TRICARE® Young Adult Plan
TRICARE Young Adult (TYA) provides medical and prescription drug benefits, but excludes dental coverage. Find out more about your benefits.
Looking to understand eligibility and enroll in TYA? Learn more here.
BENEFITS OVERVIEW
- No deductibles or cost shares for in-network preventive services
- Annual physicals, eye exams, laboratory tests, prenatal and postnatal maternity care at no additional cost
- Emergency and urgent care available anywhere in the world
- Patient advocates who will make sure you’re getting the best care possible during hospital stays
FOR MORE BENEFIT INFORMATION
If your sponsor is active-duty military, see Active-Duty Summary of Benefits document in the right column for benefit/cost information. Refer to GROUP B information.If your sponsor is retired military, see Retiree Summary of Benefits document in right column for benefit/cost information. Refer to GROUP B information.
COSTS, PREMIUMS, AND COPAYS
The TRICARE Young Adult plan has a $570 monthly premium.
Your copays and out-of-pocket maximums are determined by the status of your sponsor:
- If your sponsor is active-duty military, see Active-Duty Summary of Benefits document in the right column for benefit/cost information. Refer to GROUP B information.
- If your sponsor is retired military, see Retiree Summary of Benefits document in right column for benefit/cost information. Refer to GROUP B information.
The US Family Health Plan includes a comprehensive pharmacy benefit, which covers your prescription drugs.
WHAT DRUGS ARE COVERED?
The TRICARE formulary is a list of medications that are covered under the Martin’s Point US Family Health Plan benefit. The formulary is established by the Department of Defense Pharmacy and Therapeutics (P&T) Committee.
See if your prescriptions are covered.
HOW YOUR COVERAGE WORKS
- One-time medications, or medications you need to begin taking immediately, can be filled at any in-network retail pharmacy
- Long-term, maintenance medications you take regularly must be filled through the Martin’s Point Mail-Order Pharmacy or at the Martin’s Point Health Care Center Pharmacies in Portland, Maine, and Portsmouth, New Hampshire
COST OVERVIEW
Prescription drug costs vary depending on what type of medication it is (generic, brand name, or nonformulary) and whether you are using a retail pharmacy or the mail-order pharmacy.
TRICARE encourages the use of generic prescription drugs. Generics have the same high quality, potency, and reliability as brand-name drugs at a much lower cost.
*For 90-day supply cost, multiply by three
OVERVIEW
The Martin’s Point US Family Health Plan requires use of the Martin’s Point Mail-Order Pharmacy or Martin’s Point Health Care Center Pharmacies (on-site) for most maintenance medications.
With the mail-order pharmacy you get a 90-day supply for the same or lower price you would pay for a 30-day supply at a retail pharmacy, and your prescription is mailed directly to you at no charge.
Some restrictions apply. Some liquids, refrigerated items, and controlled substances cannot be mailed. Please refer to your Member Handbook (PDF)
WAYS TO REFILL MEDICATION
Please be sure the pharmacy has a method of payment on file to avoid delays in your prescription order: 1-800-707-9853.
Online Refill Request (Preferred Method)
- Collect your prescription containers to identify your prescription number(s)
- Remember to use your primary Zip Code when entering information
- Use the comments section for any information that may be helpful in processing your prescription
Refill by Phone: 1-800-707-9853
- Collect your prescription containers and your credit card information
Refill by Mail:
- Mail to:
Martin’s Point Mail-Order Pharmacy
PO Box 9746
Portland, ME 04104
Please allow up to 14 days for mail order medications to reach you.
Our pharmacy staff is happy to answer your questions and provide the help you need to get started. Call 1-800-707-9853, 8 am–5 pm, Monday through Friday.
Download the Mail-Order Pharmacy Quick Start Guide (PDF)
Download an Alternate Address Form (PDF)
View All Pharmacy Notices Here.
DRUGS NEWLY RELEASED TO THE MARKET
It is rare, but possible, to have differences in the search tool and coverage of your prescription drug. This will happen when your prescription medication is newly released to market, and the P&T committee has not yet made a coverage decision. The plan will make a formulary coverage decision based on clinical and financial determinations. When the DOD P&T committee makes a determination, the plan will then adjust the coverage, if needed, to match the P&T decision.
