TRICARE

For Life Handbook

May 2010

Important Information
Medicare: 1-800-633-4227
Social Security Administration: 1-800-772-1213
TRICARE National Web site: www.tricare.mil

TRICARE For Life Contractor

Wisconsin Physicians Service: 1-866-773-0404
TRICARE For Life Web site: www.TRICARE4u.com

TRICARE North Region Contractor

Health Net Federal Services, LLC: 1-877-TRICARE (1-877-874-2273)
Health Net Web site: www.healthnetfederalservices.com

TRICARE South Region Contractor

Humana Military Healthcare Services, Inc.: 1-800-444-5445
Humana Military Web site: www.humana-military.com

TRICARE West Region Contractor

TriWest Healthcare Alliance Corp.: 1-888-TRIWEST (1-888-874-9378)
TriWest Web site: www.triwest.com

An Important Note About TRICARE Program Changes

At the time of printing, this information is current. It is important to remember that
TRICARE policies and benefits are governed by public law and federal regulations. Changes
to TRICARE programs are continually made as public law and/or federal regulations are
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.
Welcome to TRICARE For Life
TRICARE For Life (TFL) is the Medicare-
wraparound coverage for “dual-eligible”
TRICARE beneficiaries. Regardless of
your age, you are considered dual-eligible
if you are entitled to premium-free Medicare
Part A and eligible for TRICARE because
you also have Medicare Part B coverage.
TFL provides comprehensive health care
coverage. You have the freedom to seek
care from any Medicare-certified provider,
at military treatment facilities on a space-
available basis, or at Veterans Affairs
facilities (if eligible).
1
Medicare-participating providers file your
claims with Medicare first. After paying
its portion, Medicare automatically forwards
the claim to TFL for processing (unless you
have other health insurance). TFL pays after
Medicare for covered health care services.
This handbook will help you make the
most of your TFL coverage. You will find
information about eligibility requirements,
getting care, and claims. This handbook
also provides details about your pharmacy
and dental coverage options.
Wisconsin Physicians Service/ The Centers for Medicare and Medicaid
TRICARE For Life Services provide Medicare entitlement data
for TRICARE beneficiaries to DEERS
Wisconsin Physicians Service (WPS/TFL) each month.
processes all TFL claims and provides
customer service. We encourage you to Maintaining your TRICARE eligibility is
visit and register at the WPS/TFL Web site, your responsibility. It is essential to verify
which includes authorization requirements, your information in DEERS any time you
claims status, and other helpful information. have a life-changing event, such as moving,
For assistance, call WPS/TFL at the toll-free marriage, or divorce.
numbers listed below.
You have several options for updating and
Phone 1-866-773-0404 verifying DEERS information:
1-866-773-0405 (TDD)
Online www.TRICARE4u.com
In Person1 • Visit a local identification
Mail WPS/TRICARE For Life (add or delete card-issuing facility.
Attn: Customer Service a family • Find a facility near you at
P.O. Box 7889 member or www.dmdc.osd.mil/rsl.
Madison, WI 53707-7889 update
• Call to verify location and
contact
business hours.
information)
Sign up to receive TFL and other
TRICARE program updates via e-mail Phone2 • 1-800-538-9552
• 1-866-363-2883 (TTY/TDD)
at www.tricare.mil/tricaresubscriptions.
Enter your e-mail address, select the topics Fax2 • 1-831-655-8317
that interest you, and click “Save” at the Mail2 • Defense Manpower Data
bottom of the page. Center Support Office
400 Gigling Road
Seaside, CA 93955-6771
Keep Your DEERS Online2 • DEERS Web site:
Information Current! www.dmdc.osd.mil/appj/address/
• Beneficiary Web
It is essential that you keep information in Enrollment Web site:
the Defense Enrollment Eligibility Reporting www.dmdc.osd.mil/appj/bwe/
System (DEERS) current for you and your 1. Only sponsors (or appointed powers of attorney)
can add or delete a family member. Family
family. DEERS is a worldwide, computerized
members age 18 and older may update their own
database of uniformed service members contact information.
(active duty and retired), their family 2. Use these methods to change contact
members, and others who are eligible for information only.
military benefits, including TRICARE.
Proper and current DEERS registration
is the key to receiving timely, effective
TFL benefits.
2
3
Table of Contents
1. How TRICARE For Life Works ............................................................ 6
Eligibility ......................................................................................................................6
Understanding Medicare ..............................................................................................6
Frequently Asked Questions: Medicare ........................................................................8
How TRICARE For Life Works with Medicare...........................................................9
Frequently Asked Questions: How TRICARE For Life Works ..................................12

2. Getting Care ..................................................................................... 15

Finding a Provider ......................................................................................................15
Emergency Care .........................................................................................................15
Urgent Care ................................................................................................................16
Prior Authorization for Care .......................................................................................16

3. TRICARE For Life Coverage .............................................................. 17

TRICARE Medical Coverage .....................................................................................17
Frequently Asked Questions: TRICARE For Life Coverage ......................................17
Prescription Drug Coverage .......................................................................................18
Dental Coverage .........................................................................................................22

4. Claims ............................................................................................... 23
Health Care Claims ....................................................................................................23
Pharmacy Claims .......................................................................................................24
Appealing a Claim or Authorization Denial...............................................................25
Third-Party Liability ..................................................................................................25
Explanation of Benefits ...............................................................................................26
Debt Collection Assistance Officers ...........................................................................26

5. Changes to Your TRICARE Coverage .............................................. 27

Getting Married or Divorced ......................................................................................27
Traveling .....................................................................................................................28
Moving .......................................................................................................................30
Survivor Coverage ......................................................................................................31
Loss of Eligibility .......................................................................................................31

4
6. For Information and Assistance ..................................................... 33
Wisconsin Physicians Service/TRICARE For Life ....................................................33
Beneficiary Counseling and Assistance Coordinators ................................................33
TRICARE Regional Contractors ................................................................................33
Appealing a Decision .................................................................................................34
Filing a Grievance ......................................................................................................35
Reporting Suspected Fraud and Abuse .......................................................................36

7. Glossary ............................................................................................ 38
8. List of Figures .................................................................................. 41
9. Index ................................................................................................. 42

For information about your patient rights and responsibilities, see the inside back cover of
this handbook.

5
How TRICARE For Life Works
Eligibility
TRICARE For Life (TFL) is available to
all Medicare/TRICARE dual-eligible
beneficiaries, regardless of age, provided
you have Medicare Part A and Medicare
Part B. You are eligible for TFL on the
date that you are entitled to premium-free
Medicare Part A and have Medicare Part B.
TRICARE Eligibility Requirements
When you are entitled to Medicare
Part A due to age, disability, or end-stage
renal disease (ESRD):
• Medicare Part B coverage is required to
remain TRICARE-eligible if you are a(n):
• Retired service member (including
retired National Guard and Reserve
members drawing retirement pay)
• Family member of a retired
service member
• Medal of Honor recipient or eligible
family member
• Survivor of a deceased sponsor
• Qualifying former spouse
• Medicare Part B coverage is not required
to remain TRICARE-eligible if:
• You are an active duty service member
(ADSM) or active duty family member
(ADFM) (ADSMs and ADFMs remain
eligible for TRICARE Prime and
TRICARE Standard and Extra options
while the sponsor is on active duty.
However, when the sponsor retires, you
must have Medicare Part B to remain
TRICARE-eligible. See “Medicare
6
Part B [Medical Insurance]” on the
following page for information about
the Medicare Part B special enrollment
period for ADSMs and ADFMs.)
Note: ADFMs who are entitled to Medicare
Part A for any reason may enroll in
TRICARE Prime if they live in a TRICARE
Prime Service Area (PSA). The Prime
enrollment fee is waived for those with
Medicare Part B coverage.
Understanding Medicare
TFL and Medicare are separate programs.
Medicare is managed by the Centers for
Medicare and Medicaid Services. Visit
www.medicare.gov to learn more about
Medicare.
Medicare is a health insurance program
for people:
• Age 65 or older
• Under age 65 with certain disabilities
• Any age with ESRD
Medicare Part A (Hospital Insurance)
Medicare Part A covers inpatient hospital
care, hospice care, inpatient skilled nursing
facility care, and some home health care.
The Social Security Administration (SSA)
determines your entitlement to Medicare
Part A based on your work history or your
spouse’s work history. You are eligible for
premium-free Medicare Part A at age 65 if
you or your spouse has 40 quarters or 10 years
of Social Security-covered employment.

