Tricare Standard vs Prime: Standard’s Benefits and Why I Left Prime
After I got married, I sat in the Tricare office at the hospital in Newport, RI, and opted in to Tricare Prime. I had no clue what I was doing, but it sounded “better.” If only I’d known how much frustration and delay that decision would cost me. Now I have switched to Tricare Standard and recommend it to everyone who asks.
The great thing about Tricare Prime is of course, the full coverage. However, you do have to weigh that coverage against one other major thing. WAITING.
Oh the Blessed Tricare Prime Referrals
In my case, I got fed up with waiting. One of the first things I learned about Navy medicine is that you have to wait a lot. You have to get a referral for everything, whereas with Tricare Standard, you don’t need one.
A referral involves getting an appointment with your Primary Care Manager (PCM- fancy term for Doctor, Nurse, or PA) who then gives you a referral out to another care specialist. Then you set up your appointment with the specialist. In my case, this process has been the cause of most of my frustration with Prime.
Going From Tricare To… Tricare
When we decided to start having kids, we knew it might be a bit difficult due to a few medical issues of mine. I got the basic tests done with my PCM in Newport, and then got referred out to a fertility specialist. The only problem was, I couldn’t get in to the specialist for a month.
By the time I got in, we were moving in the next couple of weeks. All we could fit in were a couple of tests. However, I was optimistic. I figured it would be easy to pick up right where we left off once we got down to Jacksonville, Florida, our next duty station. Not so much.
I quickly found out that Tricare is actually four different companies. Tricare North, South, West, and Overseas. So going from Rhode Island to Florida, I had to enroll in Tricare South. Which meant another visit to my new PCM (1 month wait) followed by another referral (another 1 month wait for specialist). Since we were only to be in Florida five months, it was extremely frustrating to waste two months.
After waiting so long, it was difficult for the doctors to get much done for us medically before we moved yet again. Once in Washington State, I thought this could be the end of my troubles. We would be there for a few years at least. Only now we had deployments to deal with.
Same *Stuff Different Day
Once we got to NAS Whidbey, I checked in with Tricare at the hospital. (Another downside of Prime– with Standard you just find your doctor whenever). Once again, I had an appointment with a PCM, but I was expecting it. Since I was referred to a fertility specialist in Jax, I figured the same would happen here since I knew there were no fertility specialists at that location.
Wrong again. Due to trying to keep everything “in house,” I was referred to an OB on base. With a one month wait. I was pissed. I had all my records of what had been done and which tests etc. but that didn’t matter. Plus, the doctors on base weren’t specialists. But they wouldn’t refer me off base until I saw the OB.
When I finally saw the OB, he concluded the same as other doctors… referral out for Fertility… another one month wait (surprise surprise). However, he had to refer me to a clinic 2 hours away, and that hospital wouldn’t accept me because my spouse was deploying in a couple of months!!!
Expiring Referrals and More
You get the idea. The frustration seemed endless, and I’m skipping details! Add to that an expiring referral (which meant starting the referral process over again because of deployment), my Navy doctor PCSing, and his replacement was deployed and I would see yet a different PCM in the mean time. And all this time there was a doctor 4 minutes from my house who could handle my fertility issues
Tricare Standard to the Rescue!
All this to say, I wish I had opted into Tricare Standard from the very beginning. I would have saved myself months of waiting. And I do mean months. I finally switched over to Tricare Standard, got a specialist near my home, and got on a path to pregnancy. Within 6 months, I was pregnant with my sweet little daughter.
Of course, in hindsight I know God’s timing is perfect and He can work all things for good. P is a perfect gift and I would wait months in many long lines all over again just to get her! However, if I can save myself and anyone else this trouble in the future, I’m all for it.
Here Are Some of Tricare Standard’s Advantages:
- You can pick your provider- Picking the doctor, PA, physical therapist etc that you want is a huge plus. This is especially true if you have a recommendation for someone great and want to see them.
- You don’t have to drive to base- If you’re like me and live 30+ minutes from base, it’s nice to not have to drive in every time you have an appointment.
- No referral- As I mentioned, you don’t need “permission” to see a specialist when you know you need one.
- Shorter wait times- Since you don’t have to go through your PCM for a referral, you don’t have to wait the extra few weeks for appointments.
- They still cover 80% and in some cases higher, even 100%. For pregnancy and other certain things they cover all or almost all of the cost. (I still haven’t gotten my bill from my pregnancy so I’m not sure exactly what will be on there.)
You definitely have to research it yourself to decide which is best for you and your family. There are of course many cases where Prime would be the best choice. I personally would rather have to pay a bit extra to have the convenience and choice in my care.
MOAA Supplemental Insurance
One final plus is MOAA Supplemental Insurance. MOAA (Military Officer’s Association of America) provides a Tricare Standard supplement. It covers up to 15% above whatever Tricare Standard pays. If Standard pays 80%, then you’ll have 95% coverage. If they pay 85%, you’ll have 100% coverage. And so on.
To enroll in the supplement, your spouse has to be a MOAA member, which is a yearly fee around $40 I believe. Unfortunately the MOAA supplement is only for officers as far as I know. I don’t know of anything comparable for enlisted.
Then you can enroll any dependent in the supplemental insurance. The monthly rate is low- around $12 per month per person. The 15% extra coverage typically outweighs the monthly cost, in my experience. They also reimburse for the $5 co-pay in the pharmacy.
I am convinced I’ll never go back to Prime. What about you? Are you a Prime or Standard fan? Leave your thoughts in the comments below.