a managed care health plan option, operating similarly to a civilian Health Maintenance Organization (HMO). It is available primarily in designated geographic locations within the United States known as Prime Service Areas (PSAs). Beneficiaries can verify if they reside in a PSA using the TRICARE Plan Finder tool. Variations of the Prime plan exist for those in remote US locations (TRICARE Prime Remote) and overseas (TRICARE Prime Overseas, TRICARE Prime Remote Overseas).
Key features of TRICARE Prime include the assignment of a Primary Care Manager (PCM) who coordinates most care, the general requirement for referrals to see specialists, typically lower out-of-pocket costs compared to TRICARE Select, and consequently, less freedom in choosing providers. Enrollment in TRICARE Prime is mandatory for participation.
How Prime Works: Primary Care Managers (PCMs) and Referrals
The Primary Care Manager (PCM) is central to the TRICARE Prime model. The assigned PCM provides the majority of routine medical care and acts as the gatekeeper for specialty services. A PCM can be a provider at a Military Treatment Facility (MTF) or a civilian provider within the TRICARE network. Often, care is directed to MTFs first if they have the capacity to provide the needed services.
When specialty care is necessary, the PCM initiates a referral and works with the regional TRICARE contractor to obtain authorization. Generally, obtaining this referral before seeking specialty care is required to ensure services are covered at the lowest cost under the Prime plan. Beneficiaries can usually check the status of their referrals. The PCM also typically accepts applicable copayments and files insurance claims on behalf of the beneficiary. This managed care approach, while designed for efficiency and cost control, means beneficiaries generally cannot self-refer to specialists without potentially incurring higher costs through the Point-of-Service option.
Who Can Enroll in Prime?
Eligibility for TRICARE Prime includes several beneficiary categories:
- Active Duty Service Members (ADSMs) and their families
- Retired service members and their families (provided they are not yet eligible for Medicare, typically under age 65)
- Activated National Guard and Reserve members and their families
- Non-activated National Guard and Reserve members and their families eligible under the Transitional Assistance Management Program (TAMP)
- Retired National Guard and Reserve members (age 60 and over) and their families (provided they are not yet eligible for Medicare)
- Survivors
- Medal of Honor recipients and their families
- Qualified former spouses
A critical distinction exists for ADSMs: Active duty service members are required to enroll in a TRICARE Prime plan based on their duty location (e.g., TRICARE Prime, TRICARE Prime Remote, TRICARE Prime Overseas).
For most other eligible beneficiaries, such as active duty family members (ADFMs) and retirees under age 65, enrollment in TRICARE Prime is a choice; they may opt for TRICARE Prime or TRICARE Select.
However, there is an important limitation related to Medicare: Once retired service members and their eligible family members become eligible for Medicare (usually at age 65), they are no longer eligible to enroll in TRICARE Prime. They typically transition to TRICARE For Life. Information on enrolling in Prime is available at the TRICARE Prime Enrollment page.
Finding Providers: Network and the Point-of-Service (POS) Option
Under TRICARE Prime, healthcare is primarily accessed through the assigned PCM and, via referrals, through specialists within the TRICARE network (which includes both military and civilian providers).
For situations where a Prime enrollee (excluding ADSMs) wishes to see a TRICARE-authorized provider outside the network or without a referral from their PCM, the Point-of-Service (POS) option exists.
Utilizing the POS option provides flexibility but comes at a significant cost. Beneficiaries using POS face:
- A separate annual POS deductible: This deductible must be met before TRICARE begins cost-sharing for POS services. For 2024, this deductible was $300 for an individual and $600 for a family.
- A 50% cost-share: After meeting the POS deductible, the beneficiary pays 50% of the TRICARE-allowable charge for the services received under the POS option.
Crucially, any costs incurred under the POS option (both the deductible and the 50% cost-shares) do not count towards the beneficiary’s regular annual catastrophic cap. This financial structure underscores that the POS option is intended as an exception for occasional use rather than a routine way to receive care under Prime. Adhering to the PCM referral process and using network providers remains the most cost-effective way to use the TRICARE Prime benefit.