Medicare Part B (Medical Insurance)
Medicare Part B covers provider services,
outpatient care, preventive care, home health
care, and durable medical equipment.
Medicare Part B has a monthly premium
amount, which may change annually. Visit
www.medicare.gov to find the current
premium amounts. If you sign up late for
Medicare Part B, you may have to pay a
monthly premium surcharge for as long as
you have Medicare Part B. The surcharge
is 10 percent for each 12-month period
that you were eligible for Medicare Part B
but did not enroll.
Medicare allows certain beneficiaries,
including ADSMs and ADFMs, to delay
Part B enrollment and sign up during a special
enrollment period, which waives Part B
late-enrollment premium surcharges. The
special enrollment period for ADSMs and
ADFMs is available any time the sponsor
is on active duty or within eight months
following either (1) the sponsor’s retirement,
or (2) the end of TRICARE coverage,
whichever comes first. However, signing
up during the Medicare special enrollment
period after the sponsor retires does not
guarantee continuous TRICARE coverage.
ADSMs and ADFMs must sign up for
Medicare Part B before sponsors retire to
avoid a break in TRICARE coverage.
Note: The special enrollment period does
not apply to individuals eligible for Medicare
based on ESRD. If you have ESRD, sign
up for Medicare Part A and Part B as
soon as you are eligible to avoid a break in
TRICARE coverage and late-enrollment
premium surcharges.
7
How tRicARe FoR LiFe woRkS
Section 1
Medicare Entitlement Based on
a Disability
If you receive disability benefits from the
SSA, you are entitled to Medicare in the
25th month of receiving disability payments.
The Centers for Medicare and Medicaid
Services notify you of your Medicare
entitlement date. If you return to work and
your Social Security disability payments
are suspended, your Medicare entitlement
continues for up to eight years and six
months. When your disability payments are
suspended, you receive a bill every three
months for your Medicare Part B premiums.
You must continue to pay your Medicare
Part B premiums to remain eligible for
TRICARE coverage.
Medicare Entitlement Based on Age
The Medicare entitlement age is 65. If you
already receive benefits from the SSA or the
Railroad Retirement Board, you automatically
receive Part A and are enrolled in Part B.
If you are age 65 or older and do not receive
Social Security or Railroad Retirement
Board benefits, you must apply for Medicare
benefits. Your Medicare initial enrollment
period is a seven-month period.
• If your birthday falls on the first of the
month, your initial enrollment period
begins four months before the month you
turn 65. Enroll no later than two months
before the month you turn 65 to avoid a
break in TRICARE. You are eligible for
Medicare on the first day of the month
before you turn 65.
• If your birthday falls on any day other
than the first of the month, your initial
 enrollment period begins three months
before the month you turn 65. Enroll no
later than one month before your birth
month to avoid a break in TRICARE. You
are eligible for Medicare on the first day
of the month you turn 65.
Enroll in Medicare Part B when first
eligible to avoid a break in TRICARE
coverage. If you sign up later than indicated
above, you may have to pay a monthly late-
enrollment premium surcharge for as long
as you have Part B. The Medicare Part B
surcharge is 10 percent for each 12-month
period that you were eligible to enroll in
Part B but did not enroll.
Medicare bills you every three months for
Part B premiums, unless you are already
receiving retirement benefits from either
Social Security or the Railroad Retirement
Board. Your Part B premiums are
automatically taken out of your retirement
check when you start receiving it.
See the Medicare and You handbook for
more information about what Medicare
covers. The Centers for Medicare and
Medicaid Services publishes the handbook
and mails copies to Medicare beneficiaries
annually. The handbook is also available
at www.medicare.gov.
Medicare Contact Information Figure 1.1
Online www.medicare.gov
Phone 1-800-633-4227
In Person Go to your local Social Security
Administration (SSA) office.
Visit www.ssa.gov to locate
an office near you or call SSA
at 1-800-772-1213.
8
Frequently Asked Questions:
Medicare
I will be 65 soon and will become entitled
to Medicare. I work full time and have
employer group health plan coverage,
and I don’t plan on retiring for a few
more years. Medicare says I can delay
my Part B enrollment if I have employer
group health plan coverage. How does
this affect my TRICARE benefits?
Medicare allows individuals with group
health plan coverage based on current
employment to delay Part B enrollment and
sign up during a special enrollment period,
which waives monthly late-enrollment
premium surcharges. If you or your spouse
still works and has group health plan
coverage through current employment, you
may sign up for Medicare Part B during the
special enrollment period, which is available
within the eight months following either
(1) retirement, or (2) the end of the group
health plan coverage, whichever comes first.
If you are eligible for premium-free Medicare
Part A, you must also have Part B to be
TRICARE-eligible, regardless of group
health plan coverage based on current
employment. Sign up for Part B before you
retire or lose group health plan coverage
to ensure TRICARE coverage under TFL.
Your TFL coverage begins on the same
day your Medicare Part A and Part B
coverage begins.

If I am not eligible for premium-free
Medicare Part A when I turn 65, can
I still use TFL?
No. Your TRICARE benefits remain the
same because you are not eligible for
premium-free Part A. You do not transition
to TFL. You may continue enrollment in
TRICARE Prime if you live in a PSA, or
use TRICARE Standard and TRICARE
Extra. For information about the TRICARE
program options available to you, visit
www.tricare.mil.
If you are not eligible for premium-free
Medicare Part A under your own Social
Security number (SSN) when you turn 65,
you must file for benefits under your spouse’s
(including divorced or deceased spouse’s)
SSN if he or she is 62 or older. If your
spouse (or divorced spouse) is not yet 62,
you must file for benefits under his or her
SSN when he or she turns 62.
If you will be eligible under your spouse’s
SSN in the future, you should sign up for
Medicare Part B during your initial premium
enrollment period to avoid paying monthly
Part B surcharges for late enrollment. Even
if you are not eligible for premium-free
Medicare Part A, you are eligible for Part B
at age 65. See “Medicare Entitlement Based
on Age” in this section for more information.
If you sign up for Medicare and are not
eligible for premium-free Part A under
your or your spouse’s (including divorced
or deceased spouse’s) SSN, you receive a
“Notice of Award” or “Notice of Disapproved
9
How tRicARe FoR LiFe woRkS
Section 1
Claim” from SSA. To keep your TRICARE
coverage, take the “Notice(s) of Award”
or “Notice(s) of Disapproved Claim” to a
uniformed services identification (ID) card-
issuing facility to have your DEERS record
updated and receive a new ID card. This
allows you to keep your eligibility for
TRICARE Prime or TRICARE Standard
and TRICARE Extra after you turn 65.
To ensure that your TRICARE coverage
continues without a break, contact Wisconsin
Physicians Service (WPS/TFL) after you
update your DEERS record. See the Welcome
to TRICARE For Life section for WPS/TFL
contact information.
Note: A Report of Confidential Social
Security Benefit Information (SSA-2458)
from the SSA cannot be used as proof
of non-Medicare entitlement to maintain
TRICARE eligibility.
For more answers to frequently asked
questions, visit www.tricare.mil/faqs.
How TRICARE For Life Works
with Medicare
Medicare and TFL work together to
minimize your out-of-pocket expenses.
However, there are instances in which
some health care costs may not be covered
by Medicare and/or TFL.
For cost information, visit the TFL Web
site at www.tricare.mil/tfl or contact
WPS/TFL at 1-866-773-0404.

Health Care Services Covered by
Medicare and TRICARE
When you see a Medicare-certified
provider, you have no out-of-pocket costs
for services covered by both Medicare
and TFL. Most health care services fall
into this category. After Medicare pays
its portion of the claim, TFL pays the
remaining amount and you pay nothing.
As the primary payer, Medicare approves
health care services for payment. If Medicare
does not pay because it determines that the
care is not medically necessary, TFL also
does not pay. You may appeal Medicare’s
decision. If Medicare reconsiders and
provides coverage, TFL also reconsiders
coverage.
If a health care service is covered by both
Medicare and TFL, but Medicare does not
pay because you have used up your Medicare
benefit, TFL becomes the primary payer.
In this case, you are responsible for your
TFL deductible and cost-shares.
10
If a health care service is normally covered
by both Medicare and TFL, but Medicare
does not pay because the provider has a
private contract* with the beneficiary (also
referred to as “opting out” of Medicare),
TFL will process the claim as the second
payer, unless you have other health insurance
(OHI). TFL pays the amount it would have
paid if Medicare had processed the claim
(normally 20 percent of the Medicare-
allowable charge).
* Under a private contract, there are no limits on
what the provider can charge for health care
services. Medicare does not pay the provider
or you for the health care services you receive,
even if Medicare covers the services/supplies.
Health Care Services Covered by
Medicare but Not by TRICARE
When you receive care that is covered by
Medicare only, TFL makes no payment,
regardless of any action Medicare takes.
You are responsible for the Medicare
deductible and cost-shares.
Health Care Services Covered by
TRICARE but Not by Medicare
When you receive care that is covered
by TFL but not by Medicare, TRICARE
processes the claim as the primary payer.
You are responsible for the applicable TFL
deductible and cost-shares.
TFL claims are normally filed with Medicare
first; however, when a health care service
clearly is not covered by Medicare, the claim
may be filed directly with WPS/TFL, unless
you have OHI. See the Claims section for
additional information.

Health Care Services Not Covered
by Medicare or TRICARE
When you receive care that is not covered by
Medicare or TFL, neither makes a payment
on the claim. You are responsible for the
entire bill.
See Figure 1.2 for TFL out-of-pocket costs.
Coordinating TRICARE For Life with
Other Health Insurance
Medicare and TFL coordination with
OHI depends on whether or not the OHI
is based on current employment. In either,
case, TFL is the last payer.
OHI Not Based on Current Employment
If you have OHI that is not based on your
or a family member’s current employment,
Medicare pays first, the OHI pays second,
and TFL pays third.
How tRicARe FoR LiFe woRkS
Section 1
OHI Based on Current Employment
Generally, if you have an employer-sponsored
health plan based on current employment,
that health plan pays first, Medicare pays
second, and TFL pays third. If there are
fewer than 20 employees in the employer-
sponsored plan, Medicare pays first, the
employer plan pays second, and TFL
pays third.
Because TFL pays last in either case, you
need to submit a claim to WPS/TFL for
any remaining balance after Medicare
and your OHI have paid. See the Claims
section for additional information.
Note: TRICARE pays after all health
benefits and insurance plans (including
Medicare), except for Medicaid, TRICARE
supplements, the Indian Health Service,
and other programs and plans as identified
by the TRICARE Management Activity.

TRICARE For Life Out-of-Pocket Costs Figure 1.2

Type of Service Medicare Pays TRICARE Pays You Pay
Covered by Medicare-authorized Remaining amount Nothing
TRICARE and amount
Medicare
Covered by Medicare-authorized Nothing Medicare deductible
Medicare only amount and cost-share
Covered by Nothing TRICARE-allowable TRICARE deductible
TRICARE only charge and cost-share
Not Covered by Nothing Nothing Total amount
TRICARE or Medicare charged

11
How TRICARE For Life
Works Overseas
Medicare provides coverage in U.S.
territories, including:
• American Samoa
• Guam
• Northern Mariana Islands
• Puerto Rico
• U.S. Virgin Islands
Medicare also covers health care services
received onboard ships in U.S. territorial
waters. In these locations, TFL works
exactly as it does in the United States.
Unless you have OHI, TFL is the second
payer after Medicare for most health care
services. Your provider files the claim with
Medicare first. Medicare pays its portion
and automatically forwards the claim to
WPS/TFL for processing.
Medicare does not provide coverage outside
of the United States and U.S. territories.
12
Therefore, TFL is your primary payer for
health care received overseas (except U.S.
territories), unless you have OHI. TFL
provides the same coverage as TRICARE
Standard and has the same cost-shares
and deductibles for beneficiaries who live
or travel overseas. Additionally, claims
for care received overseas are submitted
directly to the overseas WPS claims
processing address for the region where
you received care. See the Claims section
for more information.
Frequently Asked Questions:
How TRICARE For Life Works
Does TFL pay for the Medicare Part B
premium and deductible?
The Part B premium is your responsibility.
TFL covers the Medicare Part B deductible
as long as the health care service is covered
by both Medicare and TRICARE.

