Office of the Secretary of Defense, Department of Defense.
TRICARE Prime and TRICARE Select Plan Information for Calendar Year 2018.
This notice provides a notice of TRICARE Prime and TRICARE Plan Information for Calendar Year 2018.
TRICARE health plan information in this notice is valid for services during calendar year 2018 (January 1, 2018-December 31, 2018).
Defense Health Agency, TRICARE Health Plan, 7700 Arlington Boulevard, Suite 5101, Falls Church, Virginia 22042-5101.
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FOR FURTHER INFORMATION CONTACT:
Mr. Mark A. Ellis, (703) 681-0039.
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An interim final rule published in the Start Printed Page 674
Federal Register (FR) on September 29, 2017 (82 FR 45438-45461) established the requirement for the Director, Defense Health Agency, to provide a public notice to TRICARE program beneficiaries with a summary of changes to the TRICARE program each calendar year in connection with the open season enrollment period.
The following changes or improvements to the TRICARE program benefits apply for calendar year 2018:
- On January 1, 2018, TRICARE North and South regions will combine to form TRICARE East, while TRICARE West region will remain mostly unchanged. Humana Military will administer the new East region and Health Net Federal Services will administer the West region. This change will allow better coordination between the military hospitals and clinics and the civilian health care providers in each region. Go to https://tricare.mil/About/Changes/General-TRICARE-Changes/Regions for more information.
- TRICARE Select will replace TRICARE Standard and TRICARE Extra on January 1, 2018. TRICARE Select brings together the features of TRICARE Standard and TRICARE Extra in a single plan. Select enrollees may obtain care from any TRICARE authorized provider without a referral or authorization. Enrollees who obtain services from TRICARE network providers will pay lower cost sharing amounts for network care.
- All current TRICARE beneficiaries will be automatically enrolled in their respective plan on January 1, 2018. TRICARE Prime plan enrollees will remain in their TRICARE Prime plan. TRICARE Standard and Extra beneficiaries will be enrolled in a TRICARE Select plan.
- Beneficiary out-of-pocket costs: A detailed break-out of beneficiary out-of-pocket costs for 2018 is shown in Appendix A. Some out-of-pocket costs will be announced later in 2018 as we define certain high-value medications and health care services that will result in lower out of pocket expenses for beneficiaries.
- Improving what's covered: Beginning January 1, 2018:
TRICARE Select enrollees may receive most TRICARE Prime clinical preventive services with no copayment when furnished by a network provider.
TRICARE Prime and TRICARE Select will cover behavioral interventions for obese adults and children/adolescents with certain body mass indexes to promote sustained weight loss with no cost if furnished by a network provider.
- TRICARE will cost share on medically necessary foods and vitamins, including low protein modified food and amino acid preparation products for dietary management of individuals with limited or impaired capacity to absorb other nourishment.
- Beneficiaries can choose to enroll in or change their TRICARE Prime or TRICARE Select coverage during an annual open enrollment period in November-December, 2018 for coverage beginning on January 1, 2019. For calendar year 2019, failure to enroll in TRICARE Prime or TRICARE Select results in the termination of coverage for civilian care. These beneficiaries who choose to not enroll may only receive care at a military clinic or hospital on a space available basis.
- 2018 will be a transition year with a grace period for enrollment. To allow beneficiaries to adjust to making their health care option choices during an annual open season enrollment period or to remember to elect their coverage when a qualifying life event (QLE) occurs, beneficiaries can elect to make their coverage changes anytime during 2018 to ensure they have the right coverage in place starting in 2019.
- Referrals for civilian urgent care visits are no longer needed for most TRICARE Prime enrollees. Most TRICARE Prime enrollees can now seek care at an urgent care center without a referral. Point of Service charges no longer applies if seen without a referral. As a reminder, after seeking urgent care, it's always a good idea to contact the primary care manager and arrange follow-up care as needed.
However, some exceptions still apply. Active Duty Service members (ADSMs) must obtain authorization before seeking urgent care services from civilian providers.
Active Duty family members enrolled to TRICARE Overseas Program (TOP) Prime/Prime Remote must contact the TOP contractor to obtain an authorization in order to ensure their urgent care visit will be cashless/claimless. Without this authorization, overseas providers may request payment upfront and the beneficiary will then have to submit a claim for reimbursement. Additionally, any ADSM enrolled in TOP Prime/Prime Remote requiring urgent care while on temporary duty or on leave status in the 50 United States and the District of Columbia, may access urgent care without a referral or an authorization.
- For more information, visit tricare.mil/changes or call your regional TRICARE contractor.
See tables below for TRICARE Prime, TRICARE Select, and TRICARE Pharmacy out-of-pocket expenses that take effect on January 1, 2018.
