TRICARE Prime: Why I Wish I Ditched it Sooner


I did it. I finally switched from TRICARE Prime to TRICARE Standard. I’ve been a military spouse for ten years, and I never really considered Standard to be an option for my family . . . until now.

Don’t get me wrong, I LOVE TRICARE Prime. I loved knowing that when I take my children to the doctor, I wouldn’t get a bill. If I had to call an ambulance and bring them to the hospital, there wouldn’t be a bill. If someone needed a surgery, or was diagnosed with some scary medical problem, there wouldn’t be a bill.

I thought I couldn’t afford a bill.

Pharmacy-tricare

Today, I’ve realized that it’s not the bill I should be worried about. I can no longer afford the care we’ve received at our Military Treatment Facility (MTF). As a working mom, I can’t afford to wait three hours at the pharmacy for prescriptions. As a mother of four, I can’t afford not being able to get my child into the doctor when they have an ear infection, or heaven forbid, pink eye, which left untreated will spread to ALL of my children.

I can’t afford to ignore my own health issues any longer, either. I can’t afford the time it takes to fight for referrals, or wait the three months until there is an opening at the specialist, or wait the six months the MTF told me it would take to get my child a referral for a mental health evaluation.

My family is in crisis; I can’t afford to ignore red flags any longer.

What I CAN afford is the co-pay for TRICARE Standard.

We switched to Standard two weeks ago, and let me tell you what happened:

I got online, and found doctors within the network. I found and called the specialists we needed and made an appointment, no referrals needed. In a half hour, I was able to schedule four appointments with a pediatrician, one appointment with a family practice doctor, a neuropsych evaluation, and an appointment with a specialist I have been asking to see for the last year. All of the appointments were scheduled for the next two weeks.

When I walked into my appointment at the specialist, I met a physician who listened to my symptoms, and immediately scheduled further testing…for the next day. During that test, he discovered a problem that will need surgery very quickly. This diagnosis explains all the symptoms I had been complaining about to the doctors at the MTF and military emergency rooms for the past year. I believe I could have (and should have) had this surgery a year ago, if one of the Primary Care Manager (PCM) I saw at the MTF (because I never did see the same PCM twice) had given me the referral I had asked for, by name, again and again.

Two weeks is all it took for me to get every last person in my family the medical care they need and deserve.

So what will it cost me? Every last penny I will spend on our healthcare this year is worth it. For my family of six, I will pay a $300 deductible before the coverage kicks in. We have already paid this within the first two weeks–we needed a lot of testing, procedures, appointments, and prescriptions! After I pay that deductible, we will continue to pay co-pays up until we hit a $1000 dollar catastrophic cap. My family will likely hit that cap, due to the special needs and health issues we are dealing with. Once we hit that amount, I will pay nothing else, until the following year.

There were times my family could not have afforded to pay a thousand dollars a year for health insurance, and during those times, and I am grateful my husbands service earned us TRICARE Prime healthcare coverage.

3-9 Tricare Standard Pinterest PIN

I know I’m not alone with the decision to switch to TRICARE Standard because my family couldn’t get the care they needed, when they needed it. Remember Sequestration? Remember when MTF’s were closed for a number of days each week and no one could get care? My problems, and others’, isn’t the fault of the doctors and PCM’s, in most cases, it’s the policymakers who can fix this for military families. My family deserves the best care, no matter which plan we’re on. So does yours.

The National Military Family Association continues to fight for military families like yours and mine by asking Congress to end Sequestration and the unfair burden it puts on military families. And this year, NMFA is putting a heavy focus on TRICARE reform and the health proposals in the Fiscal Year 2017 budget.

Right now, I can’t afford to NOT to pay the thousand dollars for my family’s healthcare. I am kicking myself for not transitioning to Standard sooner. I could have gotten my son the evaluations, help, and services he needed sooner. I could have received the preventative care I needed sooner. I could have saved myself so much stress and time spent waiting on referrals and prescriptions, and time spent sitting in the waiting room at the ER when appointments were unavailable at the MTF.

I could have saved so much, had I switched sooner.

Did your family switch from TRICARE Prime to TRICARE Standard? What would you tell Congress about your experience?

HeatherPosted by Heather Aliano, Social Media Manager

40 Comments

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  1. 1
    Rebekah

    Thank you so much for this article!!!! I have been toying with the idea of switching my kids because they can NEVER be seen on base and end up at urgent care or the ER with doctors that don’t specialize with children. I didn’t understand the catastrophic cap meant my max out of pocket was $1000 and all I could thin was what if surgery, what if accident, what if, what if, what if. Thank you so much! We might just be ready to jump ship!