TRICARE Prime Costs
Out-of-pocket costs under TRICARE Prime vary significantly based on the beneficiary’s status:
- Active Duty Service Members (ADSMs): Pay $0 for all TRICARE-covered services. They have no enrollment fees, deductibles, or copayments.
- Active Duty Family Members (ADFMs) and Transitional Survivors: Pay no annual enrollment fee. They generally pay $0 for covered services received through their PCM or with a proper referral to a network provider. Costs are only incurred if they use the Point-of-Service (POS) option. Their annual catastrophic cap, which limits total out-of-pocket costs for covered services (excluding POS costs), is $1,288 per family for 2025.
- Retirees, Their Families, and All Others: Pay annual enrollment fees, which differ based on whether they fall into Group A or Group B. They also pay fixed network copayments for most services (e.g., primary care visits, specialty visits, urgent care, ER visits, inpatient admissions). TRICARE Prime does not have an annual deductible for these beneficiaries unless they use the POS option. Their annual catastrophic cap also differs by group ($3,000 for Group A families, $4,509 for Group B families in 2025).
The catastrophic cap is an important feature, representing the maximum amount a family pays out-of-pocket for TRICARE-covered services (including enrollment fees, deductibles where applicable, and copayments/cost-shares) within a calendar year. Once this cap is reached, TRICARE pays 100% of the allowable charges for remaining covered services for that year. Remember, POS charges do not count toward this cap.
For precise, up-to-date cost figures, beneficiaries should consult the official TRICARE Prime Costs page or the TRICARE Costs and Fees Fact Sheet.
Table: TRICARE Prime Costs (Calendar Year 2025)
Costs for Active Duty Family Members and Transitional Survivors
| Cost Type | TRICARE Prime (Groups A & B) |
|---|---|
| Annual Enrollment Fee | $0 |
| Annual Deductible | $0 |
| Covered Services | $0 |
| Annual Catastrophic Cap | $1,288 per family |
| Point-of-Service (POS) | POS Deductible + 50% Cost-Share applies if used without referral. POS costs do NOT count toward Catastrophic Cap. |
Costs for All Retirees, Their Family Members, Survivors, and Others
| Cost Type | TRICARE Prime Group A | TRICARE Prime Group B |
|---|---|---|
| Annual Enrollment Fee | Individual: $372* <br> Family: $744* | Individual: $450 <br> Family: $900.96 |
| Annual Deductible | $0 | $0 |
| Annual Catastrophic Cap | $3,000 per family | $4,509 per family |
| Clinical Preventive Services | $0 | $0 |
| Outpatient Visit – Primary Care (Network) | $25 | $25 |
| Outpatient Visit – Specialty Care (Network) | $38 | $38 |
| Urgent Care (TRICARE-authorized provider) | $38 | $38 |
| Emergency Services | $77 | $77 |
| Hospitalization (Inpatient Admission, Network) | $193 per admission | $193 per admission |
| Mental Health Inpatient Admission (Network) | $193 per admission | $193 per admission |
| Mental Health Outpatient Visit – Primary (Network) | $25 | $25 |
| Mental Health Outpatient Visit – Specialty (Network) | $38 | $38 |
| Out-of-Network Care (without referral) | POS Deductible + 50% Cost-Share applies. POS costs do NOT count toward Catastrophic Cap. | POS Deductible + 50% Cost-Share applies. POS costs do NOT count toward Catastrophic Cap. |
*Note: Enrollment fees for certain medically retired sponsors, their families, and survivors in Group A may be lower based on their date of classification in DEERS.
Deep Dive: TRICARE Select
What is TRICARE Select?
TRICARE Select is characterized as a self-managed healthcare option, structured similarly to a civilian Preferred Provider Organization (PPO) plan. It is available to eligible beneficiaries throughout the United States. An overseas version, TRICARE Select Overseas, is also available for those residing abroad.
