TRICARE: Notice of TRICARE Plan Program Changes for Calendar Year 2025

SUPPLEMENTARY INFORMATION:

A final rule published in the Federal Register (FR) on February 15, 2019, (84 FR 4326-4333) established the requirement for the Director, Defense Health Agency (DHA), to provide public notice to Military Health System (MHS) beneficiaries each calendar year in connection with the annual open season enrollment period with a summary of changes to the TRICARE program. The following changes or improvements to the TRICARE program benefits apply for CY 2025.

Announcement of Open Season

Open Season is an annual period when beneficiaries can enroll in or make changes to their healthcare, dental, and vision coverage for the next calendar year.

During the TRICARE Open Season that runs from November 11, 2024, through December 10, 2024, qualified MHS beneficiaries may enroll in or change their TRICARE Prime or TRICARE Select plan.

During the Federal Employee Dental and Vision Insurance Program (FEDVIP) Open Season that runs from November 11, 2024, through December 9, 2024, qualified MHS beneficiaries, including TRICARE for Life beneficiaries, may enroll in or make changes to their dental and vision plans. FEDVIP is operated by the U.S. Office of Personnel Management.

Any changes MHS beneficiaries make during Open Season will take effect on January 1, 2025. If a beneficiary remains eligible and does not make any changes during Open Season, then their coverage will stay the same for 2025. TRICARE enrollees can ensure they receive important health plan information by promptly listing any change in address and other information in the Defense Enrollment Eligibility Reporting System (DEERS). See the Qualifying Life Events ( https://health.mil/Military-Health-Topics/MHS-Toolkits/Toolkits/QLEhttps://health.mil/Military-Health-Topics/MHS-Toolkits/Toolkits/QLE ) guide for when to update information in DEERS throughout the year.

Annual Announcements

The following TRICARE program features are subject to a year-to-year determination and are announced each year prior to the annual TRICARE Open Season.

Urgent Care Visits: There continues to be no limit on the number of urgent care visits covered beneficiaries enrolled in TRICARE Prime can receive without a referral for Plan Year 2025. Beneficiaries may receive urgent care from TRICARE-authorized urgent care centers (UCC) and convenience clinics (CC), either network or non-network, without a referral. They may also receive urgent care from any TRICARE network provider ( i.e., family medicine; internal medicine-general practice; pediatricians). In situations when a TRICARE Prime enrollee seeks care from a non-network TRICARE authorized provider (outside of a TRICARE-authorized UCC or CC), the usual TRICARE Prime Point of Service (POS) deductible and cost-shares shall apply. Private Sector care for active duty Service members is subject to different rules. Covered beneficiaries who want assistance on decisions to seek urgent care in the United States (U.S.), except those enrolled in the Uniformed Services Family Health Plan (USFHP), may call the MHS Nurse Advice Line (NAL) at 1-800-874-2273 for health care guidance from a specially trained registered nurse. The NAL is available 24/7 to all non-USFHP TRICARE beneficiaries. Beneficiaries who live overseas can call the NAL for health care advice when traveling in the U.S. but must coordinate care with their Overseas Regional Call Center. For additional information, call the servicing TRICARE contractor or visit https://www.tricare.mil/ContactUs and click on “MHS Nurse Advice Line.”

Prime Service Area Changes: Prime Service Areas (PSAs) are geographic areas around military medical treatment facilities and Base Realignment and Closure sites. PSAs support the medical readiness of active duty members of the Uniformed Services by adding to the capability and capacity of military hospitals and clinics. There are no changes to the existing PSAs for calendar year (CY) 2025.

What's New

The following changes or improvements to the TRICARE program benefits apply to CY 2025 (although some changes were implemented in 2024):

Managed Care Support Contractors

TRICARE Managed Care Support Contracts for East and West Regions Change: Effective January 1, 2025, a set of new TRICARE Managed Care Support contracts that facilitate health care in the private sector will serve beneficiaries in the East and West regions. Under the new contracts, beneficiaries residing in Arkansas, Illinois, Louisiana, Oklahoma, Texas, and Wisconsin will shift from the East to the West region.

Note:

Beneficiaries residing in Arkansas, Illinois, Louisiana, Oklahoma, Texas, and Wisconsin, and TRICARE Prime and Select beneficiaries transitioning from HealthNet Federal Services to TriWest must contact their regional contactor if they are paying enrollment fees or premiums by recurring credit card and electronic funds transfer (EFT) to provide their payment information to ensure there is no break in TRICARE health care coverage.

Beneficiaries in the West Region will have a new contractor administering their TRICARE benefit, TriWest Health Alliance. Contractor contact information for West Region beneficiaries receiving services on or after January 1, 2025, is provided here: TriWest Healthcare Alliance, P.O. Box 43470, Phoenix, AZ 85080-3470, Phone: 1-888-TRIWEST (874-9378); Fax: 1-866-566-9915, www.tricare.mil/West. Beneficiaries in the East Region will continue to have their TRICARE benefits administered by Humana Government Business.

The TRICARE East and West contracts include new requirements added to allow enrolled beneficiaries to call their regional contractors to get help with network appointments. This requirement is intended to assist beneficiaries currently enrolled to the network who need support for making appointments. Beneficiaries who frequently encounter problems with network providers not accepting new patients can contact the regional contractor for assistance.

Benefit Changes

Coverage of Hearing Aids for Child Dependents of Former Members of the Uniformed Services: Hearing aids and hearing aid services and supplies to address profound hearing loss may be covered for child dependents of former members of the Uniformed Services who are enrolled in TRICARE Prime, effective December 22, 2023. Hearing aid benefits are available to dependents of a member of the Uniformed Services on active duty, which includes all members covered under the Transitional Assistance Management Program.

