45438 Federal Register / Vol. 82, No. 188 / Friday, September 29, 2017 / Rules and Regulations 

power and responsibilities between the 

Federal Government and Indian tribes. 

Regulatory Flexibility Act 

The Administrator, in accordance 

with the Regulatory Flexibility Act (5 

U.S.C. 601–612) (RFA), has reviewed 

this rule and by approving it certifies 

that it will not have a significant 

economic impact on a substantial 

number of small entities. The purpose of 

this rule is to remove naldemedine from 

the list of schedules of the CSA. This 

action removes regulatory controls and 

administrative, civil, and criminal 

sanctions applicable to controlled 

substances for handlers and proposed 

handlers of naldemedine. Accordingly, 

it has the potential for some economic 

impact in the form of cost savings. 

This rule will affect all persons who 

handle, or propose to handle, 

naldemedine. Due to the wide variety of 

unidentifiable and unquantifiable 

variables that potentially could 

influence handling of naldemedine, the 

DEA is unable to determine the number 

of entities and small entities which 

might handle naldemedine. However, 

the DEA estimates that all persons who 

handle, or propose to handle 

naldemedine, are currently registered 

with the DEA to handle controlled 

substances. Therefore, the 1.7 million 

(1,683,023 as of April 2017) controlled 

substance registrations, representing 

approximately 436,761 entities, would 

be the maximum number of entities 

affected by this rule. The DEA estimates 

that 425,856 (97.5%) of 436,761 affected 

entities are ‘‘small entities’’ in 

accordance with the RFA and Small 

Business Administration size standards. 

The DEA estimates all controlled 

substance registrants handle both 

controlled and non-controlled 

substances and these registrants are 

expected to continue to handle 

naldemedine. Additionally, since 

prospective naldemedine handlers are 

likely to handle other controlled 

substances, the cost benefits they would 

receive as a result of the de-control of 

naldemedine is minimal. As 

naldemedine handlers continue to 

handle other controlled substances, they 

will need to maintain their DEA 

registration and keep the same security 

and recordkeeping processes, 

equipment, and facilities in place and 

would experience only minimal 

reduction in security, inventory, 

recordkeeping, and labeling costs. 

Physical security control requirements 

are the same for controlled substances 

listed in schedules II, III, IV, and V for 

the vast majority of registrants 

(practitioners). 

While the DEA does not have a basis 

to estimate the number of affected 

entities, the DEA estimates that the 

maximum number of affected entities is 

436,761 of which 425,856 are estimated 

to be small entities. Since the affected 

entities are expected to handle other 

controlled substances and maintain 

security and recordkeeping facilities 

and processes consistent with 

controlled substances, the DEA 

estimates any economic impact will be 

minimal. Because of these facts, this 

rule will not have a significant 

economic impact on a substantial 

number of small entities. 

Unfunded Mandates Reform Act of 1995 

In accordance with the Unfunded 

Mandates Reform Act (UMRA) of 1995, 

2 U.S.C. 1501 et seq., the DEA has 

determined and certifies that this action 

would not result in any Federal 

mandate that may result ‘‘in the 

expenditure by State, local, and tribal 

governments, in the aggregate, or by the 

private sector, of $100,000,000 or more 

(adjusted for inflation) in any one year 

* * *.’’ Therefore, neither a Small 

Government Agency Plan nor any other 

action is required under UMRA of 1995. 

Paperwork Reduction Act 

This action does not impose a new 

collection of information requirement 

under the Paperwork Reduction Act, 44 

U.S.C. 3501–3521. This action would 

not impose recordkeeping or reporting 

requirements on State or local 

governments, individuals, businesses, or 

organizations. An agency may not 

conduct or sponsor, and a person is not 

required to respond to, a collection of 

information unless it displays a 

currently valid OMB control number. 

Congressional Review Act 

This rule is not a major rule as 

defined by section 804 of the Small 

Business Regulatory Enforcement 

Fairness Act of 1996 (Congressional 

Review Act (CRA)). This rule will not 

result in: An annual effect on the 

economy of $100,000,000 or more; a 

major increase in costs or prices for 

consumers, individual industries, 

Federal, State, or local government 

agencies, or geographic regions; or 

significant adverse effects on 

competition, employment, investment, 

productivity, innovation, or on the 

ability of United States-based 

enterprises to compete with foreign 

based enterprises in domestic and 

export markets. However, pursuant to 

the CRA, the DEA has submitted a copy 

of this final rule to both Houses of 

Congress and to the Comptroller 

General. 

List of Subjects in 21 CFR Part 1308 

Administrative practice and 

procedure, Drug traffic control, 

Reporting and recordkeeping 

requirements. 