Using TFL seems so easy. Should I cancel
my Medicare supplement or Medicare
Advantage plan?
We suggest you carefully evaluate your
health insurance needs to determine if you
should continue any OHI plans, including
Medicare supplements and Medicare
Advantage plans. You can contact your
local State Health Insurance Assistance
Program for free health insurance counseling
and assistance. Visit www.medicare.gov
for more information on these programs.
If you drop your OHI coverage, you must
notify WPS/TFL. See the Welcome to
TRICARE For Life section for WPS/TFL
contact information.
I am a TFL beneficiary and a retired
federal employee. Can I suspend my
Federal Employee Health Benefits (FEHB)
coverage to use TFL?
Yes. You may apply to suspend your FEHB
coverage and premium payments at any time.
Visit www.opm.gov/forms or call the
Office of Personnel Management Retirement
Information Office at 1-888-767-6738
to get a Health Benefits Election Form
(SF 2809). Eligible, unremarried former
spouses can get the form from the employing
offices or retirement system maintaining
their enrollments.
13
How tRicARe FoR LiFe woRkS
Section 1
Is a referral or TRICARE prior
authorization required for health
care services?
A referral or TRICARE prior authorization
is not required under TFL when Medicare
is the primary payer. However, when TFL
becomes the primary payer, TRICARE
authorization requirements apply as they
would for a TRICARE Standard beneficiary.
I was enrolled in TRICARE Prime at
a military treatment facility (MTF). I
received a letter from the MTF telling me
I was no longer eligible for enrollment in
TRICARE Prime. What does that mean?
Once you become eligible for Medicare
Part A because you are age 65, you may be
eligible for TFL. You are no longer eligible
for enrollment in TRICARE Prime, unless
you have an active duty sponsor.
If you don’t have an active duty sponsor,
you must have Medicare Part A and Part B
to remain TRICARE-eligible. You may
continue to seek care at the MTF, but your
priority is lower and care is subject to space
and provider availability. Therefore, you may
need to seek care from Medicare-certified
civilian providers. When you visit these
providers, you have no out-of-pocket costs
for services covered by both Medicare and
TRICARE. Visit www.medicare.gov or call
Medicare at 1-800-633-4227 for assistance
with finding Medicare-certified providers.
You may be able to sign up for TRICARE
Plus, a primary care management program
that provides improved access to care within
the MTF. TRICARE Plus is available based
on the capability and capacity of each MTF.
Visit www.tricare.mil for more information
on TRICARE Plus.

For more answers to frequently asked

questions, visit www.tricare.mil/faqs.

14

Getting Care
Finding a Provider
Under TRICARE For Life (TFL), you may
receive health care services from Medicare-
participating and nonparticipating providers,
as well as from providers who have opted-
out of Medicare. If TFL is the primary
payer, you must visit TRICARE-authorized
providers and facilities. Costs vary according
to provider type (e.g., participating,
nonparticipating, opt-out).
Visit www.medicare.gov and search the
“Physician and Other Healthcare Professional
Directory” or call 1-800-633-4227 for
assistance. To find a TRICARE-authorized
provider, contact a local provider and ask
if he or she accepts TRICARE.
Medicare-Participating Providers
Medicare-participating providers agree to
accept the Medicare-approved amount as
payment in full.
Medicare Nonparticipating
Providers
Nonparticipating providers do not accept
the Medicare-approved amount as payment
in full. They may charge up to 115 percent
of the Medicare-approved amount. TFL
pays up to the 115-percent limiting charge.
Opt-Out Providers
Providers who opt-out of Medicare enter
into private contracts with patients. Medicare
does not pay for health care services you
receive from opt-out providers. TFL pays
the amount it would have paid if Medicare
15
How tRicARe FoR LiFe woRkS
Section 1
had processed the claim (normally 20
percent of the allowable charge). You are
responsible for paying the remainder of
the bill. In cases where access to medical
care is limited (i.e., underserved areas),
TFL may, on a case-by-case basis, waive
the second-payer status for Medicare opt-
out provider care and pay the claim as the
GettinG cARe
Section 2
primary payer.
Military Treatment Facilities
A military treatment facility (MTF) is a
military hospital or clinic usually located
on or near a military base. You may receive
care at an MTF on a space-available basis.
MTF appointments are limited, and you have
the lowest priority for receiving care. See
Figure 2.1 for MTF appointing priorities.
MTF Appointment Priorities Figure 2.1
1 Active duty service members
2 Active duty family members (ADFMs)
enrolled in TRICARE Prime
3 Retired service members, their families,
and all others enrolled in TRICARE Prime
4 ADFMs not enrolled in TRICARE Prime
TRICARE Reserve Select for Selected
Reserve members and their families
5 Retired service members, their families, and
all others not enrolled in TRICARE Prime
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
immediate medical attention would result in
a threat to life, limb, or sight; when a person
has severe, painful symptoms requiring
immediate attention to relieve suffering; or
when a person is at immediate risk to self
or others.

If you require emergency care, call 911 or

go to the nearest emergency room. Make
sure your claim is filed with Medicare.

Urgent Care

Urgent care services are medically necessary

services required for an illness or injury for you. If you have questions about
that would not result in further disability authorization requirements, visit the WPS/
or death if not treated immediately, but TFL Web site at www.TRICARE4u.com.
does require professional attention within
24 hours. You could require urgent care The following services require prior
for conditions such as a sprain, sore throat, authorization:
or rising temperature, as each of these has
• Adjunctive dental services
the potential to develop into an emergency
• Extended Care Health Option services
if treatment is delayed longer than 24 hours.
If you need urgent care, contact your physician • Home health care services
or Medicare for assistance. • Hospice care
• Nonemergency inpatient admissions for
Prior Authorization for Care substance use disorders or behavioral
health care
When TFL becomes the primary payer
• Outpatient behavioral health care visits
(e.g., if your Medicare benefits are
beyond the eighth visit per fiscal year
exhausted), TRICARE prior authorization
(October 1−September 30)
requirements apply.
• Transplants—all solid organ and stem cell
A prior authorization is a review of the
Note: This list is not all-inclusive.
requested health care service to determine
if it is medically necessary at the requested
level of care. Some providers may call
Wisconsin Physicians Service (WPS)/TFL
(WPS/TFL) to obtain prior authorization

16
TRICARE For Life Coverage
TRICARE Medical Coverage
TRICARE For Life (TFL) and Medicare
cover most care that is medically necessary
and considered proven. TFL has special
rules and limitations for certain types of
care, and some types of care are not covered
at all. TRICARE policies are very specific
about which services are covered and which
are not. One of your duties under TRICARE’s
Patient Bill of Rights and Responsibilities
is to be knowledgeable about your TFL
coverage and program options. It is in
your best interest to take an active role in
verifying coverage.
Note: Medicare also has limits on the
amount of care it covers and, in some
cases, TFL may cover these health care
services after your Medicare benefits have
been exhausted.
To determine if Medicare covers a specific
service or benefit, visit www.medicare.gov
or call 1-800-633-4227. To determine if
TFL covers the service or benefit, visit the
TRICARE Web site at www.tricare.mil
or contact Wisconsin Physicians Service
(WPS/TFL) at 1-866-773-0404. See
Figure 1.2 in the How TRICARE For Life
Works section for more information on
your out-of-pocket costs.
Examples of services that are generally
not covered by either program include:
• Acupuncture
• Experimental or investigational services
(in most cases)
17
• Eye examinations (routine)
• Hearing aids*
Note: This list is not all-inclusive.
* Retired sponsors may be eligible for the Retiree-
At-Cost Hearing Aid Program. If you are a retired
service member and you need a hearing aid, you
should call a participating military treatment
GettinG cARe
Section 2
facility to learn more about the program. Visit
www.militaryaudiology.org/rachap/state.html
for more information.
Frequently Asked Questions:
TRICARE For Life Coverage
Does TFL cover long-term care?
No. Long-term care (or custodial care) is
not a covered benefit. However, you may
tRicARe FoR LiFe coveRAGe
Section 3
qualify to purchase long-term care insurance
through commercial insurance programs
or through the Federal Long Term Care
Insurance Program. For information about
the Federal Long Term Care Insurance
Program, visit www.opm.gov/insure/ltc
or call 1-800-582-3337.
Does TRICARE cover skilled
nursing care?
TFL covers reasonable and necessary skilled
nursing care and rehabilitative therapies;
semiprivate rooms, regular nursing services;
meals (including special diets); physical,
occupational, and speech therapy; drugs
furnished by the facility; and necessary
medical supplies and appliances. Skilled
nursing care is typically provided in a skilled
nursing facility (SNF).
For TFL and Medicare to cover an SNF
admission, you must have had a medical
condition that was treated in a hospital for
at least three consecutive days, and you
must be admitted to a Medicare-certified,
TRICARE-participating SNF within 30 days
of discharge from the hospital (with some
exceptions for medical reasons). Your
doctor’s plan of care must demonstrate your
need for skilled nursing services.
Note: TFL is the primary payer for SNF
care beyond Medicare’s 100-day limit as
long as the patient continues to require
medically necessary skilled nursing services.
Prior authorization is required after 150 days.
TFL covers an unlimited number of days
as medically necessary.
For more answers to frequently asked
questions, visit www.tricare.mil/faqs.
Prescription Drug Coverage
TFL offers comprehensive prescription drug
coverage and several options for filling your
prescriptions. To fill a prescription, you need
the prescription and a valid uniformed
services identification (ID) card or Common
Access Card.
Note: As long as you remain TRICARE-
eligible, you do not need a Medicare
Part D prescription drug plan to keep your
TRICARE prescription drug coverage.
18
The TRICARE Pharmacy Program is
administered by Express Scripts, Inc.
(Express Scripts). More information on
the TRICARE Pharmacy Program is
available at www.tricare.mil/pharmacy
or www.express-scripts.com/TRICARE.
Military Treatment Facility Pharmacy
A military treatment facility (MTF)
pharmacy is the least expensive option for
filling prescriptions. At an MTF pharmacy,
you may receive up to a 90-day supply of
most medications at no cost. Most MTF
pharmacies accept prescriptions written
by both civilian and military providers,
regardless of whether or not you are enrolled
at the MTF.
Non-formulary medications are generally
not available at MTF pharmacies. To check
the availability of a particular drug, contact
the nearest MTF pharmacy in person or
by phone.
Visit www.tricare.mil/militarypharmacy
for more information on MTF pharmacies.
Mail Order Pharmacy
The Mail Order Pharmacy is your least
expensive option when not using an MTF
pharmacy. With the Mail Order Pharmacy,
there is only one copayment for each
prescription filled (up to a 90-day supply).
Additionally, prescriptions are delivered to
you through free standard shipping, and
refills can be easily ordered online, by
phone, or by mail. The Mail Order Pharmacy
also provides you with refill reminders,
convenient notifications about your order
status, and assistance with renewing expired
Mail Order Pharmacy Registration Methods
Online Visit www.express-scripts.com/TRICARE
Phone Call 1-877-363-1303 or 1-877-540-6261 (TDD/TTY)
Mail Download the registration form from www.express-scripts.com/TRICARE,
and mail it to:
Express Scripts, Inc.
P.O. Box 52150
Phoenix, AZ 85072-9954
prescriptions. If you have questions about
your prescriptions, pharmacists are available
24 hours a day, seven days a week to talk
confidentially with you.
For faster processing of your mail-order
prescriptions, you can register before placing
your first order. Once you are registered, your
provider can fax or call in your prescriptions.
Register for the Mail Order Pharmacy
using any of the options in Figure 3.1.
Express Scripts sends your medications
directly to your home within about 14 days
of receiving your prescription. If you have
prescription drug coverage through other
health insurance (OHI), you can use the
Mail Order Pharmacy only if the medication
is not covered under your OHI or if you
exceed the OHI’s coverage dollar limit.
Member Choice Center
The Member Choice Center makes it easy
to reduce your out-of-pocket costs by
transferring your current maintenance
medication prescriptions to the Mail Order
Pharmacy. If you prefer the convenience
of home delivery, contact the Member
Choice Center to convert your current retail
or MTF prescriptions to the Mail Order
Pharmacy. Mail-order copayments apply.
19
Figure 3.1
Visit www.express-scripts.com/TRICARE
and click on the “get started with Home
Delivery” feature, or call 1-877-363-1433
to get started.
Note: To use the Member Choice Center,
you must have a maintenance prescription
dispensed at a retail pharmacy or MTF.
The Member Choice Center contacts your
provider to obtain a new written prescription
for home delivery.
tRicARe FoR LiFe coveRAGe
Section 3
TRICARE Retail Network Pharmacies
Another option for filling your prescriptions
is through TRICARE retail network
pharmacies. You may fill prescriptions
(one copayment per 30-day supply) when
you present your written prescription and
uniformed services ID card to the pharmacist.
This option allows you to fill prescriptions
at TRICARE network pharmacies without
submitting claims. You have access to
approximately 60,000 retail network
pharmacies in the United States and U.S.
territories (American Samoa,* Guam, the
Northern Mariana Islands, Puerto Rico,
and the U.S. Virgin Islands).
* Currently, there are no TRICARE retail network
pharmacies in American Samoa.

Visit www.express-scripts.com/TRICARE
or call 1-877-363-1303 to find the nearest
TRICARE retail network pharmacy.
Non-Network Pharmacies
When visiting non-network pharmacies,
you pay the full price of your medication
up front and file a claim for reimbursement.
Reimbursements are subject to deductibles,
out-of-network cost-shares, and TRICARE-
required copayments. All deductibles must
be met before any reimbursement can be
made. For details about filing a claim, see
the Claims section.
Quantity Limits
TRICARE has established quantity limits
on certain medications, which means the
Department of Defense (DoD) only pays up
to a specified, limited amount of medication
20
each time you fill a prescription. Quantity
limits are often applied to ensure medications
are safely and appropriately used.
Exceptions to established quantity limits
may be made if the prescribing provider
can justify medical necessity. For a general
list of TRICARE-covered prescription
drugs that have quantity limits, visit
www.tricareformularysearch.org.
Prior Authorization
Some drugs require prior authorization
from Express Scripts. Medications requiring
prior authorization may include, but are
not limited to, prescription drugs specified
by the DoD Pharmacy and Therapeutics
Committee, brand-name medications with
generic equivalents, medications with age
limitations, and medications prescribed
for quantities exceeding normal limits.
Visit www.tricareformularysearch.org
for a general list of TRICARE-covered
prescription drugs that require prior
authorization. If you do not have Internet
access, call 1-877-363-1303 to inquire
about a specific drug.
Generic Drug Use Policy
Generic drugs are medications approved
by the U.S. Food and Drug Administration
and clinically equivalent to brand-name
medications. Generic drugs provide the same
safe, effective treatment as brand-name drugs.
It is DoD policy to use generic medications
instead of brand-name medications whenever
possible. A brand-name drug with a generic
equivalent may be dispensed only after the
prescribing physician completes a clinical
assessment that indicates the brand-name
drug is medically necessary and after
Express Scripts grants approval. If a generic-
equivalent drug does not exist, the brand-
name drug is dispensed at the brand-name
copayment. If you fill a prescription with
a brand-name drug that is not considered
medically necessary and when a generic
equivalent is available, you are responsible
for paying the entire cost of the prescription.
Non-Formulary Drugs
The DoD Pharmacy and Therapeutics
Committee may recommend to the Director
of the TRICARE Management Activity
that certain drugs be placed in the third,
“non-formulary” tier. These medications
include any drug in a therapeutic class
determined to be not as relatively clinically
effective or as cost-effective as other drugs
in the same class. For an additional cost,
third-tier drugs are available through the
Mail Order Pharmacy or retail network
pharmacies. You may be able to fill non-
formulary prescriptions at formulary costs if
your provider can establish medical necessity
by completing and submitting the appropriate
TRICARE pharmacy medical-necessity
form for the non-formulary medication. Call
Express Scripts at 1-877-363-1303 or visit
www.pec.ha.osd.mil/forms_criteria.php
for forms and medical-necessity criteria.
To learn more about medications and
common drug interactions, 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.
21
For information on how to save money
and make the most of your pharmacy
benefit, visit www.tricare.mil/pharmacy
or www.express-scripts.com/TRICARE.
Specialty Medication
Care Management
Specialty medications are usually high-cost;
self-administered; injectable, oral, or infused
drugs that treat serious chronic conditions
(e.g., multiple sclerosis, rheumatoid arthritis,
hepatitis C). These drugs typically require
special storage and handling and are not
readily available at your local pharmacy.
Specialty medications may also have side
effects that require pharmacist and/or
nurse monitoring.
The Specialty Medication Care Management
program is structured to improve your health
through continuous health evaluation,
tRicARe FoR LiFe coveRAGe
Section 3
ongoing monitoring, assessment of
educational needs, and management of
medication use. This program provides:
• Access to proactive, clinically based
services for specific diseases and is
designed to help you get the most
benefit from your medication
• Monthly refill reminder calls
• Scheduled deliveries to your
specified location
• Specialty consultation with a nurse
or pharmacist at any point during
your therapy
These services are provided to you at
no additional cost when you receive your
medications through the Mail Order
Pharmacy, and participation is voluntary.
If you or your provider orders a specialty
medication from the Mail Order Pharmacy,
Express Scripts sends you additional
information about the Specialty Medication
Care Management program and how to
get started.
Using the Mail Order Pharmacy to fill
specialty medication prescriptions provides
you with access to the Specialty Medication
Care Management program benefits
described above. You may submit a specialty
medication prescription by mail, or your
provider may submit it by fax. If you are
currently using another pharmacy to fill
your specialty medication prescription, you
can contact the Member Choice Center at
1-877-363-1433 to switch to the Specialty
Medication Care Management program.
With specific mailing instructions from you
or your provider, the Mail Order Pharmacy
ships your specialty medication to your home.
For your convenience and safety, the Mail
Order Pharmacy contacts you to arrange
delivery before the medication is shipped.
Note: Some specialty medications may
not be available through the Mail Order
Pharmacy because the medication’s
manufacturer limits the drug’s distribution
to specific pharmacies. If you submit a
prescription for a limited-distribution
medication, the Mail Order Pharmacy either
forwards your prescription to a pharmacy of
your choice that can fill it or provides you
with instructions about where to send the
prescription to have it filled. To determine
if your specialty medication is available
through the Mail Order Pharmacy, visit
www.tricareformularysearch.org.
22
Pharmacy Claims
You do not need to file pharmacy claims
to fill prescriptions at an MTF pharmacy,
through the Mail Order Pharmacy, or at
a TRICARE retail network pharmacy.
However, if you fill a prescription at a non-
network pharmacy in the United States or
its territories, you must pay the full price
of your prescription up front and file a claim
for reimbursement. See “Pharmacy Claims”
in the Claims section for more information.
Dental Coverage
TFL beneficiaries are eligible for dental
coverage under the TRICARE Retiree
Dental Program (TRDP). The TRDP is
a voluntary dental insurance program
administered by Delta Dental® of
California (Delta Dental).
The TRDP offers comprehensive, cost-
effective dental coverage for uniformed
services retirees and their eligible family
members, retired National Guard and
Reserve members (including those who are
entitled to retired pay, but do not begin
receiving it until age 60) and their eligible
family members, certain surviving family
members of deceased active duty sponsors,
and Medal of Honor recipients and their
immediate family members and survivors.
For information about the TRDP, visit the
TRDP Web site at www.trdp.org or call
Delta Dental toll-free at 1-888-838-8737.
Claims
Health Care Claims
In most cases, your provider files your health
care claims with Medicare first. Medicare
pays its portion and, unless you have other
health insurance (OHI), forwards the claim
to TRICARE For Life (TFL) for processing.
However, when TFL is the primary payer
(e.g., if Medicare does not cover the health
care service), your provider may be required
to file your claim directly with Wisconsin
Physicians Service (WPS)/TFL (WPS/TFL).
If you have OHI, you must file the claim
with your OHI before filing with TFL.
You are responsible for making sure your
claims are filed within one year of either
the date of service or the date of an inpatient
Attach a readable copy of the provider’s bill
to the claim form, making sure it contains
the following:
• Patient’s name
• Sponsor’s Social Security number (SSN)
(Eligible former spouses should use their
SSNs, not their sponsors’.)
• Provider’s name and address (If more than
one provider’s name is on the bill, circle
the name of the person who provided the
service for which the claim is filed.)
• 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.)

tRicARe FoR LiFe coveRAGe

Section 3
discharge. To file a claim with TFL, obtain
and fill out a TRICARE DoD/CHAMPUS
Medical Claim—Patient’s Request for
Medical Payment (DD Form 2642) form.
You can download forms and instructions
from the TRICARE Web site at
www.tricare.mil/claims or the WPS/TFL
Web site at www.TRICARE4u.com. You
can also obtain forms and instructions at a
TRICARE Service Center (TSC) or a military
treatment facility (MTF). Fill out the form
cLAimS
Section 4

completely, and sign it. To locate a TSC or

MTF, visit www.tricare.mil/contactus.

When filing a claim with TFL, include

your Medicare Summary Notice and OHI
explanation of benefits (EOB), if applicable.

