Military Children and Behavioral Health by vow85608


									Issue 3: 2006                                         A P U B L I C AT I O N F O R T R I C A R E P R I M E B E N E F I C I A R I E S

 Military Children and Behavioral Health
 Don’t Hesitate to Seek Help When Problem Behaviors Arise
        ay is National Mental Health           depression in 2004, and fewer than            can be made worse by the frequent
 M       Month, sponsored by the
 National Mental Health Association for
                                               half were treated.                            moves required by the military
                                                                                             lifestyle, particularly because children
                                               For military children, the risk is even
 the past 50 years. Nearly a decade ago,                                                     do not get the chance to develop a
                                               more predominant. “Children of active
 Childhood Depression Awareness Day                                                          long-term support network of friends
                                               duty service members (ADSMs) are
 was added to the observance to focus                                                        and family. Additionally, children of
                                               potentially at a higher risk to develop
 on the need for Americans to pay closer                                                     ADSMs who have been deployed often
                                               mental health conditions common
 attention to children’s behavioral                                                          suffer extreme situational stress that
                                               among children in the general
 health care needs.                                                                          can generate or add to these types of
                                               population,” says Capt. Patricia Buss,
                                                                                             behavioral health problems.
 Today, that focus is as essential as ever.    Office of the Assistant Secretary of
 A December 2005 Substance Abuse and           Defense (OASD).
 Mental Health Services Administration                                                       Recognize Symptoms
                                               Conditions like depression, as well as
 study found 9 percent of teenagers, or                                                      During this period of deployment,
                                               attention-deficit hyperactivity disorder,
 nearly 2.2 million, experienced major                                                       military parents should take extra care
                                               anxiety disorder and panic disorder,
                                                                                                                  continued on page 4

                                                  brushing your child’s teeth when the       • The TRICARE Dental Program for
   The Doctor is in ...                           first tooth appears. Clean and massage       active duty family members, National
                                                  gums in areas that remain toothless,         Guard/Reserve members and their
   David N. Tornberg, MD, MPH                     and floss when all baby teeth have           family members
   Deputy Assistant Secretary of Defense
   for Clinical and Program Policy                appeared.                                  • The TRICARE Retiree Dental
                                                • Take your kids to the dentist by the         Program for retirees, survivors and
                                                  time their first tooth appears, or by        their family members
     n this message to you, I’d like to
   I talk about teeth and the importance
   of teaching children healthy oral
                                                  their first birthday.
                                                • Never let your children fall asleep with
                                                                                             Both programs pay 100 percent for
                                                                                             diagnostic and preventive services.
   hygiene habits that will last a lifetime.      a bottle containing milk, formula or       I encourage you to enroll in one of
                                                  fruit juice.
                                                                                             these programs.
   Dental decay is the single most              • Never give your children pacifiers
   common chronic childhood disease.              dipped in any sweet liquid.                Remember, good dental hygiene
   It is important to make sure your                                                         habits will help your children keep
                                                • Do not fill bottles with sugar water
   kids have regular dental checkups              and soft drinks.                           a healthy smile!
   and brush their teeth daily.
                                                • If your local water supply does not
   The American Dental Association                contain fluoride, ask your dentist             Inside This Issue . . .
   recommends the following oral                  how your children should get it.               • New Prior Authorization
   hygiene guidelines:                          • Visit the dentist regularly.                     Requirements Established
   • After each feeding, wipe your baby’s                                                        • Will TRICARE Pay for
                                                TRICARE offers two affordable
     gums with a clean gauze pad. Begin                                                            My Colonoscopy?
                                                dental insurance plans:
                                                                                                 • TRICARE Prime and PCS Moves

                                                                                                 • Avoid Surprise Health Care Bills
                                                                                                 • Storing and Protecting
                                                                                                   Your Medicines
    New Prior Authorization Requirements Established
        ffective for dates of service on or after Feb. 1, 2006, the             TRICARE Prime Remote Handbook, TRICARE Beneficiary
    E    prior authorization* requirements listed in the chart on
    page 3 will be enforced. You or your provider must obtain
                                                                                Handbook and other publications. You can also use the
                                                                                Prior Authorization Determination Tool, available at
    prior authorization from Health Net prior to these services       , to verify if a prior
    being rendered.                                                             authorization is required. Call 1-877-TRICARE if you
                                                                                have additional questions.
    These requirements supersede the prior authorization
    requirements listed in the TRICARE Prime Handbook,                                                                      continued on page 3

    *A prior authorization or authorization is a process of reviewing certain
     medical, surgical and behavioral health services to ensure medical
     necessity and appropriateness of care prior to services being rendered.