For the reasons set out above, 21 CFR 

part 1308 is amended as follows: 

PART 1308—SCHEDULES OF 

CONTROLLED SUBSTANCES 

■ 1. The authority citation for 21 CFR 

part 1308 continues to read as follows: 

Authority: 21 U.S.C. 811, 812, 871(b), 

956(b), unless otherwise noted. 

■ 2. In § 1308.12, revise the introductory 

text of paragraph (b)(1) to read as 

follows: 

§ 1308.12 Schedule II. 

* * * * * 

(b) * * * 

(1) Opium and opiate, and any salt, 

compound, derivative, or preparation of 

opium or opiate excluding 

apomorphine, thebaine-derived 

butorphanol, dextrorphan, nalbuphine, 

naldemedine, nalmefene, naloxegol, 

naloxone, and naltrexone, and their 

respective salts, but including the 

following: 

* * * * * 

Dated: September 22, 2017. 

Chuck Rosenberg, 

Acting Administrator. 

[FR Doc. 2017–20919 Filed 9–28–17; 8:45 am] 

BILLING CODE 4410–09–P 

DEPARTMENT OF DEFENSE 

Office of the Secretary 

32 CFR Part 199 

[Docket ID: DOD–2017–HA–0039] 

RIN 0720–AB70 

Establishment of TRICARE Select and 

Other TRICARE Reforms 

AGENCY: Office of the Secretary, 

Department of Defense (DoD). 

ACTION: Interim final rule. 

SUMMARY: This interim final rule 

implements the primary features of 

section 701 and partially implements 

several other sections of the National 

Defense Authorization Act for Fiscal 

Year 2017 (NDAA–17). The law makes 

significant changes to the TRICARE 

program, especially to the health 

maintenance organization (HMO)-like 

health plan, known as TRICARE Prime; 

to the preferred provider organization 

(PPO) health plan, previously called 

TRICARE Extra which is to be replaced 


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Federal Register / Vol. 82, No. 188 / Friday, September 29, 2017 / Rules and Regulations 45439 

by TRICARE Select; and to the third 

health care option, known as TRICARE 

Standard, which will be terminated as 

of December 31, 2017, and also replaced 

by TRICARE Select. The statute also 

adopts a new health plan enrollment 

system under TRICARE and new 

provisions for access to care, high value 

services, preventive care, and healthy 

lifestyles. In implementing the statutory 

changes, this interim final rule makes a 

number of improvements to TRICARE. 

DATES: This interim final rule is 

effective October 1, 2017. Comments 

will be received by November 28, 2017. 

ADDRESSES: You may submit comments, 

identified by docket number and title, 

by any of the following methods: 

• Federal eRulemaking Portal: http:// 

www.regulations.gov. Follow the 

instructions for submitting comments. 

• Mail: Department of Defense, Office 

of the Deputy Chief Management 

Officer, Directorate for Oversight and 

Compliance, Regulatory and Advisory 

Committee Division, 4800 Mark Center 

Drive, Mailbox #24, Suite 08D09B, 

Alexandria, VA 22350–1700. 

Instructions: All submissions received 

must include the agency name, docket 

number, or title for this Federal Register 

document. The general policy for 

comments and other submissions from 

members of the public is to make these 

submissions available for public 

viewing on the Internet at http://

www.regulations.gov as they are 

received without change, including any 

personal identifiers or contact 

information. 

FOR FURTHER INFORMATION CONTACT: Mr. 

Mark Ellis, Defense Health Agency, 

TRICARE Health Plan, (703) 681–0063. 

SUPPLEMENTARY INFORMATION: 

I. Executive Summary 

A. Purpose of the Interim Final Rule 

In implementing section 701 and 

partially implementing several other 

sections of NDAA–17, this interim final 

rule advances all four components of 

the Military Health System’s quadruple 

aim of improved readiness, better care, 

better health, and lower cost. The aim 

of improved readiness is served by 

reinforcing the vital role of the 

TRICARE Prime health plan to refer 

patients, particularly those needing 

specialty care, to military medical 

treatment facilities (MTFs) in order to 

ensure that military health care 

providers maintain clinical currency 

and proficiency in their professional 

fields. The objective of better care is 

enhanced by a number of improvements 

in beneficiary access to health care 

services, including increased 

geographical coverage for the TRICARE 

Select provider network, reduced 

administrative hurdles for TRICARE 

Prime enrollees to obtain urgent care 

services and specialty care referrals, and 

promotion of high value services and 

medications. The goal of better health is 

advanced by expanding TRICARE 

coverage of preventive care services, 

treatment of obesity, high-value care, 

and telehealth. And the aim of lower 

cost is furthered by refining cost-benefit 

assessments for TRICARE plan 

specifications that remain under DoD’s 

discretion and adding flexibilities to 

incentivize high-value health care 

services. 

