Tricare Assignment Of Benefits

Active duty service members and their dependents (spouses and children registered in DEERS) are eligible for TRICARE.  There are several TRICARE programs to choose from depending on your status and location. This page lists and describes the numerous benefits that active duty members and families are eligible for.

Active Duty Members

Active duty service members must enroll in one of the following TRICARE Prime plans based on their duty station:

  • TRICARE Prime - TRICARE Prime is a managed care option available worldwide. TRICARE Prime offers fewer out-of-pocket costs than TRICARE Standard and Extra, but less freedom of choice for providers
  • TRICARE Prime Remote - TRICARE Prime Remote provides healthcare coverage through civilian providers for those U.S. Uniformed Service Members, activated guard & reserve members, retirees, and families on remote assignment.  You must live AND work more than 50 miles or approximately one hour's drive time from the nearest Military Treatment Facility. TRICARE Prime Remote is offered in the 50 United States only.
  • TRICARE Prime Overseas - TRICARE Prime Overseas is similar to the TRICARE Prime program offered stateside, including cost-shares and deductibles. The program serves Active Duty members, activated reserve & guard members, and their command sponsored dependents.
  • TRICARE Prime Remote Overseas - TRICARE Prime Remote Overseas is a TRICARE Prime option offered in designated remote overseas locations for active duty service members and their families. The program is similar to TRICARE Prime Overseas but you will receive most, if not all of your care from foreign providers.

Active duty members pay no enrollment fees for TRICARE Prime.

Dependents of Active Duty Members

Active duty dependents members can enroll in one of the Prime plans listed above, or they may qualify to use one of the following plans: 

  • TRICARE Select - TRICARE Select provides the most flexibility to eligible beneficiaries. It is a fee-for-service option that gives beneficiaries the opportunities to see any TRICARE-authorized provider
  • TRICARE Young Adult - TRICARE Young Adult is an option for unmarried, adult children who have "aged out" of regular TRICARE coverage.
  • U.S. Family Health Plan - The U.S. Family Health Plan is available to eligible persons who live near selected civilian medical facilities on the East, West and Gulf coasts. 

Dental Benefits

  • TRICARE Active Duty Dental Program - The TRICARE Active Duty Dental Programs available for either active duty members who are referred for care by a military dental treatment facility to the civilian dental community or have a duty location and residence more than 50 miles from a military dental treatment facility.
  • TRICARE Dental Program - The TRICARE Dental Plan is a voluntary dental insurance program. The dental benefit is available to eligible active duty family members, eligible National Guard and Reserve members and their family members

Pharmacy Benefits

  • TRICARE Pharmacy Program - The TRICARE Pharmacy Program provides the prescription drugs you need, when you need them, in a safe, easy, and cost-effective manner.

Vision Benefits

  • TRICARE Vision Benefits - Some TRICARE programs offer free or reduced price eye examinations and corrective lenses.  
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TRICARE requires coordination of benefits with OHI coverage. TRICARE does not always pay your OHI copayment or the balance left over after the OHI payment. However, you usually owe very little to nothing. The TRICARE payment calculation is based on the provider's status. Note: Most inpatient facilities have other calculations not listed below.

TRICARE Network Providers and Non-Network Providers Who Accept TRICARE Assignment (Participating)
TRICARE pays the lowest of:

  • billed amount minus the OHI payment
  • amount TRICARE would have paid without OHI
  • amount beneficiary owes after the OHI paid (usually the OHI copayment or cost share)

Providers Who Do Not Accept TRICARE Assignment (Nonparticipating)
Nonparticipating providers may only bill the beneficiary up to 115 percent of the TRICARE allowed amount. If the OHI paid more than 115 percent of the allowed amount, no TRICARE payment is authorized, as the charge is considered paid in full and the provider may not bill the beneficiary. Otherwise, TRICARE pays the lowest of:

  • 115 percent of the allowed amount minus the OHI payment
  • Amount TRICARE would have paid without OHI
  • Amount beneficiary owes after the OHI paid (usually the OHI copayment or cost share)

Staff Model HMOs, Group HMOs and Other Capitated OHI Plan Providers
When you are enrolled in one of these OHI plans, the provider group either works directly for the HMO or is paid a monthly/annual amount rather than a fee for each service performed. In these plans, you generally only receive a copayment receipt – an itemized bill or Explanation of Benefits (EOB) is not available.

In these cases, you submit a Beneficiary Claim Form DD2642 with a copy of the receipt and the copayment is considered the billed amount. Deductibles and cost shares are applied and you may not receive full reimbursement of your HMO copayment.

Important Things to Know

  • All requirements of the OHI plan must be followed. If the OHI denies a claim because OHI authorization requirements were not followed or because a network provider was not used, TRICARE will also deny the claim and you will be responsible for the denied charges.
  • The OHI must process the claim before TRICARE can consider the charges.
  • If the OHI denies the claim for services not medically necessary, all appeal rights with the OHI must be used before TRICARE can process the claim.
  • Services must be provided by a TRICARE network or non-network provider.
  • If your OHI changes, please update your OHI information.

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