Table of Contents
- Tricare Plans: Am I Eligible?
- How To Switch Your Plan During Open Season
- Overview of Tricare Prime
- Overview of Tricare Select
- Tricare Prime vs. Select: How To Decide What’s Best For You
With the ever-expanding complexities of the military healthcare system, it can be challenging to figure out the best choice for you and your family.
How do you decide whether Tricare Prime or Tricare Select is better for you and your family? What are the most important factors to consider?
You want an easy answer. Which is better: Tricare Prime or Tricare Select?
A Quick Summary of Tricare Prime vs. Select: Tricare Prime requires you to use a Primary Care Manager (PCM) for all appointments and referrals. In exchange, you have lower out of pocket costs. Tricare Select is self-managed and does not require a referral to see a specialist. However, it may come with slightly higher out of pocket costs.
Each plan has its pros and cons, so use this comparison to make the best decision possible.
Tricare Plans: Am I Eligible?
Tricare is a health benefit for:
- Uniformed Service members and their families,
- National Guard/Reserve members and their families,
- Military retirees and their families,
- Qualified former spouses,
- Medal of Honor recipients and their families, and
- Others registered in the Defense Enrollment Eligibility Reporting System (DEERS)
Your plan eligibility will vary depending on your beneficiary category. Active duty service members (ADSMs) must be enrolled in Tricare Prime, while active duty family members (ADFMs) may choose to enroll in either Tricare Prime or Tricare Select.
Retired servicemembers and their family members also have the choice between Tricare Prime and Tricare Select until they reach age 65, at which point they become eligible for Tricare for Life.
How To Switch Your Plan During Open Season
If you are currently enrolled in Tricare Prime or Tricare Select and are considering making a change, you are eligible to do so during Open Season. Open season is the annual period when you can enroll in or change your health care coverage for the next year.
Note: The Tricare Open Season this year begins November 9, 2020, and ends December 14, 2020.
Outside of Open Season, you can only change health plans after a Qualifying Life Event (QLE). QLEs are major life events and generally include some of the following – being activated or deactivated from military service, changing your job, getting married or divorced, birth or death of a family member, moving or a PCS, and similar major events. You can find a full list on our page about Tricare Open Season.
That’s why you need to do one thing today: review your health benefits.
To change your plan:
- Visit the Beneficiary Web Enrollment Website
- Call your regional contractor
- Mail in your enrollment form
Overview of Tricare Prime
Tricare Prime is a managed care option similar to a civilian health maintenance organization program (HMO), where you see providers who participate in the plan’s network.
It offers comprehensive health care coverage with a primary care manager (PCM), who will:
- Provide your routine health care,
- Manage your health care,
- Give any referrals or authorizations you need, and
- File your medical claims on your behalf.
Once enrolled, you will choose or be assigned a provider, most likely at the local military medical facility.
The enrollment fee is waived for active-duty families, while retirees and their beneficiaries do pay an enrollment fee.
Pros: Why Tricare Prime Might Be Right For You
If you’re an ADSM, you are automatically in Tricare Prime— that’s one less decision to make.
Tricare Prime offers you services with less out-of-pocket, which can be great for those concerned about healthcare costs. As long as you get a referral for in-network providers, there is no copay.
Getting an official referral does mean you’ll have more paperwork and processing time with Tricare Prime, but the savings may very well be worth it for your family. In most cases, you won’t have any insurance claims to file, which saves you from a headache.
Cons: Why Tricare Prime Might Be Wrong For You
If you need immediate care, you’ll need to consider whether or not you need a referral. Tricare differentiates between “emergency” and “urgent” care, and the coverage is different between the two. An emergency room visit for a life-threatening issue does not need a referral from your PCM, although they will need to be called after the event. You will need a referral for a visit to urgent care for a non-life-threatening but serious issue, such as a broken bone.
Tricare Prime’s somewhat limited options may not be best for you if you or a family member has special needs.
If you are currently seeing a provider that is not in-network with Tricare, you’ll need to switch providers or pay the cost upfront and file a claim for reimbursement. If you want to stay with an out-of-network provider, Tricare Prime probably isn’t your best option.
Finally, Tricare Prime is only available for those who live in Prime Service Areas, usually within 100 miles of a primary care manager (PCM). If you are in a Prime Service Area but still relatively far from the military installation, it might not be the most convenient location.
Overview of Tricare Select
What is the difference between Tricare Prime and Tricare Select? While your PCM handles your healthcare in Tricare Prime, Tricare Select is a self-managed style of care.
Tricare Select is a pay-for-service plan that allows you the most comprehensive array of options possible. With Tricare Select, you can choose any in-network medical provider.
Referrals are not required, although you may need prior authorization from your regional contractor for some services.
Pros: Why Tricare Select Might Be Right For You
Maybe you’re seeing a provider who isn’t in the Tricare network, and you don’t want to switch. If choosing your provider is important to you, or if you need a medical specialty, it may be worthwhile to do your own research and directly contact the specialists.
If you live outside of a Prime Service Area, Tricare Select can provide the same level of service closer to where you live. Tricare Select’s freedom to choose providers also translates to including civilian providers more conveniently located to where you live.
Cons: Why Tricare Select Might Be Wrong For You
Many people choose Tricare Select for its freedom of choice, but unfortunately, that choice can come with a higher sticker price. Costs vary based on the sponsor’s military status, but these prices include:
- Enrollment fees
- Annual deductible
- Catastrophic cap
- Cost shares (or percentage) for covered services
The enrollment fee is waived for active duty family members, medically retired retirees or family members, and survivors of an active duty sponsor or medically retired retiree.
With Tricare Select, you also may have to file claims. If you visit a provider outside of the Tricare network, you may need to pay all costs upfront and file the claim independently.
Tricare Prime vs. Select: How To Decide What’s Best For You
This table offers a comparison of Tricare Prime and Tricare Select:
|Tricare Prime vs Tricare Select||Tricare Prime||Tricare Select|
|Where is the program available?||– In the United States in Prime Service Areas||– United States|
|What is it?||– A managed care option offering the most affordable and comprehensive coverage.||– A preferred provider network available to all non-active duty beneficiaries. Most freedom of choice.|
|Will I have to file my own claims?||– Your provider will file claims for you (in most cases).||– Network providers will file claims for you.|
– If you get care from a non-network provider, you may have to file your own claims.
|What are the main features?||– Enrollment required|
– Enhanced vision coverage and preventive services
– Most care received from your primary care manager (PCM)
– Time and distance access standards
– Fewer out-of-pocket costs
– No claims to file (in most cases)
|– Enrollment Required|
– Get care from any TRICARE-authorized provider
– An authorized provider is any individual, institution/organization, or supplier that is licensed by a state, accredited by a national organization, or meets other standards of the medical community, and is certified to provide benefits under TRICARE.
– There are two types of TRICARE-authorized providers: Network and Non-Network.
– DS, network, or non-network Referrals not required, but some care may require prior authorization
– You may have to pay for services up front and file your own claims for reimbursement
|How do I get care?||– Get most care from your assigned PCM.|
– Military or network provider refers you to specialists for the care he or she can’t provide
|– Get care from any TRICARE-authorized provider, network or non-network.|
– Referrals not required.Some services may require prior authorization.
|Do I have to enroll?||– Enrollment is required.|
– No enrollment fee for active duty families.
|– Enrollment is required.|
What to Consider:
When you compare Tricare Prime vs. Select, you have to consider a few factors:
- Overall cost
- Referral requirements
- Provider proximity
- Claims filing
Tricare Prime and Select’s fundamental difference is whether your care is managed by your PCM or self-managed. Everything flows from that first difference.
Consider your healthcare priorities both in the short- and long-term, and be sure that your priorities are reflected in whichever plan you select.
Please check our Tricare Reference Guide for more information on choosing the plan for you and accessing the right resources, contact information, and other helpful links.