Exclusions | TRICARE (2024)

FAQs

Why does no one accept TRICARE? ›

Among the most common reasons provided by both physicians and mental health providers for not accepting either insurance type are insufficient reimbursem*nt or their specialty not being covered; lack of awareness of TRICARE is also frequently cited, particularly among mental health providers.

The problem stems from the fact that most Tricare managed care support contractors have negotiated physician reimbursem*nt rates that are even lower than those paid by Medicare. Unhappy with their fees, some major health care provider groups have simply dropped out of the system.

In general, TRICARE excludes services and supplies that are not medically or psychologically necessary for the diagnosis or treatment of a covered illness (including mental disorder), injury, or for the diagnosis and treatment of pregnancy or well-child care.

After the point-of-service deductible is paid, Tricare will cover only 50 percent of the amount it allows to be charged. Tricare Extra and Standard have annual deductibles for outpatient care.

Having access to Walmart pharmacies has been especially convenient to military families who live in rural or remote areas that may lack a chain pharmacy. But Luddy said Walmart "declined several opportunities to offer more highly competitive discounts to continue to serve Tricare beneficiaries."

Non-participating providers won't accept the TRICARE allowable charge as the payment in full and they won't normally file claims with TRICARE. What this means for you is: You'll probably be required to pay the full amount to the provider and file a claim with TRICARE for a reimbursem*nt (minus your cost share).

Getting Care with a TRICARE Prime Option

Your PCM may be: At a military hospital or clinic. A civilian TRICARE network provider. A primary care provider under US Family Health Plan (USFHP)

Starting on January 1, 2024, the TRICARE premium-based plans will experience premium rate changes.

Not all veterans are eligible for TRICARE. Your Service decides if you and your family members are eligible. They report the information in DEERS. To learn more, visit the TRICARE Eligibility page.

TRICARE doesn't cover services and supplies: from a scientific or medical study, grant or research program. provided for free. that would be free if you or your sponsor weren't eligible for TRICARE.

Which patient is most eligible for TRICARE? ›

There are no enrollment fees or monthly premiums with this TRICARE retiree plan, because it provides “wraparound” coverage to Medicare benefits. Medicare is the primary payer. However, you must have Medicare Part A and B to qualify and pay Part B premiums, which are based on your income.

As of Oct. 24, there were 14,963 independent pharmacies that left the Tricare retail pharmacy network — primarily due to their objections about low reimbursem*nt rates — out of 55,586 retail pharmacies in the network. The loss affects an estimated 400,000 Tricare beneficiaries.

“A provider must be TRICARE-authorized for TRICARE to pay any part of your claim.”