Military Health System

1.1  The TOP is the Department of Defense’s (DoD’s) program for the delivery of health care support services overseas (all locations outside of the 50 United States (US) and the District of Columbia). The delivery of health care services overseas represents a unique situation that cannot be effectively addressed by applying all of the standards that apply in the 50 US and the District of Columbia. TOP blends many of the features of the TRICARE program in the US while allowing for significant cultural differences unique to health care practices and services in overseas locations.

1.2  TOP provides health care coverage for all overseas beneficiaries, including Service members, eligible Reserve Component (RC) personnel, Active Duty Family Members (ADFMs) (including family members of eligible RC personnel), retired military and their respective family members, and transitional survivors. This coverage applies regardless of where the services are received. TOP also provides health care coverage for stateside beneficiaries residing in the 50 US or the District of Columbia (excluding beneficiaries enrolled to the Uniformed Services Family Health Plan (USFHP) and the Continued Health Care Benefit Program (CHCBP)) who receive health care in an overseas location. TOP coverage includes all dental care for Service members permanently assigned to, and receiving dental care in, a remote overseas location. TOP coverage also includes urgent and emergency dental care for Service members who are Temporary Duty/Temporary Additional Duty (TDY/TAD), in an authorized leave status, deployed or deployed on liberty in remote overseas locations. Specific TOP program eligibility and health care coverage is based upon beneficiary status, location, and enrollment elections. All beneficiaries must be eligible for TRICARE as verified via the Defense Enrollment Eligibility Reporting System (DEERS).

1.3  TOP health care services are provided by Market/Military Medical Treatment Facilities (MTFs) and a complement of network- and non-network purchased care sector providers and institutions.

1.4  Three geographic regions have been identified for the oversight of health care delivery overseas: TRICARE Eurasia-Africa (including the European continent, the Middle East, and Africa), TRICARE Pacific (including Asia, Australia, and the islands of the Pacific and Indian Oceans), and TRICARE Latin America and Canada (TLAC) (including Puerto Rico, the Caribbean basin, Latin America, South America, and Canada). Three TRICARE Area Offices (TAOs) have been established for these geographic regions to provide management and oversight of TOP health care delivery for eligible TRICARE beneficiaries. The TAO Directors, working in concert with the MTFs and their respective services, are responsible for organizing and managing health care delivery for beneficiaries in their respective regions. A single TRICARE Overseas health care support contractor (hereinafter referred to as the “TOP contractor”) supports the TAOs, MTFs, services, beneficiaries, and purchased care sector providers by providing or arranging for the delivery of health care services, claims processing services, and a variety of health care administrative services.

2.1  The following TRICARE programs or services are available under the TOP contract: TOP Prime, TOP Prime Remote, TOP Select, TOP TRICARE for Life (TFL), TRICARE Reserve Select (TRS), TRICARE Retired Reserve (TRR), TRICARE Plus, the Extended Care Health Option (ECHO), TRICARE Young Adult (TYA), and the Transitional Assistance Management Program (TAMP).

2.2  The following TRICARE programs or services may be available in certain overseas locations, but are not administered under the TOP contract: TRICARE Dental Program (TDP), TFL, TRICARE Pharmacy (TPharm) Program, TRICARE Active Duty Dental Program (ADDP), and the CHCBP.

3.1  TOP benefit policy applies to the scope of services and items which may be considered for coverage by TRICARE within the intent of 32 CFR 199.4 and 32 CFR 199.5. Specifically, TRICARE may cost-share a procedure that is determined to be appropriate medical care, is medically or psychologically necessary, is not unproven as defined in 32 CFR 199.2, and the service or supply is not specifically limited in coverage or explicitly excluded by statute, regulation, or policy.

