Father, mother child with American flag

Many benefits are associated with the commitment to active-duty military service, including the Tricare health insurance plan – which is generous compared to many U.S. insurance plans. 

Yet some benefits come with a cost. Unfortunately, if you live off-base, health spending is one of them.

While Tricare insurance covers most service members and their dependents, with countless permanent change of station moves, military families living off base are often left on a scavenger hunt for Tricare network providers and pharmacies within driving distance. 

A 2019 article by  Health Affairs revealed significant shortages in the number of providers in the United States who accept Tricare insurance. According to the Government Accountability Office (GAO), only 67% of general and family practice physicians accept Tricare, compared to a 95% acceptance rate for private insurance companies and an 86% acceptance rate for Medicare members.

This trend continued with specialty care, leaving a 77% acceptance rate for Tricare members and a 95-98% acceptance rate for privately insured and Medicare members.

Sudden switches

This data is not surprising for military families who have experienced the recurrent disappointment of losing access to their long-term family-favored practitioners because of a sudden switch out of the Tricare network. 

For example, in 2021, more than 3,000 retail pharmacies, including Walmart and Sam’s Club, left the Tricare network. 

As a result, military families can expect an expensive copayment after a simple visit to an out-of-network retail pharmacy.

Despite major changes, military families still have access to over 14,000 major retail pharmacies, including CVS, Walgreens, and Rite Aid. Unfortunately, a quick trip to one of the biggest pharmacy corporations can lead to hefty copayments because of a Jan. 1, 2022, copayment increase of $1, $5, or $8 for generic, brand-name, and non-formulary drugs under all Tricare plans – unless a military pharmacy is used, where everything is free.

So where does this leave active-duty family members beyond 30 minutes or 100 miles from a military treatment facility (MTF) or Tricare Prime service area?

According to the Tricare Prime distance and drive time standards, beneficiaries are provided two options. Members can either waive the drive time standard, expecting to travel beyond 30 minutes for medical care, or find a network primary care manager within reach.

If Tricare Prime members find both options unfeasible, the choice to enroll in Tricare Select is available. Select members have a greater selection of network and non-network providers to choose from.

Complex health problems can be expensive

Just ask Stephanie Barone, a military spouse of over 17 years, who was diagnosed with multiple sclerosis in 2011 and epilepsy in 2016. In addition to the emotional turmoil from her sudden back-to-back diagnoses, her son, who recently celebrated his 10th birthday, was diagnosed with type 1 diabetes in 2022.

With more than 13  prescriptions and monthly copayments that cost hundreds of dollars, leaving her credit cards maxed beyond their limit,  Barone became determined to find ways to reduce her healthcare expenses.

“When he was first diagnosed, I didn’t know about the Tricare pharmacy, so I was filling at Rite Aid pharmacies and paying the co-pays,” she said. Her husband, Victor Barone, has served in the U.S. Navy since 2005. They bought their first off-base home in Virginia Beach in 2019. 

To make matters worse, Stephanie Barone soon discovered that Tricare would cover only the “necessities” for her son, Lorenzo. “We [were] running around all day trying to get all of Lorenzo’s prescriptions and medical supplies,” she said. “Tricare approved his insulin but not the device that administers it.”

When asked about her  medical spending, Mrs. Barone said: “Let’s put it this way, I get four prescriptions for my illness, and Lorenzo gets about nine…take the average copay and times it by 13, and you should have an average of our co-pay costs.” 

Copayments for medication at retail pharmacies within the Tricare network vary. Generic brands can cost up to $14, brand-name could cost up to $38, and non-formulary drugs can cost up to $68 out of pocket.

From the stress of the diagnosis partnered with the financial burden, the option to postpone additional medical procedures to catch up on medical bills is a continued sacrifice for military families across the globe.

All Tricare plans are not created equal, and selecting the right plan for your family is an essential step toward saving money.

Tricare Prime

As a family chooses an insurance plan, Tricare Prime will be the best option if saving money is the top priority. There are zero out-of-pocket costs for services received from Tricare network providers and a $0 deductible. The individual or family will have a primary care manager (P.C.M.) in charge of all care. The primary care manager is the main doctor and is responsible for everything, including both primary care and referrals to specialists, which can take time.  

For out-of-network services, if your assigned P.C.M. approves and authorizes, and refers, the authorized referral will cost what it would for an in-network provider. In other words, there will be zero out-of-pocket expenses.

Nevertheless, patience is a continued virtue. P.C.M. referrals, on average, can take between two and five business days, and in rare cases, referrals can be denied. The option to appeal is always available. 

An appeal can be submitted online, by fax, or by mail by the patient, legal guardian, or appointed representative. Appeals can take 3 to 30 calendar days, depending on the level of urgency and medical needs. 

If an individual or family chooses to get care from a network or out-of-network provider without a referral, there will be a point-of-service fee. Therefore, advocating for your healthcare needs is an option that should be considered before adding on unnecessary medical payments.

Tricare Select

If freedom matters more than the accumulation of medical debt, this plan is a good choice. As the name implies, you are authorized the option to select both a primary care provider and a specialist. This means no restraints of a primary care manager (P.C.M.), and an individual or family member can choose a Tricare network or non-network provider without a P.C.M.-approved referral. In other words, there is an increased chance of higher out-of-pocket expenses.

The cost of this freedom ranges, which includes a combination of copayments, costs per service, and an annual outpatient deductible. For E-1 to E-4 active-duty family members (these classifications mean enlisted or non-officer ranks and pay grades), there is a $50  annual deductible for individuals and a $100 annual deductible per family. For E-5 and beyond (referring to higher enlisted ranks and officers and pay grades), there is a $150 deductible per individual and a $300 deductible per family. 