23
Unlike other TRICARE beneficiaries, TFL 2. Complete the form and attach the
beneficiaries should file claims in the regions required paperwork, as described
where they received care. Send claims to the on the form.
appropriate mailing address in Figure 4.1. 3. Mail the form and paperwork to:
Regional Claims Express Scripts, Inc.
Processing Information Figure 4.1 TRICARE Claims
Region Mailing Address P.O. Box 66518
United States WPS/TRICARE For Life St. Louis, MO 63166-6518
P.O. Box 7890
Madison, WI 53707-7890 Prescription claims require the following
Eurasia-Africa TRICARE Overseas information for each drug:
Region 13
P.O. Box 8976 • Patient’s name
Madison, WI 53707-8976 • Prescription name, strength, date filled,
Latin America TRICARE Overseas days’ supply, quantity dispensed, and price
and Canada Region 15
P.O. Box 7985 • National Drug Code, if available
Madison, WI 53707-7985 • Prescription number
Pacific TRICARE Overseas • Name and address of the pharmacy
Region 14
P.O. Box 7985 • Name and address of the
Madison, WI 53707-7985 prescribing physician

Contact Express Scripts, Inc. (Express

Pharmacy Claims
You do not need to file pharmacy claims
for prescriptions filled at MTF pharmacies,
through the Mail Order Pharmacy, or at
TRICARE retail network pharmacies.
However, if you fill a prescription at a non-
network pharmacy in the United States or
U.S. territories, you must pay the full price
of your prescription up front and file a
claim for reimbursement.
To file a claim:
1. Download DD Form 2642 at
www.tricare.mil/claims.
Scripts), at 1-877-363-1303 with questions
about filing pharmacy claims.
Pharmacy Claims Appeals
If you disagree with the determination on
your pharmacy claim (i.e., if your claim is
denied), you or your appointed representative
has the right to request a reconsideration.
The request (or appeal) for reconsideration
must be in writing, signed, and postmarked
or received by Express Scripts within
90 calendar days from the date of the
decision and must include a copy of the
claim decision.
Your signed, written request must state the
specific matter you disagree with and must

24
be sent to the following address no later
than 90 days from the date of the notice:
Express Scripts, Inc.
P.O. Box 60903
Phoenix, AZ 85082-0903
Additional documentation in support of the
appeal may be submitted; however, because
the request for reconsideration must be
postmarked or received within 90 calendar
days of the date of the decision, the request for
reconsideration should not be delayed pending
acquisition of additional documentation. If
additional documentation will be submitted
at a later date, the letter requesting
reconsideration must state that additional
documentation will be submitted and specify
the expected date of submission. Upon
receiving your request, all TRICARE claims
related to the entire course of treatment
are reviewed.
25
Appealing a Claim or
Authorization Denial
You may appeal the denial of a requested
authorization of services or decisions
regarding claims payment. Medicare and
TFL have separate appeals processes.
Medicare-related appeals should be
submitted to Medicare. You should only
submit appeals to WPS/TFL if TFL is
the primary payer. For more detailed
information on appeals processes, see
“Appealing a Decision” in the For
Information and Assistance section.
cLAimS
Section 4
Third-Party Liability
If TRICARE is the primary payer, the
Federal Medical Care Recovery Act allows
TRICARE to be reimbursed for treatment
costs if you are injured in an accident
caused by someone else. The Statement
of Personal Injury—Possible Third-Party
Liability (DD Form 2527) form is 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 returning it
to the appropriate claims processor. You
can also download DD Form 2527 at
www.tricare.mil/claims.
Explanation of Benefits
A TRICARE EOB is not a bill. It is an
itemized statement that shows the action
TRICARE has taken on your claims. An
EOB is for your information and files.
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. You should keep EOBs with your
health insurance records for future reference.
For more information about appeals, see
the For Information and Assistance section
or visit www.TRICARE4u.com.
Debt Collection
Assistance Officers
TRICARE Debt Collection Assistance
Officers (DCAOs) are located at MTFs and
TRICARE Regional Offices to help resolve
your TRICARE health care collection-related
issues. Contact a DCAO if you received a
negative credit rating or were contacted by
a collection agency due to an issue related
to your TFL claim.
26
When you visit a TRICARE DCAO
for assistance, you must take or submit
documentation associated with a collection
action or adverse credit rating, including
debt collection letters, EOBs, and medical
and/or dental bills from providers. The more
information you provide, the faster the cause
of the problem can be determined. The
DCAO researches your claim, provides you
with a written resolution of your collection
problem, and informs the collection agency
that action is being taken to resolve the issue.
DCAOs cannot provide legal advice or
repair your credit rating, but they can
help by providing documentation for the
collection or credit-reporting agency to
explain the circumstances relating to the
debt. Visit the DCAO directory online
at www.tricare.mil/bcacdcao to find a
TRICARE DCAO near you.
TRICARE DCAOs can only assist you with
TFL-related issues. Contact Medicare for
assistance with Medicare-related issues.

Changes to Your TRICARE Coverage
TRICARE For Life (TFL) continues to
provide health care coverage for you and
your family as your life changes. However,
you need to take specific actions to make
sure you remain TRICARE-eligible. For
each life event listed in this section, the first
step is to update your information in the
Defense Enrollment Eligibility Reporting
System (DEERS).
You have several options for updating and
verifying DEERS information. See “Keep
Your DEERS Information Current!” in the
How TRICARE For Life Works section of
this handbook for details.
The following segments provide information
about what to do when you get married,
travel, and more.
27
cHAnGeS to YouR tRicARe coveRAGe
Section 5
Getting Married or Divorced
Marriage
It is extremely important for sponsors to
register new spouses in DEERS to ensure
they are eligible for TRICARE programs,
including TFL. To register a new spouse in
DEERS, the sponsor needs to provide a copy
of the marriage certificate to the nearest
uniformed services identification (ID)
card-issuing facility. The new spouse is
also required to show two forms of ID
(e.g., any combination of Social Security
card, driver’s license, birth certificate,
current military ID card, or Common
Access Card [CAC]). Once your spouse is
registered in DEERS, he or she receives a
uniformed services ID card and is eligible
for TFL. Your spouse must show his or
her ID card to access care.
Divorce
Sponsors must update DEERS in the event
of a divorce. The sponsor needs to provide
a copy of the divorce decree, dissolution,
or annulment.
Children
After a divorce, any children who retain
eligibility under the sponsor remain
cLAimS
Section 4
TRICARE-eligible up to age 21 (or age 23
if enrolled in a full-time course of study at
an approved institution of higher learning,
and if the sponsor provides at least 50
percent of the financial support), as long
as his or her DEERS information is current.
To extend coverage, contact DEERS to
verify what documentation is needed.
Although a child normally does not get his
or her own uniformed services ID card
until age 10, a child younger than 10 should
have an ID card if he or she is in the custody
of a parent or guardian who is not TRICARE-
eligible or who is not the custodial parent.
Patient privacy may be a factor for divorced
parents attempting to obtain information
about health care services received.
Note: Children with disabilities may remain
TRICARE-eligible beyond the normal age
limits. Contact DEERS for information
about eligibility criteria.
Former Spouses
Certain former spouses are eligible to
continue TFL coverage as long as they:
• Do not remarry (If a former spouse
remarries, the loss of benefits remains
applicable even if the remarriage ends
in death or divorce.)
• Are not covered by employer-sponsored
health plans
• Are not also former spouses of North
Atlantic Treaty Organization or “Partners
for Peace” nation members
• Meet the requirements of one of the two
situations described in Figure 5.1
Former spouses who are TFL-eligible must
change their personal information in DEERS
so their names and Social Security numbers
(SSNs) are listed for the primary contact
information. The former spouse’s TRICARE
eligibility is shown in DEERS under his or
her SSN, not the sponsor’s.
Traveling
When you travel in the United States
or overseas, you can still receive TFL-
covered care.
Traveling within the United States
If you need emergency care while traveling
in the continental United States, visit the
nearest emergency room or call 911.

Eligibility Requirements for Former Spouses Figure 5.1

1 • The former spouse must have been married to the same military member or former member
for at least 20 years, and at least 20 of those years must have been creditable in determining
the member’s eligibility for retirement pay.
• The former spouse is eligible for TRICARE coverage after the date of the divorce,
dissolution, or annulment.1
• Eligibility continues as long as the preceding requirements continue to be met and the
former spouse does not remarry.

2 • The former spouse must have been married to the same military member or former
member for at least 20 years, and at least 15—but less than 20—of those married years
must have been creditable in determining the member’s eligibility for retirement pay.
• The former spouse is eligible for TRICARE coverage for only one year from the date of
the divorce.
1. For divorce decrees, annulments, or dissolutions on or before September 29, 1988, contact DEERS for
verification of eligibility.

28
 cHAnGeS to YouR tRicARe coveRAGe
Section 5
TRICARE Overseas Program Contact Information Figure 5.2
TRICARE Eurasia-Africa TRICARE Latin America TRICARE Pacific
and Canada
Africa, Europe, and the Canada, the Caribbean Basin, Asia, Guam, India, Japan,
Middle East Central and South America, Korea, New Zealand, and
Puerto Rico, and the Western Pacific remote countries
U.S. Virgin Islands
TRICARE Overseas TOP Regional Call Center* TOP Regional Call Centers*
Program (TOP) Regional 1-215-942-8393 Singapore: 011-65-6339-2676
Call Center* tricarephl@internationalsos.com sin.tricare@internationalsos.com
011-44-20-8762-8384 Sydney: 011-61-2-9273-2710
Medical Assistance*
tricarelon@internationalsos.com sydtricare@internationalsos.com
1-215-942-8320
Medical Assistance* Medical Assistance*
011-44-20-8762-8133 Singapore: 011-65-6338-9277
Sydney: 011-61-2-9273-2760
TRICARE Area Office TRICARE Area Office TRICARE Area Office
011-49-6302-67-6314 011-1-706-787-2424 011-81-6117-43-2036
314-496-6314 (DSN) 312-773-2424 (DSN) 315-643-2036
1-888-777-8343, option 1 1-888-777-8343, option 3 1-888-777-8343, option 4
(stateside toll-free) (stateside toll-free) (stateside toll-free)
teoweb@europe.tricare.osd.mil taolac@tma.osd.mil tpao.csc@med.navy.mil
www.tricare.mil/eurasiaafrica www.tricare.mil/tlac www.tricare.mil/pacific
* Visit www.tricare-overseas.com for toll-free numbers.

When traveling within the United States,
you can visit any provider for care. To find
a Medicare-certified provider while on the
road, call 1-800-633-4227 for assistance
or visit www.medicare.gov and search
the “Physician and Other Healthcare
Professional Directory.” When you visit the
doctor, you need to show your Medicare
card and your uniformed services ID card.
Traveling Overseas
If you need emergency or urgent care while
traveling overseas, contact the nearest
American Embassy Health Unit or TRICARE
Area Office (TAO) for the overseas area
where you are traveling to find a host nation
provider. Visit www.usembassy.state.gov
for a list of every American Embassy and
Consular Office worldwide. Figure 5.2 lists
contact information for the TAO in each
overseas area.
Note: When seeking care from a host
nation provider, you should be prepared to
pay up front for services and submit a claim
to the overseas claims processor, Wisconsin
Physicians Service (WPS). Mail your claim
to the WPS address for the region where
you received care.
See “How TRICARE For Life Works
Overseas” in the How TRICARE For Life
Works section for more information. Visit
the TFL Web site at www.tricare.mil/tfl
or contact WPS/TFL at 1-866-773-0404
for cost information.

