This document provides information about TRICARE For Life (TFL), which is Medicare-wraparound coverage for TRICARE beneficiaries who have Medicare Part A and Part B. The summary includes: 1) TFL is available to TRICARE beneficiaries regardless of age or location if they have Medicare Part A and Part B. Retirees and some family members must have Part B to remain TRICARE eligible. 2) The document explains how Medicare and TFL work together, with Medicare paying first and TFL paying after Medicare. It provides contact information for Medicare and resources for questions. 3) The document provides an overview of how to get care under TFL, including finding providers, emergency

1. TRICARE
®
For Life Handbook

2. September 2011
Important Information
Medicare: 1-800-MEDICARE (1-800-633-4227)
Social Security Administration: 1-800-772-1213
TRICARE National Web site: www.tricare.mil
TRICARE For Life Contractor
Wisconsin Physicians Service: 1-866-773-0404
TRICARE For Life Web site: www.TRICARE4u.com
TRICARE North Region Contractor
Health Net Federal Services, LLC: 1-877-TRICARE (1-877-874-2273)
Health Net Web site: www.hnfs.com
TRICARE South Region Contractor
Humana Military Healthcare Services, Inc.: 1-800-444-5445
Humana Military Web site: www.humana-military.com
TRICARE West Region Contractor
TriWest Healthcare Alliance: 1-888-TRIWEST (1-888-874-9378)
TriWest Web site: www.triwest.com
An Important Note About TRICARE Program Changes
At the time of printing, this information is current. It is important to remember that
TRICARE policies and benefits are governed by public law and federal regulations. Changes
to TRICARE programs are continually made as public law and/or federal regulations are
amended. For the most recent information, contact your regional contractor or local
TRICARE Service Center. More information regarding TRICARE, including the Health
Insurance Portability and Accountability Act (HIPAA) Notice of Privacy Practices, can be
found online at www.tricare.mil.

3. Important Contact Information
Use this page as a guide for the most important resources available to you.
TRICARE’s Web Site: www.tricare.mil
TRICARE’s official Web site is your first stop for the most up-to-date information about your
benefit. Go to www.tricare.mil for information about eligibility and TRICARE-covered services;
answers to frequently asked questions; information on your TRICARE pharmacy benefit; to
download claims forms and instructions; to locate a TRICARE Service Center or military
treatment facility; to find a TRICARE Debt Collection Assistance Officer; and to answer questions
about survivor coverage, loss of eligibility, and program option information, among other things.
Subscribe to TRICARE For Life (TFL) program updates at www.tricare.mil/subscriptions.
General Contact Claims
Information
Phone: 1-866-773-0404 WPS/TRICARE For Life (U.S.) TRICARE Overseas (Eurasia-Africa)
Web: www.TRICARE4u.com P.O. Box 7890 P.O. Box 8976
Madison, WI 53707-7890 Madison, WI 53708-8976 USA
Written Correspondence:
TRICARE Overseas
WPS/TRICARE For Life (Latin America and Canada)
Grievances
P.O. Box 7889 P.O. Box 7985
Madison, WI 53707-7880 E-mail: reportit@wpsic.com Madison, WI 53707-7985 USA
TRICARE Overseas * TRICARE Overseas Grievances TRICARE Overseas (Pacific)
P.O. Box 7992 P.O. Box 7992 P.O. Box 7985
Madison, WI 53707-7992 Madison, WI 53707-7992 Madison, WI 53707-7985 USA
* Use this address for overseas appeals and grievances as well as general inquiries.
Defense Enrollment Eligibility Reporting System (DEERS)
DEERS is a database of uniformed service members (sponsors), family members, and others
worldwide who are entitled under law to military benefits, including TRICARE. Sponsors are
required to keep DEERS updated, including their residential and mailing address for themselves
and eligible dependents.
You have several options for updating and verifying DEERS information:
In Person Phone
Visit a local identification card-issuing facility. 1-800-538-9552
Find a facility near you at www.dmdc.osd.mil/rsl. 1-866-363-2883 (TTY/TDD)
Call to verify location and business hours.
Online Fax
DEERS Web site: www.dmdc.osd.mil/appj/address/ 1-831-655-8317
Beneficiary Web Enrollment Web site: Mail
www.dmdc.osd.mil/appj/bwe/
Defense Manpower Data Center Support Office
400 Gigling Road
Seaside, CA 93955-6771

4. TRICARE Regional Contractors
Regional contractors provide health care services and support in the TRICARE regions and can
help TFL beneficiaries with prior authorizations, but do not provide referrals for TFL beneficiaries.
Wisconsin Physicians Service administers the TFL program and should be your primary
contact for TRICARE-related customer service needs in the United States or U.S. territories
(American Samoa, Guam, the Northern Mariana Islands, Puerto Rico, and the U.S. Virgin
Islands). Go to www.medicare.gov and click on “Facilities & Doctors” for help finding
providers. Overseas, contact your TRICARE Overseas Program (TOP) Regional Call Center.
Regional Contractors (Stateside)
TRICARE North Region TRICARE South Region TRICARE West Region
Health Net Federal Services, LLC Humana Military Healthcare TriWest Healthcare Alliance
1-877-TRICARE (1-877-874-2273) Services, Inc. 1-888-TRIWEST (1-888-874-9378)
www.hnfs.com 1-800-444-5445 www.triwest.com
www.humana-military.com
Regional Contractor (Overseas)
TRICARE Eurasia-Africa TRICARE Latin America TRICARE Pacific
and Canada
TOP Regional Call Center TOP Regional Call Center TOP Regional Call Centers
+44-20-8762-8384 (overseas) +1-215-942-8393 (overseas) Singapore: +65-6339-2676 (overseas)
1-877-678-1207 (stateside) 1-877-451-8659 (stateside) 1-877-678-1208 (stateside)
tricarelon@internationalsos.com tricarephl@internationalsos.com sin.tricare@internationalsos.com
Sydney: +61-2-9273-2710 (overseas)
1-877-678-1209 (stateside)
sydtricare@internationalsos.com
Other Contact Information
For More Information Resource Numbers Web Sites
Medicare 1-800-633-4227 www.medicare.gov
Social Security Administration 1-800-772-1213 www.ssa.gov
TRICARE Pharmacy Program 1-877-363-1303 www.tricare.mil/pharmacy
www.express-scripts.com/TRICARE
Prescription Drug Formulary Search 1-877-363-1303 www.pec.ha.osd.mil
TRICARE Dental Program 1-800-866-8499 www.TRICAREdentalprogram.com
TRICARE Retiree Dental Program 1-888-838-8737 www.trdp.org
Office of Personnel Management 1-888-767-6738 www.opm.gov/forms
1-800-582-3337 www.opm.gov/insure/ltc
Find a Debt Collection See Web site www.tricare.mil/bcacdcao
Assistance Officer
Find a Beneficiary Counseling and See Web site www.tricare.mil/bcacdcao
Assistance Coordinator
Find a military treatment facility See Web site www.tricare.mil/mtf
Toll-free overseas contact information See chart above www.tricare-overseas.com