Tricare Select members are responsible for 20% of the cost per service for care received from out-of-network providers, and the military will cover the remaining 80%. If in-network, a Tricare Select member must pay between $25 to $103 for Tricare in-network services.

For a side-by-side comparison, this site allows investigation of copays and cost-sharing for active-duty military personnel, dependents, and retirees across various plans.

Tricare Overseas is different; military members often say that overseas health coverage is far better than coverage in the United States.

Health insurance for retirees is also very different. 

Further complicating the Tricare Select and Tricare Prime choices, the plans are different for people who joined the military before Jan. 1, 2018, which is more generous than the plans for those who joined on or after Jan. 1, 2018.

Catastrophic cap

The catastrophic cap is the maximum amount a  family can expect to pay out of pocket per year. This applies to both Tricare Select and Tricare Prime members. 

The catastrophic cap for all active-duty Tricare insurance plans is $1,000 per family for those who enlisted before Jan. 1, 2018, and $1,217 per family for those who joined on or after Jan. 1, 2018. This covers in-network medical services, deductibles, and copayments — but only those that are approved by your plan. This does not count toward out-of-network services and point-of-service fees. 

It is crucial to keep track of all medical spending throughout the year. “Once you hit the catastrophic cap, then you won’t have to pay for anything else. Tricare immediately takes over.  As far as copays, you won’t have to pay anymore,” said a Tricare representative, Tiffany Darby. 

She stressed the importance of using the Tricare online patient portal and pointed out that Prime members are less likely to reach the cap than are  Tricare Select members, because Select members have more out-of-pocket spending.

“Create a login, and log into your portal, and then you should have all of your personal information” and medical expenses, she said. “And authorizations, all of your claims, you can check on your authorization statuses, whether it has been approved, what doctors it’s been approved to, that kind of information…”

According to the Consumer Financial Protection Bureau, more than half of the 2021 medical debt collection reports from service members confirmed that medical billing errors negatively affected their credit history. 

“Despite the widespread expectation that a core benefit of military service will be full coverage of medical expenses, service members experienced a range of debt collection and credit reporting activity related to allegedly unpaid medical bills,”  the C.F.P.B. reported.

Network vs. non-network vs. military pharmacies

If saving money on pharmacy-related copayments is a  priority, a trip to the nearest military pharmacy will be the best option. Both generic and brand-name prescriptions are fully covered, making this the only zero-cost option for a military family’s medication. 

The nearest Tricare pharmacy is listed on Tricare’s website. If your spouse is on active duty, there is a great chance that a military pharmacy is within reach.

If a military pharmacy is too far away for convenience, a local in-network retail pharmacy is the second best option. With Tricare Select and Tricare Prime, at a non-military in-network retail pharmacy, you can expect to pay up to $14 for generic brands, $38 for brand-name, and up to $68 for non-formulary drugs out of pocket.

At non-network pharmacies, generic and brand-name medication will cost $38 or 20% of the total cost and $68 for non-formulary drugs or 20% of the total cost for Tricare Select members. However, after the point-of-service fee, Tricare Prime members can expect to pay 50% of the total cost per generic, brand-name, and non-formulary medication.

Tricare dental plan

The Tricare Dental Plan (TDP) is covered under United Concordia, and costs for covered services are determined by the active-duty enlisted member’s pay grade. 

All enrollees should expect a $1,500 maximum annual benefit, $1,200 for accidental dental coverage, and $1,750 for orthodontic coverage up to the age of 23 for spouses and ages between 21 and 23 for children if enrolled in school. 

Diagnostic exams and preventive care are fully covered one or two times per year in a 12 – 36-month period for all pay grades. Sealants are also covered up to the age of 18.

As mentioned above, depending on the enlisted member’s pay grade, families of active-duty personnel from pay grades E-5 and above can expect to pay 10% more for oral surgery, endodontic, and periodontic care than pay grades E-4 and below.

For all other visits, including the initial consultation, restorative care, etc., all members are expected to pay an equal cost per service, ranging between 20% and 50% of the bill. 

All pay grades must pay 50% of the total cost of dental medication. 

Beneficiaries who are pregnant or diagnosed with a chronic illness are automatically enrolled in the Dental Tricare   Wellness Program, which covers 100% of up to 4 periodontal surgical procedures and an added periodontal visit per year. 

Mental health coverage

Almost all in-network mental healthcare services are fully covered for Tricare Prime members.

As in civilian mental health treatment, coverage is often limited because there are no in-network providers or appointments for routine mental health care or specialty care, so the patient winds up paying cash. Out-of-network mental healthcare services are not covered, and Tricare Prime members will pay out-of-pocket point-of-service fees to be determined by the selected out-of-network provider.

Tricare Select members will pay a fee for both in-network and out-of-network mental healthcare services. The total service cost depends on whether the enlistment date is before or after January 2018.

Active-duty members and their families enrolled in Tricare Select before January 2018 will pay a minimum of $25 per mental health primary care visit, $37 for specialty care, and 20% of all out-of-network services. 

Tricare Select members enrolled after January 2018 will pay between $18 and $78 for in-network mental health services and 20% for out-of-network services. 

What is officially not covered: Aversion therapy, elective psychotherapy, psychiatric treatment for sexual dysfunction, psychogenic surgery, and sensory integration therapy. 

Kimberly Gladden-Eversley is a military spouse, life coach, and journalist. After earning her bachelor of communications, she became a member of the National Society of Leadership & Success before...