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TRICARE Program Options

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TRICARE Pharmacy Program Transitional Health Care Benefits TRICARE Extended Care Health Option Autism Care Demonstration

TRICARE Pharmacy Program

The TRICARE Pharmacy Program provides prescription drug coverage through safe, easy, and affordable options. TRICARE beneficiaries are eligible for the TRICARE Pharmacy Program managed through pharmacy contractor, Express Scripts. For more information on how beneficiaries can sign up for secure services with Express Scripts, download the free mobile app, search the TRICARE formulary, and check pharmacy costs (refer to the TRICARE Pharmacy Program webpage).

TRICARE beneficiaries have the following options for filling prescriptions:

For information on how beneficiaries may be able to get prescriptions filled from a non-network pharmacy, see the Non-Network Pharmacy webpage.

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Transitional Health Care Benefits

TRICARE offers three options for beneficiaries separating from active duty or who are losing TRICARE eligibility:

  • Transitional Assistance Management Program (TAMP)
  • Transitional Care for Service-Related Conditions Program (TCSRC)
  • Continued Health Care Benefits Program (CHCBP)

Transitional Assistance Management Program

The Transitional Assistance Management Program (TAMP) provides 180 days of health care benefits after regular TRICARE benefits end. Beneficiaries do not have to pay any premiums for TAMP.

TAMP may cover beneficiaries and their family members if they are:

  • Involuntarily separating from active duty under honorable conditions, including:
    • Members receiving a voluntary separation incentive (VSI) or
    • Members receiving a voluntary separation pay (VSP) and cannot receive retired or retainer pay upon separation
  • A National Guard or Reserve member separating from a period of more than 30 consecutive day of active duty served for:
    • A pre-planned mission
    • Support of a contingency operation
    • Support of the government coronavirus (COVID-19) response
  • Separating from active duty following involuntary retention (stop-loss) in support of a contingency operation
  • Separating from active duty following a voluntary agreement to stay on active duty for less than one year in support of a contingency operation
  • Receiving a sole survivorship discharge
  • Separating from regular active duty service and agreeing to become a member of the Selected Reserve of a Reserve Component. The Service member must become a Selected Reservist the day immediately following release from regular active duty service to qualify

The Services determine TAMP eligibility and document eligibility in the Defense Enrollment Eligibility Reporting System (DEERS). TAMP eligibility can be viewed online via milConnect. 

Qualified Service Members and their families are eligible to use one of the following health plan options* in addition to Military Treatment Facilities (MTF):

* Please see the table TRICARE plans administered by TriWest for the West Region.

For more information about TAMP, visit TRICARE’s Transitional Assistance Management Program webpage.

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Transitional Care for Service-Related Conditions Program

The Transitional Care for Service-Related Conditions (TCSRC) program extends TRICARE coverage to former active duty, Guard, and Reserve members for certain service-related conditions beyond their regular 180-day TAMP coverage period. The benefit is available worldwide.

Beneficiaries that are eligible for TAMP and have a newly diagnosed medical condition related to active duty service may qualify for TCSRC if the beneficiary’s medical condition is:

  • Service related
  • Newly discovered or diagnosed during the 180-day TAMP period
  • Able to be resolved within 180 days
  • Validated by a DOD physician

Once the DOD validates a medical condition eligible for TCSRC, coverage will show in DEERS.

To get started, beneficiaries should follow the instructions found on the TCSRC webpage. These instructions include:

  • Preparing a letter requesting coverage
  • Collecting copies of documents showing the condition is service-related
  • Completing the TCSRC Application Worksheet
  • Completing the Provider Checklist & Instructions
  • Submitting the letter and completed Application Worksheet

Beneficiaries should mail the letter and completed Application Worksheet and all other supporting documentation to the address found on the TCSRC webpage.

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Continued Health Care Benefit Program

The Continued Health Care Benefit Program (CHCBP) is a premium-based health care program that offers temporary transitional health care coverage for 18 to 36 months after TRICARE eligibility ends and acts as a bridge between military health care benefits and the beneficiary’s new civilian health care plan. It provides the same coverage as TRICARE Select, including prescriptions. It also gives the beneficiary minimum essential coverage as required by the Affordable Care Act.

For more information on eligibility, see the CHCBP webpage.