    Announcing a New Baby or Adopted Child?
    Don’t Forget to Tell TRICARE
         ongratulations on the new addition            • Fax your registration paperwork to          application provides instructions to
    C     to your family! Whether you’ve
    recently had a baby or adopted a child,
                                                         DEERS at 1-831-655-8317.                    help you complete the form. Contact
                                                                                                     Health Net at 1-877-TRICARE or visit
                                                       • Mail your registration paperwork to:
    remember to include TRICARE when                                                        for
                                                         Defense Manpower Data Center
    you send those announcements.                        Support Office                              a copy of the form or for assistance.
    We don’t need a card and picture.                    Attn: COA                                   After your application is processed,
    We just need to know—within 60                       400 Gigling Road                            you will receive a TRICARE Prime
    days—that we should add a new                        Seaside, CA 93955-6771                      Enrollment Card for your child. Until
    family member to your TRICARE                      DEERS registration paperwork includes:        you have received the card, keep a copy
    Prime coverage.                                                                                  of your enrollment application to present
                                                       • Either a legal birth certificate or a
                                                                                                     when accessing care with your child’s
    The faster you notify TRICARE,                       certificate of live birth from a hospital
                                                                                                     PCM. Be sure to fill in your child’s PCM
    the better you can ensure that:                      or TRICARE-approved birthing center.
                                                                                                     name and telephone number on your
    • Your child’s care is continuously                • A copy of a verified and approved           baby’s card.
      managed under TRICARE Prime by his                 DD Form 1172 (Application for
      or her primary care manager (PCM).                 Uniformed Services Identification Card
                                                         and DEERS Enrollment), signed by the        Tips for Completing the
    • You won’t incur extra health care costs.           child’s sponsor.                            Enrollment Application
                                                       Note that you do not need to wait until       When choosing your child’s PCM:
    A Simple, Two-Step Process                         you get a Social Security number (SSN)
                                                                                                     • You must select a PCM at a military
    Getting TRICARE benefits for your new              for your child. Just be sure to update his
                                                                                                       treatment facility (MTF) if one is
    addition is a simple, two-step process.            or her DEERS information once you
                                                                                                       available within a 30-minute drive
    First, you must register your child in the         receive the SSN.
                                                                                                       of the child’s home address.
    Defense Enrollment Eligibility Reporting
                                                                                                     • You should contact the PCM’s office
    System (DEERS), and then you can                   2. Enroll your child in TRICARE
                                                                                                       to verify that the provider is accepting
    enroll him or her in TRICARE Prime.                Prime.
                                                                                                       new patients. If you cannot decide on
                                                       Once your child is registered in DEERS,         a PCM, one can be assigned to you.
    1. Register your child in DEERS.                   simply complete a TRICARE Prime                 You can change PCMs, subject to
    Parents or legal guardians can register            Enrollment Application and PCM Change           MTF PCM availability criteria.
    children in DEERS in several ways:                 Form, and then follow the directions for      If you do not already have a provider
                                                       mailing the form to Health Net or for         in mind, you can contact your MTF
    • Visit a local uniformed services ID card         returning it to the nearest TRICARE
      facility. Find the nearest one online at                                                       or Health Net. You can read about
                                                       Service Center. The enrollment                many MTF PCMs by visiting
                                                                                                                            continued on page 5

2                                                                                             Issue 3: 2006
New Prior Authorization Requirements Established
continued from page 2

                              TRICARE North Region Prior Authorization Requirements
For active duty service members (ADSMs) and TRICARE Prime Remote (TPR) ADSMs
• Inpatient and outpatient services from a civilian network or non-network provider
          Exception: Ancillary services within the following code ranges do not require prior authorization when the care has been referred
          by the ADSM’s primary care manager (PCM) or specialist to a network provider:
                   - Diagnostic radiology and ultrasound services CPT code range 70000 through 76999
                   - Diagnostic nuclear medicine services CPT code range 78000 through 78999
                   - Pathology and laboratory services CPT code range 80000 through 89399
                   - Cardiovascular studies CPT code range 93000 through 93350
ADSM care is typically provided at a military treatment facility (MTF), which authorizes care. However, TPR ADSMs are often not
located near an MTF and may need care from a civilian (network or non-network) provider. All ADSMs must also notify Health Net
of emergency room services within 24 hours or the next business day of care being received.
For TRICARE Prime and TRICARE Prime Remote For Active Duty Family Members (TPRADFM)
• Adjunctive dental care1 including:
          - Craniofacial and maxillofacial procedures
          - Dental procedures not related to the basic dental benefit
• Durable medical equipment (DME):
          - Durable medical equipment—purchase greater than or equal to $2,000
          - Durable medical equipment—rental for all DME categorized by the Centers for Medicare and Medicaid Services as Capped Rentals
          - Payment Class: Capped Rental Items—These are DME items that do not fall under any of the other DME payment categories.
            They are generally expensive items that have historically been routinely rented.
• Extended Care Health Option (ECHO) services1
• Home health services, including home infusion1
• Hospice1
• Inpatient admissions:
          - All elective acute inpatient admissions
          - Emergency medical/surgical and behavioral health inpatient admissions require notification to Health Net within 24 hours of
            admission or the next business day.
• Non-network provider services
• Obstetrical services including global maternity and high-risk maternity
• Oral surgery
• Psychiatric services1:
          - All nonemergency inpatient admissions for substance abuse or behavioral health
          - Psychotherapy after the initial eight outpatient visits
          - Psychoanalysis
          - Intensive outpatient treatment programs, partial hospitalization programs and residential treatment center programs
• Rehabilitation:
          - Occupational, physical and speech therapy
• Transplants1:
          - All solid organ and stem cell transplants

    These prior authorization requirements also apply to TRICARE Reserve Select (TRS), TRICARE Standard and TRICARE Extra beneficiaries,
    as well as those with other health insurance (excluding ADSMs and TPR ADSMs).

For TRICARE dual-eligible beneficiaries (including TRICARE For Life)
• TRICARE dual-eligible beneficiaries (those with Medicare Part B coverage and TRICARE coverage—that includes TRICARE For Life
  beneficiaries) do not require a prior authorization from Health Net for health care services. These beneficiaries should follow Medicare
  rules for services requiring authorization.

