Active Duty Family Tricare Options: Prime, Select, Or US Family Health Plan?

This entire article is for Active Duty family members. For a similar conversation for retirees, see this article.

Military families are blessed to have two (or three) different health plans from which to pick. If you’re not familiar with the ins and outs of each plan, it can be hard to pick. Which health care coverage should I choose?

The first thing to do is to see which plans you are eligible to use, based upon your location. You can find your options by using the Tricare Plan Finder. It will ask your eligibility status and location, and tell you which plans are available there.

Another very useful tool is the Tricare Costs and Fees chart. This chart is updated every year, and this article talks you through how to read it and use it to make the right decision for your family.

Tricare Prime, not USFHP

With regular Tricare Prime, active duty family members receive care at a Military Treatment Facility (MTF) unless they can not accommodate you and send you out into town. It’s 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. Specialty care may be provided at your MTF, at another MTF, or by civilian providers. Any care that is not with your primary care provider or at an MTF will require a referral. This is one of the primary complaints about Tricare Prime – the need to get referrals for everything. But specialty care with a valid referral should be completely covered.

Prescriptions are filled at any MTF, or you can use civilian pharmacies that accept Tricare (with co-payments) or you can use the Express Scripts mail order pharmacy.

You do not pay for your medical care at MTFs or when referred to a civilian provider. 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. Also, Tricare Prime Point of Service costs DO NOT apply to your catastrophic cap.)

One important difference between Tricare Prime and Tricare Select is that IF you are on Tricare Prime, and you require specialty care that can not be provided near your home, and you have a valid referral for that care, Tricare Prime may reimburse your travel expenses. This can be huge if you are receiving specialty treatment far from home, especially if it includes hotel stays.

Tricare Select

With regular Tricare Select, get your care from authorized civilian providers. In theory, you are able to obtain care from MTF on a space available basis, but that’s not the general idea of the program.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 (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. Once you reach your catastrophic cap, you will only have costs if you go to non-network providers. Deductibles, co-pays, and catastrophic caps may change each year, so you have to know the current information to know what’s going on.

Note: If you use Tricare Select, you may be interested in a Tricare Supplement.

Uniformed Services Family Health Plan

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!)

What Is A USFHP?

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.

It’s important to understand that there are USFHPs in the country. If you do an internet search on USFHP, you may go to a page for another plan. They’re often not very clear. I once spent 45 minutes on the phone with a USFHP rep from the Johns Hopkins plan, 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 it is a large network, the USFHP is 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 the plan and demonstrate why they can’t meet their needs within their network.

How the USFHP Works

If you have selected an 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.

You do not have copays for your care, but you do have copays for prescriptions.

Why We’ve Picked Tricare Select

Our family has used Tricare Prime, an USFHP, and Tricare Select. Our last switch was from USFHP to Tricare Select, and we are not switching back. (My husband has chosen to remain Tricare Prime since his recent retirement, to finish up some care in progress, but he’ll be switching to Tricare Select at some point.)

For us, the three biggest considerations were:

1. We were paying almost $1,000 per year just in pharmacy co-pays on USFHP, though we could have shaved that amount by using the mail order pharmacy more often.
2. Getting referrals for everything was a hassle, and on either Prime or USFHP, we were limited to certain providers.
3. Four kids at college outside our USFHP region.

So we were paying almost $1,000 per year for prescriptions, and we had to use in-network providers, get referrals for everything, and use that one specific pharmacy. Under Select, we pay the deductible and then co-pays, but once we reach our catastrophic cap, we are done paying anything until next January. When we need a specialist (which is all the time here), I just call and make sure that they are an in-network provider.

Obviously, this is a relatively simple overview, but I think I’ve hit most of the big points. I wasn’t unhappy with the USFHP – it was a lot easier than Prime, for me – but I love Select and it isn’t costing us any more. The small amount of the catastrophic cap is absolutely worth my time and energy, plus my kids are already getting better care because I have a better selection of providers.

You Can Decide

There are a ton of factors to consider when picking which Tricare is right for your situation. Questions to ask, either yourself or others:

How far is my nearest MTF? Is it accepting family members? Can it take the entire family, or is that even important to you? What’s their access to care like? We all know that some MTFs are notoriously hard to get an appointment.

How much/what type of specialty care do you typically use? Will you be asked to travel to a more distant MTF for that care, or will you be referred to civilian providers? What’s traffic like in your area, and how does that impact the driving time for care. (DC people – you know what I’m talking about – a trip to Walter Reed is basically a whole day event.)

If you already have providers, do they accept Tricare Prime? Select? Are they in-network for your area’s USFHP?

Do you have any preferred providers that aren’t in-network?

Do you take regular prescriptions? Are the medications you need available at your MTF pharmacy? Are you comfortable with the mail-order pharmacy services? Are your prescriptions available in generic or are they more expensive brands?

How flexible are you with the time and dates of your appointments? Are you taking off work to sit in a waiting room somewhere, or wait for a prescription to be filled?

What’s your capacity to pay up to the catastrophic cap? $1,000 for Group A beneficiaries – the sponsor entered the military before 1 January 2018, $1058 for Group B beneficiaries –  the sponsor entered the military after 1 January 2018.

How do you feel about having to get a referral for everything?

There’s no single right answer for every family situation. Some people adore Tricare Prime, some people absolutely hate it, and others find a USFHP to be a good fit for their needs. Understanding each choice makes it easier to choose correctly, but thankfully you have the option to switch every year or with a qualifying life event. With the low catastrophic cap for active duty families, the only way you’re really risking a “wrong decision” is you use out-of-network providers.

I’d love to hear how you decided which plan was best for your family, or if you’re changing plans for any reason!