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TriCare Help: If couple enroll in Prime, other plan not required

Nov. 27, 2013 - 08:46PM   |  

Q. I’m the spouse of an active-duty retiree, and we’re both eligible for the Federal Employee Health Benefits plan through our jobs. We’d like to enroll in Tricare Prime. If we do, would we need to keep our FEHB as our primary coverage? Also, if we enroll in Prime, is our coverage based on our income, or is it the same for everyone?

A. You can enroll in Tricare Prime and use it as backup coverage to your FEHB plan, but you don’t need to keep FEHB in order to enroll in Prime and use that as your primary coverage.

Your spouse is eligible for Tricare because he’s a military retiree, and you’re eligible for Tricare because you’re married to a military retiree. Your employer does not factor into that equation.

If you decide to enroll in Prime and keep FEHB, Prime would be your secondary coverage; by law, Tricare must be last payer to all other health insurance except in very narrow and specialized circumstances.

However, keeping both plans would probably amount to being “overinsured.” As an alternative, you can also keep your FEHB and use Tricare Standard, which unlike Prime requires no enrollment and charges no premiums, as your backup coverage.

If you decide to give up your FEHB and go with Tricare only, be sure to suspend your FEHB; don’t cancel it. That leaves you the option of returning to it at some point.

This kind of question has no definitive answer. It’s a personal decision that individuals must make based on how much health care coverage they think they need and are comfortable paying for.

The fee structure for Tricare Prime is not based in any way on personal income; Prime rates are the same for all enrollees. You and your spouse would pay the family enrollment fee of $547.68 per year (along with standard co-payments for doctor’s visits, prescription drugs, etc.).

Q. Does Tricare cover invitro fertilization?

A. Tricare does not cover IVF or any other services related to what it calls “noncoital reproductive technologies,” a category that also includes artificial insemination.

What Tricare does cover related to infertility:

■ Diagnostic services for both sexes to identify physical illnesses or injuries to the reproductive system. Infertility treatments, corrective treatments and surgeries for women are also covered. However, male infertility treatments may be cost-shared with beneficiaries on a case-by-case basis.

■ Therapies such as hormonal treatment, corrective surgery, antibiotics, human chorionic gonadotropin and radiation therapy are covered for both sexes.

■ Medically necessary and appropriate medical care for erectile dysfunction that’s due to biologically organic — not psychological or psychiatric — causes.

Write to Tricare Help, Times News Service, 6883 Commercial Drive, Springfield, VA 22159; or tricarehelp@militarytimes.com. In email, include the word “Tricare” in the subject line and do not attach files. Get Tricare advice any time at http://blogs.militarytimes.com/tricarehelp/.

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