29
Filling Prescriptions on the Road
You may use any TRICARE pharmacy
option when traveling, but be sure your
DEERS information is current. To fill a
prescription, you need a valid uniformed
services ID card. At overseas host nation
pharmacies, you may have to pay up front
and submit a claim to the overseas WPS
claims processing address for the region
where you filled the prescription.
TRICARE Retail Network Pharmacy
You can fill prescriptions at any TRICARE
retail network pharmacy in the United States
and U.S. territories (American Samoa,*
Guam, the Northern Mariana Islands,
Puerto Rico, and the U.S. Virgin Islands).
Visit www.express-scripts.com/TRICARE
or call 1-877-363-1303 to find the nearest
TRICARE retail network pharmacy.
* Currently, there are no TRICARE retail network
pharmacies in American Samoa.
Military Treatment Facility Pharmacy
If you are traveling, you can fill a new
prescription at any military treatment facility
(MTF) pharmacy with no copayment, if the
medication is on the MTF formulary and in
stock. You will need the prescription and
your uniformed services ID card or CAC.
An MTF pharmacy determines if you can
obtain a refill of a prescription that was
originally filled at another MTF.
Mail Order Pharmacy
If you are staying away from home for a
longer period of time, you can plan ahead to
receive prescriptions through the TRICARE
Mail Order Pharmacy. Provide Express
30
Scripts, Inc. (Express Scripts), with your
temporary address so prescriptions can be
mailed to you at your travel destination.
The Mail Order Pharmacy is only available
overseas if you have an APO/FPO address.
Note to military retirees: If you and your
family are living or traveling overseas
without serving in an official capacity, you do
not have APO/FPO mail access. Therefore,
you cannot receive medications by mail
through the Mail Order Pharmacy. Visit
www.express-scripts.com/TRICARE or
call 1-877-363-1303 for assistance.
Non-Network Pharmacy
If there is no other option, you can fill
prescriptions at any non-network pharmacy.
You are required to pay for prescriptions up
front and file a claim with Express Scripts
for reimbursement. See the Claims section
for details about filing a pharmacy claim.
Filling Prescriptions Overseas
Your pharmacy coverage is limited overseas.
TFL recommends that you fill all of your
prescriptions before traveling overseas.
TRICARE retail network pharmacies are
only located in the United States and U.S.
territories. You must have an APO/FPO
address to use the Mail Order Pharmacy
overseas, and the prescription must be
from a U.S.-licensed provider. Be prepared
to pay up front for medications and file
a claim for reimbursement for non-MTF
and non-network pharmacy services when
traveling overseas.

Moving
Whether you are moving across the street
or overseas, moving with TFL is easy. All
you need to do is update your personal
information in DEERS, find a provider who
is Medicare-certified (in the United States
and U.S. territories) and TRICARE-
authorized, and continue to receive care
when you need it.
Moving within the United States
Visit www.medicare.gov and search
the “Physician and Other Healthcare
Professional Directory” to find Medicare-
certified providers in your area, or call
1-800-633-4227 for assistance.
Moving Overseas
See the How TRICARE For Life Works
section for information about how TFL
works when you live overseas.
Survivor Coverage
If your sponsor dies, you remain TRICARE-
eligible and will continue to receive TFL
benefits as long as your DEERS information
is up to date and you are either of
the following:
• A surviving spouse and do not remarry
(If you remarry, TRICARE eligibility
cannot be regained later, even if you
divorce or your new spouse dies.)
• An unmarried child under age 21 (or
age 23 if enrolled in a full-time course
of study at an approved institution
of higher learning and if the sponsor
provided at least 50 percent of the
financial support)
31
cHAnGeS to YouR tRicARe coveRAGe
Section 5
Note: Children with disabilities may remain
eligible beyond normal age limits. Check
DEERS for eligibility criteria.
Upon the death of your sponsor, you will
receive a letter from DEERS telling you
about your program options and how your
benefits will eventually change. If you have
any questions, visit www.tricare.mil/deers.
Loss of Eligibility
Upon loss of TRICARE eligibility, each
family member automatically receives
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.
Certificates may be issued in the following
circumstances:
• Upon the sponsor’s separation from active
duty, a certificate is issued to the sponsor
listing all eligible family members.
• Upon the loss of eligibility for a dependent
child (age 21, or 23 if enrolled in a full-
time course of study at an approved
institution of higher learning and if the
sponsor provides at least 50 percent of
the financial support), a certificate is
issued to the dependent child.
• Upon loss of coverage after divorce, a
certificate is issued to the former spouse
as soon as the information is updated
in DEERS.
Certificates automatically 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
family member it is issued for, the dates
TRICARE coverage began and ended, and
the certificate issue date.

Send written requests for certificates of

creditable coverage to the Defense Manpower
Data Center Support Office at:

Defense Manpower Data Center

Support Office
ATTN: Certificate of
Creditable Coverage
400 Gigling Road
Seaside, CA 93955-6771

The request must include:

• Sponsor’s name and SSN
• Name of person the certificate is
requested for
• Reason for the request
• Name of person and address the
certificate should be sent to
• Requester’s signature

Certificates cannot be requested by phone.

If there is an urgent need for a certificate
of creditable coverage, fax your request
to 1-831-655-8317 and/or request that the
certificate be faxed to a particular number.

Additional information is available at

www.tricare.mil/certificate.

32

For Information and Assistance
Wisconsin Physicians Service/
TRICARE For Life
TRICARE For Life (TFL) beneficiaries
should contact Wisconsin Physicians
Service (WPS/TFL) for information about
benefits, authorization requirements, and
claims assistance.
WPS/TFL Contact Information Figure 6.1
Phone 1-866-773-0404 (toll-free)
1-866-773-0405 (toll-free TDD)
Online www.TRICARE4u.com
Mail WPS/TRICARE For Life
Attn: Customer Service
P.O. Box 7889
Madison, WI 53707-7889
Beneficiary Counseling and
Assistance Coordinators
TRICARE Beneficiary Counseling and
Assistance Coordinators (BCACs) can help
you with TFL and Military Health System
inquiries and concerns, and they can advise
you about obtaining health care. BCACs
are located at military treatment facilities
and TRICARE Regional Offices. To locate
a BCAC, visit the online directory at
www.tricare.mil/bcacdcao.
TRICARE Regional Contractors
TRICARE North Region
The TRICARE North Region includes
Connecticut; Delaware; the District of
Columbia; Illinois; Indiana; Kentucky;
Maine; Maryland; Massachusetts; Michigan;
33
cHAnGeS to YouR tRicARe coveRAGe
Section 5
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).
FoR inFoRmAtion And ASSiStAnce
Section 6
TRICARE North Regional
Contractor Information Figure 6.2
Regional Health Net Federal
contractor Services, LLC
Phone 1-877-TRICARE
(1-877-874-2273)
Web site www.healthnetfederalservices.com
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 South Regional
Contractor Information Figure 6.3
Regional Humana Military Healthcare
contractor Services, Inc.
Phone 1-800-444-5445
Web site www.humana-military.com
TRICARE West Region
The TRICARE West Region includes
Alaska, Arizona, California, Colorado,
Hawaii, Idaho, Iowa (excluding the Rock
Island Arsenal area), Kansas, Minnesota,
Missouri (excluding the St. Louis area),
Montana, Nebraska, Nevada, New Mexico,
North Dakota, Oregon, South Dakota, TRICARE For Life Appeals
Texas (the southwestern corner, including Requirements
El Paso), Utah, Washington, and Wyoming. You may appeal a TFL denial of a requested
authorization of services even if no care
TRICARE West Regional
was provided and no claim was submitted.
Contractor Information Figure 6.4
There are some things you may not appeal.
Regional TriWest Healthcare
contractor Alliance Corp. For example, when TFL is the primary
payer, you may not appeal the denial
Phone 1-888-TRIWEST
of care from a provider who is not
(1-888-874-9378)
TRICARE-authorized.
Web site www.triwest.com

When services are denied based on a

Appealing a Decision
medical necessity or a benefit decision,
you are automatically notified in writing.
If you believe a service or claim was
The notification includes an explanation
improperly denied, in whole or in part, you
of what was denied or why a payment
(or another appropriate party) may file an
was reduced and the reasoning behind
appeal. An appeal must involve an appealable
the decision.
issue. For example, you have the right to
appeal Medicare or TFL decisions regarding
Your TFL appeal must meet the requirements
payment of your claims.
listed in Figure 6.5 on the following page.
Medicare and TFL have separate claims
Filing TRICARE For Life Appeals
processes. For most services, Medicare is
TFL appeals must be filed with WPS/TFL
your primary payer. If you want to appeal a
within 90 days from the date that appears
decision Medicare makes, you must contact
on the explanation of benefits (EOB) or
Medicare. Contact WPS/TFL to appeal
denial notification letter. If you are not
TFL decisions.
satisfied with a decision rendered on an
Medicare Denials appeal, there may be further levels of appeal
available to you. For specific information
Any services or supplies denied payment
about filing a TFL appeal, contact WPS/TFL.
by Medicare and appealable under Medicare
are not considered for coverage by TFL.
Prior authorization denial appeals may be
However, if a Medicare appeal results in
either expedited or non-expedited, depending
some payment by Medicare, TRICARE
on the urgency of the situation. You or an
considers coverage as the second payer.
appointed representative must file for an
For more information on Medicare appeals,
expedited review of a prior authorization
visit www.medicare.gov or call
denial within three calendar days of receipt
1-800-633-4227.
of the initial denial. A non-expedited

34
TRICARE For Life Appeals Requirements Figure 6.5

1 An appropriate appealing party must submit the appeal. Proper appealing parties include:
• You, the beneficiary
• A person appointed, in writing, by you to represent you for the purpose of the appeal
• An attorney filing on your behalf
• Non-network participating providers
If a party other than those listed above submits the appeal, you must complete and sign the
Appointment of Representative and Authorization to Disclose Information form, which is
available on the Wisconsin Physicians Service Web site at www.TRICARE4u.com. Appeals
submitted without this form will not be processed.
Note: Network providers are not appropriate appealing parties, unless appointed, in writing,

FoR inFoRmAtion And ASSiStAnce

Section 6
by you.
2 The appeal must be submitted in writing. See the mailing address below.