The CHCBP contractor is Humana Military. Humana Military provides services for enrollment, authorization, claims processing and customer service. For more information about CHCBP or to see if a beneficiary qualifies:

  • Visit Humana’s CHCBP website
  • Call Humana Military at 1-800-444-5445

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TRICARE Extended Care Health Option

TRICARE’s Extended Care Health Option (ECHO) provides assistance to eligible beneficiaries with special needs for an integrated set of services and supplies beyond those offered by the basic TRICARE programs (e.g., Prime, TPR, Select).

Potential ECHO beneficiaries must be enrolled in the Exceptional Family Member Program (EFMP) through the sponsor’s branch of service to receive ECHO benefits. Under certain circumstances, this requirement may be waived. Beneficiaries can be referred to this program online in the secure provider portal (specific link to be updated prior to start of health care delivery) or providers can call our dedicated ECHO line (Specific phone number to be updated prior to start of health care delivery) to begin the registration process.

The following beneficiaries who are diagnosed with moderate or severe intellectual disability, a serious physical disability, or an extraordinary physical or psychological condition may qualify for ECHO:

The qualifying family member’s disability must be entered properly in DEERS to have access to ECHO services.

Children may remain eligible for ECHO beyond the usual age limits in some circumstances. Beneficiaries may call the dedicated ECHO line (specific phone number to be updated prior to start of health care delivery) to determine eligibility for ECHO benefits if they believe a qualifying condition exists.

ECHO Benefits

ECHO benefits can include:

  • Training
  • Rehabilitation
  • Special education
  • Assistive technology devices
  • Institutional care in private nonprofit, public, and state facilities (may include transport to and from)
  • Home health care
  • Respite care for the primary caregiver

Some services may be cost-shared under ECHO or the beneficiary’s basic TRICARE program. This includes services needed to establish or confirm the severity of a qualifying condition or measure functional loss. For more information, visit the ECHO benefits webpage.

Additional ECHO benefits include ECHO Home Health Care (EHHC) and Respite Care for Primary Caregivers. Beneficiaries must use resources such as public funds and other programs if they are available in their communities. These resources include training, rehabilitation, special education, assistive technology devices, and institutional care in private nonprofit, public, and state facilities (may include transport to and from). If these resources are not available or sufficient, beneficiaries may request ECHO benefits by providing a Public Facility Use Certificate along with an explanation of why the resources are not available or sufficient.

ECHO Costs

There are no enrollment fees for ECHO benefits, but beneficiaries must pay a monthly copayment based on the sponsor’s pay grade. This information can be found on the ECHO Costs and Coverage Limits webpage.

The coverage limit for the cost of ECHO services combined (excluding ECHO Home Health Care, see section 3.3.3.3) is $36,000 per beneficiary per calendar year. Costs cannot be shared between family members.

Coverage for the ECHO Home Health Care benefit is capped annually and limited to the maximum fiscal amount TRICARE would pay if the beneficiary resided in a skilled nursing facility. This amount is based on the beneficiary’s geographic location.

For more information about TRICARE ECHO, refer to the TRICARE Policy Manual (TPM), Chapter 9 or see the Extended Care Health Option Fact Sheet.

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ECHO Home Health Care Benefits

The ECHO Home Health Care (EHHC) benefit provides services or respite care to those ECHO-registered beneficiaries who:

  • Are homebound
  • Require skilled services beyond the level of coverage that TRICARE Home Health Care Prospective Payment System provides
  • Require frequent interventions that their primary caregiver normally provides
  • Have a case manager who periodically assesses their needs and required services
  • Have a physician-certified plan of care that details the services that are provided

Beneficiaries must obtain a referral or prescription before obtaining certain EHHC services. TRICARE Prime beneficiaries should contact their Primary Care Manager (PCM) and TRICARE Select beneficiaries should contact their family provider/primary care physician who will then:

  • Decide eligibility for EHHC services
  • Develop a plan of care

The physician, case manager, and/or TriWest, as the regional contractor, must review the beneficiary’s plan every 90 days or when there is a change in condition.

Respite Care

The EHHC respite care benefit provides a maximum of eight hours per day up to five days per week to give primary caregivers time to rest/temporary relief. EHHC cannot be used for child care services, sibling care, employment, deployment, or when pursuing education. It also cannot accumulate if un-used. Only one of the respite care benefits (ECHO respite or EHHC respite) can be used in the same calendar month.

EHHC Benefit Cap

EHHC benefit coverage caps out on an annual basis and the amount is determined by the beneficiary’s geographic location. TRICARE coverage caps out at the maximum amount TRICARE would pay if the beneficiary resided in a skilled nursing facility.