B. Legal Authority for the Regulatory 

Action 

This interim final rule is required to 

implement or partially implement 

several sections of NDAA–17, including 

701, 706, 715, 718, and 729. The legal 

authority for this rule also includes 

chapter 55 of title 10, United States 

Code. 

C. Summary of Major Provisions of the 

Interim Final Rule 

The major provisions of the interim 

final rule are: 

➢ The establishment of TRICARE 

Select as a self-managed, PPO option 

under the TRICARE program. TRICARE 

Select replaces the TRICARE Extra and 

Standard programs and adopts a number 

of improvements, including fixed 

copayments rather than cost shares for 

covered benefits provided by a civilian 

network provider. TRICARE Select 

beneficiaries can choose any provider 

for their healthcare; however, they will 

enjoy lower out-of-pocket costs if they 

choose preferred providers within the 

TRICARE civilian network. 

➢ The continuation of TRICARE 

Prime as a managed care, HMO-like 

option under the TRICARE program. 

TRICARE Prime adopts a number of 

changes to conform to specifications in 

the new law, including categories of 

health care services applicable to the 

determination of copayment amounts 

(such as primary care, specialty care, 

emergency care). 

➢ Improved access to care, including 

a codified requirement that the 

TRICARE Select health care plan is 

available in all locations and at least 

85% of the U.S. beneficiary TRICARE 

Select population is covered by the 

TRICARE network. Also, for TRICARE 

Prime enrollees, there are new 

procedures to ensure timely 

appointments for health care services 

and to authorize some or all urgent care 

visits without the need for referral from 

a primary care manager. 

➢ Promotion of high value services 

and medications, telehealth services, 

preventive health care, and healthy 

lifestyles. 

➢ A new design for the health care 

enrollment system, including 

mandatory enrollment to maintain 

TRICARE coverage, an annual open 

season enrollment period, and hasslefree enrollment procedures. 

➢ Other features include preservation 

of benefits for active duty dependents 

and TRICARE-for-Life beneficiaries, and 

changes to the TRICARE Young Adult 

(TYA), TRICARE Reserve Select (TRS), 

TRICARE Retired Reserve (TRR), 

Continued Health Care Benefit Program 

(CHCBP), and TRICARE Retiree Dental 

Program (TRDP) to conform with new 

statutory requirements. 

II. Provisions of Interim Final Rule 

A. Establishment of TRICARE Select 

The rule implements the new law 

(section 701 of NDAA–17) that 

establishes TRICARE Select as a selfmanaged, PPO program. It allows 

beneficiaries to use the TRICARE 

civilian provider network, with reduced 

out-of-pocket costs compared to care 

from non-network providers, as well as 

military treatment facilities (when space 

is available). Similar to the longoperating ‘‘TRICARE Extra’’ and 

‘‘TRICARE Standard’’ plans, which 

TRICARE Select replaces, a major 

feature is that enrollees will not have 

restrictions on their freedom of choice 

with respect to health care providers. 

TRICARE Select is based primarily on 

10 U.S.C. 1075 (as added by section 701 

of NDAA–17) and 10 U.S.C. 1097. With 

respect to beneficiary cost sharing, the 

statute introduces a new split of 

beneficiaries into two groups: One 

group (which the rule refers to as 

‘‘Group A’’) consists of sponsors and 

their family members who first became 

affiliated with the military through 

enlistment or appointment before 

January 1, 2018, and the second group 

(referred to as ‘‘Group B’’) who first 

became affiliated on or after January 1, 

2018. In general, beneficiary out-ofpocket costs for Group B are higher than 

for Group A. 

In addition to implementing the 

statutory specifications, the interim 

final rule also makes improvements for 

TRICARE Select Group A enrollees, 

compared to the features of the old 

TRICARE Extra plan. One such 

improvement is to convert the current 

cost-sharing requirement of 15% for 

active duty family members and 20% 

for retirees and their family members of 

the allowable charge for care from a 

network provider to a fixed dollar 


asabaliauskas on DSKBBXCHB2PROD with RULES
45440 Federal Register / Vol. 82, No. 188 / Friday, September 29, 2017 / Rules and Regulations 

1Congressional Budget Office Cost Estimate, S. 