The defining feature of TRICARE Select is flexibility. Beneficiaries have the freedom to choose any TRICARE-authorized healthcare provider, whether they are part of the TRICARE network or not. Unlike TRICARE Prime, there is no requirement to have an assigned Primary Care Manager (PCM), and referrals are generally not needed to see specialists. This freedom of choice typically comes with higher out-of-pocket costs compared to Prime, including annual deductibles, cost-shares, and, for some beneficiaries (primarily retirees), annual enrollment fees. Enrollment is required to use TRICARE Select.
How Select Works: Provider Choice and Accessing Care
Under TRICARE Select, beneficiaries take a more active role in managing their healthcare. They can schedule appointments directly with any TRICARE-authorized provider – encompassing both network and non-network providers – without needing permission or coordination from a PCM.
Referrals are not necessary for most visits to primary care doctors or specialists. This direct access model is a significant departure from the TRICARE Prime structure. However, it’s important to be aware that pre-authorization from the regional TRICARE contractor may still be required for certain specific medical services or procedures.
When seeking care, TRICARE Select beneficiaries use their Uniformed Services ID card as proof of coverage; a separate plan-specific wallet card is not issued. Depending on the provider seen (especially non-network providers), beneficiaries might need to pay for the services upfront at the time of the visit and then submit a claim to TRICARE for reimbursement. Network providers are generally more likely to file claims directly with TRICARE on the beneficiary’s behalf. This potential need for upfront payment and claim filing represents an increased administrative responsibility for the beneficiary compared to the typical experience under TRICARE Prime.
Who Can Enroll in Select?
TRICARE Select is available to a range of beneficiaries registered in DEERS:
- Active Duty Family Members (ADFMs)
- Retired service members and their families
- Family members of activated National Guard and Reserve members
- Non-activated National Guard and Reserve members and their families eligible under the Transitional Assistance Management Program (TAMP)
- Retired National Guard and Reserve members (age 60 and over) and their families
- Survivors
- Medal of Honor recipients and their families
- Qualified former spouses
The most significant exclusion is that Active Duty Service Members (ADSMs), including activated Guard and Reserve members, are not eligible to use TRICARE Select. They must enroll in a TRICARE Prime option. Information on enrolling in Select can be found on the TRICARE Select Enrollment page.
Finding Providers: Network vs. Non-Network Care and Costs
While TRICARE Select allows beneficiaries to see any TRICARE-authorized provider, understanding the distinction between network and non-network providers is crucial due to significant cost implications:
- Network Providers: These are TRICARE-authorized providers who have signed an agreement with the regional TRICARE contractor. They agree to accept the TRICARE-negotiated rate (often lower than the full allowable charge) as payment in full (minus applicable deductibles and copayments/cost-shares). They will file claims directly with TRICARE and cannot “balance bill” beneficiaries for amounts above the negotiated rate. Using network providers generally results in lower out-of-pocket costs for the beneficiary.
- Non-Network Providers: These providers are TRICARE-authorized (meaning they meet TRICARE’s licensing and certification requirements) but do not have a contractual agreement with TRICARE. They can be further divided into:
- Participating Non-Network Providers: Agree to accept TRICARE payment and file claims for beneficiaries. They accept the TRICARE-allowable charge as payment in full and cannot balance bill.
- Non-Participating Non-Network Providers: Do not have an agreement with TRICARE and may not accept TRICARE payment directly or file claims. They can legally charge beneficiaries up to 15% more than the TRICARE-allowable charge. This practice is known as balance billing, and the beneficiary is fully responsible for paying this additional amount, on top of their regular deductible and cost-share. Beneficiaries using non-participating providers often have to pay the full cost upfront and file their own claims for reimbursement.