NONFORMULARY DRUG LIST
Nonformulary medications, as well as the criteria for medical necessity, are established by the DoD P&T Committee. If you meet the criteria for medical necessity, you may receive the nonformulary medication at a lower cost share. Have your provider call 1-888-674-8734 to start the authorization process. Please refer to the formulary search tool to check that your medication is on the formulary.
MEDICATIONS REQUIRING PRIOR-AUTHORIZATION
Some medications require a prior authorization before they can be dispensed. Obtaining this authorization is necessary before the prescription can be paid for by the US Family Health Plan. Please refer to the formulary search tool to check that your medication requires prior authorization.
Call Member Services at 1-888-674-8734 or talk to your doctor for more information.
MEDICATIONS REQUIRING STEP THERAPY
Step therapy is used to provide safe, clinically effective, and cost-effective medication in drug categories that have multiple agents with comparable therapeutic effectiveness. Generic drugs are commonly used as the preferred medication due to their established safety and effectiveness for treating a given condition. This means that medications requiring step therapy are only covered if you have already tried certain medications and those did not work. Please refer to the formulary search tool to check if your medication requires step therapy. Call Member Services at 1-888-674-8734 or talk to your doctor for more information.
- Excluded drugs listed in the Noncovered Category
- Drugs prescribed for cosmetic purposes
- Fluoride preparations
- Food supplements
- Homeopathic and herbal preparations
- Multivitamins (some prenatal vitamins are covered with a prescription)
- Over-the-counter products (except insulin and diabetic supplies)
BENEFIT OVERVIEW
TRICARE Young Adult is a TRICARE Prime plan (HMO-type) plan that includes two benefit levels: In-Network and Point-of-Service.
The Point-of-Service benefit allows you greater flexibility in provider choice at added cost. While this benefit can give you greater freedom, it is important to understand what the added out-of-pocket costs will be before using this option. We recommend that you call Member Services to talk through options before seeking care from out-of-network providers.
The two benefit levels available under the US Family Health Plan are:
- IN-NETWORK: Members generally receive health care from one of the Plan’s contracted network providers—the doctors, health care providers, hospitals, and durable medical equipment (DME) vendors who have agreed to take care of our members at negotiated rates. This care is provided at no or very low costs to members with no deductibles.
- POINT-OF-SERVICE (POS): This benefit allows you the flexibility to choose to receive care from an out-of-network (TRICARE®-authorized) provider when the care is available from an in-network provider. You incur higher costs if you use the Point-of-Service option (see details below). When using the POS benefit, you do not need a referral from your primary care provider (PCP). We still strongly encourage you to get a referral from your PCP, as they know your health best and can help you choose the best specialist for your needs.
OUT-OF-NETWORK INFORMATION
When services are not available from an in-network provider and you are referred out of network, the referring provider may request an authorization for services to be covered at the in-network benefit level.
Out-of-network authorization requests are reviewed using the following criteria:
- During the authorization process, the plan will review medical criteria and policies to determine which benefit level is appropriate.
- If it is determined that the referred services are available from an in-network provider, your authorization request to see an out-of-network provider may be approved, but it will be at the Point-of-Service (more costly) benefit level.
YOUR COSTS UNDER POINT-OF-SERVICE BENEFIT
When using the Point-of-Service option to get care outside of the US Family Health Plan network, you pay a deductible of $300 per year for an individual or $600 per year for a family for outpatient services, and a cost share for inpatient and outpatient services of 50% of the TRICARE Maximum-Allowable Charge (TMAC).
In addition, you may be subject to “balance billing” by the provider. Members are responsible for paying these bills, which may be amounts up to 115% of the TMAC. Any amounts paid for services received through the Point-of-Service benefit are NOT applied to the “catastrophic cap,” which means there is no maximum limit to these charges. If the provider does not participate with Medicare or TRICARE, you might be responsible for the entire bill.
This Point-of-Service benefit does not apply to:
- Newborns and adopted children during the first 60 days after birth or adoption
- Urgent and emergency care
- Radiology
- Pathology
- Anesthesiology while inpatient
- If you have other health insurance
- Care being sought is not TRICARE benefit or is determined not to be medically necessary
- Zostavax vaccine
- Non-emergent ambulance
- Diagnostic services
- Diagnostic drugs
- Dialysis
- Sleep studies
Please note: This is not a comprehensive list; depending on billing, there may be other services that may or may not be covered under the Point of Service benefit. Some Durable Medical Equipment (DME) requires preauthorization by the US Family Health Plan, and not all durable medical equipment is covered under the Plan.