    • 2
      Jen c

      I am so upset. We are still prime but going to switch after our pcs and new fiscal year. . I was told the MTF case manager should be able to help with getting new referrals and even get appointments made before we leave. This is done on a case by case basis. We were t able to the last PCS. Than I am switching to Standard. I’m so done with prime

      But I had to reply to your comment. In Jan both my daughters got sick. I followed the rules and got authorization from the nurse care line from MTF. I have the ENC# to urgent care. Unfortunately I only kept the one. Not sure where the other one is. I’m praying I will find it written somewhere. But seriously I noticed on the EOB saying they were going to charge $92.78. At first thought maybe they charged the wrong social. Than I get the bill from urgent care and says Tricare applied $92.78 to deductible , as required authorization not obtained. Contact Tricare to resolve or pay amount due. I ended up getting this for both my kids. I went to them last year and didn’t have any problem and now I do? I did the right thing. Waited forever for a nurse to call me than all that. I even wrote the ENC# a couple of times on the form. I wrote where it asked for insurance info. Oh, I think I know how this happened, maybe saved info but didn’t bother to look for the enc number. I don’t know.
      This happened a few years ago in a different state. Same thing nurse care line, not Tricare had civilian PCM than and waited for nurse to call me. She sent me to their urgent care, gave me the address and everything. I couldn’t get help from Pcm because they never spoke to me. It was a weekend. I called the nurse company and again couldn’t help me. So begrudgingly I paid the $74. I think I’m done with urgent care until I switch to standard. But so pissed. Even when play by the rules and still this bs.

      But yes MTFs closed for family day or training day. The worst is will only write one referral a visit. I need more specialists for myself. Plus I have 2 kids with special needs. I am needing more than 1 referral. The thing is I had a MTF PCM last in 2006 because of my chronic medical issues. I was in a few different states. Move to Tricare South (sucks compared to west) and won’t let me see PCM. They keep changing my PCM. They won’t order things and if do doesn’t know how to read tests and than again can’t get a dang referral. My referrals I do have expire so have to start all over. I have 2 kids that see at least 8-10 different specialties. But yea, I am done. I finally talked my husband into it. I’ve been wanting to since moving here in Florida.

  2. 3
    Bill

    The reasons you listed are why we never went to Tricare Prime. However, Congress at this very moment is proposing to initiate an Annual Enrollment Fee of $900 with an Annual Deductible of $600 for out of network service providers. RX copays will increase from $826 to as much as $1,760 under current proposals. Contact your senators and representatives. http://www.moaa.org/Content/Take-Action/Top-Issues/Currently-Serving/TRICARE-Reform,-or-Just-Fee-Increases-.aspx

  3. 6
    Stacie Dumas

    If you can find a provider under standard that is fabulous. If you are in area that is mildly rural you cannot find a physician that accepts new patients with TRICARE standard. I will stick with Prime as it is beneficial to my family.

  4. 7
    kccgm

    We are about to retire in February and we’ve been discussing the very issue you describe. My biggest concern was losing access to all of my daughter’s specialists.
    Do you know how Echo benefits through the EFMP program carry over since EFMP would disappear at retirement?
    Who are you utilizing for dental and eye now since the carry over on those seems quite outrageous? Thanks.

  5. 14
    malorimayor

    Great post! I wholeheartedly agree that Tricare Standard is worth it. I couldn’t stand the care I was getting with Prime. Also, I wanted to see a functional medicine doctor, who doesn’t take insurance but gives me a super bill that I can then file with Standard and get partially reimbursed. It has been worth EVERY penny!! 🙂

  6. 15
    Robert Twarkins

    Tricare has come a long way over the years. I switched to standard when I retired. Now that my wife and I are 65 we have
    MEDICARE and Tricare for Life as a secondary. It’s fantastic!

  7. 16
    REHatfield

    As soon as the spousal unit came home and said that Prime was required, I said maybe for you, but not for us! Made sure that me and the kiddos were on standard from day one. I needed to know that I could take the kids anywhere they needed to go whenever they needed to be there. The one thing that I have learned, is that when the government changes something it is NEVER to the benefit of the citizen.

  8. 17
    Art

    Apparently I have to switch. Tricare Prime isn’t an option in Panama, yet standard is. Your article helped ease my mind about it, thanks!