2943, National Defense Authorization Act for Fiscal 

Year 2017, June 10, 2016, page 17. 

copayment calculated to approximately 

equal 15% or 20% of the average 

allowable charge for the category of care 

involved. Consistent with prevailing 

private sector health program practices, 

the fixed dollar copayment is more 

predictable for the patient and easier for 

the network health care provider to 

administer. The breakdown of categories 

of care (such as outpatient primary care 

visit, specialty care visit, emergency 

room visit, etc.) contained in the rule is 

the same as the categories now specified 

in the statute for Group B Select 

enrollees. 

A second improvement in TRICARE 

Select (for both Group A and Group B) 

is that additional preventive care 

services that previously were only 

offered to TRICARE Prime beneficiaries 

will now (under the authority of 10 

U.S.C. 1097 and NDAA–17) also be 

covered for Select enrollees when 

furnished by a network health care 

provider. These are services 

recommended by the United States 

Preventive Services Task Force and the 

Health Resources and Services 

Administration of the Department of 

Health and Human Services. 

These improvements are based partly 

on the statutory provision (10 U.S.C. 

1075(c)(2)) that Group A Select enrollee 

cost-sharing requirements are calculated 

as if TRICARE Extra were still being 

carried out by DoD. TRICARE Extra 

specifications are based on the 

underlying authority of 10 U.S.C. 1097, 

which allows DoD to adopt special rules 

for the PPO plan. This statute was the 

basis for the original set of rules for 

TRICARE Extra, which were adopted in 

1995, and is the authority for these 

improved rules for TRICARE Select 

Group A, adopted as if TRICARE Extra 

were still being carried out by DoD. 

Under the interim final rule, the cost 

sharing rules applicable to TRICARE 

Select Group B are those specified in 10 

U.S.C. 1075. For TRICARE Select Group 

A, in addition to the copayment rules 

noted above, consistent with 10 U.S.C. 

1075, an enrollment fee of $150 per 

person or $300 per family will begin 

January 1, 2021, for most retiree 

families, with annual updates thereafter 

based on the cost of living adjustment 

(COLA) applied to retired pay. At the 

same time, the catastrophic cap will 

increase from $3,000 to $3,500 for these 

retiree families. These changes, 

however, will not apply to TRICARE 

Select Group A active duty families, 

survivors of members who died while 

on active duty, or disability retiree 

families; that is, no enrollment fee will 

be applicable to this group and the 

applicable catastrophic cap will 

continue to be $1,000 for active duty 

families as established under 10 U.S.C. 

1079(b) and $3,000 for survivors of 

members who died while on active duty 

or disability retiree families as 

established under 10 U.S.C. 1086(b). 

B. Continuation of TRICARE Prime 

A second major feature of this interim 

final rule, based primarily on 10 U.S.C. 

1075a (also added by section 701 of 

NDAA–17), is the continuation of 

TRICARE Prime as a managed care, 

HMO-like program. It generally features 

use of military treatment facilities 

(MTFs) and substantially reduced outof-pocket costs for authorized care 

provided outside MTFs. Beneficiaries 

generally agree to use military treatment 

facilities and designated civilian 

provider networks and to follow certain 

managed care rules and procedures. 

Like with TRICARE Select, with respect 

to beneficiary cost sharing, the statute 

introduces a new split of beneficiaries 

into two groups (again referred to in the 

rule as Group A and Group B) based on 

the military sponsor’s initial enlistment 

or appointment before January 1, 2018 

(Group A), or on or after that date 

(Group B). Beneficiary cost sharing for 

Group B is slightly higher than for 

Group A. 

As with TRICARE Select, the cost 

sharing specifications for TRICARE 

Prime Group B are set forth in the 

statute, and those for Group A are 

calculated in accordance with other 

health care provisions of title 10 (rather 

than the new section 1075a). The 

primary original statutory authority for 

the TRICARE Prime health plan, 

established by DoD regulation in 1995, 

was 10 U.S.C. 1097, and this continues 

to be relied upon for the continued 

operation of TRICARE Prime for Group 

A. Also relevant to the original terms of 

TRICARE Prime was section 731 of the 

National Defense Authorization Act for 

Fiscal Year 1994. That law required DoD 

to include, to the maximum extent 

practicable, the HMO-like option under 

TRICARE. That law also required that 

the HMO-like option ‘‘shall be 

administered so that the costs incurred 

by the Secretary under the TRICARE 

program are no greater than the costs 

that would otherwise be incurred’’, to 

provide health care to beneficiaries. The 

extent to which this ‘‘cost neutrality’’ 

requirement has not been maintained 

was recently highlighted by the 

Congressional Budget Office: ‘‘CBO 

estimates that under current law, a 

typical retiree household enrolled in 

TRICARE Prime as a ‘family’ in 2018, 

and for whom TRICARE is the primary 

payer of health benefits, will cost DoD 

about $17,400, and a typical family that 

uses Standard/Extra will cost DoD about 

$12,700.’’ 1

Based on the TRICARE Prime cost 

neutrality provision in NDAA–1994, the 

original 1995 TRICARE Prime regulation 

included (at 32 CFR 199.18(g)) that cost 

sharing requirements ‘‘may be updated 

for subsequent years to the extent 

necessary to maintain compliance with 

statutory requirements pertaining to 

government costs.’’ Since NDAA–1994, 

Congress took away DoD’s discretion for 

enrollment fee increases, which are now 

tied by law to the retired pay COLA. 