For the lowest out-of-pocket cost, you can find in-network providers on our online provider directory.
Call Member Services at 1-888-674-8734 to discuss specific questions you may have about the Point-of-Service option.
OVERVIEW
The US Family Health Plan covers outpatient and inpatient care related to the treatment of diagnosed mental health or substance abuse conditions. The Behavioral Health Care Program (BHCP) and its affiliated providers provide all mental health services to members of the US Family Health Plan.
Referrals are not required for mental health and substance abuse visits with a participating network provider. However, you must arrange for this care through the Behavioral Health Care Program.
A BHCP Customer Service Representative can be reached at all times by calling, toll-free, 1-888-812-7335.
Because the US Family Health Plan is based on the TRICARE Prime universal benefits, there are some limitations to the mental health and substance abuse benefits.
For additional information about the mental health benefit or to obtain names of participating network mental health professionals, please contact the Behavioral Health Care Program, toll-free, at 1-888-812-7335.
ADDITIONAL HELPFUL RESOURCES
Mental Health
Substance Abuse
US Family Health Plan members receive eyewear discounts up to 35% off retail prices through our partnership with EyeMed Vision Care.
Use this discount program to save on your purchase of a new set of glasses or on additional eye care services that are over and above your free annual routine eye exam provided through the US Family Health Plan.
How to Find Your Discount
2. Select Discount Plans
3. Find USFHP at Martin’s Point
4. Choose Access Network
5. Enter Plan ID: 3021937
Receive discounts of 10–30% off complementary and alternative medical treatments through our partnership with WholeHealth Living Choices through tivity health.
Access beneficial treatment options you may otherwise not be able to afford, or enjoy discounts on services you may already use such as:
- Acupuncture
- Chiropractic
- Massage Therapy
- Naturopathy
- Nutritional Counseling
- Tai Chi
- Yoga
See a list of participating providers.
NOTE: You will need to set up a user name and password to access the provider list. For assistance, please contact WholeHealth directly at 1-800-274-7526.
Members have access to substantial discounts on hearing aids and hearing aid batteries through our partnership with Amplifon.
The Amplifon program should be used only to purchase hearing aids and batteries.
Important note: Hearing tests and medical services should be through a US Family Health Plan network provider. Call Martin’s Point US Family Health Plan Member Services at 1-888-674-8734 for a network provider near you.
Talk to a trained nurse anytime, 24 hours a day, 7 days a week, to answer questions about symptoms, injuries, or illness.
Call 1-800-574-8494 and choose option #2 if you need to know:
- What to do about your child’s fever
- If a cut requires stitches
- If you should head to the ER or wait until morning to see your doctor
- General information about a condition, medication, or other health concerns
Submit your question online. Send a secure message to the nurses. You will have the option to either receive an email response (within 24 hours) or have a nurse call you back directly (within an hour).
Log in to send a message.
This service is provided by Carenet Healthcare Services in partnership with Martin's Point. This service is not intended to take the place of your primary care provider.
Get deals on monthly fees or enrollment fee waivers through our partnership with WholeHealth.
Offers vary by fitness center, and may include:
- 100% of the standard initiation fee may be waived (monthly fees still apply)
- 10–20% discount off the monthly membership fee
END OF COVERAGE INFORMATION
You may choose to end TYA coverage at any time by completing the fields related to terminating coverage on the TRICARE Young Adult Application and submitting it to Martin’s Point. If you decide to end TYA coverage, you will be locked out from purchasing TYA coverage for one year from the date of termination.
There will be no lockout if the coverage is terminated because you gain access to employer-sponsored coverage.
Nonpayment
Your premium payment is due no later than the last day of the month for the next month’s coverage. Failure to pay total premium amounts due and any insufficient fund fees owed will result in a termination of coverage. A 12-month TYA purchase lockout will go into effect.
Change in Status
Your TYA coverage ends when any of the following occurs. Your sponsor must always report all family and status changes to DEERS.
- You reach age 26
- You get married
- You become eligible for an employer-sponsored health plan as defined in TYA regulations
- You gain other TRICARE coverage
- You lose eligibility because your sponsor ends TRICARE coverage