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TRICARE and TRICARE for Life
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Keeping up with TRICARE Changes
TRICARE News
Contract extensions issued by TRICARE Management Activity (TMA) mean TRICARE beneficiaries in the United States won’t need to learn new phone numbers and Web sites any time soon. Current regional health care contractors, Health Net Federal Services in the North, Humana Military Healthcare Services in the South and TriWest Healthcare Alliance Corp. in the West, will continue to provide services to beneficiaries until March 31, 2011.
Transition to new regional contracts, known as “T-3,” was initially slated for completion by April 1, 2010, but formal protests filed with the Government Accountability Office (GAO) by two of the current contractors put transition activities on hold. Both protests were subsequently sustained by the GAO, and TMA is reevaluating the awards and considering options as recommended by the GAO. “Our regional contracts provide critical health, medical and administrative support services to our 9.6 million TRICARE beneficiaries,” said TMA Deputy Director Rear Adm. Christine Hunter. “Extensions to our current contracts will allow time for transition to the T-3 contracts, while ensuring beneficiaries continue to receive high-quality care and outstanding customer service.” Hunter explained that a formal transition period of at least 10 months ensures that beneficiaries and stakeholders get the information they need well in advance, and allows enough time to establish new processes and test interoperability.
The T-3 contracts announced in July of 2009 are worth an estimated $55.5 billion over the base and five option periods. Aetna Government Health Plans, Hartford, Conn., was the contractor selected for the North Region, and UnitedHealth Military & Veterans Services, Minnetonka, Minn., was selected in the South Region, while TriWest was retained in the West Region. In addition to the sustained protests filed by Humana and Health Net, UnitedHealth filed an agency-level protest regarding the West Region award to TriWest, delaying transition for the entire United States. Under T-3, the three-region structure in the United States and all of the TRICARE benefit options offered under the current contracts remain the same. T-3 also features incentives encouraging the regional contractors to deliver:
• High quality care
• Exceptional customer service
• Improved preventive care
• Increased electronic claims processing
• Better program management
• Cost savings
• Detection of fraud, waste, and abuse
There are also measures to assure network provider, beneficiary and military treatment facility command satisfaction. T-3 contract information and updates can be found on a special TRICARE Web page at www.tricare.mil/T3contracts.
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TRICARE OVERVIEW
Medical Care Benefits:
Active duty, retired and their eligible family members and survivors under age 65 are eligible to receive medical care under DoD's TRICARE Program. A beneficiary under age 65 qualifies for medical care in uniformed services hospitals and Army, Navy, Air Force, & Coast Guard clinics. Limited space-available care for those age 65 and over may be available.
By law, care at these facilities is on the following space-available priority basis: 1) active duty service members; 2) active duty family members enrolled in TRICARE Prime; 3) retirees and their family members/survivors enrolled in TRICARE Prime; 4) active duty family members not enrolled in TRICARE Prime; and 5) all other beneficiaries.
There are also seven Uniformed Services Family Health Plan (USFHCP) facilities available for care. They operate under a DoD contract. These former Public Health hospitals are an integral part of TRICARE. They are located in Baltimore, Md.; Staten Island, N.Y.; Boston, Mass.; Portland, Maine; Cleveland, Ohio; Houston, Texas; and Seattle, Wash
Some Important Considerations:
While space-available care in uniformed services facilities continues for you and your spouse regardless of your ages, care under the TRICARE program will end under the following circumstances: At age 65 if you are entitled to Social Security Hospital Insurance, Part A of Medicare, then you are no longer eligible for TRICARE but will be eligible for TRICARE for Life with the purchase of Medicare Part B. This also applies to spouses when they reach 65. If you are under age 65 and Medicare eligible (Part A), TRICARE can act as a second payer (supplement to Medicare and any Medicare Supplement or other health insurance) provided you elect to participate in Medicare Part B. However, if you or your spouse do not qualify for Part A Medicare at age 65, your TRICARE benefits will continue beyond that age. This is a complicated subject and should be addressed by your BCAC or MOAA's Online Benefits Assistance.