For more information about EHHC, visit the EHHC webpage.

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Autism Care Demonstration

The Autism Care Demonstration (ACD) provides TRICARE reimbursement for Applied Behavior Analysis (ABA) services to TRICARE-eligible beneficiaries diagnosed with autism spectrum disorder (ASD). To qualify for ACD, children must be enrolled in a TRICARE health plan and have an ASD diagnosis from an approved provider.

Active duty service members (ADSM) that have a child diagnosed with ASD must be enrolled in the Exceptional Family Member Program (EFMP) and in the Extended Care Health Option (ECHO).

ACD program steps are available on the Autism Care Demonstration (ACD) webpage.

Step 1: Get Diagnosed

  • Have proof of a definitive diagnosis by an approved diagnosing provider as listed on the Autism Care Demonstration (ACD) The diagnosis must include the initial date of diagnosis, through either a referral reflecting a diagnosis of ASD or a diagnostic evaluation and the DSM-5 criteria documented in a DHA-approved checklist.
  • Submit one of the following validated assessment tools administered by a TRICARE-authorized diagnosing provider (See TRICARE Operations Manual (TOM) Chapter 18 Section 3 Paragraph 4.3.1.2 for a complete list). A parent questionnaire alone is not sufficient for diagnostic documentation.
    • Screening Tool for Autism in Toddlers and Young Children (STAT)
    • Autism Diagnostic Observation Schedule, Second Edition (ADOS-2)
    • Autism Diagnostic Interview, Revised (ADI-R)
    • Childhood Autism Rating Scale, Second Edition (CARS-2)
    • Gilliam Autism Rating Scale, Third Edition (GARS-3)
  • Be enrolled in their service’s EFMP and registered in ECHO to receive ABA under the ACD if they are a dependent of an ADSM.

Step 2: Get a Referral and Pre-Authorization

  • Obtain referral and prior authorization for ABA services and meet all requirements of the ACD (TOM Chapter 18 Section 3) in order for care to be reimbursable.
  • Covered services under the ACD include:
    • Autism services coordination via the ASN
    • ABA services

Step 3: Follow Documentation Requirements

Step 4:  Complete Outcome Measures

  • Complete all outcome measures as required by policies:
    • Pervasive Developmental Disorder Behavior Inventory (PDDBI)
    • Parental Stress Index (PSI)
    • Stress Index for Parents of Adolescents (SIPA)
    • Vineland 2
    • Social Responsiveness Scale (SRS)
  • All are due at baseline and every six months or annually: PDDBI, PSI, and SIPA are due with every six-month reauthorization; Vineland 2 and SRS 3 are due every year.

Step 5: Coordinate Care with Autism Services Navigator (ASN)

  • An Autism Services Navigator (ASN) is assigned to new beneficiaries and acts as a primary care coordinator
  • The ASN develops the Comprehensive Care Plan (CCP) to include setting goals, tracking timelines, connecting with the beneficiary with clinical and non-clinical resources, and providing discharge, moving, or transition support
  • Participate in medical team meetings scheduled by the ASN

Exclusions/non-covered services under the ACD include (See TOM Chapter 18 Section 3 paragraph 8.10 for a full list.):

  • Training of Behavioral Therapists (BTs)
  • ABA services for any other diagnoses other ASD
  • ABA services are not covered for symptoms and/or behaviors that are not part of the core symptoms of ASD (i.e., impulsivity due to ADHD, reading difficulties due to learning disability, excessive worry due to anxiety disorder)
  • Billing for emails and phone calls
  • Billing for driving to and from ABA services appointments (i.e., beneficiary’s house, clinic, or other locations). Mileage/time traveling is not to be billed to the TRICARE program
  • Rendering and billing for ABA services involving any aversive techniques or restraints
  • Educational/academic and vocational rehabilitation; all educational/academic and vocational goals must be removed from the treatment plan prior to approval
  • TRICARE will authorize and reimburse only Current Procedural Terminology (CPT) code 97153 rendered by the authorized ABA supervisor (not delegated to the assistant or BT) in the school setting
  • Authorizations for BTs in a school setting will not be approved
  • Autism schools are not TRICARE-authorized providers; if an Autism school has a clinic setting as part of their offered services, the clinic must have a separate TIN

Please review the ACD policy (TOM Chapter 18 Section 3) in its entirety for complete overview of TRICARE requirements for provider credentialing and ACD participation.

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Updated: 12/30/2024 3:01:27 PM