Issue 3: 2006                                                                                                             1-877-TRICARE       3
    Signs at the Commissary Lead to Healthy Choices
    Article contributed by Bonnie Powell, Defense Commissary Agency

       ooking for quick tips on choosing healthier foods or             families to think more about using
    L   preparing meals more safely? Look no further than
    your local commissary.
                                                                        their commissary as a resource to
                                                                        help win the battle of the bulge.
    Earlier this year, the Defense Commissary Agency (DeCA)             “Commissaries and medical benefits
    debuted a series of shelf signs featuring healthy tips from the     are consistently listed as the top
    Dietary Guidelines for Americans, as well as food safety            military benefits,” said Patrick B.
    tips. The signs are part of the ongoing It’s Your Choice,           Nixon, chief executive officer and acting director of DeCA.
    Make It Healthy campaign.                                           “Since we serve the same customer base, it makes sense to
                                                                        partner in our outreach efforts, both as an agency and at the
    The campaign ties in with TRICARE’s Healthy Choices for
                                                                        installation level.”
    Life awareness campaign, which addresses three major health
    problems identified by the Department of Defense. “Tobacco,         In addition to the shelf signs, DeCA is encouraging store
    alcohol and obesity-related issues are leading causes of            directors at all 268 commissaries worldwide to partner with
    preventable death in the United States,” said Dr. William           health-and-wellness professionals for commissary tours and
    Winkenwerder, Jr., assistant secretary of defense for health        health-and-wellness events, particularly during Commissary
    affairs. “Preventing these unhealthy behaviors is critical to the   Awareness Month in May.
    readiness of our forces and the health of our nation as a whole.”
                                                                        “We want to be the nutritional leader of the military
    DeCA’s partnership with TRICARE and the medical and                 community,”—Patrick B. Nixon, chief executive officer
    nutrition community is intended to encourage military               and acting director of DeCA.

    Military Children and Behavioral Health
    continued from page 1

    to watch for signs of depression,            As a TRICARE Prime beneficiary, you         Find the Right Provider
    as well as anxiety and compulsive            don’t have to guess. TRICARE makes
                                                                                             Behavioral health experts stress the
    behaviors, in their children. Often          it easy to obtain a consultation with a
                                                                                             importance of finding an age-specific
    the child’s school will identify a           behavioral health care professional.
                                                                                             provider who specializes in the type
    potential behavioral health problem.         Just as with adult active duty family
                                                                                             of disorder you believe your child may
                                                 members, children are entitled to eight
    Symptoms include some or all of                                                          have. Behavioral health care for children
                                                 unmanaged behavioral health outpatient
    the following:                                                                           is most successful when every family
                                                 visits with a network provider per
                                                                                             member is committed to the outcome,
    • Sleep disturbances, including              fiscal year without a referral or prior
                                                                                             and, in many cases, is willing to
      wakefulness or oversleeping                authorization. (Exception: Visits to
                                                                                             participate in therapy sessions and work
    • A change in behavioral patterns            Licensed Mental Health Counselors
                                                                                             on behavioral techniques at home.
                                                 and Licensed Professional Counselors
    • Trouble in school
                                                 require a physician referral prior to       When seeking an outpatient therapist
    • Change in toileting behavior, especially   evaluation or treatment.) Further           for your child, be careful to select a
      in young children                          necessary treatment is covered by           provider in the TRICARE network.
    • Frequent crying, tantrums or withdrawal    TRICARE when authorized.                    Otherwise, you may incur additional
                                                                                             charges under the TRICARE Prime
                                                 Don’t hesitate to seek professional
    Use Your Eight Unmanaged                     help. In extreme cases, untreated
                                                                                             point-of-service (POS) option.
    Visits                                       depression can lead to substance            To find TRICARE network providers,
    If your child shows these signs, how do      abuse or even suicide.                      use the “Find a Provider” tool at
    you distinguish between the everyday                                            or
    challenges of growing up and a                                                           call Health Net at 1-877-TRICARE.
    behavioral health problem?