  9. 19
    jcmwright

    Just today I took my child to the ER for pink eye because there was no appointment available THIS WEEK at an MTF. I would be happy to share my story with Congress.

  10. 20
    George Tomlinson

    Too bad you didn’t need all of those tests, procedures, and drugs. The people you are now seeing are in it for the profit, not for your health. You think you got better care, but what you really got was taken to the cleaners.

  11. 21
    J Suh

    I understand there are frustrations with Tricare Prime. I have had many friends feel like they are continually fighting for decent medical care. But, I have had a pretty positive experience with it in the 5 places we’ve lived in the last 10 years. Some considered remote. I feel like if there is a constant backlash against it that Congress will be more interested in making all family members Standard as a good cost saving measure. For some families that would be an extreme burden. MTF’s I think are trying to improve and utilizing ICE is good way to make your voice heard.

  12. 22
    Melissa

    Actually your catastrophic cap is 3000 for a family and 1000 for just one individual. Great article though I just wanted to clarify since I used to work for the contractor.

  13. 25
    nicole

    I’ve been on Standard since 1999…I also have a secondary insurance which is $39 a month for myself and 3 children which pays the co-pays Tricare after I hit the $300 (which is usually billed in January for October visits). I get reimbursed for all prescription co-pays as well. Total out of pocket for the 4 of us is $768…totally worth it!!!

  14. 26
    A military MD

    The sad thing is that there are PLENTY of physicians in military medicine, but the epic bureaucracy that the military health system imposes, as well as a system in which physicians are not allowed to JUST practice medicine. The system is not designed to allow physicians to focus 100% on patient care (as many of us would like to do seeing as we have committed our life to becoming doctors). Instead, if you want to stick around the military you are expected to take more and more administrative roles, which removes you from the availability of being able to see patients and treat them exclusively. As a fairly new physician out of training, every evaluation I had within the first 2-3 years of graduating residency was focused on me taking “leadership roles” and doing things like striving to be a department head. All I wanted to do was become a better surgeon. I was not anywhere near the point in my career where I wanted to take on administrative roles, but alas, the military sees that as career progression, rather than perfecting your art. I currently am in a department in which there are at least 10 surgeons, yet we only see the amount of patients a practice of 3-4 does in the civilian world. Yet within that department, there are at least 4 people with the word “chief” or “chair” in their titles, and they are wrapped up in admin tasks. The system is remarkably inefficient, to the detriment of the patients (and the physicians who would like nothing more than devote the majority of their time to taking care of patients). It is sad, and unfortunate that the reasons it takes so long to get these appointments has to do with the utter inefficiencies in the system. And if this gets brought up, the military health system’s answer is to form yet some more committees and working groups to try to solve the problem, which really just creates more of a bureaucracy. The real unfortunate reality is that the military system has no incentive to do better. In the civilian world, the physicians are much more efficient, because it is their livelihood on the line. If they privatized military health care, it would become efficient overnight when those in charge realized they cannot afford to run things as they have.

  15. 27
    Lori

    Look into getting the supplement insurance with Selman CO – it will cost you $253 a quarter but it will cover all your co-pays and deductibles!!!! Standard and the Supplement is better than Prime!

  16. 29
    Amy

    I will never willingly trust my health to MTF again. In September of 2014 I ended up hospitalized for severe abdominal pain. NMC Portsmouth physicians said they could not find anything wrong and decided my pain was psychological in nature. I was told to either allow them to admit me to the Psych. Ward or they would discharge me. The nurses were horrible and rather than address the severity of the pain I was in, I got told to be quiet, I was disturbing the other patients on the unit. Fast forward less than 3 days after being discharged, I was hospitalized again at a civilian hospital. after a full battery of tests, I underwent an emergency surgery to untangle my intestines, which had twisted on themselves resulting in 70% loss of blood flow to my intestines,. The Petersen defect hernia, a very serious RNY post-op complication nearly killed me. So much for being a “mental” case.

    This is not my only horrible experience with MTF, I could go on and on about being forced to accept medical treatment at a MTF that resulted in a less than desirable outcome!

  17. 30
    Marie

    I have prime and love it. We are all seen by civillian practices in our town not at a MTF. We havent seen a military doctor in years. Yes, we still deal with referral requests but never have i been denied or it taken more than 7 days to get a response. I have a ton of medical care and i love never having to pay for any visits. If u are stuck on a base and are forced to see those doctors, than yes i would switch to standard but if u live in town…prime is awesome.