Group A beneficiaries are service members who enlisted or were appointed in a Uniformed Service before January 1, 2018 and their family members.
Group B are service members who enlisted or were appointed in a Uniformed Service on or after January 1, 2018 and their family members.
Group B cost shares also apply to enrollees in the TRICARE Reserve Select, TRICARE Retired Reserve, TRICARE Young Adult, and the Continued Health Care Benefit Program health plans. Monthly premiums apply in lieu of enrollment fees.
Table 1—TRICARE Select and TRICARE Prime Cost Sharing for Active Duty Family Members (ADFMs) for Calendar Year 2018
| ||TRICARE select group A ADFMs||TRICARE select group B ADFMs||Prime group A ADFMs||Prime group B ADFMs|
|Annual Deductible||E1-E4: $50/$100 E5 & above: $150/$300||E1-E4: $50/$100 E5 & above: $150/$300||0||0|
|Annual Catastrophic Cap||$1,000||$1,000||1,000||1,000|
|Preventive Care Outpatient Visit||$0||$0||0||0|
|Primary Care Outpatient Visit||$21 IN 20% OON||$15 IN 20% OON||0||0|
|Specialty Care Outpatient Visit||$31 IN 20% OON||$25 IN 20% OON||0||0|
|Emergency Room Visit||$81 IN 20% OON||$40 IN 20% OON||0||0|
|Urgent Care Center||$21 IN 20% OON||$20 IN 20% OON||0||0|
|Ambulatory Surgery||$25||$25 IN 20% OON||0||0|
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|Ambulance Service (not including air)||$74 IN 20% OON||$15 IN 20% OON||0||0|
|Durable Medical Equipment||15% IN 20% OON||10% IN 20% OON||0||0|
|Inpatient Hospital Admission||$18.60/day, minimum $25/admission||$60/admission IN; 20% OON||0||0|
|Inpatient Skilled Nursing/Rehab Facility||$18.60/day, minimum $25/admission||$25/day IN; $50/day OON||0||0|
Table 2—TRICARE Select and TRICARE Prime Cost Sharing for Retiree Families for Calendar Year 2018
| ||TRICARE select group A retirees||TRICARE select group B retirees||TRICARE prime group A retirees 1||TRICARE prime group B retirees|
|Annual Deductible||$150/$300||$150/$300 IN $300/$600 OON||0||0|
|Annual Catastrophic Cap||$3,000||$3,500||3,000||3,500|
|Preventive Care Visit||$0||$0||0||0|
|Primary Care Outpatient Visit||$28 IN 25% OON||$25 IN 25% OON||20||20|
|Specialty Care Outpatient Visit||$41 IN 25% OON||$40 IN 25% OON||30||30|
|Emergency Room Visit||$109 IN 25% OON||$80 IN 25% OON||60||60|
|Urgent Care Center Visit||$28 IN 25% OON||$40 IN 25% OON||30||30|
|Ambulatory Surgery||20% IN 25% OON||$95 IN 25% OON||60||60|
|Ambulance Service (not including air)||$98 IN 25% OON||$60 IN 25% OON||40||40|
|Durable Med. Equip.||20% IN 25% OON||20% IN 25% OON||20%||20%|
|Inpatient Admission||$250/day up to 25% hosp. charge + 20% separately billed services IN $901/day up to 25% hosp. charge + 25% separately billed services OON||$175/admission IN 25% OON||150/admission||150/admission|
|Inpatient Skilled Nursing/Rehab Admission||$250/day up to 25% hospital charge + 20% separately billed services IN 25% OON||$50/day IN Lesser of $300/day or 20% OON||30/day||30/day|
|1 TRICARE Prime enrollees who are (1) survivors of active duty deceased sponsors, or (2) medically retired Uniformed Services members and their family members, have their TRICARE Prime enrollment fees frozen at the rate in effect when classified and enrolled in a fee paying Prime plan. (This does not include TRICARE Young Adult (TYA) plans).|
Table 3—Pharmacy Copayments for Calendar Year 2018
|Year||Copayment amount for a 30-day supply of a retail generic is:||Copayment amount for a 30-day supply of a retail formulary is:||Copayment amount for a 90-day supply of a mail order generic is:||Copayment amount for a 90-day supply of a mail order formulary is:||Copayment amount for a 90-day supply of a mail order non-formulary is:|
|Note: Pharmacy copayment amounts for (1) survivors of active duty deceased sponsors, or (2) medically retired Uniformed Services members and their family members are equal to the copayment amounts, if any, for 2017.|
End Supplemental Information
Dated: January 2, 2018.
Alternate OSD Federal Register Liaison Officer, Department of Defense.
[FR Doc. 2018-00018 Filed 1-4-18; 8:45 am]
BILLING CODE 5001-06-P