5. Welcome to TRICARE For Life
TRICARE For Life (TFL) is the Medicare- processing (unless you have other health
wraparound coverage for TRICARE insurance [OHI]). TRICARE pays after
beneficiaries who have Medicare Part A and Medicare and OHI for covered health
Part B, regardless of age or place of residence. care services.
TFL provides comprehensive health care This handbook will help you make the
coverage. You have the freedom to seek most of your TFL coverage. You will find
care from any Medicare-participating or information about eligibility requirements,
nonparticipating provider, or military getting care, and claims. This handbook
treatment facilities on a space-available also provides details about your pharmacy
basis. Medicare-participating providers and dental coverage options.
file your claims with Medicare. After
paying its portion, Medicare automatically
forwards the claim to TRICARE for
1

6. Table of Contents
1. How TRICARE For Life Works ............................................................ 4
Eligibility ......................................................................................................................4
Understanding Medicare ..............................................................................................4
Frequently Asked Questions: Medicare ........................................................................6
How TRICARE For Life Works with Medicare...........................................................7
Frequently Asked Questions: How TRICARE For Life Works ..................................10
2. Getting Care ..................................................................................... 12
Finding a Provider ......................................................................................................12
Emergency Care .........................................................................................................13
Urgent Care ................................................................................................................13
Behavioral Health Care ..............................................................................................14
Prior Authorization for Care .......................................................................................14
3. TRICARE For Life Coverage .............................................................. 15
TRICARE Medical Coverage .....................................................................................15
Dental Coverage .........................................................................................................15
Frequently Asked Questions: TRICARE For Life Coverage ......................................16
4. Pharmacy .......................................................................................... 17
Prescription Drug Coverage .......................................................................................17
Filling Prescriptions ...................................................................................................17
Pharmacy Policy .........................................................................................................19
Pharmacy Claims .......................................................................................................21
5. Claims ............................................................................................... 23
Health Care Claims ....................................................................................................23
Appealing a Claim or Authorization Denial...............................................................23
Third-Party Liability ..................................................................................................24
Explanation of Benefits ...............................................................................................24
Debt Collection Assistance Officers ...........................................................................24
2

7. 6. Life Changes: Update Your DEERS Record ..................................... 25
Getting Married or Divorced .....................................................................................25
Children ......................................................................................................................26
Moving .......................................................................................................................27
Survivor Coverage ......................................................................................................27
Loss of Eligibility .......................................................................................................27
Suspension of Social Security Disability Insurance ...................................................28
7. For Information and Assistance ..................................................... 29
Beneficiary Counseling and Assistance Coordinators ................................................29
Your Right to Appeal a Decision ................................................................................29
Filing a Grievance ......................................................................................................31
8. Glossary ............................................................................................ 32
9. List of Figures .................................................................................. 38
10. Index ................................................................................................. 39
See the inside back cover of this handbook for “TRICARE Expectations for Beneficiaries.”
3

8. How TRICARE For Life Works
Eligibility Insurance]” on the following page
for information about the Medicare
TRICARE For Life (TFL) is available to Part B special enrollment period for
TRICARE beneficiaries, regardless of age ADSMs and ADFMs.)
and place of residence, if you have Medicare
Part A and Medicare Part B. You are eligible Note: Regardless of age, ADFMs who have
for TFL on the first date that you have both Medicare Part A may enroll in TRICARE
Medicare Part A and Medicare Part B. Prime if they live in a TRICARE Prime
Service Area (PSA). The TRICARE Prime
TRICARE Eligibility Requirements
enrollment fee is waived for retiree family
When you are entitled to premium-free members with Medicare Part B coverage.
Medicare Part A:
Understanding Medicare
• Medicare Part B coverage is required to
remain TRICARE-eligible if you are a:
TFL is managed by the Department of
• Retired service member (including Defense. Medicare is managed by the
retired National Guard and Reserve Centers for Medicare and Medicaid
members drawing retirement pay) Services (CMS). The two agencies work
• Family member of a retired together to coordinate benefits.
service member
Medicare is a federal entitlement health
• Medal of Honor recipient or eligible
insurance program for people:
family member
• Age 65 or older
• Survivor of a deceased sponsor
• Under age 65 with certain disabilities
• Qualifying former spouse
• Any age with end-stage renal
• Medicare Part B coverage is not required disease (ESRD)
to remain TRICARE-eligible if:
Medicare Part A (Hospital Insurance)
• You are an active duty service member
(ADSM) or active duty family member Medicare Part A covers inpatient hospital
(ADFM) (ADSMs and ADFMs remain care, hospice care, inpatient skilled nursing
eligible for TRICARE Prime and facility care, and some home health care.
TRICARE Standard and TRICARE The Social Security Administration (SSA)
Extra options while the sponsor is on determines your entitlement to Medicare
active duty. However, when the sponsor Part A based on your work history or your
retires, you must have Medicare Part B spouse’s work history. You are eligible for
to remain TRICARE-eligible. See premium-free Medicare Part A at age 65 if
“Medicare Part B [Medical you or your spouse has 40 quarters or 10 years
of Social Security-covered employment.
4

9. HOW TRICARE FOR LIFE WORKS
SECTION 1
If, when you turn 65, you are not eligible for Note: If you have ESRD, sign up for
premium-free Medicare Part A under your Medicare Part A and Part B as soon
own Social Security number (SSN), you as you are eligible to avoid a break in
must file for benefits under your spouse’s TRICARE coverage and the Medicare
(this includes divorced or deceased spouses) Part B late-enrollment premium surcharge.
SSN, if he or she is 62 or older. If your spouse
Medicare Entitlement Based on
is not yet 62, you should enroll in Medicare
a Disability
Part B at age 65 to avoid paying a surcharge
If you receive disability benefits from the
for late enrollment, and you should file for
SSA, you are entitled to Medicare in the
Part A benefits under your spouse’s record
25th month of receiving disability payments.
when he or she turns 62.
The CMS will notify you of your Medicare
Medicare Part B (Medical Insurance) entitlement date.
Medicare Part B covers provider services,
If you return to work and your Social
outpatient care, preventive care, home health
Security disability payments are suspended,
care, and durable medical equipment.
your Medicare entitlement continues for up
Medicare Part B has a monthly premium,
to eight years and six months. When your
which may change annually and varies based
disability payments are suspended, you
on income. If you sign up after your initial
will receive a bill every three months for
enrollment period for Medicare Part B,
your Medicare Part B premiums. You
you may have to pay a monthly premium
must continue to pay your Medicare
surcharge for as long as you have Medicare
Part B premiums to remain eligible for
Part B. The surcharge is 10 percent for each
TRICARE coverage.
12-month period that you were eligible for
Medicare Part B but did not enroll. Medicare Entitlement Based on Age
The Medicare entitlement age is 65. If you
Medicare allows ADSMs and ADFMs who
already receive benefits from the SSA or
are entitled to Medicare based on age or
the Railroad Retirement Board, you will
disability (does not apply to those with ESRD)
automatically receive Part A and be enrolled
to delay Part B enrollment and sign up
in Part B at age 65.
during a special enrollment period, which
waives the late enrollment surcharge. The
If you are age 65 or older and do not receive
special enrollment period for ADSMs and
Social Security or Railroad Retirement
ADFMs is available any time the sponsor
Board benefits, you must apply for Medicare
is on active duty or within eight months
benefits. Your Medicare initial enrollment
following either (1) the sponsor’s retirement
period is a seven-month period.
or (2) the end of TRICARE coverage,
• If your birthday falls on the first of the
whichever comes first. To avoid a break in
month, your initial enrollment period
coverage, ADSMs and ADFMs must sign up
begins four months before the month you
for Medicare Part B before sponsors retire.
5

10. turn 65. Enroll no later than two months Frequently Asked Questions:
before the month you turn 65 to avoid a Medicare
break in TRICARE coverage. You are
eligible for Medicare coverage on the first I will be 65 soon and will become entitled
day of the month before you turn 65. to Medicare. I work full time and have
employer group health plan coverage,
• If your birthday falls on any day other
and I don’t plan on retiring for a few more
than the first of the month, your initial
years. Medicare says I can delay my Part B
enrollment period begins three months
enrollment if I have employer group health
before the month you turn 65. Enroll no
plan coverage. How does this affect my
later than one month before your birth
TRICARE benefit?
month to avoid a break in TRICARE
coverage. You are eligible for Medicare
Medicare allows individuals with group
on the first day of the month you turn 65.
health plan coverage based on current
employment to delay Part B enrollment and
Enroll in Medicare Part B when first
sign up during a special enrollment period,
eligible to avoid a break in TRICARE
which waives the late-enrollment premium
coverage. If you sign up after your initial
surcharge. If you or your spouse still works
enrollment period, you may have to pay a
and has group health plan coverage through
premium surcharge for as long as you have
current employment, you may sign up for
Part B. The Medicare Part B surcharge is
Medicare Part B during the special enrollment
10 percent for each 12-month period that you
period, which is available within the eight
were eligible to enroll in Part B but did not.
months following either (1) retirement
Your Part B premiums are automatically or (2) the end of the group health plan
taken out of your Social Security or coverage, whichever comes first.
Railroad Retirement Board checks. If you
If you are entitled to premium-free Medicare
are not receiving these types of payments,
Part A, you must also have Part B to remain
Medicare bills you every three months for
TRICARE-eligible, even if you have group
Part B premiums.
health plan coverage based on current
employment. Sign up for Part B before you
retire or lose group health plan coverage to
ensure your TRICARE coverage under TFL
will begin immediately following the end of
your group health plan coverage. Your TFL
coverage begins on the first day you have
both Medicare Part A and Part B coverage.
6

11. HOW TRICARE FOR LIFE WORKS
SECTION 1
If I am not entitled to premium-free Claim” from SSA. To keep your TRICARE
Medicare Part A when I turn 65, can coverage, take the “Notice(s) of Award” or
I still use TFL? “Notice(s) of Disapproved Claim” to a
uniformed services identification (ID)
Because you are not entitled to premium- card-issuing facility to have your Defense
free Medicare Part A, you do not need Enrollment Eligibility Reporting System
Medicare Part B to keep your TRICARE (DEERS) record updated and receive a new
benefit. You do not transition to TFL. You ID card. This allows you to keep your
may continue enrollment in TRICARE eligibility for TRICARE Prime or TRICARE
Prime if you live in a PSA, or use TRICARE Standard and TRICARE Extra after you
Standard and TRICARE Extra. For turn 65. To confirm that your TRICARE
information about TRICARE program coverage will continue without a break,
options, visit the TRICARE Web site at contact Wisconsin Physicians Service (WPS)
www.tricare.mil. after you update your DEERS record.
If you are not eligible for premium-free Note: A Report of Confidential Social
Medicare Part A under your own SSN Security Benefit Information (SSA-2458)
when you turn 65, you must file for benefits from the SSA is not accepted as proof of
under your spouse’s (this includes divorced non-entitlement to premium-free Part A to
or deceased spouses) SSN if he or she is 62 keep TRICARE eligibility.
or older. If your spouse is not yet 62, you
must file for benefits under his or her SSN How TRICARE For Life Works
when he or she turns 62. with Medicare
If you will be eligible under your spouse’s Medicare and TFL work together to
SSN in the future, you should sign up minimize your out-of-pocket expenses.
for Medicare Part B during your initial However, there are instances when some
enrollment period to avoid paying a Part B health care costs may not be covered by
premium surcharge for late enrollment. Medicare and/or TFL.
Even if you are not entitled to premium-
Health Care Services Covered by
free Medicare Part A, you are eligible for Medicare and TRICARE
Part B at age 65. See “Medicare Entitlement
When you see a participating or
Based on Age” earlier in this section for
nonparticipating Medicare provider, you
more information.
have no out-of-pocket costs for services
covered by both Medicare and TFL. Most
If you sign up for Medicare and are not
health care services fall into this category.
eligible for premium-free Part A under your
After Medicare pays its portion of the claim,
or your spouse’s (this includes divorced
TFL pays the remaining amount and you
or deceased spouses) SSN, you receive a
pay nothing.
“Notice of Award” or “Notice of Disapproved
7

12. allowable charge) and you are responsible
for the remainder of the billed charges.
Opt-out providers establish private contracts
with patients. Under a private contract, there
are no limits on what the provider can charge
for health care services.
Health Care Services Covered by
Medicare but Not by TRICARE
When you receive care that is covered by
Medicare only (e.g., chiropractic care),
Medicare processes the claim as the primary
payer. TFL makes no payment, regardless
of any action Medicare takes. You are
As the primary payer, Medicare approves responsible for the Medicare deductible
health care services for payment. If Medicare and copayments.
does not pay because it determines that the
Health Care Services Covered by
care is not medically necessary, TFL also does
TRICARE but Not by Medicare
not pay. You may appeal Medicare’s decision,
When you receive care that is covered
and if Medicare reconsiders and provides
only by TFL (e.g. TRICARE-covered
coverage, TFL also reconsiders coverage.
services received overseas), TRICARE
If a health care service is covered by both processes the claim as the primary payer.
Medicare and TFL, but Medicare does not You are responsible for the applicable TFL
pay because you have used up your Medicare deductible, cost-shares, and remaining
benefit, TFL becomes the primary payer. In billed charges.
this case, you are responsible for your TFL
TFL claims are normally filed with Medicare
deductible and cost-shares.
first; however, when a health care service is
If a health care service is normally covered not covered by Medicare, the claim may be
by both Medicare and TFL, but you receive filed directly with WPS, unless you have
the service from a provider who has opted OHI. See the Claims section of this
out of Medicare, the provider cannot bill handbook for additional information.
Medicare and, therefore, Medicare will pay
Health Care Services Not Covered
nothing. When you see an opt-out provider, by Medicare or TRICARE
TFL will process the claim as the second
When you receive care that is not covered
payer, unless you have other health insurance
by Medicare or TFL (e.g., cosmetic surgery),
(OHI). TFL pays the amount it would have
neither makes a payment on the claim. You
paid if Medicare had processed the claim
are responsible for the entire bill.
(normally 20 percent of the TRICARE-
8

