Military Health System

1.1  The TOP Standard benefit is in effect through December 31, 2017. On January 1, 2018,TOP Standard is replaced with TOP Select except for TRICARE For Life (TFL) beneficiaries who will still be subject to TRICARE Standard (see TRICARE Reimbursement Manual (TRM), Chapter 2) as if TRICARE Standard is still being implemented. All TRICARE requirements regarding TOP Standard or TOP Select shall apply to the TOP unless specifically changed, waived, or superseded by the provisions of this section; the TRICARE Policy Manual (TPM), Chapter 12; or the TRICARE contract for health care support services outside the 50 United States (U.S.) and the District of Columbia (hereinafter referred to as the “TOP contract”).

1.2  TRICARE beneficiaries enrolled to TRICARE Select and residing overseas have the same enrollment fees, when implemented, as those TRICARE Select beneficiaries residing in the 50 United States (U.S.) and the District of Columbia. TRICARE Select deductibles and copays/cost-shares are determined based on the date which the Service member first became affiliated with the military through enlistment or appointment and if the healthcare services were received by a network or non-network purchased care sector provider (see the TRM, Chapter 2). Beneficiaries seeking healthcare overseas may be required to pay up front and file a claim for reimbursement.

3.1  The TOP contractor shall process claims and provide claims assistance for TOP Standard through December 31, 2017) and TOP Select (starting January 1, 2018) beneficiaries who reside in an overseas location (regardless of where the care was rendered), and for TRICARE Standard through December 31, 2017) and TRICARE Select (starting January 1, 2018) beneficiaries residing in the U.S. and the District of Columbia who receive health care services in an overseas location. This includes claims for prescriptions unless these claims are otherwise covered under the TRICARE Pharmacy (TPharm) contract.

3.2  The TOP contractor shall not develop purchased care sector provider networks to support the TOP Standard beneficiary population through December 31, 2017, and TRICARE Select beneficiary population starting on January 1, 2018. Effective January 1, 2018, the TOP contractor shall develop a preferred provider network for TOP Select only in overseas areas where the Director, Defense Health Agency (DHA) determines that it is economically in the best interest of the Department of Defense (DoD). The use of this authority to establish a TRICARE preferred provider network for any particular geographical area will be published on the publicly available contractor Internet website and the notice will include a description of the preferred provider network program and other pertinent information.

3.3  The TOP contractor shall not provide health care services on a cashless, claimless basis for TOP Standard (through December 31, 2017) and TOP Select (starting January 1, 2018) beneficiaries/enrollees residing overseas, or for TRICARE Standard (through December 31, 2017) and TRICARE Select (starting January 1, 2018) beneficiaries residing in the U.S. and the District of Columbia who receive health care services in an overseas location.

3.4  The TOP contractor shall not make appointments with purchased care sector providers for TOP Standard (through December 31, 2017) and TOP Select (starting January 1, 2018) beneficiaries/enrollees, or for TRICARE Standard (through December 31, 2017) and TRICARE Select (starting January 1, 2018) beneficiaries residing in the U.S. and the District of Columbia who receive health care services in an overseas location. However, upon beneficiary request, the contractor shall provide the name, telephone number, and address of purchased care sector network or non-network providers of the appropriate clinical specialty located within the beneficiary’s geographic area.