  18. 31
    Darla Winstead

    Wow! Your story sounds so familiar to ours. We had Tricare Prime for 21 years. We also fought for referrals and treatment for specific problems. We were fortunate at one assignment to have no MTF available and had civilian PCM. I thought I was in heaven and saw what it could be like with proper, thorough care. Then we went back to MTF. Like you we thought we couldn’t afford Standard. But with Prime that didn’t cover our infertility treatments or meds we paid thousands a month for over two years. Otherwise I would have no children today which is what the MTF PCM told us when he simply said you are unable to have children and Tricare in our area wouldn’t cover it. So we paid out of pocket. When I had extreme pain in my abdomen and vomiting for approximately 8 months the doctor told me he didn’t know what was wrong but ran no tests. After one bad night of it he finally sent me for an ultrasound. My gall bladder was on the verge of rupturing it was so full of crystals. I had emergency surgery. I have no doubt a civilian doctor would have noticed I was a textbook case for gall bladder issues and would have ordered the test much sooner and I could have avoided all the pain and stress. I have many other examples of undesirable care and fighting for referrals. The hours of my life I’ve wasted getting referrals. I feel I’m weaker and less healthy because of the lack of care. I have not been comfortable with most of the PCM’s I’ve had at MTF. I’m not the active duty one. I’m a person with feelings that deserves good compassionate understanding care. When my husband retired last year we decided to give Standard a try. We have only had it a few months but now my family is getting the care it needs and deserves. I am getting testing, conditions are being monitored, things are being explained in a way I understand, new medicines are being tried. I’m being treated as a living breathing person with feelings and not just a social security number whose spouse was in the military. I used to stress going to the clinic and usually leave frustrated.

  19. 32
    Liz

    Excellent article! We switched for the exact reasons you mention. Unfortunately it was not soon enough – our son was routinely misdiagnosed by MTFs and is now partially deaf as a result. It took switching to Stsndard, being seen by a true professional at Children’s National Medical Center to learn that he had an easy to diagnose, benign tumor destroying his middle ear. I will never, ever again step inside a military health facility. Thanks for a great article.

  20. 33
    Military physician tired of being abused

    I have worked in both the civilian and military systems. Your choice of Standard vs Prime is a personal one that every family should consider. I take no issue with your choice of Standard and wish you best in your future. I do feel that you very poorly portrayed ALL military physicians and used a sensational anecdote rather than factual evidence to tear apart physicians that are equally if not better trained than our civilian counterparts. I can tell stories of “mismanagement” that have occurred in both the civilian and military facilities. I will tell you that in my experience the military facilities do a more thorough job of investigating alleged malpractice and taking action to correct the problem then my civilian experiences. In my experience, civilian facilities practice more defensive medicine and order more unnecessary testing and procedures for fear of lawsuits. I would question whether your surgery is really “needed”. For the record I work with military physicians trained at Harvard and Brown at my MTF. Your civilian specialist is likely to be a foreign medical school graduate who speaks English as a second language. Finally, our residency programs are required to meet the same standards as our civilian counterparts. For that reason we are often sent to train at a civilian hospital in order to ensure we are competent. In case you can’t draw the conclusion that means we are trained along side your civilian specialists! If you want the convenience of Tricare Standard then so be it but don’t take an unfair shot at the doctors serving your country because you are disgruntled with how you perceived your health was handled. We don’t have the right to fight back!

  21. 34
    Meg

    I LOVE the tricare prime in my area. Maybe the kicker is the MTF. We don’t have one. We have clinics which run very efficiently and anything “hospital” is referred out to town. I also love that I have free urgent care visits each year (2/person). My son broke is arm and it was casted at the UC. I then called the military clinic on Monday (accident was on Sunday) and we were referred to ortho for a follow-up that Thursday. I have lived here for 8 years and have NEVER had any issues with waiting, getting services, getting referrals, anything. I do see where the author probably needed to go standard. Some of those MTF’s are a nightmare.

