One of the big questions during military retirement is: Which Tricare health care coverage should I choose? Or maybe you’ve been retired for a while, and you’re wondering if the Tricare health plan you’re using is the right one for your situation? Or you’re moving to a new area and need to figure out your new options. Whatever the reasons that you’re looking, this article should answer your questions for active duty retirees and their families. (My Guard and reserve friends, you have a different set up.)
Important Note: After retirement, you need to sign up for whichever Tricare you choose. If you do not sign up, you will only have direct care on a space-available basis at military treatment facilities.
This post is part of my comprehensive retirement content. You can find the main post and tons of links at The Comprehensive Military Retirement Checklist. Definitely go read it!
What Options Do You Have?
The first thing to know is that your retiree options may be different than the options that you had as an active duty service member or family. All retirees and family members have access to Tricare Select, but there are geographic limitations on Tricare Prime or a Uniformed Services Family Health Plan (USFHP). You can find out what options are available in your area by using the Tricare Plan Finder tool. It will use your zip code to tell you which Tricare plans you can use.
Once you know which choices are available, you can explore each plan. You may find it easier if you print out the document in this article and do some scratching out and highlighting on it.
Tricare Prime, not USFHP
With regular (non-USFHP) Tricare Prime, retirees and family members may be able to receive care at a Military Treatment Facilities (MTF), or you may have to use civilian providers. Some MTFs do accept retirees, and some may allow you to remain at the MTF with your current providers but push you out if you need to change providers. Also, MTFs reserve the right to change their acceptance of retirees at any time, meaning that they can just decide that you need to leave at any time. It’s also possible that your nearest MTF won’t have room for you and that Tricare will expect you to travel to a different MTF before they send you to civilian providers. Like any managed care plan, Tricare Prime offers the least control over who provides your care.
Prescriptions are filled at any MTF, or you can use civilian pharmacies that accept Tricare/Express Scripts (with co-payments) or you can use the Express Scripts mail-order pharmacy.
Tricare Prime for retirees requires an enrollment fee, currently $606 (2020) per family for those whose sponsor entered the military prior to 1 January 2018. The Tricare Prime for retirees enrollment fee for 2021 is $606 per family, or $303 for an individual. Enrollment fees may be paid by military allotment, by electronic funds transfer, by credit or debit card.
If you have Tricare Prime, you do not pay for your medical care at MTFs, but you will have co-pays when you use a civilian provider. Retirees have an annual catastrophic cap, currently $3,000 per year* (2021), so the most you’ll pay for in-network service with the right referrals is $3,000.
(*The catastrophic cap is higher for those who have a family member using Tricare Young Adult or those whose sponsor entered the military after 1 January 2018.)
You will pay for a relatively hefty portion of your care if you go to a provider who is not in the network or you don’t have a referral for non-emergency care. This is called Point of Service and it can add up in specific situations. The Prime Point of Service option includes both a deductible and cost-shares. Also, Tricare Prime Point of Service costs DO NOT apply to your catastrophic cap – this is an important consideration.
There are two major benefit differences between Prime and Select as retirees. First, retirees on Tricare Prime have one covered routine eye exam every two years. Select for retirees does not have a vision benefit. This point may be irrelevant if you are obtaining vision insurance from other sources.
The other benefit of Prime over Select is that Prime offers a travel allowance if you require care far away from home. This may be important if you are getting care from a facility not near your house, or if that seems likely in your future.
Retirees on Tricare Prime may find that a Tricare Supplement reduces their costs or makes them more balanced over the year.
With regular Tricare Select, you get your care from civilian providers. In theory, you can get care from an MTF on a space-available basis, but that’s not the general idea of the program and obviously, space is always limited. You do not require referrals for most specialty care, but certain services may require pre-authorization.
Prescriptions are filled at any MTF, or you can use civilian pharmacies that accept Tricare/Express Scripts (with co-payments) or you can use the Express Scripts mail order pharmacy.
Each year, you will pay a deductible, and then co-pays for most care and prescriptions, until you reach your catastrophic cap. The co-pays on Select are higher than they are on Prime. Once you reach your catastrophic cap, you will only have costs if you go to non-network providers. Beginning in 2021, Tricare Select for retirees will have an enrollment fee of $25 per month for a family. This will be applied to your catastrophic cap.