Automatic Blood Pressure Monitors: Automatic blood pressure monitors may be covered under TRICARE's Durable Medical Equipment policy, when prescribed for a beneficiary who is also receiving covered Remote Physiologic Monitoring services, for medically necessary self-measured blood pressure monitoring, effective June 29, 2023.

Lipectomy (Liposuction) for Treatment of Lipedema: Medically necessary liposuction for the treatment of lipedema may be covered when certain coverage criteria are met and with prior authorization, effective May 28, 2021.

TRICARE Coverage for Over-The-Counter (OTC) Norgestrel: The TRICARE pharmacy formulary for OTC drugs covers Norgestrel (Opill) tablet with a doctor's prescription. TRICARE plan copayments or cost-shares may apply. This addition to the TRICARE drug formulary does not change OTC coverage of Levonorgestrel (Plan B One-Step Emergency Contraceptive) for free without a doctor's prescription. Beneficiaries may see the TRICARE drug formulary search tool for further information.

Demonstration Changes and Extensions

Childbirth and Breastfeeding Support Demonstration (CBSD) Childbirth Support Services Adjustments: The CBSD will continue into calendar year 2025 and is available to all beneficiaries except those enrolled in USFHP, the Continued Health Care Benefit Program, and those receiving TRICARE coverage under TRICARE for Life, with the following adjustments.

First, starting January 1, 2025, all Certified Labor Doulas (CLDs) performing services under the CBSD must have an agreement to participate with TRICARE, which means the CLD must file claims and accept TRICARE reimbursement as payment in full. Beneficiaries must select a CLD who has agreed to participate (in-network or out-of-network) to have TRICARE pay for services. No coverage will be provided for services received from a CLD without a TRICARE participation agreement. Beneficiaries who select a TRICARE-participating CLD will have no out-of-pocket expenses (after the annual deductible has been met). Second, the allowance for six untimed visits with a CLD either before or after delivery are replaced by six hours of visits, which can be used in 15-minute increments for visits of different lengths. Third, TRICARE raised the reimbursement rates for CLDs. Fourth, the National Black Doula Association has been added as an accepted certifying organization for CLDs. Finally, TRICARE is waiving the certification requirement for CLDs with active Medicaid participation in the state where practicing. Phase 1 will end on January 1, 2025, and a new Phase 2 reimbursement for childbirth support services provided in the 50 United States and District of Columbia will be effective from January 1, 2025, through December 31, 2026. For overseas locations, the effective date for Phase 2 reimbursement is also January 1, 2025, through December 31, 2026.

CBSD Overseas: Starting January 1, 2025, beneficiaries enrolled to the TRICARE Overseas Program (TOP) are eligible for demonstration services (doula support and breastfeeding support by authorized demonstration providers) when all demonstration requirements are met. Unlike in the U.S., TOP beneficiaries must enroll in the CBSD with the overseas contractor to be eligible. Beneficiaries can search provider directories to locate CBSD providers near them in Germany, Japan, Italy, South Korea, Puerto Rico, and the United Kingdom; in other countries, the overseas contractor will work with the enrolled beneficiary to find a qualified provider, if available.

Preventive Service Changes

Pre-Exposure Prophylaxis (PrEP) for, for the Prevention of HIV Acquisition: Effective January 1, 2025, HIV pre-exposure prophylaxis with effective antiretroviral therapy ( i.e., Apretude), as well as related office visits, for adolescents and adults at increased risk of acquiring HIV, when provided to TRICARE Prime patients of by network providers to TRICARE Select patients, will be considered clinical preventive services not subject to cost-sharing.

Digital Breast Tomosynthesis for Breast Cancer Screening as a Clinical Preventive Services Benefit: DHA will permanently cover digital breast tomosynthesis (DBT), also known as 3D mammography, as a clinical preventive services benefit not subject to cost-sharing.

Provisional Coverage Changes

Digital Breast Tomosynthesis for Breast Cancer Screening as a Clinical Preventive Services Benefit: Provisional Coverage of DBT for breast cancer screening, which spanned from January 1, 2020, to December 31, 2024, will lapse. However, as noted above, DHA will continue to cover DBT as a clinical preventive services benefit not subject to cost-sharing.

Platelet-Rich Plasma for Major Joint Treatment and Rehabilitation: Platelet-rich plasma (PRP) injections are excluded from coverage for all indications. The use of PRP for knee osteoarthritis and lateral elbow tendinopathy was covered under Provisional Coverage status from October 1, 2019, to September 30, 2024. Provisional Coverage of PRP lapsed on September 30, 2024, and will not be replaced with permanent coverage.

Appendix A

Certain TRICARE enrollee out-of-pocket costs (enrollment fees, premiums, catastrophic caps, deductibles, and copayments) are adjusted annually by federal law and regulations based on the annual Cost of Living Adjustment (COLA) applied to Uniformed Service member retired pay. A difference in copayments remains between those who joined a Uniformed Service before January 1, 2018, (Group A), and those who joined on or after that date (Group B).

The retiree COLA is typically announced after the federal fiscal year begins in October. Beneficiary out-of-pocket expenses impacted by the 2025 COLA will be posted to the tricare.mil/changes web page before the start of TRICARE Open Season, November 11, 2024.

Premium Based Plans

The CY 2025 monthly premiums for TRICARE Reserve Select, TRICARE Retired Reserve, and TRICARE Young Adult and the quarterly premiums for Continued Health Care Benefit Program will be posted to the tricare.mil/changes web page once announced.

Pharmacy Out-of-Pocket Expenses for CY 2025

TRICARE Pharmacy copayments will remain unchanged on January 1, 2025: