Step 1- Tricare Prime or Tricare Standard? [Military Spouse Basic Training]

by Heather on June 11, 2015

tricare prime or tricare standard

Step 1- Tricare Prime or Tricare Standard?

[Military Spouse Basic Training Series]

Hi! This post is the first in my series called Military Spouse Basic Training series. In this series, I’m giving you four steps to walk through in order to have a handle on the most important and significant issues we deal with as military spouses. (go here if you missed the intro)

Today’s topic is Tricare Insurance, and the basics of choosing Tricare Prime or Tricare Standard. It can be SO confusing trying to decide which one is best for your family. When I started out, I had no idea and my husband didn’t either. He’d never been married before so he had never gone through enrolling anyone. We were clueless!

Should You Be Prime Or Standard?

In this post, I’ll give you the basic features of going Tricare Prime or Tricare Standard. I’ll also touch on the dental insurance, which is separate through Metlife. Then I’ll give you some questions to ask yourself to evaluate which one is best for you.

One tip before we dive in– You may have to revisit this question and possibly change which insurance you have at each duty station or at other times, based on many factors (discussed below). Just know that you’re not signing your life away forever, you can make changes as your location/family/living situation change etc.

Features of Tricare Prime:

  • Less out-of-pocket expenses
  • Must see a provider- known as a “PCM” or Primary Care Manager- on base/at military facility if you’re within a 30-60 minute drive (depends on duty station)
  • Must get referrals in order to see specialists
  • Must enroll- once you get married you are automatically on Standard unless you enroll in Prime (Of course your spouse must add you in DEERS).
  • You can switch to Standard at any time, with one switch back within the year. After that, you must wait until Prime enrollment to switch back to Prime.
  • Must re-enroll every time you “PCS” (Permanent Change of Station = move) to a new region (north, south or west)
  • Less consistency in care (PCM may PCS or deploy frequently)

Features of Tricare Standard:

  • Individual deductible: $50 (E-4 and below) or $150 (E-5 and up)
  • Family deductible: $100 (E-4 and below) or $300 (E-5 and up)
  • $1000 yearly catastrophic cap (catastrophic cap is actually same if choosing Tricare Prime or Tricare Standard, but you typically go through it faster with your Standard payment portion)
  • If officer spouse, look into MOAA supplement, espically if you or your dependents see specialists often. They cover 15% above what Standard covers, plus can reimburse pharmacy co-pay too. They cover the yearly catastrophic cap but not the deductible.
  • Your choice of providers out in town, in or out of network. Pay slightly more for out of network.
  • No referrals needed for specialists
  • No need to enroll– you’re automatically standard when you register in DEERS or move to a new region

**If you’ll be living overseas, have teenage children, other dependents, or other special situations, you may want to take a look at Tricare’s Compare Plan page to get more detailed information on plan options.

Tricare Dental Through MetLife

This program is voluntary and you MUST enroll separately in order to get coverage. Do NOT (ahem, speaking from experience here)… I repeat, do NOT go to an appointment before you
1) enroll
and
2) your coverage begins.

Again, this is separate, whether you’re going Tricare Prime or Tricare Standard.

I made this mistake when I first got married. I did not know I had to enroll so I made an appointment. (We got married and immediately moved cross-country). When I arrived, they checked my insurance and it wasn’t popping up…. because I didn’t have it. Eek!

They did the cleaning but were gracious and they didn’t have the doctor see me (would have cost a lot more!). I had to pay out of pocket for the cleaning and rescheduled the Dr visit.

Bottom line, enroll here if you want coverage. One good thing: once enrolled, new dependents are automatically covered- no need to enroll when a baby is born.

Action Plan: Evaluate your situation with these questions:

When to consider Prime:

  • Will you be living on base or very near a military clinic or hospital?
  • Do you prefer to have no payment responsibility?
  • Are you ok sacrificing more choice in provider?
  • Are you ok with less consistency in your care?
  • Do you and your children rarely need to see a doctor for sickness or specialties?

When to consider Standard:

  • Do you need to see specialists frequently for specific needs, especially when waiting for a referral could hinder your care? (fertility, etc)
  • Do you highly value choice of provider and consistency in care for you and your children?
  • Are you in a season where you will be moving several times to different regions within a short amount of time, leaving you to wait for repeated referrals?

RememberYou and your spouse are ultimately the ones who must decide on the coverage for you and your dependents.  Be sure to do your own research. and hopefully this has been a good starting point for you!

*** Some military hospitals can treat things such as some fertility issues. In that case, Prime may cover those expenses when it normally would not. Be sure to ask Tricare about your own specific conditions and what’s covered.

*** All information is subject to change.This article is only meant as a guide. Please consult the Tricare website or call them in order to ensure that your health care information is up to date and fits with you and your family’s needs.

Once you have completed Step 1, you’re ready for step 2! Go to:

Step 2- 5 Things You MUST Know To Survive Deployment


tricare prime or tricare standard

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{ 2 comments… read them below or add one }

1 Alexis Turner July 23, 2015 at 5:10 pm

Stumbled upon this site and you are giving my hope with this insurance “thing”! Like you my husband and I were married (Jan.3,15) and he has no idea how the insurance works for spouse/beneficiaries- he’s also never been married, and hasn’t a clue the differences between the two. We are hoping to be expecting our first pregnancy by the end of the year, so I’m trying to figure out which will be the best- especially with care provided DURING pregnancy, ultrasounds, midwives etc.. My girlfriend recommended Prime, but I’m wondering how the “care” while pregnant factors in.

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2 Heather July 24, 2015 at 11:04 pm

I’m so glad to be providing a bit of hope! It is definitely a confusing process/decision. That’s awesome that you want to start a family. How good the care is definitely depends on which base you’re at and how close you are to it. I’ve heard good things about some base facilities and some not-so-good things about others. At times you can go out in town and still be on Prime, so you can ask at the Tricare office or on the phone to see if that is a possibility. Also you can research the local clinics in town and see if they would be something you would like, before you switch to Standard. =)

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