Tricare Prime: Coverage Basics, Enrollment & Costs

Tricare is the military health care provider for military members, retirees and their family members. Whether you are located in the United States or anywhere else in the world, Tricare provides comprehensive health care coverage, prescription programs and dental plans.

But which Tricare plan should you choose?

Here’s a helpful guide on Tricare Prime coverage, enrollment and costs to help you decide if the plan is right for you.

Table of Contents
  1. Five Tricare Prime Facts You Need to Know
  2. What is Tricare Prime?
  3. Tricare Prime Eligibility
    1. Enrollment Fees
    2. Catastrophic Cap
    3. Prescription Medications
    4. Co-Pays
  4. Important Tricare Prime Resources
  5. Enrollment Basics
  6. Advantages and Disadvantages
    1. Tricare Prime: Advantages
    2. Tricare Prime: Disadvantages

Five Tricare Prime Facts You Need to Know

  1. Automatic Enrollment: If you’re on active duty, the military automatically enrolls you in Tricare Prime. However, your family may be eligible for Tricare Select.
  2. Lowest Cost Option: Assuming beneficiaries utilize in-network providers, Tricare Prime has the lowest deductibles and co-pays, although enrollment fees might be higher. For a thorough analysis of this, check out our Tricare Prime vs. Select guide.
  3. Available in Three Prime Service Areas: Tricare Prime service areas include Tricare East, West and Overseas.
  4. Less Freedom of Choice: Tricare Prime beneficiaries must use in-network providers to get the lowest costs. Tricare Prime requires the use of military treatment facilities where they are available.

Many “Flavors” of Prime: Tricare Prime, Prime Remote, Prime Overseas, Remote Overseas, Young Adult Prime, and the US Family Health Plan all share HMO-like managed health care features.

What is Tricare Prime?

Tricare Prime is a military health care option that works like a health maintenance organization (HMO). HMOs are network-based options that provide health insurance coverage to beneficiaries using contracted providers.

Tricare assigns you to a primary care manager (PCM) when you enroll in Prime or move to a new area. You’ll see your PCM for checkups and basic medical care. If you need specialized care, your PCM must write you a referral before Tricare will cover the charges.

While Tricare determines your PCM, you may be able to request reassignment to a different provider.

Depending on your military status and location, you may have access to Tricare Prime Remote, Prime Overseas, Remote Overseas, Young Adult Prime or the US Family Health Plan. These all function as managed-care Prime plans. In exchange for lower out-of-pocket costs, beneficiaries must use their assigned PCMs in most cases to receive primary care and initialize specialized care referrals.

Tricare Prime Eligibility

Active duty service members get Tricare Prime automaticallybut lots of others are also eligible to enroll in Tricare Prime.

Here are the categories of people that potentially qualify for Tricare Prime coverage:

Click on the links above to see if you qualify.

Inactive National Guard and reserve service members aren’t eligible for Prime plans but should look into Tricare Reserve Select.

If you’re an active-duty dependent or retiree and don’t want Prime, you can enroll in Tricare Select. However, retirees must transfer to Tricare for Life when at age 65.

Low Out-of-Pocket Costs

Active-duty service members and eligible dependents (spouses and children enrolled in DEERS) pay no out-of-pocket costs for covered in-network services with Prime. For this reason, Tricare Prime often equates to the lowest out-of-pocket costs for the categories.

Active-duty personnel have no enrollment fees, deductibles, network co-pays or point-of-service fees. Non-active duty beneficiaries – including retirees, their families and other Prime eligible members – pay some coverage fees.

Enrollment Fees

Annual enrollment fees differ depending on when the service member entered active duty. Those who entered active duty before 2018 (Group A beneficiaries) will pay an enrollment fee of $351.96 for a single member or $703.92 for a family in 2023, according to a Nov. 7 Tricare news release. Service members who entered active duty during or after 2018 (Group B beneficiaries) will pay enrollment fees of $426 for individual plans and $852 for family plans in 2023.

Catastrophic Cap

In addition to enrollment fees, all non-active duty service members and their dependents are responsible for paying the catastrophic cap, which is the maximum annual out-of-pocket cost, including deductibles, cost-shares and co-pays.

This is the breakdown of catastrophic caps per Prime service category in 2023, according to the news release:

  • Active-duty members don’t have a catastrophic cap. They receive all health care at no added cost.
  • The catastrophic cap for family members enrolled in Prime is $1,000 for Category A (sponsor entered service before 2018) and $1,217 for Category B (sponsor entered service after 2018).
  • For Group A retirees, their family members and all others, the catastrophic cap is $3,000. For Group B, the catastrophic cap is $4,262.

Prescription Medications

Finally, military treatment facilities (MTFs) fill prescription medications at no cost for Tricare Prime beneficiaries. For those who fill their prescriptions at retail pharmacies or by mail, prices rose slightly as of January 2020 to fund the increasing costs of the Tricare program.

An itemized list of out-of-pocket expenses for 2023 can be found on the Tricare Prime website via their calculator tool.

Co-Pays

Besides enrollment fees, if you are not an active-duty service or family member, you will have to pay co-pays, updated as of 2023including these:

  • $24 primary care visits
  • $36 co-pay for specialty care visits
  • $73 co-pay for emergency room visits
  • $36 for urgent care visits
  • $73 for outpatient surgery
  • $48 for ground ambulance
  • $20 for an air ambulance
  • $182 for inpatient admissions
  • $36 per day for inpatient skilled nursing facilities

While your enrollment fees are slightly higher, these co-pays are lower than Tricare Select.

Important Tricare Prime Resources

To better manage the Tricare system, Tricare has three regions: east, west, and overseas. Different contractors administer your health care services, depending on your location:

Enrollment Basics

To enroll in Tricare Prime, first ensure your DEERS profile is up to date. DEERS enrollment determines Tricare plan eligibility and geographic coverage region.

Remember that enrolling in Tricare Prime or switching health care options is only permitted during the open season or otherwise qualifying life events. QLEs include retiring from active duty, the birth of a child, marriage, divorce, a permanent change of station move and other life-changing circumstances.

Advantages and Disadvantages

Before selecting any health care option, it is essential to understand the advantages and disadvantages. Below are several pros and cons of Tricare Prime that will help you to determine what’s best for you:

Tricare Prime: Advantages

  • Fewer Out-of-Pocket Costs: Of all Tricare-sponsored plans, Tricare Prime is often considered the most affordable option, with the fewest out-of-pocket costs. However, some beneficiaries may pay higher enrollment fees.
  • Free Enrollment: There are no enrollment costs for active-duty service members and their families.
  • Less Paperwork: Health care services performed by in-network providers do not require claims to be submitted, leading to fewer administrative burdens for Tricare Prime beneficiaries.

Tricare Prime: Disadvantages

  • Less Freedom: You must select providers from an existing network, which can limit your provider and health care facility choices.
  • Referrals Needed: You’ll usually need a PCM referral – which Tricare must approve – before receiving specialty care. This adds an administrative burden to the appointment-making process.
  • MTF Assignments: Tricare might assign beneficiaries who live in a Tricare Prime service area to receive health care at an MTF. This can be a major pain point for military families with complex medical needs. To qualify for Tricare Prime Remote, beneficiaries must live more than an hour away from an MTF, according to Tricare.

More information:

Please visit our Tricare Reference Guide for more information on Prime and other Tricare programs.

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