13. HOW TRICARE FOR LIFE WORKS
SECTION 1
For more information on covered When your OHI processes the claim after
services, visit www.medicare.gov Medicare, you need to submit a claim to
or www.tricare.mil or contact WPS. WPS for any remaining balance. See
the Claims section of this handbook for
See Figure 1.1 for TFL out-of-pocket costs. additional information.
Coordinating TRICARE For Life with
Note: TRICARE pays after most insurance
Other Health Insurance
plans with the exception of Medicaid,
How Medicare coordinates with OHI
TRICARE supplements, the Indian Health
depends on whether or not the OHI is
Service, and other programs and plans as
based on current employment. In either
identified by the TRICARE Management
case, TFL is the last payer.
Activity.
OHI Not Based on Current Employment
How TRICARE For Life Works Overseas
If you have OHI that is not based on your
Medicare provides coverage in the United
or a family member’s current employment,
States and U.S. territories, which are:
Medicare pays first, the OHI pays second,
• American Samoa
and TFL pays last.
• Guam
OHI Based on Current Employment
• Northern Mariana Islands
Generally, if you have an employer-
• Puerto Rico
sponsored health plan based on current
• U.S. Virgin Islands
employment, that health plan pays first,
Medicare pays second, and TFL pays last.
Medicare also covers health care services
If there are fewer than 20 employees in the
received onboard ships in U.S. territorial
employer-sponsored plan, Medicare pays
waters. In these locations, TFL works
first, the employer plan pays second, and
exactly as it does in the United States.
TFL pays last.
TRICARE For Life Out-of-Pocket Costs Figure 1.1
Type of Service Medicare Pays TRICARE Pays You Pay
Covered by TRICARE Medicare-authorized Remaining amount Nothing
and Medicare amount
Covered by Medicare Medicare-authorized Nothing Medicare deductible
only amount and cost-share
Covered by TRICARE Nothing TRICARE-allowable TRICARE deductible
only amount and cost-share
Not Covered by Nothing Nothing Billed charges (which
TRICARE or Medicare may exceed the
Medicare amount or
balance billing cap)
9

14. Unless you have OHI, TFL is the second processing address for the region where
payer after Medicare for most health care you received care. See the Claims section
services. Your provider files the claim of this handbook for more information.
with Medicare first. Medicare pays its
Frequently Asked Questions:
portion and automatically forwards the
How TRICARE For Life Works
claim to WPS for processing.
Does TFL pay for the Medicare Part B
Medicare does not provide coverage outside
premium and deductible?
of the United States, U.S. territories, and
ships in territorial waters. Therefore, TFL is
The Part B monthly premium is your
your primary payer for health care received
responsibility. TFL covers the Medicare
in all other overseas locations, unless you
Part B deductible as long as the health
have OHI. TFL provides the same coverage
care service is covered by both Medicare
as TRICARE Standard and has the same
and TRICARE.
cost-shares and deductibles for beneficiaries
who live or travel overseas. When seeking Using TFL seems so easy. Should I cancel
care from a host nation provider, region- my Medicare supplement, Medicare
or country-specific requirements may also Advantage Plan, or other OHI?
apply. You should be prepared to pay up front
for services and submit a claim to the You should carefully evaluate your health
overseas claims processor. Claims for care insurance needs to determine if you
received overseas are submitted directly to should continue any OHI plans, Medicare
the TRICARE Overseas Program claims- supplements, and Medicare Advantage
10

15. HOW TRICARE FOR LIFE WORKS
SECTION 1
Plans. You may contact your local State Once you become entitled to premium-free
Health Insurance Assistance Program for Medicare Part A because you are age 65,
free health insurance counseling and you are eligible for TFL when you also
assistance. have Medicare Part B. You are no longer
eligible for enrollment in TRICARE Prime,
Note: If you drop your OHI coverage, you unless you have an active duty sponsor.
must notify WPS.
You may continue to seek care at an MTF
I am a TFL beneficiary and a retired on a space-available basis, but will likely
federal employee. Can I suspend my need to seek care from civilian Medicare
Federal Employees Health Benefits providers. When you visit civilian Medicare
(FEHB) coverage to use TFL? providers, you have no out-of-pocket costs
for services covered by both Medicare and
Yes. You may suspend your FEHB coverage
TRICARE. Contact Medicare for assistance
and premium payments at any time. Visit
with finding Medicare-certified providers.
www.opm.gov/forms or call the Office
of Personnel Management Retirement You may be able to sign up for TRICARE
Information Office at 1-888-767-6738 to Plus. TRICARE Plus is a program that
get a Health Benefits Election Form allows beneficiaries who normally are only
(SF 2809). Eligible unremarried former able to get MTF care on a space-available
spouses can get the form from the basis to enroll and receive primary care
employing offices or retirement system appointments at the MTF within the
maintaining their enrollments. same primary care access standards as
beneficiaries enrolled in a TRICARE
Is a referral or TRICARE prior
Prime option. Beneficiaries should contact
authorization required for health
their local MTFs to determine if they may
care services?
participate in TRICARE Plus.
A referral or TRICARE prior authorization
Enrollment in TRICARE Plus at one MTF
is not required under TFL when Medicare
does not automatically extend TRICARE
is the primary payer. However, when TFL
Plus enrollment to another MTF. The MTF
becomes the primary payer, TRICARE
is not responsible for any costs when a
authorization requirements apply as they
TRICARE Plus enrollee is referred outside
would for a TRICARE Standard beneficiary.
the MTF for additional civilian care.
I was enrolled in TRICARE Prime at
a military treatment facility (MTF).
I received a letter from the MTF
telling me I was no longer eligible for
enrollment in TRICARE Prime. What
does that mean?
11

16. Getting Care
Finding a Provider of the billed charges. In cases where access
to medical care is limited (i.e., underserved
You may receive health care services from areas), TFL may waive the second-payer
Medicare-participating and nonparticipating status for Medicare opt-out providers and
providers, as well as from providers who pay the claim as the primary payer.
have opted out of Medicare. If TRICARE
For Life (TFL) is the primary payer, you Veterans Affairs Providers
must visit TRICARE-authorized providers Medicare cannot pay for services received
and facilities. You will incur higher out- from VA. Therefore, TRICARE is the
of-pocket costs when you obtain care from primary payer for VA claims and you will
opt-out providers or Veterans Affairs (VA) be responsible for the TRICARE annual
providers. Costs vary according to the type deductible and cost-shares. Alternatively,
of provider you see (i.e., participating, you may choose to use your VA benefit.
nonparticipating, opt-out, VA).
Military Treatment Facilities
Medicare-Participating Providers A military treatment facility (MTF) is a
Medicare-participating providers agree to military hospital or clinic usually located
accept the Medicare-approved amount as on or near a military base. You may receive
payment in full. care at an MTF on a space-available basis.
See Figure 2.1 for MTF appointment
Medicare Nonparticipating Providers
priorities.
Nonparticipating providers do not accept
the Medicare-approved amount as payment MTF Appointment Priorities Figure 2.1
in full. They may charge up to 115 percent 1 Active duty service members
of the Medicare-approved amount. TFL pays 2 Active duty family members (ADFMs)
enrolled in TRICARE Prime
up to the 115-percent limiting charge.
3 Retired service members, their families,
Opt-Out Providers and all others enrolled in TRICARE
Prime or TRICARE Plus
Providers who opt out of Medicare enter
into private contracts with patients and are
4 ADFMs not enrolled in TRICARE Prime
TRICARE Reserve Select members and
not allowed to bill Medicare. Therefore, their families
Medicare does not pay for health care
5 Retired service members, their families,
services you receive from opt-out providers. TRICARE Retired Reserve members and
their families, and all others not enrolled
When you see an opt-out provider, TFL
in TRICARE Prime
pays the amount it would have paid if
Medicare had processed the claim (normally
20 percent of the allowable charge) and
you are responsible for paying the remainder
12