The potential for significantly higher costs (through higher cost-shares and potential balance billing) and increased administrative work (paying upfront, filing claims) creates a strong financial incentive for TRICARE Select users to prioritize seeking care from network providers whenever possible.
TRICARE Select Costs
Out-of-pocket costs under TRICARE Select are generally structured around an annual deductible and then either fixed copayments (for network care) or percentage-based cost-shares (for non-network care). Specific costs depend on the beneficiary’s status and group:
- Active Duty Family Members (ADFMs) and Transitional Survivors: Do not pay an annual enrollment fee. They have an annual deductible that varies based on the sponsor’s pay grade (E-4 and below vs. E-5 and above) and whether they are in Group A or Group B. After meeting the deductible, they pay network copayments or non-network cost-shares for services. Their annual catastrophic cap is $1,288 per family for 2025.
- Retirees, Their Families, and All Others: Pay an annual enrollment fee, which differs significantly between Group A and Group B. Group A retirees began paying enrollment fees effective January 1, 2021. They also have an annual deductible, which varies between Group A and Group B. Notably, Group B retirees have separate, higher deductibles for using out-of-network care compared to network care. After the deductible, they pay network copayments or non-network cost-shares. Their annual catastrophic cap also differs by group ($4,261 for Group A families, $4,509 for Group B families in 2025).
The catastrophic cap functions similarly to Prime’s, limiting the total amount a family pays out-of-pocket for TRICARE-covered services (including enrollment fees, deductibles, copayments, and cost-shares) within a calendar year.
For precise, up-to-date cost figures, beneficiaries should consult the official TRICARE Select Costs page, use the TRICARE Compare Costs tool, or review the TRICARE Costs and Fees Fact Sheet.
Table: TRICARE Select Costs (Calendar Year 2025)
Costs for Active Duty Family Members and Transitional Survivors
| Cost Type | TRICARE Select Group A | TRICARE Select Group B |
|---|---|---|
| Annual Enrollment Fee | $0 | $0 |
| Annual Deductible | E1-E4: $50 Ind / $100 Fam <br> E5+: $150 Ind / $300 Fam | E1-E4: $64 Ind / $128 Fam <br> E5+: $193 Ind / $386 Fam |
| Annual Catastrophic Cap | $1,000 per family | $1,288 per family |
| Clinical Preventive Services | $0 | $0 |
| Outpatient Visit – Primary Care | Network: $27 <br> Out-of-Network: 20% Cost-Share* | Network: $19 <br> Out-of-Network: 20% Cost-Share* |
| Outpatient Visit – Specialty Care | Network: $38 <br> Out-of-Network: 20% Cost-Share* | Network: $32 <br> Out-of-Network: 20% Cost-Share* |
| Urgent Care | Network: $27 <br> Out-of-Network: 20% Cost-Share* | Network: $25 <br> Out-of-Network: 20% Cost-Share* |
| Emergency Services | Network: $105 <br> Out-of-Network: 20% Cost-Share* | Network: $51 <br> Out-of-Network: 20% Cost-Share* |
| Hospitalization (Inpatient Admission) | Network/OON: $23.45/day ($25 min/admission)* | Network: $77/admission <br> Out-of-Network: 20% Cost-Share* |
| Mental Health Inpatient Admission | Network/OON: $23.45/day ($25 min/admission)* | Network: $77/admission <br> Out-of-Network: 20% Cost-Share* |
| Mental Health Outpatient – Primary Care | Network: $27 <br> Out-of-Network: 20% Cost-Share* | Network: $19 <br> Out-of-Network: 20% Cost-Share* |
| Mental Health Outpatient – Specialty Care | Network: $38 <br> Out-of-Network: 20% Cost-Share* | Network: $32 <br> Out-of-Network: 20% Cost-Share* |
*Cost-shares for Out-of-Network care are applied after the annual deductible is met. Non-participating providers may balance bill up to 15% above the TRICARE-allowable charge.
