Navigating Tricare: Prime vs. Standard

00c636e00bee0ba03b364841363f738b.jpg

Navigating Tricare: Prime vs. StandardFor many people, including our service men and women, Tricare Prime and our medical treatment facilities around the world provide an excellent standard of care. But not all duty stations offer care consistent with what you had been receiving before you moved, and as a family member, your options may feel limited.

To find a more personalized and specialized wellness plan, it sometimes requires looking beyond the Tricare Prime insurance network, which is a task that can seem overwhelming. I remember being a newlywed at my first duty station and finding the Tricare system so different than what I was used to with civilian insurance. I didn't understand the structure or have anyone to really help me get a grasp on it. In turn I found myself bitter and angry that this system wouldn't let me see the doctor I wanted to see. As a kid who grew up in a medical family, I was used to having a very tight relationship with a doctor that my parents or I hand picked. The fact that this new insurance was not letting me do what I wanted or what I was used to frustrated me. Almost five and half years later, I can say that Tricare is actually one of the best medical insurance programs available, especially if you’re trying to find a more holistic or functional medicine practitioner.

The number one piece of advice I have for people who are really wanting to craft their own healthcare situation to their own unique needs and preferences is to switch from Tricare Prime to Tricare Standard. Why?

For Tricare Standard, no referrals are needed to see in network or out of network providers. There is no need to go to an medical treatment facility, and you can choose your doctor. For me, this would have been important to know as a new military spouse. I was living in uptown New Orleans next to two of the best hospitals in the state with hundreds of associated doctors. But, on Tricare Prime, I had to drive 45 minutes one way in heavy traffic and over a toll bridge to go to my assigned medical treatment facility in Belle Chasse, LA every three months just to have a simple prescription filled. No wonder I had high blood pressure at every one of those appointments! According to the Tricare system, I was within their 30 minute radius for assignment to the medical treatment facility, so there was no changing. But, if I had simply called and asked about switching to Standard, the issue would have been resolved and I could have seen a doctor off-post, covered by Tricare, and saved myself a lot of anger and stress.

However, unlike Prime, with Tricare Standard there are yearly deductibles and cost shares.

The deductibles are as follows (source | Catastrophic Cap info):

Navigating Tricare: Prime vs. Standard

Once you have met your deductible, the costs are then dependent on the care given. You can see a complete list of cost shares at the following links:

Active Duty Family Members

National Guard/Reserve Members and Their Families

Retired Service Members and Their Families

It is often between 15-20% of the allowable charge or negotiated fee. This also depends on whether you see an out of network, or network doctor. Confused about what kind of providers are available under each plan? Hopefully this chart will help.

Navigating Tricare: Prime vs. Standard

This again depends completely on your provider, and the service given. The structure completely changes for treatment such as prenatal care. For more info on the specifics associated with your birth options under Tricare, read Kate Dornstadter’s blog post here. While this is a broad overview, when in doubt, never hesitate to contact your regional Tricare office. Their contact numbers can be found here and their representatives have always been quick, efficient, and helpful. If I had just called and explained my situation to a Tricare representative back in my early married days, it would have saved me a lot of heartache.

I will also add that Tricare Standard is available overseas. I discovered Tricare Standard existed right before we PCSed to Germany, and was misinformed by someone that it was not an option available overseas. It wasn’t until two years into our three year duty station at a small garrison that I found out that it did indeed exist. If you’re overseas and wanting to see a host-nation provider without a referral, then Tricare Standard Overseas is the way to go. At least in Germany, host-nation providers usually speak excellent English, and many receive their medical training in the United States. Rates are exactly as shown in the charts above. If you have questions, then always call your installation’s Tricare office.

If you are happy with your existing doctor and your level of health care, then switching to Standard may not be for you at this time. The level of care at military treatment facilities meets and surpasses the needs of so many service members and their families. But, if you’re looking for something to fit your needs beyond what is offered through Prime, then switching to Standard might be the best bet for you. And truth be told, while not having to pay for Prime seems like a great military benefit, the cost-share and deductible rates for Standard are very low compared to most civilian insurance plans. Having access to the low costs is a benefit in itself. It really is Tricare's best kept not-secret secret.

Stay tuned for the next installment of our Navigating Tricare series where we break down how to find an alternative or holistic doctor using Tricare.

Have you made the switch to Tricare Standard? How has it worked out for you?