17. immediate medical attention would result in
a threat to life, limb, or sight; when a person
has severe, painful symptoms requiring
immediate attention to relieve suffering; or
when a person is at immediate risk to
self or others. The TRICARE health care
benefit covers adjunctive dental care (i.e.,
dental care that is medically necessary
to treat a covered medical-not dental-
condition). The TRICARE health care
GETTING CARE
SECTION 2
benefit does not cover non-adjunctive dental
care, which refers to any routine, preventive,
restorative, prosthodontic, periodontic,
or emergency dental care that is not
related to a medical condition. Eligible
TRICARE beneficiaries may receive
non-adjunctive dental services if enrolled
in the TRICARE Dental Program or the
Overseas Providers
TRICARE Retiree Dental Program.
With TFL overseas, you may generally use
any host nation provider and receive care If you need emergency care, call 911 or go
at MTFs on a space-available basis, unless to the nearest emergency room. Make sure
region- or country-specific requirements you present your Medicare card so that your
apply. When seeking care from a host claim is filed with Medicare.
nation provider, you should be prepared
to pay up front for services and submit a If traveling or living overseas, first attempt
claim to the overseas claims processor. to seek care from the nearest MTF. If an
For more information about getting care MTF is not available, seek care from the
overseas, call your TRICARE Overseas nearest emergency room. You can contact
Program (TOP) Regional Call Center or the TOP Regional Call Center for your
visit www.tricare-overseas.com. region for assistance in finding a host
nation provider.
Emergency Care
Note: Most dental conditions that may be
TRICARE defines an emergency as a considered emergencies are not covered
medical, maternity, or psychiatric condition under Medicare or TFL.
that would lead a “prudent layperson”
(someone with average knowledge of health Urgent Care
and medicine) to believe that a serious
Urgent care services are medically necessary
medical condition exists; that the absence of
services required for an illness or injury that
13

18. would not result in further disability or death Prior authorization is a review of
if not treated immediately, but does require the requested health care service to
professional attention within 24 hours. You determine if it is medically necessary at
could require urgent care for conditions such the requested level of care. If you have an
as a sprain, sore throat, or rising temperature, authorization from a TRICARE regional
as each of these has the potential to develop contractor (Health Net Federal Services,
into an emergency if treatment is delayed LLC; Humana Military Healthcare
longer than 24 hours. Services, Inc.; TriWest Healthcare Alliance;
or International SOS Assistance, Inc.)
Behavioral Health Care
that covers the dates on your claim,
Wisconsin Physicians Service (WPS) will
Medicare helps cover visits with the
honor those authorizations and no TFL
following types of health care providers:
authorization is required. The TRICARE
• A psychiatrist or other doctor
For Life Authorization Request form is
• Clinical psychologist available on the WPS Web site. Providers
• Clinical social worker should fill out the TRICARE For Life
• Clinical nurse specialist Authorization Request form and submit it
to the fax number provided in the top right
• Nurse practitioner
corner of the form.
• Physician’s assistant
If you have questions about authorization
Medicare only covers these visits when
requirements, contact WPS.
they are provided by health care providers
who accept Medicare payment. To pay even The following services require prior
less, you should also ask your health care authorization:
providers if they accept assignment, which
• Adjunctive dental services
means they accept the Medicare-approved
• All outpatient behavioral health care
amount as payment in full, before you
after the first eight sessions in a fiscal
schedule an appointment.
year (October 1–September 30) from
For more information on Medicare’s an authorized, independent behavioral
behavioral health care coverage, visit health provider
www.medicare.gov. • Dental anesthesia and institutional care
• Hospice care
Prior Authorization for Care
• Inpatient behavioral health care services
When TFL becomes the primary payer • Organ and stem cell transplants
(e.g., if your Medicare benefits are
• Partial hospitalization
exhausted), TRICARE prior authorization
• Psychoanalysis
requirements apply.
Note: This list is not all-inclusive.
14

19. TRICARE For Life Coverage
TRICARE Medical Coverage • Eye examinations (routine)
• Hearing aids*
TRICARE For Life (TFL) and Medicare
Note: This list is not all-inclusive.
cover proven, medically necessary, and
appropriate care. TFL has special rules and * Retired sponsors may be eligible for the Retiree-
limitations for certain types of care, and At-Cost Hearing Aid Program. If you are a
retired service member and you need a hearing
some types of care are not covered at all.
aid, you should call a participating military
TRICARE policies are very specific about treatment facility. For more information, visit
GETTING CARE
SECTION 2
which services are covered and which are www.militaryaudiology.org/rachap/state.html.
not. It is in your best interest to take an
Dental Coverage
active role in verifying coverage.
TRICARE offers two voluntary dental
Note: Medicare also has limits on the
insurance programs, the TRICARE Dental
amount of care it covers and, in some
Program (TDP) and the TRICARE Retiree
cases, TFL may cover these health care
Dental Program (TRDP).
services after your Medicare benefits have
been exhausted. TRICARE Dental Program
The TDP provides worldwide dental
To determine if Medicare covers a specific
coverage for family members of all
service or benefit, visit www.medicare.gov
TRICARE FOR LIFE COVERAGE
SECTION 3
active duty service members and National
or call 1-800-633-4227. To determine if
Guard and Reserve members and their
TFL covers the service or benefit, visit the
families. For information about the TDP,
TRICARE Web site at www.tricare.mil
visit the TRICARE dental Web site at
or contact Wisconsin Physicians Service
www.tricare.mil/dental.
(WPS) at 1-866-773-0404. See Figure 1.1
in the How TRICARE For Life Works TRICARE Retiree Dental Program
section of this handbook for more
The TRDP is available to retired service
information on your out-of-pocket costs.
members and their eligible family members,
including retired National Guard and
Examples of services that are generally
Reserve members who are entitled to
not reimbursable by either program include:
retirement pay but do not begin receiving
• Acupuncture
it until age 60, their eligible family members,
• Experimental or investigational services certain surviving family members of
(in most cases) deceased active duty sponsors, and Medal
of Honor recipients and their immediate
family members and survivors. For
information about the TRDP, including
15

20. possible restrictions, visit the TRDP Web exceptions for medical reasons). Your
site at www.trdp.org or call Delta Dental® doctor’s plan of care must demonstrate
of California toll-free at 1-888-838-8737. your need for skilled nursing services.
Frequently Asked Questions: Note: TFL is the primary payer for SNF
TRICARE For Life Coverage care beyond Medicare’s 100-day limit as
long as the patient continues to require
Does TFL cover long-term care?
skilled nursing services and no other
health insurance is involved. SNF care
No. Long-term care (or custodial care)
requires prior authorization on day 101,
is not a covered benefit. However, you
when TRICARE is the primary payer.
may qualify to purchase long-term care
TFL covers an unlimited number of days
insurance through commercial insurance
as medically necessary.
programs or through the Federal Long
Term Care Insurance Program. For more
information about the Federal Long
Term Care Insurance Program, visit
www.opm.gov/insure/ltc or call
1-800-582-3337.
Does TRICARE cover skilled
nursing care?
TFL covers reasonable and necessary skilled
nursing care and rehabilitative therapies,
including semiprivate rooms; regular nursing
services; meals (including special diets);
physical, occupational, and speech therapy;
drugs furnished by the facility; and necessary
medical supplies and appliances. Skilled
nursing care is typically provided in a
skilled nursing facility (SNF).
For TFL and Medicare to cover SNF
admission, you must have had a medical
condition that was treated in a hospital for
at least three consecutive days, and you
must be admitted to a Medicare-certified,
TRICARE-participating SNF within 30 days
of discharge from the hospital (with some
16