Costs for Retirees, Their Family Members, and Others
| Cost Type | TRICARE Select Group A | TRICARE Select Group B |
|---|---|---|
| Annual Enrollment Fee | Individual: $181.92 <br> Family: $364.92 | Individual: $579 <br> Family: $1,158.96 |
| Annual Deductible | Individual: $150 <br> Family: $300 | Network: $193 Ind / $386 Fam <br> Out-of-Network: $386 Ind / $772 Fam |
| Annual Catastrophic Cap | $4,261 per family | $4,509 per family |
| Clinical Preventive Services | $0 | $0 |
| Outpatient Visit – Primary Care | Network: $37 <br> Out-of-Network: 25% Cost-Share* | Network: $32 <br> Out-of-Network: 25% Cost-Share* |
| Outpatient Visit – Specialty Care | Network: $51 <br> Out-of-Network: 25% Cost-Share* | Network: $51 <br> Out-of-Network: 25% Cost-Share* |
| Urgent Care | Network: $37 <br> Out-of-Network: 25% Cost-Share* | Network: $51 <br> Out-of-Network: 25% Cost-Share* |
| Emergency Services | Network: $140 <br> Out-of-Network: 25% Cost-Share* | Network: $103 <br> Out-of-Network: 25% Cost-Share* |
| Hospitalization (Inpatient Admission) | Network: $250/day (or 25% charge) + 20% services* <br> OON: $1,306/day (or 25% charge) + 25% services* | Network: $225/admission <br> Out-of-Network: 25% Cost-Share* |
| Mental Health Inpatient Admission | Network: $250/day (or 25% charge) + 20% services* <br> OON: $1,306/day (or 25% charge) + 25% services* | Network: $225/admission <br> Out-of-Network: 25% Cost-Share* |
| Mental Health Outpatient – Primary Care | Network: $37 <br> Out-of-Network: 25% Cost-Share* | Network: $32 <br> Out-of-Network: 25% Cost-Share* |
| Mental Health Outpatient – Specialty Care | Network: $51 <br> Out-of-Network: 25% Cost-Share* | Network: $51 <br> Out-of-Network: 25% Cost-Share* |
*Cost-shares for Out-of-Network care are applied after the annual deductible is met. Non-participating providers may balance bill up to 15% above the TRICARE-allowable charge.
Deep Dive: TRICARE For Life (TFL)
What is TRICARE For Life?
TRICARE For Life (TFL) is fundamentally different from TRICARE Prime and Select. It is not a health plan that beneficiaries enroll in; rather, it is Medicare-wraparound coverage that works in conjunction with Medicare. TFL acts as a secondary payer to Medicare Parts A and B for individuals who are eligible for both TRICARE and Medicare. This coverage is available to eligible beneficiaries worldwide.
A key aspect of TFL is that it is an individual entitlement. This means TFL coverage only applies to the person who is eligible for TRICARE and enrolled in Medicare Parts A and B. It does not automatically extend to other family members who may be TRICARE-eligible but are not yet eligible for or enrolled in Medicare. Those family members typically remain enrolled in TRICARE Prime or TRICARE Select.
Who is Eligible for TFL?
Eligibility for TRICARE For Life rests on meeting two primary conditions simultaneously:
- TRICARE Eligibility: The individual must be eligible for TRICARE benefits, which generally includes military retirees, their eligible family members, and eligible survivors.
- Medicare Part A and Part B Enrollment: The individual must be enrolled in both Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance).
Once an individual meets both these requirements and is shown as eligible in DEERS, TFL coverage begins automatically. There is no separate application or enrollment process for TFL itself. Coverage starts on the first day that both Medicare Part A and Part B are effective.