4                                                                                   Issue 3: 2006
Will TRICARE Pay for My Colonoscopy?
     here’s been a lot of talk in the news       beginning 10 years earlier than the         colonoscopies are covered under
T     lately about the benefits of getting
a colonoscopy. What is a colonoscopy
                                                 youngest affected relative.                 TRICARE benefit guidelines. In
                                                                                             particular, preventive or “screening”
and when will TRICARE pay for one?              Similar Routine Screening                    colonoscopies that are done in the
                                                Exams Are Covered                            absence of symptoms or known
Routine Colonoscopies Are                                                                    disease are covered only in limited
                                                Even if there are no risk factors present    circumstances. For example, screening
Not Covered                                     in your situation, TRICARE covers            colonoscopies requested solely because
A colonoscopy is a medical procedure            several routine—and highly valuable—         of a person’s age would not be covered.
to detect various forms of colorectal           screening exams beginning at age 50.         Further information concerning benefit
cancer. For TRICARE purposes,                   These exams include:                         coverage for screening colonoscopies
a routine colonoscopy is not an                                                              is available in the TRICARE Beneficiary
                                                • Digital rectal exams (annually for high-
automatically covered benefit, regardless                                                    Handbook under Preventive Care, or can
                                                  risk men ages 40-49 and for all men
of age. In fact, it is a covered benefit          over age 50)                               be obtained by calling 1-877-TRICARE
only if certain factors are present.                                                         and choosing the option for “referrals
                                                • Fecal occult blood testing (annually
                                                                                             and authorizations.” If you have a
                                                  after age 50)
Colonoscopies Are Covered                                                                    specific concern about coverage
                                                • Proctosigmoidoscopy or sigmoidoscopy       guidelines, your provider may also
for Those at Risk                                 (every 3 to 5 years after age 50)          submit a prior authorization request to
TRICARE covers colonoscopies for                                                             Health Net and indicate that he or she
those who have symptoms or who                  Note to Medicare-Covered                     would like a benefit determination.
have closely related family member(s)           Beneficiaries
with a history of colorectal cancer.
Your provider must determine that one           If you are age 65 and over: Routine          Costs for Self-Referred
of these two risk factors is present:           screening colonoscopies will most likely     Colonoscopy
                                                be covered separately by Medicare.           If your PCM does not coordinate the
• You have hereditary non-polyposis
  colorectal cancer syndrome. In this                                                        referral request with Health Net when
  instance, TRICARE covers a                    Referral May Be Needed                       it is required, or if you self-refer to a
  colonoscopy every two years beginning         If your primary care manager (PCM)           gastroenterologist without a referral
  (i) at age 25 or (ii) at five years younger   determines that you qualify for a            from your PCM, you will be responsible
  than the earliest age of diagnosis of         colonoscopy, he or she may need to           for payment of your colonoscopy. The
  colorectal cancer in your family,             submit a referral request to Health          cost of a colonoscopy depends on a
  whichever is earlier. Then, annual            Net to refer you to a gastroenterologist.    combination of several factors, including
  screenings should occur after age 40.         Access the Referral Decision Tool at         the complexity of the procedure and
• You have familial risk of sporadic   to          where you receive the colonoscopy in
  colorectal cancer, such as first-degree       see if your PCM needs to obtain a            terms of ZIP code and type of facility.
  relatives with sporadic colorectal cancer     referral from Health Net.                    If you aren’t sure about whether a
  or adenomas before the age of 60 or                                                        colonoscopy would be covered in
  multiple first degree relatives with          The referral request is for a consultation
                                                with the gastroenterologist, not for the     your case—and you want to keep your
  colorectal cancer or adenomas. In
                                                colonoscopy. The colonoscopy itself          costs down—just call Health Net at
  this instance, TRICARE covers a
                                                does not require a prior authorization,      1-877-TRICARE to see whether you
  colonoscopy every three to five years
                                                but it is important to note that not all     qualify.

Announcing a New Baby or Adopted Child?
continued from page 2, and you                  Remember to sign and date your               sections of the enrollment application
can research civilian PCMs at                   application and to include both your         so that your request is processed in a               home and daytime telephone numbers           timely manner.
In addition, you can change your                where you can be reached. Be sure
PCM through the Health Net Web site.            to complete all of the necessary

Issue 3: 2006                                                                                                       1-877-TRICARE        5
    A TRICARE Prime Pre-Vacation Checklist
         our much anticipated summer vacation is fast
    Y     approaching. Here is a pre-vacation checklist that will
    help ensure you receive maximum TRICARE Prime coverage
                                                                         Refill current prescriptions and remember
                                                                         to bring your medications.
    while you travel, at the lowest expense to you.                  To ensure you won’t run out of your medications, have
                                                                     your current prescriptions refilled before you go. Don’t
                                                                     forget to bring your medications and any other necessary
        Verify your information in DEERS.
                                                                     medical supplies.
    Call 1-800-538-9552 to confirm that the Defense Enrollment
    Eligibility Reporting System (DEERS) is updated with your            Take your uniformed services ID card
    most current information. Before rendering services or filling
    prescriptions, network providers and pharmacies must verify
                                                                         and TRICARE Prime enrollment card.
    your TRICARE eligibility. If DEERS records are incorrect         In the event you require medical care or need to fill a
    or outdated, you and your family may be denied coverage.         prescription while on vacation, you need to have your
                                                                     cards with you. Your TRICARE Prime enrollment card lists
        Schedule routine care before you travel.                     Health Net’s telephone number on the back. You should
                                                                     call that number before seeking care or being hospitalized.
    TRICARE recommends that you seek routine care (office            If you have an older enrollment card, be sure to update the
    visits, management of chronic health conditions, routine         telephone number to 1-877-TRICARE.
    physicals, etc.) from your primary care manager (PCM)
    before you travel.

    When You Need Care on the Road
             hile you hope you won’t need      3. Use TRICARE’s pharmacy                  Sun Safety
    W         medical treatment while
    traveling, you should be prepared in
                                                                                          If you like to have fun in the sun,
                                               If you forget to bring your medications
    case it is necessary. Here are a few                                                  here are some tips to protect you
                                               or need to fill a new prescription,
    things you need to know when using                                                    and your family:
                                               TRICARE’s pharmacy options are
    TRICARE away from home.
                                               available to you everywhere in the         • Avoid or limit sun exposure between
                                               United States, Puerto Rico, Guam and         10 a.m. and 4 p.m. when UV rays
    1. Call your PCM to coordinate a           the U.S. Virgin Islands:                     are strongest.
    referral and authorization before
    seeking nonemergency care,                 • MTF Pharmacies: To locate a nearby       • Seek shade under a tree, an umbrella
                                                 MTF, visit        or a sun-screening canopy.
    including urgent care.
                                               • TRICARE Retail Pharmacy (TRRx)           • Use sunscreen with a sun protection
    If you don’t, you may pay higher out-                                                   factor (SPF) of 15 or higher, 30 minutes
    of-pocket costs under the TRICARE            Program: To locate a TRICARE
                                                 retail pharmacy, visit                     before going outdoors, and apply
    Prime point-of-service (POS) option, or                                                 liberally. Choose a sunscreen that has
    payment may be denied altogether.                                                       both UVA and UVB protection. Reapply
                                                 or call toll free 1-866-DoD-TRRx.
                                                                                            sunscreen every two hours or more
    2. Seek emergency care at the              • TRICARE Mail Order Pharmacy                frequently if swimming or perspiring.
    nearest hospital immediately.                (TMOP) Program: Call
                                                 1-866-DoD-TMOP for information           • Wear protective clothing, such as a
    Emergency care does not require prior        about using the program while on an        long-sleeved shirt, long pants, a wide-
    authorization before treatment.              extended vacation.                         brimmed hat and UV-protective
    However, your PCM and Health Net                                                        sunglasses.
    should be notified within 24 hours         4. Call your regional contractor if        • Be sure to protect your skin on cloudy
    or by the next business day of any         you have questions.                          and overcast days since UV rays
    emergency inpatient admission.             When in doubt, it’s best to call             travel through clouds.
                                               Health Net at 1-877-TRICARE                For more health information and
                                               with specific questions.                   resources, visit the Healthy Living page

6                                                                                 Issue 3: 2006
Don’t Let a Permanent Change of Station Interrupt
Your Coverage
It’s Easy to Take TRICARE Prime with You
     or many uniformed services                 checking on arrival of your household     • For emergency care, go to the nearest
F     members and their families,
packing up for yet another relocation
                                                goods,” emphasizes Lt. Col. Strawder.
                                                If you are moving to a new region,
                                                                                            hospital emergency room or call “911.”
                                                                                            Emergency care does not require a
is a routine exercise. But how easy is          contact the new regional contractor and     referral before treatment. You must
it to move one’s medical coverage?              fill out the necessary forms (including     notify your PCM within 24 hours
And how do you make sure that your              the TRICARE Prime Enrollment                after receiving emergency care or being
benefits are valid during the 30-day            Application and PCM Change Form to          admitted to the hospital so that your
travel leave period while making                select a new PCM) to avoid a lapse in       PCM can help manage and coordinate
a permanent change of station                   coverage. If you are moving overseas,       your care. You must also notify your
(PCS) move?                                     family members must be listed on            regional contractor within 24 hours or
                                                orders as command-sponsored in order        by the next business day of an emergency
“Military families are constantly on            to be eligible for TRICARE Overseas         inpatient admission.
the go, and when we move, we want               Program (TOP) Prime, TRICARE              For additional information regarding
to be confident that our health care            Global Remote Overseas or TRICARE         TRICARE coverage during a PCS,
benefit goes with us,” says Director            Prime Puerto Rico.                        visit the TRICARE Web site at
of TRICARE Prime Operations                   • If you are staying in the same region
Lt. Col. Guy Strawder, U.S. Army.               and will need to change your PCM as a
“TRICARE Prime is portable, which               result of relocation, you must complete
means you can easily transfer your              the TRICARE Prime Enrollment
enrollment when you are reassigned.”            Application and PCM Change Form.
                                                This form is available on each regional
Lt. Col. Strawder suggests following            contractor’s Web site.
the steps outlined below to ensure
continued health care coverage during          North Region—Health Net
a travel leave period and subsequent 
PCS, whether you are moving to a               South Region—Humana Military
nearby state or overseas.            
• Before you leave, ensure the sponsor’s       West Region—TriWest
  and each family member’s Defense   
  Enrollment Eligibility Reporting
  System (DEERS) records are updated.          Overseas
  Also, familiarize yourself with the new
  regional contractor if you are relocating
                                              • Plan ahead for routine care
  to a new region.
                                                and prescriptions.
• Stay enrolled. Do not disenroll before
                                              • For care that cannot wait until you
  you arrive at your next duty station.
                                                transfer, contact your PCM to
  Your former primary care manager
                                                coordinate a referral. Without this
  (PCM) remains responsible for your
                                                referral, you may pay significantly
  care until you enroll at your next
                                                higher out-of-pocket costs under the
  duty station.
                                                TRICARE Prime point-of-service
• Enroll yourself and each family               (POS) option or, even worse, your
  member at a new military treatment            claim may be denied (for more about
  facility (MTF) or TRICARE network             POS charges, access the TRICARE
  PCM shortly after you arrive at your          fact sheet at
  new duty station. “This priority is right
  up there with securing housing and            viewfactsheet.cfm?id=183).

Issue 3: 2006                                                                                                    1-877-TRICARE         7
    Patient Bill of Rights
    What You Need to Know
         s a TRICARE beneficiary, it’s           danger or you would be seriously injured        Your Responsibilities
    A     important to understand that you
    have both rights and responsibilities
                                                 or disabled without immediate care.
                                                                                                 As a beneficiary in the MHS, you are
                                                                                                 expected and encouraged to assume
    when it comes to your health and the         Participating in Your Treatment
                                                                                                 reasonable responsibility for your health.
    health care services you receive within
                                                 You have the right to receive and review        Such responsibilities include:
    the Military Health System (MHS).
                                                 information about diagnosis, treatment
    The health care Consumer Bill of Rights      and the progress of your condition, and         Maximizing Your Health
    and Responsibilities (Patient Bill of        to fully participate in all decisions related
                                                                                                 You have the responsibility to maximize
    Rights) was created in 1997 by the           to your health care. If you are unable to
                                                                                                 healthy habits, such as exercising,
    Clinton administration’s Presidential        fully participate in treatment decisions,
                                                                                                 maintaining a healthy diet, and not
    Advisory Commission on Consumer              you have the right to be represented by
    Protection and Quality in the Health         family members, conservators or other
    Care Industry.                               duly appointed representatives.
                                                                                                 Making Smart Health Decisions
    Many health plans, including all of
                                                 Respect and Nondiscrimination                   You have the responsibility to be involved
    the plans sponsored by the federal
                                                                                                 in health care decisions. This means
    government, have adopted these               You have the right to considerate,
                                                                                                 working with providers in developing
    general principles. The following is         respectful care from all members of the
                                                                                                 and carrying out agreed-upon treatment
    a summary of TRICARE’s Patient Bill          health care system at all times and under
                                                                                                 plans, disclosing relevant information
    of Rights.                                   all circumstances.
                                                                                                 and clearly communicating your needs.
                                                 If you are eligible for coverage under
    Your Rights                                  the terms and conditions of TRICARE             Becoming TRICARE Savvy
    Patient rights fall into the following       or as required by law, you must not be
                                                                                                 You have the responsibility to be
    seven categories:                            discriminated against in marketing and
                                                                                                 knowledgeable about TRICARE
                                                 enrollment practices based on race,
                                                                                                 coverage and program options, including
    Getting Information                          ethnicity, national origin, religion, sex,
                                                                                                 covered benefits; limitations; exclusions;
                                                 age, mental or physical disability, sexual
    You have the right to receive accurate,                                                      rules regarding use of network providers;
                                                 orientation, genetic information or
    easy-to-understand information through                                                       coverage and referral rules; appropriate
                                                 source of payment.
    written materials, presentations and                                                         processes to secure additional
    TRICARE representatives to help you                                                          information; and appeals, claims
                                                 Confidentiality of Your Health
    make informed decisions about                                                                and grievance processes.
    TRICARE programs, medical                                                                    You also have the responsibility to:
    professionals and facilities.                You have the right to communicate
                                                 with health care providers in confidence        • Show respect for other patients and
    Choosing Providers and Plans                 and to have the confidentiality of your           health care workers.
                                                 individually identifiable health care           • Make a good-faith effort to meet
    You have the right to a choice of            information protected. You also have              financial obligations.
    health care providers that is sufficient     the right to review and copy your own
    to ensure access to appropriate,                                                             • Use the disputed claims process when
                                                 medical records and request amendments
    high-quality health care.                                                                      there is a disagreement.
                                                 to your records.
                                                                                                 • Report wrongdoing and fraud to
    Emergency Care                                                                                 appropriate resources or legal authorities.
                                                 Complaints and Appeals
    You have the right to access emergency                                                       • Keep your Defense Enrollment
                                                 You have the right to a fair and efficient        Eligibility Reporting System (DEERS)
    health care services when and where the      process for resolving differences with
    need arises. You are not required to                                                           information current.
                                                 your health plan, health care providers
    obtain prior authorization for care if you                                                   Visit
                                                 and the institutions that serve them. This
    have reason to believe your life is in                                                       to read the complete text of the “Patient
                                                 includes a rigorous system of review.
                                                                                                 Bill of Rights and Responsibilities in
                                                                                                 the Military Health System.”

8                                                                                          Issue 3: 2006
Avoid Surprise Bills
Follow These Tips to Minimize Out-of-Pocket Health Care Costs
    et’s face it. Unexpected health care bills are a drag.       The chart below describes the costs incurred by TRICARE
L                                                                Prime beneficiaries who use the POS option.
A little bit of knowledge about your TRICARE Prime                                 Point-of-Service Option Costs
benefits goes a long way toward helping you make effective              Charges            Individual                Family
health care decisions while minimizing your out-of-pocket        Deductible per fiscal
costs (copayments, cost-shares and deductibles).                 year—for outpatient     $300              $600
                                                                 care only
Here are a few ways you can save.
                                                                 Cost-share for          50% of TRICARE allowable charge, after
                                                                 outpatient care         annual deductible is met
The MTF: Your Lowest Cost Option for Care
                                                                 Cost-share for
                                                                                         50% of TRICARE allowable charge
Whenever possible, seek care within a military treatment         inpatient care
facility (MTF). This is your lowest cost option for receiving    Additional charges by
                                                                                         Up to 15% above the allowable charge is
care. Outpatient services are provided at no cost to             certain non-network
                                                                                         permitted by law; fully paid by the beneficiary
beneficiaries. Inpatient services are also free to active duty
service members (ADSMs), their families and retirees.            Even if you visit a TRICARE network provider, you must
Retirees’ families pay a low copayment for hospitalization.      get a PCM referral and regional contractor authorization for
Active duty service members, followed by TRICARE                 certain health care services; otherwise, the POS charges apply.
Prime beneficiaries, have the highest priority to receive
care at the MTF.                                                 Covered Services, Referrals and
To find an MTF near you, visit the MTF Locator on the
TRICARE Web site at or visit             The best way to avoid incurring POS charges, as well as
the Health Net Provider Directory at                             paying completely out of pocket for non-covered services,                                is to check TRICARE coverage before receiving care.
                                                                 Refer to your TRICARE Prime Handbook or
Network Providers                                       for listings of excluded
When services are not available at an MTF, the MTF and           services, limited services and specialty care services that
your regional contractor will assist you in coordinating your    require PCM referral and regional contractor authorization.
care with a TRICARE network provider—your next best              If you are still unsure, call Health Net at 1-877-TRICARE
option for minimizing out-of-pocket costs.                       to speak with a representative.