21. Pharmacy
Prescription Drug Coverage military providers, regardless of whether
or not you are enrolled at the MTF.
TRICARE offers several options for
filling your prescriptions. TRICARE Non-formulary medications are generally
covers proven, medically necessary, and not available at MTF pharmacies. To check
appropriate prescription medication. To fill the availability of a particular drug, contact
a prescription, you need the prescription the nearest MTF pharmacy.
and a valid uniformed services
TRICARE Pharmacy Home Delivery
identification (ID) card or a Common
Access Card. When traveling overseas, TRICARE Pharmacy Home Delivery is
be prepared to pay up front for medications your least expensive option when not using
and file a claim for reimbursement for an MTF pharmacy. Additionally,
non-military treatment facility (MTF) prescriptions are delivered to you through
and non-network pharmacy services. free standard shipping, and refills can be
TRICARE For Life recommends that easily ordered online, by phone, or by mail.
you fill all of your prescriptions before TRICARE Pharmacy Home Delivery
traveling overseas. also provides you with refill reminders,
convenient notifications about your order
In certain overseas locations, region- status, and assistance with renewing
specific or country-specific requirements expired prescriptions. If you have questions
TRICARE FOR LIFE COVERAGE
SECTION 3
may require using a TRICARE-approved about your prescriptions, pharmacists are
pharmacy. For more information, contact available 24 hours a day, seven days a
your TRICARE Overseas Program week to talk confidentially with you.
(TOP) Regional Call Center or visit
www.tricare-overseas.com. For faster processing of your mail-order
prescriptions, register before placing
Note: You do not need a Medicare Part D your first order. Once you are registered,
prescription drug plan to keep your your provider can fax or call in your
TRICARE prescription drug coverage. prescriptions. Express Scripts, Inc.
(Express Scripts) sends your medications
Filling Prescriptions
directly to your home within about 14
PHARMACY
SECTION 4
Military Treatment Facility Pharmacy days of receiving your prescription.
An MTF pharmacy is the least expensive
Note: Overseas beneficiaries must have
option for filling prescriptions. At an
an APO/FPO or embassy address to use
MTF pharmacy, you may receive up to
TRICARE Pharmacy Home Delivery,
a 90-day supply of most medications at
and the prescription must be from a
no cost. Most MTF pharmacies accept
U.S.-licensed provider.
prescriptions written by both civilian and
17

22. If you have prescription drug coverage This option allows you to fill prescriptions
through other health insurance (OHI), at TRICARE network pharmacies without
you can use TRICARE Pharmacy Home submitting claims. You have access to
Delivery only if the medication is not approximately 60,000 retail network
covered under your OHI or if you exceed pharmacies in the United States and U.S.
the OHI’s coverage limit. Register for territories (American Samoa,* Guam, the
TRICARE Pharmacy Home Delivery Northern Mariana Islands, Puerto Rico,
using any of the options in Figure 4.1. and the U.S. Virgin Islands). TRICARE
retail network pharmacies are only located
Member Choice Center
in the United States and U.S. territories.
The Member Choice Center makes it easy
* Currently, there are no TRICARE retail
to reduce your out-of-pocket costs by
network pharmacies in American Samoa.
transferring your current maintenance
medication prescriptions to TRICARE Visit www.express-scripts.com/TRICARE
Pharmacy Home Delivery. or call 1-877-363-1303 for customer service,
including finding the nearest TRICARE
Note: To use the Member Choice Center, you
retail network pharmacy.
must have a maintenance prescription from
a retail pharmacy or MTF. The Member Non-Network Pharmacies
Choice Center contacts your provider to get When visiting non-network pharmacies,
new written prescriptions for home delivery. you pay the full price of your medication
up front and file a claim for reimbursement.
TRICARE Retail Network Pharmacies
Reimbursements are subject to deductibles,
Another option for filling your prescriptions
out-of-network cost-shares, and TRICARE-
is through TRICARE retail network
required copayments. All deductibles must
pharmacies. You may fill prescriptions (one
be met before any reimbursement can be
copayment per 30-day supply) when you
made. For details about filing a claim, see
present your written prescription and
the Claims section of this handbook.
uniformed services ID card to the pharmacist.
TRICARE Pharmacy Home Delivery Registration Methods Figure 4.1
Online Visit www.express-scripts.com/TRICARE
Phone Call 1-877-363-1433 (Member Choice Center) or 1-877-540-6261 (TDD/TTY)
Mail Download the registration form from www.express-scripts.com/TRICARE,
and mail it to:
Express Scripts, Inc.
P.O. Box 52150
Phoenix, AZ 85072-9954
18

23. Pharmacy Policy be dispensed only after the prescribing
physician completes a clinical assessment
Quantity Limits
indicating the brand-name drug is medically
TRICARE has established quantity limits necessary and after Express Scripts
on certain medications, which means the grants approval. Prescribers may call
Department of Defense (DoD) pays for a 1-866-684-4488 to submit a request for
specified, limited amount of medication a brand-name drug to be dispensed in
each time you fill a prescription. Quantity lieu of a generic, or a completed form
limits are often applied to ensure medications may be faxed to: 1-866-684-4477. The
are safely and appropriately used. Brand over Generic Prior Authorization
Request Form may be found at
Exceptions to established quantity limits
www.pec.ha.osd.mil/forms_criteria.php.
may be made if the prescribing provider
If a generic-equivalent drug does not exist,
can justify medical necessity, or in cases of
the brand-name drug is dispensed at the
natural disasters, as approved by TRICARE.
brand-name copayment.
Prior Authorization
If you fill a prescription with a brand-name
Some drugs require prior authorization from
drug that is not considered medically
Express Scripts. Medications requiring
necessary and when a generic equivalent
prior authorization may include, but are
is available, you are responsible for paying
not limited to, prescription drugs specified
the entire cost of the prescription.
by the DoD Pharmacy and Therapeutics
(P&T) Committee, brand-name medications Non-Formulary Drugs
with generic equivalents, medications The DoD P&T Committee may recommend
with age limitations, and medications to the director of TRICARE Management
prescribed for quantities exceeding normal Activity that certain drugs be placed in
limits. If you do not have Internet access, the third, “non-formulary” tier. These
call 1-877-363-1303 to inquire about a medications include any drug in a
specific drug. therapeutic class determined to be less
relatively clinically effective or cost-
Generic Drug-Use Policy
effective than other drugs in the same
Generic drugs are medications approved
class. For an additional cost, third-tier
by the U.S. Food and Drug Administration
drugs are available through TRICARE
PHARMACY
SECTION 4
and are clinically equivalent to brand-name
Pharmacy Home Delivery or retail network
medications. Generic drugs provide the same
pharmacies. You may be able to fill non-
safe, effective treatment as brand-name
formulary prescriptions at formulary
drugs. It is DoD policy to use generic
costs if your provider can establish
medications instead of brand-name
medical necessity by completing and
medications whenever possible. A brand-
submitting the appropriate TRICARE
name drug with a generic equivalent may
pharmacy medical-necessity form for
19