However, DoD continues to have 

discretion to update copayment 

amounts—which have not changed 

since 1995—and this discretion is 

confirmed by the newly enacted 10 

U.S.C. 1075a(a)(3). 

This discretion to update copayment 

amounts is continued in the interim 

final rule, but the framework for setting 

Prime Group A copayment amounts is 

being revised. Specifically, DoD is 

adopting for Group A the same structure 

of categories of care that Congress 

adopted for Group B. Thus, for example, 

while the current TRICARE Prime 

copayment amount makes no 

distinction between primary care and 

specialty care services, the new Group 

B structure under the statute does have 

a different copayment for primary care 

and specialty care. Under the rule, 

copayment amounts for Group A 

beneficiaries will be set for each of those 

categories, as well as the other 

categories of care the statute now 

specifies for Group B enrollees. The 

interim final rule does not specify the 

amount for each category of care. 

Rather, consistent with DoD’s discretion 

under current statute and regulation, the 

actual amount will be set each year 

prior to open season enrollment. The 

interim final rule does, however, specify 

that the amount for each category of care 

for Group A enrollees may not exceed 

the amount that Congress set for Group 

B enrollees. In this way, the Prime 

copay structure would be in alignment 

with proposed legislative changes 

recommended by the Department to 

Congress for enactment this year to 

eliminate the ‘‘grandfathering’’ of Group 

A retiree families and return to a single 

TRICARE Prime model for all workingage retiree families. Again, it should be 

noted that this applies only to perservice copayments; enrollment fee 

increases for Group A enrollees will 

continue to be based on the retired pay 

COLA. 


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Federal Register / Vol. 82, No. 188 / Friday, September 29, 2017 / Rules and Regulations 45441 

The interim final rule also continues 

the point-of-service provision of the 

current TRICARE Prime plan. Any 

health care services obtained by a Prime 

enrollee not in accordance with the 

rules and procedures of Prime (e.g. 

failure to obtain a primary care manager 

referral when such a referral is required 

or seeing a non-network provider when 

a network provider is available) will not 

be paid for under Prime rules, but may 

be covered by the point-of-service 

option. This results in higher cost 

sharing—specifically, a deductible of 

$300 per person and $600 per family, 

and a copayment of 50 percent of the 

allowable charges after the deductible. 

Point-of-service charges do not count 

against the annual catastrophic cap. 

These point-of-service rules continue for 

TRICARE Prime Group A and are also 

applicable to Group B. For Group B, the 

rules for point-of-service charges are 

specified in 10 U.S.C. 1075a(c), which 

clarifies that point-of-service cost 

sharing is ‘‘notwithstanding’’ the usual 

cost sharing rules of Prime Group B 

enrollees. 

One other matter on which the 

interim final rule preserves DoD 

discretion, similar to that in the current 

regulation, is with respect to the 

locations where TRICARE Prime is 

offered. This is noted in the current 

regulation at 32 CFR 199.17(a)(5). Under 

the interim final rule, the locations 

where TRICARE Prime will be offered 

will be determined by the Director, 

Defense Health Agency (DHA) and 

announced prior to the annual open 

season enrollment period. The guiding 

principle for this decision is that the 

purpose of TRICARE Prime is to support 

the medical readiness of the armed 

forces and the readiness of medical 

personnel. Codification in regulation of 

this guiding principle is a corollary to 

the codification by Congress in statute, 

specifically sections 703 and 725 of 

NDAA–17 that MTFs exist to support 

the medical readiness of the armed 

forces and the readiness of medical 

personnel. 

TRICARE Prime, especially for 

working age retirees and family 

members, provides MTFs clinical 

workload, including for a range of 

medical specialty areas that permit 

military health care providers to 

maintain currency and proficiency in 

their respective clinical fields. This 

important support of a ready medical 

force is what justifies the higher 

government cost of Prime (which CBO 

estimates at $17,400 per retiree family), 

notwithstanding the original statutory 

requirement of cost neutrality between 

TRICARE Prime and TRICARE 

Standard. This cost-benefit assessment 

supports the conclusion that it is 

practicable to offer TRICARE Prime in 

areas where it supports the medical 

readiness of one or more MTFs. 