Non-network Providers                                             Keeping Your Prescription Costs Down
If a network provider is not available, you may seek care from    Selecting generic drugs (when available) and filling
a non-network provider only if you obtain a referral from your    your prescriptions at an MTF are your most cost-effective
primary care manager (PCM) and an authorization from              options. Avoiding non-network pharmacies will save you
your regional contractor.                                         from paying top-dollar for your prescriptions.
                                                                  By using the TRICARE Mail Order Pharmacy program,
Point-of-Service Option                                           you can obtain a 90-day supply of medication for the
Should you bypass referral and authorization requirements,        same copayment that you’d pay for a 30-day supply at
you’ll be responsible for additional costs under the TRICARE      a TRICARE retail pharmacy.
Prime point-of-service (POS) option.                              Additionally, some drugs require prior authorization
The POS option lets TRICARE Prime enrollees receive               from Express Scripts, Inc. (ESI), the TRICARE pharmacy
nonemergency, TRICARE-covered services from any                   benefit contractor. Without it, you could be required to
TRICARE-authorized/certified provider without referral or         pay the entire cost of the medication.
authorization. The POS option features higher out-of-pocket       Visit ESI’s Web site at
costs, however, so it is advisable to avoid using this option     or call 1-866-DoD-TRRx for more information.
whenever possible.

Issue 3: 2006                                                                                                       1-877-TRICARE          9
     Compounded Drugs
     Customized Medicine for Those with Unique Needs
       ust as every patient has unique health care needs,              Whether you need a medication that is not commercially
     J  on occasion, these special needs cannot be met by
     commercially available prescription drugs. On such
                                                                       available or your child won’t take a liquid medicine unless
                                                                       it tastes like bubble gum, compounded prescription drugs
     occasions, your provider may prescribe a specially formulated     could be the solution. As with any medication, talk to your
     compounded medication. Compounded medications offer               doctor about what is best for you and your family.
     safe alternatives for patients who have special prescription
     drug needs.
                                                                       Q: What is a compounded medication?

     What Is Compounding?                                              A: Compounded drugs are medications, usually ointments,
                                                                          creams, suppositories or liquid medications, that are
     Compounding involves preparing a specialized drug product
                                                                          not commercially available in the desired strength,
     when an FDA-approved drug cannot meet the patient’s needs.
                                                                          concentration or dosage form, and are prepared for
     Compounding is achieved through an essential relationship            you by a pharmacist following your doctor’s directions.
     among patient, doctor and pharmacist. The doctor prescribes
                                                                          Compounded drug prescriptions must be filled at a
     the medication, and the pharmacist compounds the necessary
                                                                          pharmacy that offers this service and has an assigned
     ingredients and dispenses it to the patient after a thorough
                                                                          NABP® (National Association of Boards of Pharmacy®)
                                                                          number. For more information on compounded drugs,
                                                                          contact your local pharmacy. To find a pharmacy near
     Why Compound Medications?                                            you that compounds medications, call Express Scripts
     There are several reasons for compounding prescription               at 1-866-DoD-TRRx (1-866-363-8779).
     medications. Many patients are allergic to preservatives          Q: Are compounded medications available through my
     or dyes, for example, or are sensitive to standard drug              TRICARE Retail Pharmacy (TRRx) benefit?
     strengths. Compounding is also used as follows:
                                                                       A: In most cases, as long as one ingredient of the
     • To make any strength of a medication when specific doses are       compound is covered by TRICARE, then the
       not commercially available                                         compound is available when filled at a TRRx network
     • To prepare a medication that has been withdrawn from the           pharmacy. Note: You may file a paper claim for
       marketplace due to economic, not safety, concerns                  reimbursement for compounded prescriptions filled
     • To create a concentrated liquid or a suppository for patients      at a non-network pharmacy, but deductibles and a
       who cannot swallow or have trouble swallowing                      higher copayment will apply.
     • To create allergy-free medications for patients who may have
       sensitivity to dyes, preservatives or fillers
     • To create child friendly flavors for children who have
       problems with the taste of a liquid medication
     • To combine medications into one dosage, when possible, for
       patients who take several medications