24. the non-formulary medication. Call These services are provided to you at no
Express Scripts at 1-877-363-1303 or visit additional cost when you receive your
www.pec.ha.osd.mil/forms_criteria.php medications through TRICARE Pharmacy
for forms and medical-necessity criteria. Home Delivery. Participation is voluntary.
For information on how to save money and If you or your provider orders a specialty
make the most of your pharmacy benefit, medication from TRICARE Pharmacy
visit www.tricare.mil/pharmacy or Home Delivery, Express Scripts sends you
www.express-scripts.com/TRICARE. additional information about the Specialty
Medication Care Management program and
Specialty Medication
how to get started.
Care Management
Specialty medications are usually high-cost; Using TRICARE Pharmacy Home Delivery
self-administered; injectable, oral, or infused to fill specialty medication prescriptions
drugs that treat serious chronic conditions provides you with access to the Specialty
(e.g., multiple sclerosis, rheumatoid arthritis, Medication Care Management program
hepatitis C). These drugs typically require benefits previously described. With specific
special storage and handling and are not mailing instructions from you or your
readily available at your local pharmacy. provider, TRICARE Pharmacy Home
Specialty medications may also have side Delivery ships your specialty medication
effects that require pharmacist and/or to your home. For your convenience and
nurse monitoring. safety, TRICARE Pharmacy Home Delivery
contacts you to arrange delivery before the
The Specialty Medication Care Management
medication is shipped.
program is structured to improve your
health through continuous health evaluation, Note: Some specialty medications may not
ongoing monitoring, assessment of be available through TRICARE Pharmacy
educational needs, and medication-use Home Delivery because the medication’s
management. This program provides: manufacturer limits the drug’s distribution
• Access to proactive, clinically based to specific pharmacies. If you submit a
services for specific diseases and is prescription for a limited-distribution
designed to help you get the most benefit medication, TRICARE Pharmacy Home
from your medication Delivery either forwards your prescription
• Monthly refill reminder calls to a pharmacy of your choice that can fill
it or provides you with instructions about
• Scheduled deliveries to specified locations
where to send the prescription to have
• Specialty consultation with a nurse
it filled.
or pharmacist at any point during
your therapy
20

25. Pharmacy Claims Prescription claims require the following
information for each drug:
You do not need to file pharmacy claims
• Patient’s name
for prescriptions filled at MTF pharmacies,
• Prescription name, strength, date filled,
through TRICARE Pharmacy Home
days’ supply, quantity dispensed, and price
Delivery, or at TRICARE retail network
pharmacies. However, if you fill a prescription • National Drug Code, if available
at a non-network pharmacy in the United • Prescription number
States or U.S. territories (American Samoa,* • Name and address of the pharmacy
Guam, the Northern Mariana Islands,
• Name and address of the
Puerto Rico, and the U.S. Virgin Islands),
prescribing physician
you must pay the full price of your
prescription up front and file a claim Contact Express Scripts at 1-877-363-1303
for reimbursement. with questions about filing pharmacy claims.
If you live in the Philippines, you are Pharmacy Claims Appeals
required to visit an approved pharmacy. If you disagree with the determination
An approved pharmacy has been verified on your pharmacy claim (i.e., if your
to meet required TOP contract standards claim is denied), you or your appointed
and is allowed to invoice TRICARE for representative has the right to request a
TRICARE beneficiary claims. reconsideration. The request (or appeal)
* Currently, there are no TRICARE retail for reconsideration must be in writing,
network pharmacies in American Samoa. signed and postmarked or received by
Express Scripts within 90 calendar days
To file a claim: from the date of the decision and must
1. Download TRICARE DoD/CHAMPUS include a copy of the claim decision.
Medical Claim Patient’s Request for
Medical Payment form (DD Form 2642) Your signed, written request must state the
at www.tricare.mil/claims. specific matter you disagree with and must
be sent to the following address no later than
2. Complete the form and attach the
90 days from the date of the notice:
required paperwork as described on
the form. Express Scripts, Inc.
PHARMACY
SECTION 4
3. Mail the form and paperwork to: P.O. Box 60903
Phoenix, AZ 85082-0903
Express Scripts, Inc.
TRICARE Claims
P.O. Box 66518
St. Louis, MO 63166-6518
21

26. Additional documentation in support of the documentation will be submitted at a later
appeal may be submitted; however, because date, the letter requesting reconsideration
the request for reconsideration must be must state that additional documentation will
postmarked or received within 90 calendar be submitted and specify the expected date
days of the date of the decision, do not delay of submission. Upon receiving your request,
the request for reconsideration for the sake all TRICARE claims related to the entire
of additional documentation. If additional course of treatment are reviewed.
22

27. CLAIMS
SECTION 5
Claims
Health Care Claims Attach a readable copy of the provider’s
bill to the claim form, making sure it
In most cases, your provider files your health contains the following:
care claims with Medicare first. Medicare
• Patient’s name
pays its portion and, unless you have other
• Sponsor’s Social Security number (SSN)
health insurance (OHI), forwards the claim
(Eligible former spouses should use their
to TRICARE For Life (TFL) for processing.
SSNs, not their sponsors’.)
However, when TFL is the primary payer • Provider’s name and address (If more than
(e.g., if Medicare does not cover the health one provider’s name is on the bill, circle
care service), your provider may be required the name of the person who provided the
to file your claim directly with Wisconsin service for which the claim is filed.)
Physicians Service (WPS)/TFL (WPS). • Date and place of each service
If you have OHI, you must file the claim
• Description of each service or
with your OHI before filing with TFL.
supply furnished
You are responsible for making sure • Charge for each service
your claims are filed within one year of • Diagnosis (If the diagnosis is not on
either the date of service or the date of the bill, be sure to complete block 8a
an inpatient discharge. To file a claim on the form.)
with TFL, fill out a TRICARE DoD/
CHAMPUS Medical Claim—Patient’s Unlike other TRICARE beneficiaries, TFL
Request for Medical Payment form beneficiaries should file claims in the regions
(DD Form 2642). You can download where they received care. Send claims to the
forms and instructions from TRICARE appropriate mailing address provided in the
at www.tricare.mil/claims or the WPS beginning of this handbook.
Web site at www.TRICARE4u.com. You
Appealing a Claim or
can also obtain forms and instructions
Authorization Denial
at a TRICARE Service Center (TSC) or
a military treatment facility (MTF). Fill You may appeal authorization denials of
out the form completely and sign it. Visit requested services or decisions regarding
PHARMACY
SECTION 4
www.tricare.mil/contactus to locate a claims payments. Medicare and TFL have
TSC or MTF. separate appeals processes. Medicare-
related appeals should be submitted to
When filing a claim with TFL, include
Medicare. You should only submit appeals
your Medicare Summary Notice and OHI
to WPS if TFL is the primary payer.
explanation of benefits (EOB), if applicable.
23