Additionally, where TRICARE Prime is 

offered, it may be limited to active duty 

family members if the Director, DHA 

determines it is not practicable to offer 

TRICARE Prime to retired beneficiaries 

as well—a determination that again 

would take into account the nature of 

the supported MTF and the range of 

services it offers. 

C. Improved Access to Care 

A third significant change in the 

interim final rule is a set of 

improvements in standards for access to 

care. The TRICARE Select plan replaces 

TRICARE Standard as the generally 

applicable plan in all areas. Under 

TRICARE Select, eligible beneficiaries 

can choose any provider for their 

healthcare, and they will enjoy lower 

out-of-pocket costs if they choose 

providers within the TRICARE civilian 

network. The vast majority of TRICARE 

beneficiaries located in the United 

States will have access to TRICARE 

network providers (it is DoD’s plan that 

at least 85% of the U.S. beneficiary 

population under TRICARE Select will 

be covered by the network upon 

implementation), similar to the current 

TRICARE Extra option, but with the 

benefit of predictable fixed dollar 

copayments. In cases in which a 

network provider is not available to a 

TRICARE Select enrollee, such as in 

remote locations where there are very 

few primary or specialty providers, 

enrollees will still have access to any 

TRICARE authorized provider, with cost 

sharing comparable to the current 

TRICARE Standard plan (i.e. 25% for 

retired category beneficiaries). 

A second interim final rule 

enhancement for access to care is that if 

a TRICARE Prime enrollee seeks to 

obtain an appointment for care from the 

managed care support contractor but is 

not offered an appointment within the 

applicable access time standards from a 

network provider, the enrollee will be 

authorized to receive care from any 

authorized provider without incurring 

the additional fees associated with 

point-of-service care. 

A third access to care improvement 

under the interim final rule is that the 

TRICARE Prime referral requirement 

may be waived for urgent care visits for 

Prime enrollees other than active duty 

members. This is similar to the current 

pilot program, which waives the referral 

requirement (other than for active duty 

members) for up to two urgent care 

visits per year. The specific number of 

urgent care visits without a referral will 

be determined annually prior to the 

beginning of the open season enrollment 

period. 

A fourth access to care improvement 

is adoption of the new statutory 

provision that a primary care manager 

who believes a referral to a specialty 

care network provider is medically 

necessary and appropriate need not 

obtain pre-authorization from the 

managed care support contractor. 

Managed care support contractor 

preauthorization is only required with 

respect to a primary care manager’s 

referral for inpatient hospitalization, 

inpatient care at a skilled nursing 

facility, inpatient care at a residential 

treatment center and inpatient care at a 

rehabilitation facility. 

D. Promotion of High Value Services 

and Medications and Telehealth 

Services 

In addition to the expansion noted 

above concerning preventive care 

services, the interim final rule makes a 

number of other improvements in 

TRICARE Prime and TRICARE Select 

based on provisions of sections 701(h), 

706, 718, and 729 of NDAA–17. Section 

701(h), among other things, provides for 

a four-year pilot program to encourage 

use by patients of high value services 

and medications. Section 706, among 

other things, authorizes special 

arrangements with provider groups that 

will improve population-based health 

outcomes and focus more on preventive 

care. Section 729 calls for special 

actions to incentivize medical 

intervention programs to address 

chronic diseases and other conditions 

and healthy lifestyle interventions. 

Section 718, among other things, 

requires actions to promote greater use 

of telehealth services under TRICARE. 

While these sections of NDAA–17 also 

require actions outside the scope of this 

interim final rule (such as contracting 

actions) they can be partially 

implemented, consistent with 

Congressional intent, in this rule. The 

interim final rule does this in several 

ways. 

First, the interim final rule authorizes 

coverage under TRICARE Prime and 

TRICARE Select for medically necessary 

treatment of obesity even if it is the sole 

or major condition treated. Under 10 

U.S.C. 1079(a)(10), this is disallowed 

under the basic program. However, it is 

DoD’s conclusion that the underlying 

authority of 10 U.S.C. 1097, together 

with section 729 of NDAA–17 (which 

specifically authorizes medical 

intervention for obesity), allow the 

Department to cover these services 

when provided by a network provider 


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45442 Federal Register / Vol. 82, No. 188 / Friday, September 29, 2017 / Rules and Regulations 

for a TRICARE Prime or TRICARE Select 

enrollee. 