The requirement to have and maintain Medicare Part B is absolutely critical. Beneficiaries must pay the monthly Medicare Part B premiums to remain eligible for TFL. Failure to enroll in Part B when first eligible (usually around age 65, unless an exception applies, such as the sponsor still being on active duty) or failure to pay Part B premiums can result in the loss of all TRICARE coverage, not just TFL. This linkage is a potential pitfall for beneficiaries approaching Medicare eligibility, highlighting the need for proactive enrollment in Medicare Part B to ensure continuity of TRICARE benefits. Medicare eligibility typically begins at age 65, although individuals under 65 may qualify based on disability or certain medical conditions. Information on Medicare enrollment is available from the Social Security Administration or the official Medicare website.
How TFL Works with Medicare (Claims, Payments, Using Your Cards)
In the United States and its territories, TFL operates seamlessly with Medicare for processing claims. When a TFL beneficiary receives care from a Medicare-accepting provider:
- The provider submits the claim to Medicare first.
- Medicare processes the claim and pays its share for covered services.
- Medicare automatically forwards the remaining claim information electronically to the TFL claims processor, which is Wisconsin Physicians Service (WPS) Military and Veterans Health for the U.S. and territories.
- TRICARE (via WPS) then pays the provider directly for the portion of the costs that TRICARE covers (typically the remaining amount for services covered by both programs).
Because of this coordination, beneficiaries generally have $0 out-of-pocket expenses for services that are covered by both Medicare and TRICARE when received in the U.S.
When seeking care, TFL beneficiaries should present both their Medicare card and their Uniformed Services ID card to the provider. There is no separate TFL enrollment card. Beneficiaries can see any healthcare provider who accepts Medicare patients. It is advisable to confirm the provider accepts Medicare before receiving services. Access to care at Military Treatment Facilities (MTFs) is limited to a space-available basis for TFL beneficiaries.
If a TFL beneficiary also has Other Health Insurance (OHI), such as an employer-sponsored plan, the payment coordination becomes more complex. Generally, the OHI pays first, followed by Medicare, with TRICARE paying last.
TRICARE For Life Costs (Coordination with Medicare, When TRICARE is Primary)
While TFL significantly reduces healthcare costs for many services, it’s not entirely free. There are no TFL-specific enrollment fees, but the mandatory Medicare Part B monthly premium must be paid. Medicare Part A is typically premium-free for those who have sufficient work history paying Medicare taxes.
Out-of-pocket costs under TFL depend entirely on whether the service received is covered by Medicare, TRICARE, both, or neither:
- Covered by Both Medicare and TRICARE: The beneficiary generally pays $0. Medicare pays its share, and TRICARE covers the remaining Medicare deductible and coinsurance amounts.
- Covered by Medicare Only: The beneficiary pays the Medicare deductible and cost-share/coinsurance. TRICARE pays nothing.
- Covered by TRICARE Only: Medicare pays nothing. The beneficiary pays the TRICARE annual deductible and applicable TRICARE cost-shares (these costs are generally similar to those under TRICARE Select for retirees).
- Covered by Neither Medicare nor TRICARE: The beneficiary pays 100% of the billed charges.
TRICARE becomes the primary payer in specific situations:
- When receiving care overseas (outside the U.S. and its territories), as Medicare provides little to no coverage abroad.
- When receiving services that are covered by TRICARE but not by Medicare (e.g., inpatient hospital stays beyond Medicare’s limits, certain services received overseas).
In these “TRICARE-primary” scenarios, the beneficiary is responsible for the TRICARE annual deductible and cost-shares applicable to their beneficiary category (generally, the costs align with TRICARE Select retiree costs). Finding the precise deductible and cost-share figures for these TRICARE-primary situations directly within TFL-specific documents can sometimes be challenging; beneficiaries may need to refer to TRICARE Select cost sheets or contact the TFL contractor (WPS or International SOS) for clarification.
The official TRICARE For Life Cost Matrix provides details on what Medicare pays for various services. For a summary of TFL costs, visit the TFL Costs page. This structure means that while TFL offers excellent protection against high costs for services covered by both programs in the US, beneficiaries can still face out-of-pocket expenses under certain conditions, particularly when traveling overseas or using TRICARE-only benefits.