3.2  While “appropriate medical care” references the norm for medical practice in the US, TOP gives consideration to the significant cultural differences unique to foreign countries. The TOP contractor shall exercise reasonable judgment to accommodate cultural differences relevant to the practices and delivery of host nation health care services. Services and supplies which otherwise fall within the range of TRICARE benefits (including, but not limited to, clinical preventive services, prescription drugs, and Durable Equipment (DE)/Durable Medical Equipment (DME)) may be eligible for coverage under TOP when the diagnosis or description of illness supports the reasonableness of the procedure, service, or supply and is commonly accepted practice in an overseas location. Services and supplies, which are specifically excluded from TRICARE coverage cannot be covered under TOP simply because of cultural differences. A specific waiver is required if the service or supply would not normally be considered a TRICARE benefit. Refer to Section 1.2 for a list of authorized benefit variations for TOP.

3.3  Cultural differences may apply to things like location of care (provider comes to the patient’s home) or the manner in which care is provided (services commonly done by a provider class in the US may be performed by a provider assistant or physician overseas, depending on the country). Cultural differences may also apply to the manner in which claims are submitted to TRICARE. For example, certain countries may require a separate delineation of charges for health care delivery and administrative practices that are attendant to the delivery of health care. These charges may be payable under TRICARE if they are determined to be reasonable and customary for a particular overseas location. Also, due to cultural differences, purchased care sector providers may, and frequently do submit claims containing narrative summaries in lieu of diagnostic and/or procedural codes. These claims may be payable under TRICARE; however, the TOP contractor shall establish processes to ensure that narrative claims are converted to codes that accurately describe the services rendered and billed by the host nation provider. Fees for transplant donor searches in Germany may be reimbursed on a global flat fee basis since the German Government does not permit health care facilities to itemize such charges. Itemized fees for supplies that are related or incidental to inpatient treatment in Japanese hospitals (e.g., hospital gowns) may be reimbursed if similar supplies would be covered under reimbursement methodologies used within the US. In some countries, multi-specialty group practices may submit claims that do not identify the name of the provider who actually rendered the care, the individual’s professional status, or the provider number. Such cultural differences in billing practices shall be accommodated for foreign multi-specialty group practices (subject to all provider licensure/certification requirements in the contract). The TOP contractor shall implement internal management controls to ensure that all payments are reasonable and customary for the location.

3.4  The TOP benefit package includes pharmacy services through the TOP contractor for drugs dispensed by purchased care sector pharmacies, institutions, and providers. TOP beneficiaries may also receive limited services through the TPharm contract, to include retail network pharmacy services (in US territories) and mail order pharmacy (MOP) services. The TPharm MOP may be used by all TOP beneficiaries provided certain criteria are met, such as a US credentialed provider to write the prescription and a US ZIP coded address to ship to (Army Post Office (APO), Fleet Post Office (FPO), or Diplomatic Pouch Mail). Some countries, such as Germany, prohibit prescription drugs being mailed from the US or any other country. Additionally, Service members or ADFMs assigned to US Embassies/State Departments may also use TPharm MOP services. TOP beneficiaries who are covered by Other Health Insurance (OHI) with a prescription drug benefit may not use TPharm MOP services unless the OHI plan does not cover the medication needed, or the OHI coverage limit has been met. The TPharm MOP cannot ship drugs which must be refrigerated (e.g., insulin) to an address outside the 50 US and the District of Columbia.

4.1  All TRICARE requirements set forth in the TRICARE Policy Manual (TPM), the TRICARE Reimbursement Manual (TRM), TRICARE Operations Manual (TOM), and the TRICARE Systems Manual (TSM) apply to the TOP, unless specifically waived or superseded by the TOP contract, this chapter, or the TOM, Chapter 24.

4.2  For purposes of TOP implementation, any applicable manual language that refers to “TRICARE Prime” and “TRICARE Prime Remote” shall apply to TOP Prime and TOP Prime Remote, and language that refers to “TRICARE Select” shall apply to TOP Select.

4.3  Waiver of rigid application of the requirements for processing/review of claims has been granted by the Defense Health Agency (DHA) to overcome variations between US standards of health care practice and standards of health care practice in foreign countries. Examples of these variations are: