Networkin’ Your Wallet

Knowing which doctors, facilities and pharmacies are in the TRICARE network can help you watch your health care costs and avoid unexpected point-of-service fees, cost-shares or copays.

TriWest’s online Provider Directory is constantly being updated at www.triwest.com. You can also locate your local network retail pharmacy and your local military treatment facility (MTF) online.

Network

A network provider is a professional or institutional provider who has a contractual relationship with the TRICARE regional contractors to provide care at a negotiated rate. A network provider agrees to file claims and handle other paperwork for TRICARE beneficiaries, and typically administers care to TRICARE Prime beneficiaries and those TRICARE Standard beneficiaries using TRICARE Extra (the preferred provider option). A network provider accepts the negotiated rate as payment in full for services rendered.

Benefits of using Network providers

Network providers will participate on a claim, also known as accepting assignment. These providers agree to file the claim for you, to accept payment directly from TRICARE and to accept the amount of the TRICARE allowable charge. Beneficiaries using TRICARE Extra will have lower out-of-pocket cost-shares.

Out of Network

Non-network providers do not have a signed agreement with your regional contractor and are therefore considered out-of-network.

There are two types of non-network providers:

• Participating providers have agreed to file claims for you, to accept payment directly from TRICARE and to accept the TRICARE allowable charge, plus applicable cost shares (if applicable) paid by you, as payment in full for their services. Providers may participate on a claim-by-claim basis.
• Non-participating providers have not agreed to accept the TRICARE allowable charge or file your claims. Non-participating providers may charge you up to 15 percent above the TRICARE allowable charge for services in addition to any POS deductible and cost shares, if applicable. This amount is your responsibility and will not be paid by TRICARE.

TRICARE Prime: Using a non-network provider when enrolled in TRICARE Prime without a referral will result in point-of-service charges.

TRICARE Standard: If you are eligible for TRICARE coverage but not enrolled in Prime, you are using the TRICARE Standard option and will pay the required cost-share level when you visit a non-network provider.

Pharmacy

The TRICARE pharmacy benefit is available to all eligible TRICARE beneficiaries.

The MTF pharmacy is the lowest-cost option.

Using the TRICARE Mail Order Pharmacy (TMOP) will allow you to receive up to a 90-day supply of your medication at the same cost as a 30-day supply from a retail network pharmacy, delivered right to your door. Switch your prescriptions from retail to home-delivery by calling the Member Choice Center (MCC) at 1-877-363-1433.

A retail network pharmacy (check the online network (civilian) pharmacy locator for the one nearest to you) can be a neighborhood chain or stand-alone pharmacy. Your copay at a network retail pharmacy will be lower than if you use a non-network pharmacy.