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The TRICARE Retiree Dental Program
Uniformed Services retirees and their families are encouraged to check into the TRICARE Retiree Dental Program (TRDP) which is administered by Delta Dental of California. Benefits are enhanced under the current TRDP contract to form the most comprehensive dental benefit program available to Uniformed Services retirees and their family members.(The TRDP is separate from the TRICARE Dental Program (TDP), which is available only to active duty family members and National Guard and Reserve members and their family members.)
The TRDP enrollment is voluntary and open to retired Uniformed Services members and their family members and National Guard and Reserve retirees and their family members, including "gray area" retired reservists who are entitled to retired pay but will not receive it until age 60. Enrollment is also open to certain surviving family members of deceased active duty sponsors and Medal of Honor recipients, and their immediate family members and their survivors. Delta Dental handles all enrollments. There is an initial 12-month commitment for new enrollees after which enrollment may be continued on a month-to-month basis. During the 30-day grace period from the coverage effective date, voluntary termination of enrollment is allowed without further enrollment obligation provided that no benefits have been used.
The TRDP offers dental coverage throughout the 50 United States, the District of Columbia, Puerto Rico, Guam, the U.S. Virgin Islands, American Samoa, the Commonwealth of the Northern Mariana Islands and Canada. All premiums are paid by the enrollee and vary depending on where the enrollee lives.The TRDP network includes more than 67,000 participating dentists in the Delta Dental Select and Delta Dental PPO networks.
If the enrollee visits a Delta Dental Select or Delta Dental PPO dentist, all claims will be submitted for the enrollee, and the enrollee will be responsible only for the enrollee's percentage of the TRDP-allowed amount as indicated in “Benefits” chart below. Enrollees also have the option of selecting a dentist from the Delta Dental Premier network. Although not part of the TRDP network, Delta Dental Premier dentists will provide the same administrative services and will not charge more than the agreed fees they have with Delta Dental. If a Delta Dental Premier dentist is selected, the enrollee is responsible for co-payments and deductibles as applicable, plus any difference in agreed fees and the TRDP allowable amount for non-participating dentists. Benefits offered with the TRICARE Retiree Dental Program:
| Covered Services |
Delta Pays |
Applied to Annual Deductible |
Applied to Annual Maximum |
| Available during the First 12 months of enrollment |
| Diagnostic (exams) |
100% |
N |
N |
| Preventive Services |
100% |
N |
N |
| Basic Restorative (fillings) |
80% |
Y |
Y |
| Endodontics (root canals) |
60% |
Y |
Y |
| Periodontics (gum treatment) |
60% |
Y |
Y |
| Oral Surgery (extractions) |
60% |
Y |
Y |
| Emergency (treatment for minor pain) |
100% |
Y |
Y |
| Dental Accident Coverage |
100% |
N |
N |
| Additional services available after 12 months of continuous enrollment |
| Cast Crowns, Onlays, & Bridges |
50% |
Y |
Y |
| Partial/Full Dentures |
50% |
Y |
Y |
| Orthodontics |
50% |
N |
N |
| Deductibles and Maximums |
| Annual Deductible |
$50 per person, limit $150 per family per benefit year |
| Annual Maximum |
$1,200 per person per benefit year |
| Orthodontics Maximum |
$1,200 per person per life time benefit |
| Dental Accident Maximum |
$1,000 per person per benefit year |
| Benefit Year |
1 May – 30 April |
Enrollees are not required to visit a TRDP participating or Delta Dental Premier dentist for treatment; they may visit any licensed dentist of their choice. If an enrollee visits a dentist outside of the Delta networks, the same coverage percentages and benefit levels apply. However, the enrollee must pay the dentist and then submit a claim to Delta for reimbursement. The enrollee is responsible to pay the difference between the TRDP-allowed amount and the dentist's bill. The annual deductible is $50 per person with a $150 deductible cap per family. The annual deductible accrues during the benefit year (May 1 through April 30). The annual maximum coverage is $1,200 per person. The deductible and maximum do not apply to the diagnostic and preventive services covered at 100 percent as described above, or to dental accident procedures or orthodontia. Orthodontic services have a separate $1,200 lifetime maximum and dental accident coverage has a separate $1,000 annual maximum benefit.