Table: Simplified TRICARE For Life Cost Scenarios (U.S. Care)
| If the Service Is Covered By: | Medicare Pays | TRICARE Pays | You Pay |
|---|---|---|---|
| Both Medicare & TRICARE | Medicare-authorized amount | Remaining amount | $0 |
| Medicare Only | Medicare-authorized amount | $0 | Medicare Deductible & Cost-Share |
| TRICARE Only | $0 | TRICARE-allowable amount | TRICARE Deductible & Cost-Share |
| Neither Medicare nor TRICARE | $0 | $0 | 100% of Billed Charges |
Using TFL Overseas
Medicare generally does not cover healthcare services received outside the United States and its territories. Consequently, when a TFL beneficiary receives care in other overseas locations, TRICARE functions as the primary payer.
In this situation, the beneficiary is responsible for paying the TRICARE annual deductible and applicable cost-shares for the covered services received overseas, similar to how TRICARE Select costs apply. Beneficiaries may need to pay upfront for care and submit claims to the overseas TRICARE contractor, International SOS, for reimbursement.
Critically, even if living or traveling overseas indefinitely, beneficiaries must continue to be enrolled in and pay premiums for Medicare Part B to maintain their TFL eligibility. Letting Part B coverage lapse will result in the loss of TFL, even if Medicare itself is not being used for overseas care.
Comparing Your Options: Prime vs. Select vs. For Life
Key Differences at a Glance
TRICARE Prime, Select, and For Life offer distinct approaches to healthcare coverage within the military community:
- TRICARE Prime: Functions like an HMO (managed care). Requires enrollment, uses a Primary Care Manager (PCM) to coordinate care, generally needs referrals for specialists, focuses on network providers, and typically has the lowest out-of-pocket costs (primarily copayments for retirees/families). Active Duty Service Members must enroll in Prime.
- TRICARE Select: Functions like a PPO (preferred provider organization). Requires enrollment, offers freedom to choose any TRICARE-authorized provider (network or non-network), does not require a PCM or referrals for most specialty care, but involves potentially higher out-of-pocket costs (annual deductibles, cost-shares, possible enrollment fees for retirees) and potentially more administrative work (filing claims).
- TRICARE For Life (TFL): Is not an enrolled plan but automatic Medicare-wraparound coverage for TRICARE beneficiaries who also have Medicare Parts A & B. It acts as a secondary payer to Medicare in the U.S., significantly reducing costs for services covered by both. It requires paying Medicare Part B premiums.
The fundamental choice for eligible beneficiaries under age 65 often boils down to the trade-off between TRICARE Prime and TRICARE Select: lower, predictable costs with managed care (Prime) versus greater provider flexibility with potentially higher or less predictable costs and more self-management (Select). TFL operates under a different framework entirely, leveraging the beneficiary’s Medicare enrollment.
Table: TRICARE Plan Comparison
| Feature | TRICARE Prime | TRICARE Select | TRICARE For Life (TFL) |
|---|---|---|---|
| Plan Type | Managed Care (HMO-like) | Preferred Provider Organization (PPO-like) | Medicare Wraparound Coverage |
| Key Eligibility | ADSM mandatory; Choice for ADFM/Retiree <65 in PSA | Choice for ADFM/Retiree <65; ADSM ineligible | TRICARE-eligible + Medicare Parts A & B required |
| Enrollment Required | Yes | Yes | No (Automatic with Medicare A & B) |
| Primary Care Manager (PCM) | Required/Assigned | Not Required | Not Applicable (Follow Medicare/Provider Rules) |
| Referrals Needed | Generally Yes (from PCM for specialists) | Generally No (Direct access to specialists) | Not Applicable (Follow Medicare/Provider Rules) |
| Provider Choice | Network/PCM-focused; POS option for out-of-network | Any TRICARE-Authorized Provider (Network preferred) | Any Medicare Provider (U.S.); TRICARE provider (O/S) |
| Typical Out-of-Pocket Costs (U.S.) | Lowest (Copays for Retirees/Families) | Higher (Deductible + Copays/Cost-Shares) | Often $0 for dual-covered care; Medicare/TRICARE costs apply otherwise |
| Filing Claims | Usually handled by PCM/Network | May need to file for non-network care | Medicare/Provider files (U.S.); Beneficiary files (O/S) |
Factors to Consider When Choosing (Prime vs. Select)
For beneficiaries who have a choice between TRICARE Prime and TRICARE Select (primarily ADFMs and retirees under 65), several factors should influence the decision:
- Cost Sensitivity: Prime generally offers lower and more predictable out-of-pocket costs (fixed copayments after enrollment fees for retirees) if care is received within the network and according to referral rules. Select involves annual deductibles and cost-shares, which can lead to higher overall expenses, especially if non-network providers are frequently used or if balance billing occurs. Both plans have a catastrophic cap providing a safety net against very high costs for covered services.