Second, the interim final rule codifies 

authority of the Director, DHA to waive 

or reduce copayment requirements for 

TRICARE Prime and TRICARE Select 

enrollees for care received from network 

providers for certain health care services 

that provide especially high value in 

terms of better health outcomes for 

patients. Authority for this includes 

section 706 and 729 of NDAA–17. This 

is also consistent with the four-year 

pilot program authority of section 

701(h), but does not necessarily rely on 

that time-limited authority. Consistent 

with the intent of these sections, the 

Department also intends to use the 

authority of § 199.21(j)(3) of the 

TRICARE Pharmacy Benefits Program 

section of the TRICARE regulations to 

encourage use of high value medications 

by reducing or eliminating the 

copayment of selected medicines. 

Third, consistent with section 718 of 

NDAA–17, the interim final rule 

provides that health care services 

covered by TRICARE and provided 

through the use of telehealth modalities 

are covered services to the same extent 

as if provided in person at the location 

of the patient if those services are 

medically necessary and appropriate for 

such modalities. The Director, DHA will 

establish standardized payment 

methods to reimburse for such services, 

and shall reduce or eliminate, as 

appropriate, beneficiary copayments or 

cost-shares for such services in cases in 

which a copayment would otherwise 

apply. This may be done by designating 

some telehealth services as high value 

services for which lower copays apply 

as well as the elimination of any 

beneficiary cost-sharing related to 

originating site fees when used to 

support the provision of telehealth 

services. 

E. Changes to Health Plan Enrollment 

System 

A fourth major change in the interim 

final rule is its implementation of the 

new statutory design for the health care 

enrollment system. Starting in calendar 

year 2018, beneficiaries other than 

active duty members and TRICARE-forLife beneficiaries must elect to enroll in 

TRICARE Select or TRICARE Prime in 

order to be covered by the private sector 

care portion of TRICARE. While 

TRICARE-for-Life beneficiaries under 

the age of 65 are permitted to enroll in 

TRICARE Prime under limited 

circumstances, their failure to enroll 

will not affect their coverage by the 

private sector care portion of TRICARE. 

Enrollment will be done during an open 

season period prior to the beginning of 

each plan year, which operates with the 

calendar year. An enrollment choice 

will be effective for the plan year. As an 

exception to the open season enrollment 

rule, enrollment changes can be made 

during the plan year for certain 

qualifying events, such as a change in 

eligibility status, marriage, divorce, 

birth of a new family member, 

relocation, loss of other health 

insurance, or other events. 

Eligible Prime or Select beneficiaries 

who do not enroll will no longer have 

private sector care coverage under the 

TRICARE program (including the 

TRICARE retail pharmacy and mail 

order pharmacy programs) until the next 

open enrollment season or they have a 

qualifying event, except that they do not 

lose any statutory eligibility for spaceavailable care in military medical 

treatment facilities. There is a limited 

grace period exception to this 

enrollment requirement for calendar 

year 2018, as provided in section 

701(d)(3) of NDAA–17, to give 

beneficiaries another chance to adjust to 

this new requirement for annual 

enrollment. For the administrative 

convenience of beneficiaries, there are 

also procedures for automatic 

enrollment in Prime and Select for most 

active duty family members, and 

automatic renewal of enrollments of 

covered beneficiaries, subject to the 

opportunity to decline or cancel. 

Due to a compressed implementation 

schedule that precludes an annual open 

season enrollment period in calendar 

year 2017 for existing TRICARE 

beneficiaries to elect or change their 

TRICARE coverage, the Department will 

convert existing TRICARE Standard 

coverage to TRICARE Select coverage 

effective January 1, 2018. All other 

existing TRICARE coverages will be 

renewed effective January 1, 2018. As 

noted previously, beneficiaries may 

elect to change their TRICARE coverage 

anytime during the limited grace period 

in calendar year 2018. 

F. Additional Provisions of Interim Final 

Rule 

The interim final rule has several 

other noteworthy provisions. First, there 

are no changes in benefits for TRICAREfor-Life beneficiaries, or generally in 

cost sharing levels for active duty family 

members. Second, although ‘‘TRICARE 

Standard’’ is terminated as a distinct 

TRICARE plan as of December 31, 2017, 

basic program benefits (as established 

under 32 CFR 199.4) continue under 

both TRICARE Prime and TRICARE 

Select. In addition, when a TRICARE 

Select beneficiary receives services 

covered by the basic program benefits 

from an authorized health care provider 

who is not part of the TRICARE 

provider network, that care is covered 

by TRICARE as ‘‘out-of-network’’ care 

under terms that match the old 

TRICARE Standard plan. Third, in order 

to transition enrollment fees, 

deductibles, and catastrophic caps from 

a fiscal year basis to a calendar year 

basis, special rules apply for the last 

quarter of calendar year 2017, including 

that a Prime enrollee’s enrollment fee 

for the quarter is one-fourth of the 

enrollment fee for fiscal year 2017, and 

the deductible amount and the 

catastrophic cap amount for fiscal year 

2017 will be applicable to the 15-month 

period of October 1, 2016, through 

December 31, 2017. A similar transition 

rule will apply to TRICARE for Life, 

TYA, TRR and TRS to align remaining 

program deductibles and/or catastrophic 

caps from a fiscal year to calendar year 

basis for consistency and ease of 

administration. 