  22. 35
    Kate Patterson

    I have been on TRICARE Prime for the last 3 years. We are stationed at Ft. Hood and must use the MTF on . I have had the same issue for the last 3 years and nothing has been done to help me. I will admit that my trips to the ER were probably the best care I have received while on TRICARE Prime. My first issue was severe shoulder pain. I swam for 14 years (4 in college) and I currently coach the sport. I KNOW it is a rotator cuff issue. I have done physical therapy. My PCM refused to x-ray my shoulder. Instead I was told I could go to physical therapy. The physical therapy clinic called and said that I could have appointments on Tuesday at 10. I asked if there was any other way to get the care I needed because I couldn’t do that. I’m a high school math teacher and I can’t leave my class (even with a sub) that often. I’ve also had issues with getting pregnant. I have had 3 miscarriages in the last year (All of my ER trips). I was referred to radiology to have a procedure to look at my uterus. You must have blood drawn for a pregnancy test 2 hours before so I did that. My doctor comes into the room questioning my doctors decision to send me to get that procedure. He also asked me if I was pregnant and I said you tell me I just took your required pregnancy test to which I got no response (ended up having a miscarriage less than a month later). I elect to go through with it because I trust my doctor. I kid you not, this guy picked up something of of the tray of medical instruments and says to the nurse “what is this?”
    The nurse replies “that’s a catheter.” to which he replied “oh, I’m not used to seeing this type.” He then proceeded to reprimand the nurse for electing to lay out that type of catheter. My dumb ass should have gotten off of that table right then and there, but I didn’t because I wanted to trust in my educated doctors. He decided to use the catheter but cuts the top of it so it has a jagged plastic edge which he proceeds to stick into my lady parts. It was the most excruciating pain I have ever experienced. I had to tell him to stop. He did. He got up and walked out of the room and left me with the nurse. He didn’t say anything to me and never came back to check on me or talk to me. When I sat up there was blood all over me, all over the table, all over the tray of instruments… I freaked. I felt like the nurse was the only competent person in that room. She at least tried to console me when I was in hysterics. I walked out of that hospital crying and I NEVER cry. I was crying because I was seriously freaked out and no one did anything to make it better. I was handed my clothes and tossed out the door. I have completed several of the surveys they send in the mail reviewing my doctor. I always give my doctor good reviews. For this guy I wrote a 3 page letter about my experience. The hospital contacted me and asked me to sit in a meeting with this doctor. I am not about to go sit in a room with this guy so he can tell me what I witnessed was not malpractice. They may be able to fool some, but I have a Master’s Degree in Mathematics. I’m not and idiot. I know what happened. I was there. My PCM told me that I could go see a fertility specialist, but it wouldn’t be provided by TRICARE and I would have to pay for it out of pocket (she said around $10k). I am at a complete loss as to what to do. I cannot convince my husband to switch to standard so I am considering purchasing my own insurance through work.

  23. 37
    Renee G

    Thank you so much for this article. Sadly, I am active duty for the moment, but had amazing federal government health insurance for 11 years as I served as a reservist, and now suffering at the hands of TRICARE Prime… they won’t even cover medically necessary (as Rx’ed by my doctor) prescriptions, so we are considering activating my husband’s Blue Cross, Blue Shield (ANTHEM) — but this may help my family, just not me. :_( Thanks again for the information and the chance to write the lobby and interest groups so that TRICARE may change one day.

  24. 38
    Cheng V

    I changed my wife to Standard back when we got married. Tricare gave us the run around to get her seen off base, we lived about 50 miles away from base. That wasn’t just the case too. Bad attitude from the nurses, like they don’t care, when we went to them informing my wife was pregnant. I rather pay the co-pays than deal with bad contracted/military hospital personnel. Sadly for me, I’m stuck with them. Best department I’ve dealt with so far is optometry. Besides that, I try to stay away.

  25. 39
    JC

    I fully agree that the “Standard” plan wins out over so called “Prime”. Prime is deliberately misleadingly named to confuse families and that alone is disgraceful.

    We have Standard and so, did not need a referral, thank God.

    But I’m very disappointed. Two reasons:

    My teen needed urgent psychiatric care (not quite emergent, YET).

    1) the list of providers – is woefully inaccurate. Half (yes, HALF) of the providers listed locally have inoperable phone numbers.

    AND the other half are Not taking new patients OR have a minimum 5 week wait for an appointment.

    Let that^^ sink in…`

    2) to address this problem by phone OR online, GOOD LUCK! There is a maze of repetitive questions and menu options that circle back to the original menu! OMG incredibly frustrating. If this were my teen trying to navigate this system, I have to wonder what would have happened.

    After 2 hours of this circus, we are going out of pocket to an out of network provider. We will get seen soon (today, btw). And it’s $300 out of pocket.

    Disgraceful.

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