Tricare Select for retirees have a catastrophic cap of $3500* (2021) per year, per family. (*The catastrophic cap is higher for those who have a family member using Tricare Young Adult or those whose sponsor entered the military after 1 January 2018.)
Retirees on Tricare Select, you may be interested in a Tricare Supplement to decrease your total out of pocket costs and balance your health care spending over the year.
Uniformed Services Family Health Plan
What Is A USFHP?
While the USFHP is technically part of Tricare Prime, there are enough differences that it is effectively a third choice. (There is one situation where that is important to know – we’ll get to that later!) There are six USFHP locations around the country.
A USFHP is a provider of Tricare Prime services. I know it’s a little confusing to think of USFHP as being part of Prime, because there are such visible differences. But at the core of the program, they are very similar: you still have a primary care manager (PCM), and you still require referrals for most care beyond your PCM.
The reason it is important to know that a USFHP is a provider for Tricare Prime is because that means that you can switch from MTF-based Tricare Prime to USFHP Tricare Prime (or the other way) without having to wait for the annual open season. You can switch back and forth at any time during the year without having a qualifying life event, because it’s technically just a PCM change, not a plan change.
What’s Is The Difference Between The Different USFHPs?
From a management standpoint, it’s important to understand that there are six USFHPs in the country. While they all follow the basic rules of Tricare Prime, there can be minor administrative differences, and some USFHPs offer additional benefits. If you do an internet search on USFHP, it can be hard to know if you’re looking at the page for YOUR USFHP or another area’s plan. They’re often not very clear. I once spent 45 minutes on the phone with a JHUSFHP rep, trying to understand why they were telling me one thing when the handbook said something different, before I figured out that I was reading the handbook for a different USFHP.
The other important thing to consider is that while they are large networks, USFHPs are still network-based plan. If you want to go see a specialist that is not in the network, you’ll need to get authorization from USFHP and demonstrate why they can’t meet their needs within their network.
How A USFHP Works
If you have selected a USFHP as your Tricare Prime PCM, you can not use any MTF for your medical care. You go to civilian doctors, with the same referral requirements as Prime.
USFHP members can not use the MTF pharmacies and must fill their prescriptions at the designated civilian pharmacy, or use the USFHP mail order pharmacy.
Because USFHP is a Tricare Prime provider, you’ll pay the same enrollment fees and co-pays as Tricare Prime. You also have the same catastrophic cap and Point of Service costs.
Thinking About Other Health Insurance?
If you have other health insurance available to you, such as employer-sponsored coverage, that is an entirely different conversation. We discuss it here: Should You Take Your Employer’s Health Insurance If You Have Tricare?
Which Plan Is Right For You?
There’s no single right answer, and that’s not a bad thing. All the Tricare options are more affordable and offer better coverage than nearly any other civilian plan out there. And you don’t have to put the entire family on the same plan, though your total costs may be lower if you do.
Regardless of what you choose, your catastrophic cap will be $3,000 per year (or $3,598 – 2019 if you have a family member on Tricare Young Adult, or you are on Tricare Retired Reserve, or your sponsor entered the military after 1 January 2019). I just budget that amount for medical and call it a day. (The baseline catastrophic cap for Group A beneficiaries will rise to $3,500 in 2021.)
One HUGE variable with Prime is that any non-network, non-emergency (“Point of Service”) care does not count towards your catastrophic cap if you are on Prime but it does if you are on Select. This can push your “top end” costs a lot higher on Prime, if you find you need a particular doctor not in the network or if you are in a situation where you can’t ask every specialist whether they are in-network (like the ER or a surgery.)
Personally, I prefer Tricare Select. It gives you much greater control over your care with the same maximum liability (catastrophic cap) each year. I think that’s a win-win. There are certain families with mid-range medical needs who might, possibly save a little bit of money on Tricare Prime, and Prime is a good choice if you are hoping to stay within your MTF (and your MTF will let you stay there.)
Obviously, this is a relatively simple overview, but I think I’ve hit most of the big points. Please ask your questions in the comments so that I can make this article better and more helpful for the next person!