10                                                                                Issue 3: 2006
Storing and Protecting Your Medicines
    rescription medications and over-the-counter drugs do           • Some medicines need to be kept in the refrigerator—but do
P    not last forever. Each one has a shelf life. To avoid waste
and make sure your medicines stay effective, follow these steps.
                                                                      not put them in the freezer.
                                                                    • Ask your pharmacist about the best way to store a particular
                                                                      medicine, since different types (tablets and liquids) may have
1. Keep medicines in their original containers                        special storage requirements.
Some drugs (like certain heart medications) break down if           Visit for more
they are taken out of their original container. Keep your           information on your prescription drug benefit or call
drugs in their original containers, with lids tightly closed.       1-866-DoD-TRRx.
If you use a pillbox to keep track of when to take medication,
fill the box for one week at a time. Keep the rest of the
tablets in their original containers.                               Q: I thought generic drugs were always less expensive
                                                                       than brand-name drugs. Why is the copayment for my
By keeping prescription products in their original containers,         generic prescription $22?
you also are preserving the valuable information the label
provides. Your name on the label helps ensure that you take         A: Recently, the Uniform Formulary was created to help
your own medicine and not someone else’s in the household.             manage rising pharmacy costs for the Department of
Should you still take the wrong medication by accident,                Defense and beneficiaries. While most generics will
the label offers a quick way to know the name and strength             continue to be available at a lower copayment, some
of the drug.                                                           drugs will be moved to third-tier non-formulary status
                                                                       with a $22 copayment. Drugs placed on the non-
The label also lists a prescription number, which tells the            formulary list have been determined to be not as cost-
pharmacist how many tablets or capsules were originally                effective in terms of relative safety, effectiveness or
in the bottle, the date the prescription was last filled, and          clinical outcome compared to similar medications in
the number of refills remaining.                                       the same therapeutic class. They will continue to be
                                                                       available, just at the higher copayment. If your doctor
2. Check expiration dates                                              proves medical necessity, a non-formulary drug may
Both prescription and over-the-counter drugs have expiration           be obtained for the lower formulary copayment from
dates. As drugs age past their expiration date, they begin to          a TRICARE retail network pharmacy (30-day supply)
lose their potency.                                                    or through the TRICARE Mail Order Pharmacy
                                                                       (TMOP) program (90-day supply).
Make it a point to check the expiration date on all of your
medicines every six months. Most medicines expire about             Q: What is the easiest and most cost-effective way for
one to two years after they are purchased, but some may                me to get my medications?
expire more quickly.                                                A: For the greatest savings on prescriptions you need
When your medicines expire, dispose of them safely. Flush              quickly (such as antibiotics), use a military treatment
them down the toilet and rinse out the containers to remove            facility (MTF) pharmacy or a TRICARE network retail
all residues.                                                          pharmacy. For the greatest savings on prescriptions you
                                                                       take on an ongoing basis (such as drugs for high blood
                                                                       pressure or arthritis), use an MTF pharmacy or TMOP.
3. Store medicines properly
                                                                       Using TMOP is safe, convenient and economical.
• Keep your medicines in a cool, dry place out of direct sunlight
  and away from moisture. For instance, the bathroom medicine       Q: What do I need to bring to the pharmacy to fill a
  cabinet is not a good place because it is warm and humid.            prescription?
• Always keep medicines where children can’t see or reach them.     A: When you visit a TRICARE network retail pharmacy,
• Ask for childproof caps and keep all bottles tightly closed.         you need two things: your uniformed services ID card
• Most drugs should be stored at room temperature (59°F to             and your written prescription.
  86°F or 15°C to 30°C).
• Do not store medicine in the glove compartment of your car.
  Extreme high or low temperatures can damage it.

Issue 3: 2006                                                                                                     1-877-TRICARE        11
                                                                                                        An Excellent Value
                                                                                                            Generous coverage
                                                                                                            Superior health care
     Health Net Federal Services, Inc.
     P.O. Box 2890                                                                                          Decisions are health
     Rancho Cordova, CA 95741                                                                               driven, not insurance
                                                                                                            High satisfaction
                                                                                                            with care
                                                                                                            Low out-of-pocket costs
                                                                                                            Easy access

     Health Matters is published by the TRICARE Management Activity. Please provide feedback at

     Health Information Policy
     Know Where to Find Your Notice of Privacy Practices
     1. Is the protection of                      As of April 14, 2003, health care plans         or are covered by the various TRICARE
     your health information                      and providers are required to provide           health plans. It is important to us that
                                                  patients with a Notice of Privacy               you are fully aware of how we may use
     important to you?
                                                  Practices. The notice describes how your        and disclose your health information
                                                  medical and dental information may be           and that you notify us if you have
     2. Do you want to protect                    used and with whom it may be shared.            any concerns.
     your rights to health                        It also describes your rights and how
     information privacy?                                                                         The notice is available in several
                                                  to file a complaint if you believe your
                                                                                                  languages. To obtain a copy:
                                                  rights have been violated. The provision
     3. Do you know what those                    of the notice is a requirement of the           • Contact your MTF HIPAA Privacy
     rights are?                                  Health Insurance Portability and                  Officer or access your MTF Web site.
                                                  Accountability Act of 1996 (HIPAA).             • Go to
     Most of us answer “yes” to the first
     two questions without hesitation, but        Please take a moment to review the              • Mail a written request to:
     how about that third question? Do you        Military Health System Notice of Privacy          TRICARE Management Activity
     know where you can read about your           Practices and share it with members of            Privacy Office
     health information privacy rights            your household who are receiving care             Five Skyline Place, Suite 810
     and protections?                             at a military treatment facility (MTF)            5111 Leesburg Pike
                                                                                                    Falls Church, VA 22041-3206

12                                                                                                                            Issue 3: 2006

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