3 The issue in dispute must be an appealable issue. The following are not appealable issues:
• Allowable charges
• Eligibility
• Denial of services from an unauthorized provider
• Denial of treatment plan when an alternative treatment plan is selected
4 An appeal must be filed within 90 days of the date on the explanation of benefits or denial
notification letter.
5 There must be an amount in dispute to file an appeal. In cases involving an appeal of a denial
of an authorization in advance of receiving the actual services, the amount in dispute is
deemed to be the estimated TRICARE-allowable charge for the services requested. There
is no minimum amount to request a reconsideration.

review of a denial must be filed no later • Any appropriate supporting documents

than 90 days after receipt of the initial denial.
Mail TRICARE appeals and supporting
Appeals should contain the following: documentation to:
• Beneficiary’s name, address, and WPS/TRICARE For Life
telephone number ATTN: Appeals
• Sponsor’s Social Security number (SSN) P.O. Box 7490
• Beneficiary’s date of birth Madison, WI 53707-7490
• Beneficiary’s or appealing party’s signature Filing a Grievance

A description of the issue or concern must This section provides information about
include: filing TFL-related grievances. Contact
• The specific issue in dispute Medicare to file Medicare-related grievances.
• A copy of the previous denial
determination notice
35
A grievance is a written complaint or
concern about a non-appealable issue
regarding a perceived failure by any
member of the TFL health care delivery
team, including TRICARE-authorized
providers or military providers, to provide
appropriate and timely health care services,
access, or quality, or to deliver the proper
level of care or service.
The TFL grievance process allows full
opportunity to report, in writing, any concern
or complaint regarding health care quality
or service. Any TFL civilian or military
provider; TFL beneficiary; sponsor; or
parent, guardian, or other representative
of an eligible dependent child may file a
grievance. WPS/TFL is responsible for the
investigation and resolution of all grievances.
Grievances are generally resolved within
60 days of receipt. Following resolution,
the party that submitted the grievance is
notified of the review completion.
Grievances may include such issues as:
• The quality of health care or services
(e.g., accessibility; appropriateness; level,
continuity, and timeliness of care)
• The demeanor or behavior of providers
and their staffs
• The performance of any part of the
health care delivery system
• Practices related to patient safety
When filing a grievance, include the
following information:
• Beneficiary’s name, address, and
telephone number
• Sponsor’s SSN
36
• Beneficiary’s date of birth
• Beneficiary’s signature
A description of the issue or concern must
include the following:
• Date and time of the event
• Name(s) of the provider(s) and/or
person(s) involved
• Address of the event
• Nature of the concern or complaint
• Details describing the event or issue
• Any appropriate supporting documents
File grievances with WPS/TFL using one
of the following methods:
1. Mail:
WPS/TRICARE For Life
Priority Grievances
P.O. Box 8974
Madison, WI 53708
2. E-mail: reportit@wpsic.com
Reporting Suspected Fraud
and Abuse
This section provides information about
reporting suspected fraud and abuse related
to TFL. Contact Medicare about Medicare’s
process for reporting suspected fraud
and abuse.
Fraud happens when a person or organization
deliberately deceives others to gain an
unauthorized benefit. Health care abuse
occurs when providers supply services or
products that are medically unnecessary
or that do not meet professional standards.
TFL beneficiaries are important partners To report fraud or abuse regarding the
in the ongoing fight against fraud and abuse. TRICARE Retiree Dental Program, contact
Because an EOB is a tangible statement of Delta Dental® of California using one of
TFL services and/or supplies received, it the methods listed in Figure 6.8.
is one of the first lines of defense against
TRICARE Retiree Dental
health care fraud. Each EOB provides a
Program Fraud and Abuse
toll-free number to call if you have concerns Reporting Information Figure 6.8
about services you believe were billed Phone 1-888-838-8737 (toll-free)
fraudulently. For information about reporting 1-866-847-1264 (toll-free TTY/TDD)
fraud and abuse, you can also visit the Online www.trdp.org

FoR inFoRmAtion And ASSiStAnce

Section 6
TRICARE Fraud and Abuse Web site at Mail Delta Dental of California
www.tricare.mil/fraud. Use claims tools Federal Services
on the WPS/TFL Web site to view your P.O. Box 537015
Sacramento, CA 95853-7008
EOBs and claims history and track the costs
TRICARE pays. We strongly encourage
you to read your EOBs carefully. You can also report fraud or abuse
issues directly to TRICARE at
To report suspected fraud and abuse fraudline@tma.osd.mil.
regarding TFL, contact WPS/TFL using
one of the methods listed in Figure 6.6.

WPS/TFL Fraud and Abuse

Reporting Information Figure 6.6
Phone 1-866-773-0404
Online reportit@wpsic.com
Mail WPS/TRICARE For Life
Attn: Program Integrity
P.O. Box 7516
Madison, WI 53707-7516

To report fraud or abuse regarding the

TRICARE Pharmacy program, contact
Express Scripts, Inc. using one of the
methods listed in Figure 6.7.

TRICARE Pharmacy Program

Fraud and Abuse
Reporting Information Figure 6.7
Phone 1-800-332-5455, ext. 367079
E-mail fraudtip@express-scripts.com

37
Glossary
Beneficiary Counseling and Assistance Dual-Eligible
Coordinator (BCAC)
TRICARE beneficiaries who also are
BCACs are persons at military treatment eligible for Medicare are considered dual
facilities and TRICARE Regional Offices eligible and are covered under TRICARE
who are available to answer questions, help For Life if they are entitled to Medicare
solve health care-related problems, and Part A and have Medicare Part B coverage.
assist beneficiaries in obtaining medical
care through TRICARE. To locate a BCAC, Explanation of Benefits (EOB)
visit www.tricare.mil/bcacdcao. An EOB is a statement sent to a beneficiary
showing that a claim was processed, and it
Cost-share
includes the amount paid to the provider. If
A cost-share is the percentage or portion denied, an explanation of denial is provided.
of costs that the beneficiary will pay for
inpatient or outpatient care. Medicare Nonparticipating Provider
Nonparticipating providers do not accept
Debt Collection Assistance
the Medicare-approved amount as payment
Officer (DCAO)
in full. They may charge up to 115 percent of
DCAOs are persons at military treatment
the Medicare-approved amount. TRICARE
facilities and TRICARE Regional Offices
For Life pays up to the 115-percent limiting
who assist TRICARE beneficiaries in
charge for covered services.
resolving health care collection-related
issues. Beneficiaries should contact a DCAO Medicare Participating Provider
if they received a negative credit rating or
A Medicare participating provider is a
were contacted by a collection agency due
physician, hospital, skilled nursing facility,
to an issue related to TRICARE services.
home health agency, hospice, or other
health care provider that has agreed to
Defense Enrollment Eligibility
Reporting System (DEERS) accept the Medicare-approved amount as
payment in full.
DEERS is a database of uniformed service
members (sponsors), family members, and
Military Treatment Facility (MTF)
others worldwide who are entitled under law
An MTF is a medical facility (e.g., hospital,
to military benefits, including TRICARE.
clinic) owned and operated by the uniformed
Beneficiaries are required to keep DEERS
services and usually located on or near a
updated. DEERS is the official record system
military base. Beneficiaries can locate an
for TRICARE eligibility.
MTF by visiting www.tricare.mil/mtf.

38
Negotiated Rate
The negotiated rate is the rate TRICARE
network providers and TRICARE
participating non-network providers have
agreed to accept for covered services.
Network Provider
A TRICARE network provider is a
professional or institutional provider who has
a contractual relationship with a TRICARE
contractor to provide care at a contracted
rate. A network provider agrees to file
claims for TRICARE beneficiaries. A
network provider accepts the negotiated rate
as payment in full for services rendered.
Non-Network Provider
A non-network provider has no contractual
relationship with a TRICARE contractor but
is authorized to provide care to TRICARE
beneficiaries. There are two categories of
non-network providers—participating and
nonparticipating.
Nonparticipating Non-Network
Provider
A nonparticipating non-network provider
is a TRICARE-authorized hospital,
institutional provider, physician, or other
provider that furnishes medical services
and supplies to TRICARE beneficiaries,
but has not signed a contract and does not
agree to accept the TRICARE-allowable
charge or file claims for TRICARE
beneficiaries.
39
Opt-Out Provider
Providers who opt-out of Medicare enter
into private contracts with patients. Medicare
does not pay for health care services received
from opt-out providers. For covered services,
TRICARE pays the amount that TRICARE
would have paid had Medicare processed
the claim (normally 20 percent of the
allowable charge). In cases where access to
medical care is limited (i.e., underserved
areas), TRICARE may waive the second
payer status for the health care services of
a Medicare opt-out provider and pay the
claim as the primary payer.
Other Health Insurance (OHI)
OHI is any non-TRICARE health insurance
that is not considered a supplement. This
insurance is acquired through an employer,
entitlement program (including Medicare), or
other source. Under federal law, TRICARE
GLoSSARY
Section 7
is the last payer to all health benefits and
insurance plans, except for Medicaid,
TRICARE supplements, the Indian Health
Service, and other programs or plans as
identified by the TRICARE Management
Activity.
Participating Non-Network Provider
A participating non-network provider agrees
to file claims for TRICARE beneficiaries,
accept payment directly from TRICARE,
and accept the TRICARE-allowable charge
as payment in full for services delivered.
Non-network providers may participate on
a claim-by-claim basis. Providers may seek
payment of applicable copayments, cost-
shares, and deductibles from the beneficiary.
Prime Service Area (PSA)
A PSA is an area around a military treatment
facility and in other predetermined areas,
as defined by ZIP codes where TRICARE
Prime is offered.
Prior Authorization
Prior authorization is the process of
reviewing certain medical, surgical, and
behavioral health care services to ensure
medical necessity and appropriateness of
care before services are rendered or within
24 hours of an emergency admission. A
TRICARE prior authorization is not required
under TRICARE For Life when Medicare
is the primary payer. However, when
TRICARE becomes the primary payer,
TRICARE authorization requirements
apply. Visit your TRICARE contractor’s
Web site for a list of services that require
prior authorization.
Regional Contractor
A regional contractor is a TRICARE civilian
partner who provides health care services
and support in the TRICARE regions.
Health Net Federal Services, LLC is the
regional contractor for the North Region;
Humana Military Healthcare Services, Inc.
is the regional contractor for the South
Region; and TriWest Healthcare Alliance
Corp. is the regional contractor for the
West Region.
TRICARE-Authorized Provider
A TRICARE-authorized provider meets
TRICARE’s licensing and certification
requirements and is certified by TRICARE
to provide care to TRICARE beneficiaries.
When TRICARE is the primary payer, you
are responsible for the full cost of care if
you see a provider who is not TRICARE-
authorized and can never be certified.
TRICARE-authorized providers include
doctors, hospitals, ancillary providers
(laboratories and radiology centers),
and pharmacies. There are two types
of authorized providers—network and
non-network.
TRICARE Supplement
A TRICARE supplement is a health plan
you may purchase specifically to supplement
your TRICARE coverage. It pays after
TRICARE. A TRICARE supplement is
not employer-sponsored health insurance.

TRICARE-Allowable Charge
The TRICARE-allowable charge (also
called allowable charge) is the maximum
amount TRICARE pays for services.