Benefits Offered to National Guard and Reserve Members National Guard and Reserve personnel who elect to enroll in the TRDP within 120 days after retirement are now eligible to skip the 12-month waiting period normally required for certain TRDP benefits. Effective February 1, 2005, TMA has authorized a waiver from requiring retired National Guard and Reserve members who meet the criteria to enroll in the TRDP for 12 months prior to gaining the maximum allowed benefits for cast crowns, cast restorations, bridges, dentures and orthodontics for adults and children.
Additionally, this new waiver will be applied retroactively to February 1, 2004, for any National Guard and Reserve enrollees who can document their enrollment in the TRDP within 120-days after their retirement-effective date. Delta will process any claim adjustments resulting from this retroactive waiver upon notification from the enrollee and submission of the appropriate documentation. All new enrollees seeking to obtain the waiver should submit a copy of their retirement orders with their TRDP application. Eligible retirees and their family members may find information about the program by visiting the TRDP Web site and toll-free number listed below.
Allowance for Posterior (Back Teeth) Fillings
In the TRDP, basic restorative procedures (fillings) have a cost share of 20 percent for the member with the contractor paying the remaining 80 percent when the care is received from a TRDP network provider. The most common materials used for fillings are amalgam (silver) and composite resin (tooth-colored). For both TRDP Basic and Enhanced, the covered benefit for posterior (back) fillings is the amalgam (silver) while resin fillings are the covered benefit for anterior (front) teeth. However, for members of the Enhanced program, an allowance is made for posterior resin fillings. Therefore, if the dentist and member select resin for back teeth fillings, the member must pay the difference between what the silver fillings would have cost and the cost of the resin. For members of the Basic program, composite resin restorations are not covered and the patient is responsible for full payment. For example, if a member enrolled in TRDP Enhanced needs a filling on a back tooth, the dentist places a silver filling at the allowable reimbursement rate of $100. Under the TRDP, the contractor pays 80 percent or an $80 cost share and the member pays a 20 percent cost or $20 cost share. If the dentist places a resin filling on a posterior tooth at the member’s request and bills $140, the contractor still pays only $80 (the 80 percent cost share for a silver filling). The member now pays $60 (the $20 cost for the silver filling and the additional $40 in billed charges). If a TRDP Basic member receives a resin filling on a posterior tooth, he or she will be responsible for the total amount ($140 in the example above).According to the American Dental Association (ADA), both amalgam and resin materials are safe and effective options for filling back teeth. Amalgam is an affordable, durable material with a long history of safe and effective use, while the resin offers a more natural appearance but with an increased cost. Determining what filling material is best for the member should be based on discussions between the TRDP dentist and member. If a TRDP network provider does not offer a choice of filling materials, the TRDP contractor, Delta Dental, may be contacted for assistance in locating other local participating dentists who provide both silver and tooth-colored fillings.
For more information about the TRDP, beneficiaries may call toll-free at 1-888-838-8737, or visit Delta Dental online at www.trdp.org.
*See also: TRICARE Dental Program Fact Sheet
TRICARE Dental Program Overseas Fact Sheet
TRICARE Dental Program Survivor Benefit Fact Sheet
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The Tri-Service Drug Formulary |
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Specific information is available on the formularies used at military pharmacies, the TRICARE network pharmacies, and the TRICARE Mail Order Pharmacies.
Military pharmacies in MTFs are required to stock medications on the Basic Care Formulary, but they might have a more extensive list of drugs based on their mission as a clinic, community hospital, regional hospital, or medical center. The rule is if the medication you need is routinely stocked, then the military pharmacy must fill the prescription.
DoD PharmacoEconomic Center (PEC): www.pec.ha.osd.mil
(Since the formulary changes, you should review this Web site periodically.)
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