TRICARE Overview
TRICARE is the healthcare program of the U.S. Department of Defense (DoD), providing health coverage to approximately 9.6 million beneficiaries — active duty military service members, retirees, and their families. TRICARE is administered by the Defense Health Agency (DHA), not by CMS.
TRICARE Plan Options
| Plan | Who It's For | Cost | Network |
|---|---|---|---|
| TRICARE Prime | Active duty members (required), others may enroll | Lowest cost; active duty = $0 | HMO-style; PCM required, referrals needed |
| TRICARE Select | Retirees, family members, Guard/Reserve | Moderate cost-sharing | PPO-style; self-referral, higher out-of-network costs |
| TRICARE For Life | Medicare-eligible retirees (65+) | Medicare Part B premium required | Wraps around Medicare; TRICARE pays what Medicare doesn't |
| TRICARE Reserve Select | Guard and Reserve members | Monthly premiums | PPO-style |
| TRICARE Young Adult | Dependent children 21-26 | Monthly premiums | Prime or Select options |
| TRICARE Retired Reserve | Gray-area retirees not yet 60 | Monthly premiums | PPO-style |
Key Features
Military Treatment Facilities (MTFs)
Active duty members typically receive care at MTFs — military hospitals and clinics on or near military installations. TRICARE Prime enrollees are assigned to an MTF or network provider as their Primary Care Manager (PCM).
Managed Care Support Contractors
TRICARE contracts with regional managed care support contractors to provide civilian network management:
- TRICARE East Region — Humana Military
- TRICARE West Region — TriWest Healthcare Alliance
- TRICARE Overseas Program — International SOS
Pharmacy Benefits
TRICARE provides prescription drug coverage through:
- Military pharmacies (MTF pharmacies) — $0 cost
- TRICARE mail-order pharmacy (Express Scripts) — low copays
- Retail network pharmacies — moderate copays
- Non-network pharmacies — highest cost (point-of-service claims)
TRICARE and CMS Interoperability
While TRICARE is not a CMS-administered program, it interacts with CMS programs in important ways:
- TRICARE For Life coordinates with Medicare (Medicare pays first, TRICARE covers remaining costs)
- TRICARE-eligible individuals who also qualify for VA, Medicaid, or Medicare must coordinate between programs
- DHA is adopting FHIR standards for data interoperability, though on a separate timeline from CMS mandates