- Provider Choice and Flexibility: Select provides maximum freedom to choose specialists and other providers directly without needing referrals. This is advantageous for those with established relationships with specific doctors (check their network status) or who prefer direct access. Prime requires working through a PCM for referrals, which some may find restrictive.
- Geographic Location: Prime enrollment requires living within a designated Prime Service Area (PSA). The convenience and availability of assigned MTFs or civilian network PCMs and specialists within the PSA are important considerations. Select is available more broadly, but the density and availability of network providers can vary by location, impacting potential costs.
- Administrative Preferences: Prime generally involves less administrative work for the beneficiary, as PCMs and network providers typically handle referrals and claims filing. Select users may need to manage their own specialist appointments and potentially pay upfront and file claims for reimbursement, particularly when using non-network providers.
- Other Health Insurance (OHI): If a beneficiary has other health insurance (e.g., through an employer), TRICARE Select often coordinates more easily as a secondary payer. Coordinating OHI with TRICARE Prime’s managed care structure can sometimes be more complex.
Ultimately, the “best” plan between Prime and Select is highly dependent on an individual’s or family’s specific circumstances, healthcare needs, budget, location, and preferences regarding provider access versus cost management. TRICARE For Life is not typically part of this choice equation, as eligibility is determined by meeting Medicare requirements.
Finding Official Information and Getting Help
Key TRICARE Resources
Navigating TRICARE requires access to accurate, official information. The following resources are essential:
- Official TRICARE Website: The primary source for all TRICARE information.
- TRICARE Plan Finder: Helps determine eligibility and available plans based on location and status.
- TRICARE Compare Costs Tool: Provides detailed cost breakdowns for different plans and beneficiary groups.
- TRICARE Find a Doctor Tool: Helps locate TRICARE-authorized network providers.
- TRICARE Publications: Offers downloadable handbooks, fact sheets, and cost matrices. Key documents include:
- Regional Contractors: Provide customer service, claims processing, and network management. Contact information is available on the TRICARE website for:
- milConnect Portal: Secure portal for managing benefits, updating DEERS information, obtaining proof of coverage, and enrolling in or changing plans via Beneficiary Web Enrollment (BWE).
- MHS Nurse Advice Line: Provides 24/7 access to registered nurses for urgent medical questions.
- TRICARE Contact Us / Ask a Benefit Question: Online forms and phone numbers for specific inquiries.
Final Reminder: Keep DEERS Updated!
Maintaining accurate information in the Defense Enrollment Eligibility Reporting System (DEERS) is absolutely essential for accessing TRICARE benefits without interruption. Ensure all personal and family information, including addresses, marital status, births, and Medicare eligibility, is kept current. Updates can be made through milConnect or by contacting the DMDC/DEERS Support Office (1-800-538-9552). Failure to update DEERS can lead to significant problems with eligibility verification and healthcare access.
Our articles make government information more accessible. Please consult a qualified professional for financial, legal, or health advice specific to your circumstances.