40
List of Figures
Figure 1.1 Medicare Contact Information ...................................................................... 8
Figure 1.2 TRICARE For Life Out-of-Pocket Costs .....................................................11
Figure 2.1 MTF Appointment Priorities ....................................................................... 15
Figure 3.1 Mail Order Pharmacy Registration Methods .............................................. 19
Figure 4.1 Regional Claims Processing Information .................................................... 23
Figure 5.1 Eligibility Requirements for Former Spouses ............................................. 28
Figure 5.2 TRICARE Overseas Program Contact Information.................................... 29
Figure 6.1 WPS/TFL Contact Information .................................................................. 33
Figure 6.2 TRICARE North Regional Contractor Information .................................... 33
Figure 6.3 TRICARE South Regional Contractor Information .................................... 33
Figure 6.4 TRICARE West Regional Contractor Information ..................................... 34
Figure 6.5 TRICARE For Life Appeals Requirements ................................................ 35
Figure 6.6 WPS/TFL Fraud and Abuse Reporting Information ................................... 37
Figure 6.7 TRICARE Pharmacy Program Fraud and Abuse Reporting Information ..... 37
Figure 6.8 TRICARE Retiree Dental Program
Fraud and Abuse Reporting Information ...................................................... 37

GLoSSARY
Section 7
LiSt oF FiGuReS
Section 8

41
Index
A Defense Manpower Data Center Support
Accident, 25, 42 Office, 2, 32
Active duty family member (ADFM), 6–7, Delta Dental® of California (Delta Dental),
15, 42 22, 37
Active duty service member (ADSM), Dental care, 16
6–7, 15 Dependent child, 31, 36
Active duty sponsor, 13, 22 Disability, 6–7, 16, 28, 31
Acupuncture, 17 Divorce, 2, 9, 27–28, 31
Age limitations, 20, 28, 31 Durable medical equipment, 7
Allowable charge, 11, 15, 35, 39–40 E
Ancillary providers, 40 Eligibility, 1–2, 6–9, 13, 17–18, 22–23,
Appeal, 10, 24–26, 34–35 27–28, 31–32, 35–36, 38, 42
Appointment, 15, 35 Emergency, 15–16, 28–29, 40
Authorization, 2, 13, 16, 18, 20, 25, End-stage renal disease (ESRD), 6–7
33–35, 40 Enrollment, 2, 6–9, 13, 15, 18, 27, 31, 38, 42
B Explanation of benefits (EOB), 23, 26,
Behavioral health care, 16, 40, 42 34–35, 37–38
Beneficiary Counseling and Assistance Express Scripts, Inc. (Express Scripts),
Coordinator (BCAC), 26, 33, 38, 42 18–22, 24–25, 30, 37
Bill, 7–8, 11, 15, 17, 23, 26, 42 Eye examinations, 17
Brand-name drug, 20–21, 42 F
C Federal Employees Health Benefits
Centers for Medicare and Medicaid (FEHB), 13
Services, 2, 6–8, 42 Former spouse, 6, 13, 23, 28, 31
Certificate of creditable coverage, 31–32, 42 Fraud and abuse, 36–37
Charge, 10–11, 15, 23, 35, 38–40, 42 G
Children, 27–28, 31, 36, 42 Generic drug, 20, 42
Claim, 1–2, 9–12, 15–16, 19–20, 22–26, Generic equivalent, 20–21, 42
29–30, 33–34, 37–39, 42 Grievance, 35–36, 42
Common Access Card (CAC), 18, 27, 30, 42 Guardian, 28, 36, 42
Copayment, 18–21, 30, 39, 42
Cost-share, 10–12, 20, 38–39, 42 H
Custodial care, 17, 42 Health Net Federal Services, LLC
Custodial parent, 28, 42 (Health Net), 33, 40, 42
D Hearing aids, 17, 42
Home health care, 6–7, 16, 42
Debt Collection Assistance Officer (DCAO), Hospice care, 6, 16, 42
26, 38, 42 Hospital, 6, 15, 18, 38–40, 42
Deductible, 10–12, 20, 39, 42 Humana Military Healthcare Services, Inc.
Defense Enrollment Eligibility Reporting (Humana Military), 33, 40
System (DEERS), 2, 9, 27–28, 30–31, 38

42
 index
Section 9
I Pharmacy, 1, 18–22, 24, 30, 37, 40, 43
Identification (ID) card, 9, 18–19, 27–30, 43 Physical therapy, 17
Indian Health Service, 11, 39, 43 Premium, 1, 6–9, 12–13
Prescription, 18–22, 24, 30
L Preventive care, 7
Limitations, 17, 20, 43 Prime Service Area (PSA), 6, 9, 40
Long-term care, 17, 43 Prior authorization, 13, 16, 18, 20, 34, 40
M Program options, 9, 17, 31
Mail Order Pharmacy, 18–19, 21–22, 24, 30 Q
Marriage, 2, 27–28 Quantity limits, 20, 43
Medicaid, 2, 6–8, 11, 39, 42 R
Medical equipment, 7
Medicare nonparticipating provider, 15, 38 Referral, 13, 43
Medicare Part A, 1, 6–9, 13, 38 Reimbursement, 20, 22, 24–25, 30, 43
Medicare Part B, 1, 6–9, 12, 38 Renal disease, 6, 43
Medicare Part D, 18 Retail network pharmacy, 19–22, 24,
Medicare participating provider, 38 30, 43
Medicare-certified provider, 1, 10, 13, Retired, 2, 6–8, 13, 15, 17, 22, 28, 30,
29, 31 37, 43
Medication, 18–22, 30, 43 S
Member Choice Center, 19, 22 Skilled nursing care, 17–18, 43
Military treatment facility (MTF), 1, 13–15, Skilled nursing facility (SNF), 6, 18, 38, 43
17–19, 22–24, 26, 30, 33, 38, 40 Social Security Administration (SSA),
Moving, 2, 31 6–9, 43
N Social Security number (SSN), 9, 23, 28,
National Guard and Reserve, 6, 22, 43 32, 35–36, 43
Network pharmacy, 19–22, 24, 30, 43 South Region, 33, 40, 43
Network provider, 35, 39, 43 Specialty Medication Care Management,
Non-formulary drugs, 18, 21, 43 21–22, 43
Non-network pharmacy, 20, 22, 24, 30, 43 Specialty medication, 21–22, 43
Non-network provider, 39, 43 Speech therapy, 17, 43
Nonparticipating provider, 15, 38, 43 Spouse, 6, 8–9, 13, 23, 27–28, 31, 43
North Region, 33, 40, 43 Substance use disorder, 16, 43
Survivor, 6, 22, 31, 43
O
T
Occupational therapy, 17, 43
Other health insurance (OHI), 1, 10–13, 19, Third-party liability, 25–26, 43
23, 39 Transplants, 16, 43
Out-of-pocket costs, 9–11, 13, 17, 19 Travel, 12, 27–30, 43
Outpatient care, 7, 38 TRICARE Area Office (TAO), 29, 43
TRICARE Eurasia-Africa, 29, 43
P TRICARE Extended Care Health Option
Participating provider, 35, 38, 43 (ECHO), 16, 43
Payment, 7, 10–11, 13, 15, 23, 25, 34, TRICARE Extra, 6, 9, 43
38–39, 43 TRICARE Formulary Search Tool, 21, 43

43
TRICARE Latin America and Canada,
29, 43
TRICARE Management Activity, 11, 21,
29, 37, 39, 43
TRICARE Overseas Program (TOP), 29
TRICARE Pacific, 29
TRICARE Pharmacy Program, 18, 37
TRICARE Plus, 14
TRICARE Prime, 6, 9, 13, 15, 40
TRICARE Regional Office, 26, 33, 38
TRICARE Retiree Dental Program
(TRDP), 22, 37
TRICARE Service Center (TSC), 23
TRICARE Standard, 6, 9, 12–13
TRICARE supplement, 11, 39–40
TRICARE-allowable charge, 11, 35, 39–40
TRICARE-authorized hospital, 39
TRICARE-authorized provider, 10, 15,
36, 40
TriWest Healthcare Alliance Corp.
(TriWest), 34, 40
U
Uniformed services identification (ID) card,
9, 18–19, 27–30
Urgent care, 16, 29
V
Veterans Affairs, 1, 44
W
West Region, 33, 40, 44
Wisconsin Physicians Service (WPS), 2,
9–13, 16–17, 23–25, 29–30, 33–37, 44

44
Patient Bill of Rights and Responsibilities
As a patient in the military health As a patient in the military health
system, you have the right to: system, you have the responsibility to:
• Receive accurate, easy-to-understand • Maximize healthy habits, such as
information to help you make informed exercising, not smoking, and maintaining
decisions about TRICARE programs, a healthy diet.
medical professionals, and facilities. • Be involved in health care decisions,
• Have a choice of health care providers which means working with providers in
that is sufficient to ensure access to developing and carrying out agreed-upon
appropriate high-quality health care. treatment plans, disclosing relevant
• Access emergency health care services information, and clearly communicating
when and where the need arises. your wants and needs.
• Receive and review information about • Be knowledgeable about TRICARE
diagnosis, treatment, and the progress of coverage and program options.
your condition, and to fully participate in
all decisions related to your health care, You also have the responsibility to:
or to be represented by family members, • Show respect for other patients and
conservators, or other duly appointed health care workers.
representatives.
• Make a good-faith effort to meet
• Receive considerate, respectful care from financial obligations.
all members of the health care system
without discrimination based on race, • Use the disputed claims process when
ethnicity, national origin, religion, sex, there is a disagreement.
age, mental or physical disability, sexual • Report wrongdoing and fraud to
orientation, genetic information, or appropriate resources or legal authorities.
source of payment.
• Communicate with health care
providers in confidence and to have
the confidentiality of your health care
information protected. You also have
the right to review, copy, and request
amendments to your medical records.
• Have a fair and efficient process for
resolving differences with your health
plan, health care providers, and the
institutions that serve them.
• For more information, visit
www.tricare.mil/patientrights/default.cfm.

Please provide feedback on this handbook at:

www.tricare.mil/evaluations/booklets
TRICARE
TRICARE ForRegion
North Life
Health Net Federal Services, LLC
Wisconsin Physicians Service
www.healthnetfederalservices.com
www.TRICARE4u.com
1-877-TRICARE (1-877-874-2273)
1-866-773-0404
TRICARE South Region
Humana
TRICARE Military Healthcare
North RegionServices, Inc.
www.humana-military.com
Health Net Federal Services, LLC
1-800-444-5445
www.healthnetfederalservices.com
1-877-TRICARE
TRICARE (1-877-874-2273)
West Region
TriWest Healthcare Alliance Corp.
www.triwest.com
TRICARE South Region
1-888-TRIWEST (1-888-874-9378)
Humana Military Healthcare Services, Inc.
www.humana-military.com
1-800-444-5445

TRICARE West Region

TriWest Healthcare Alliance Corp.
www.triwest.com
1-888-TRIWEST (1-888-874-9378)
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HA642BET05101

www.tricare.mil