28. Third-Party Liability TRICARE Regional Offices to help resolve
your TRICARE health care collection-
If TRICARE is the primary payer, the related issues. Contact a DCAO if you
Federal Medical Care Recovery Act allows received a negative credit rating or were
TRICARE to be reimbursed for treatment contacted by a collection agency due to an
costs if you are injured in an accident caused issue related to your TFL claim.
by someone else. The Statement of Personal
Injury—Possible Third-Party Liability When you visit a TRICARE DCAO for
form (DD Form 2527) is sent to you if a assistance, you must take or submit
claim appears to have third-party liability documentation associated with a collection
involvement. Within 35 calendar days, action or adverse credit rating, including
you must complete and sign this form debt collection letters, EOBs, and medical
and follow the directions for returning it and/or dental bills from providers. The more
to the appropriate claims processor. Visit information you provide, the faster the cause
www.tricare.mil/claims to download of the problem can be determined. The
DD Form 2527. DCAO researches your claim, provides you
with a written resolution of your collection
Explanation of Benefits
problem, and informs the collection agency
that action is being taken to resolve the issue.
A TRICARE EOB is not a bill. It is an
itemized statement that shows the action
DCAOs cannot provide legal advice or
TRICARE has taken on your claims. An
repair your credit rating, but they can
EOB is for your information and files.
help by providing documentation for the
collection or credit-reporting agency to
After reviewing the EOB, you have the
explain the circumstances relating to the
right to appeal certain decisions regarding
debt. Visit the DCAO directory online
your claims and must do so in writing
at www.tricare.mil/bcacdcao to find a
within 90 days of the date of the EOB
TRICARE DCAO near you.
notice. You should keep EOBs with your
health insurance records for future reference.
TRICARE DCAOs can only assist you with
TFL-related issues. Contact Medicare for
For more information about appeals, visit
assistance with Medicare-related issues.
www.TRICARE4u.com or see the For
Information and Assistance section of
this handbook.
Debt Collection
Assistance Officers
TRICARE Debt Collection Assistance
Officers (DCAOs) are located at MTFs and
24

29. CLAIMS
SECTION 5
Life Changes: Update Your DEERS Record
TRICARE For Life (TFL) continues to have a life-changing event. You have
provide health care coverage for you and your several options for updating and verifying
family as your life changes. However, you DEERS information. See “Important
need to take specific actions to make sure Contact Information” at the beginning of
you remain TRICARE-eligible. It is essential this handbook.
that you keep information in the Defense
Enrollment Eligibility Reporting System Note: Only sponsors (or those appointed
(DEERS) current for you and your family. power of attorney) can add or delete a family
LIFE CHANGES: UPDATE YOUR DEERS RECORD
SECTION 6
DEERS is a computerized database of member. Family members age 18 and older
uniformed service members (active duty may update their own contact information.
and retired), their family members, and
Getting Married or Divorced
others who are eligible for military benefits,
including TRICARE. Proper and current Marriage
DEERS registration is key to receiving It is extremely important for sponsors to
timely, effective TFL benefits. register new spouses in DEERS to ensure
they are eligible for TRICARE programs,
Maintaining your TRICARE eligibility is
including TFL. To register a new spouse in
your responsibility. It is essential to verify
DEERS, the sponsor needs to provide a copy
your information in DEERS any time you
of the marriage certificate to the nearest
uniformed services identification (ID)
card-issuing facility. The new spouse is also
required to show two forms of ID (e.g., any
combination of Social Security card, driver’s
license, birth certificate, current military
ID card, or Common Access Card). Once
your spouse is registered in DEERS, he
or she receives a uniformed services ID
card and is eligible for TFL. Your spouse
must show his or her ID card to access care.
Divorce
Sponsors must update DEERS in the event
of a divorce. The sponsor needs to provide
a copy of the divorce decree, dissolution,
or annulment.
25

30. Former Spouse Coverage Children
Certain former spouses are eligible to
continue TFL coverage as long as they: Your dependent’s coverage does not change
because you are entitled to TFL. Any
• Do not remarry (If a former spouse
children who retain eligibility under the
remarries, the loss of benefits remains
sponsor remain TRICARE-eligible until
applicable even if the remarriage ends
reaching age 21 (or age 23 if enrolled in
in death or divorce.)
a full-time course of study at an approved
• Are not covered by employer-sponsored
institution of higher learning, and if the
health plans
sponsor provides over 50 percent of
• Are not also former spouses of North the financial support), as long as his or
Atlantic Treaty Organization or “Partners her DEERS information is current. To
for Peace” nation members extend coverage beyond your child’s 21st
• Meet the requirements of one of the two birthday, contact DEERS to verify what
situations described in Figure 6.1 documentation is needed.
Former spouses who are TFL-eligible must At age 21 (or 23), children may be eligible
change their personal information in DEERS for the TRICARE Young Adult (TYA)
so their names and Social Security numbers program, and later for the Continued
(SSNs) are listed for the primary contact Health Care Benefit Program (CHCBP).
information. The former spouse’s TRICARE For more information on TYA, visit
eligibility is shown in DEERS under his or www.tricare.mil/tya. For more information
her SSN, not the sponsor’s. on CHCBP, visit www.tricare.mil/chcbp.
Eligibility Requirements for Former Spouses Figure 6.1
1 • The former spouse must have been married to the same military member or former member
for at least 20 years, and at least 20 of those years must have been creditable in determining
the member’s eligibility for retirement pay.
• The former spouse is eligible for TRICARE coverage after the date of the divorce,
dissolution, or annulment.1
• Eligibility continues as long as the preceding requirements continue to be met and the
former spouse does not remarry.
2 • The former spouse must have been married to the same military member or former
member for at least 20 years, and at least 15—but less than 20—of those married years
must have been creditable in determining the member’s eligibility for retirement pay.
• The former spouse is eligible for TRICARE coverage for only one year from the date of
the divorce.
1. For divorce decrees, annulments, or dissolutions on or before September 29, 1988, contact DEERS for
eligibility verification.
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31. Note: Children with disabilities may remain benefits will eventually change. If you have
TRICARE-eligible beyond the normal age any questions, visit www.tricare.mil/deers.
limits. Contact the DEERS support office
Loss of Eligibility
for eligibility criteria.
Moving Upon loss of TRICARE eligibility, each
family member automatically receives a
Whether you are moving across the street certificate of creditable coverage. The
or overseas, moving with TFL is easy. All certificate of creditable coverage is a
you need to do is update your personal document that serves as evidence of prior
information in DEERS, find a provider who health care coverage under TRICARE, so
LIFE CHANGES: UPDATE YOUR DEERS RECORD
SECTION 6
is Medicare-certified (in the United States that you cannot be excluded from a new
and U.S. territories) and TRICARE- health plan for preexisting conditions.
authorized, and continue to receive care
Certificates may be issued in the
when you need it. See “Finding a Provider”
following circumstances:
in the Getting Care section of this handbook.
• Upon the sponsor’s separation from active
Survivor Coverage duty, a certificate is issued to the sponsor
listing all eligible family members.
If your TFL sponsor dies, you remain • Upon the loss of eligibility for a dependent
TRICARE-eligible and will continue to child (age 21, or age 23 if enrolled in a
receive TFL benefits as long as your DEERS full-time course of study at an approved
information is up to date and you are either institution of higher learning, and if the
of the following: sponsor provides over 50 percent of the
• A surviving spouse and do not remarry financial support), a certificate is issued
(If you remarry, TRICARE eligibility to the dependent child.
cannot be regained later, even if you • Upon loss of coverage after divorce, a
divorce or your new spouse dies.) certificate is issued to the former spouse
• An unmarried child under age 21 (or age once information is updated in DEERS.
23 if enrolled in a full-time course of
study at an approved institution of higher Certificates automatically reflect the most
learning, and if the sponsor provided over recent period of continuous coverage under
50 percent of the financial support) TRICARE. Certificates issued upon a
beneficiary request reflect each period of
Note: Children with disabilities may remain continuous TRICARE coverage that ended
eligible beyond normal age limits. Check within the 24 months prior to the date of
DEERS for eligibility criteria. loss of eligibility. Each certificate identifies
the name of the sponsor or family member
Upon the death of your sponsor, you will it is issued for, the dates TRICARE
receive a letter from DEERS telling you coverage began and ended, and the
about your program options and how your certificate issue date.
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