Additionally, the interim final rule 

adopts several changes to regulatory 

provisions applicable to the TYA, TRS, 

TRR, and TRDP programs to conform 

with new statutory requirements. In 

implementing section 701(a) of NDAA– 

17, together with section 701(j)(1)(F), 

the rule conforms the TYA regulation to 

the statutory language which 

established the eligibility of TYA under 

10 U.S.C. 1110b to enroll in TRICARE 

Select and provided that the TYA 

premium shall apply instead of the 

otherwise applicable TRICARE Prime or 

Select enrollment fee. In implementing 

section 701(j)(1)(B), the rule conforms 

the TRICARE Reserve Select plan 

regulation to the statutory language 

which defines ‘‘TRICARE Reserve 

Select’’ as the TRICARE Select selfmanaged, preferred-provider network 

option under 10 U.S.C. 1075 made 

available to beneficiaries under 10 

U.S.C. 1076d and requires payment of a 

premium for coverage instead of the 

TRICARE Select enrollment fee. In 

implementing section 701(j)(1)(C), the 

rule conforms the TRICARE Retired 

Reserve plan regulation to the statutory 

language which defines ‘‘TRICARE 

Retired Reserve’’ as the TRICARE Select 

self-managed, preferred-provider 

network option under 10 U.S.C. 1075 

made available to beneficiaries under 10 

U.S.C. 1076e and requires payment of a 

premium for coverage instead of the 

TRICARE Select enrollment fee. In 

implementing section 701(a) and 701(e), 

the rule conforms the CHCBP regulation 

to replace TRICARE Standard with 

TRICARE Select as the continuation 

health care benefit for Department of 

Defense and the other uniformed 

services beneficiaries losing eligibility. 


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Federal Register / Vol. 82, No. 188 / Friday, September 29, 2017 / Rules and Regulations 45443 

In implementing section 715, the rule 

conforms the TRDP regulation to the 

statutory language which authorizes an 

interagency agreement between the 

Department of Defense and the Office of 

Personnel Management to allow 

beneficiaries otherwise eligible for the 

TRDP to enroll in a dental insurance 

plan offered under the Federal 

Employees Dental and Vision Insurance 

Program. Under the statute, TRDP 

beneficiaries will have the opportunity 

to access a dental plan with 

significantly higher annual maximum 

benefit and a lower premium cost than 

available under the current TRDP, while 

giving the Department an opportunity to 

eliminate costs associated with 

procuring and administering a separate 

TRDP contract. 

Also, the interim final rule adopts 

several changes to regulatory provisions 

applicable to benefit coverage of 

medically necessary food and vitamins. 

Section 714 of NDAA–17 confirms longstanding TRICARE policy authorizing 

benefit coverage of medically necessary 

vitamins when prescribed for 

management of a covered disease or 

condition. In addition, while section 

714 confirms long-standing TRICARE 

policy authorizing medical nutritional 

therapy coverage of medically necessary 

food and medical equipment/supplies 

necessary to administer such food when 

prescribed for dietary management of a 

covered disease or condition, the law 

also allows the medically necessary 

food benefit to include coverage of low 

protein modified foods. Consistent with 

this we also recognize the role of 

Nutritionists and Registered Dieticians 

in the appropriate planning for the use 

of medically necessary foods. 

Additionally, the interim final rule 

adopts several conforming changes to 

regulatory provisions applicable to 

general TRICARE administration, the 

TRICARE Pharmacy Benefits Program 

and the Extended Health Care Option to 

reflect transition of deductibles, 

catastrophic caps, and program 

reimbursement limitations, as 

applicable, from a fiscal year basis to a 

calendar year basis for consistency and 

ease of administration. Simultaneously, 

technical corrections are being made to 

the TRICARE Pharmacy Benefits 

Program to conform regulation 

provisions to statutory provisions 

enacted by section 702 of the National 

Defense Authorization Act for Fiscal 

Year 2016. 

Finally, the interim final rule includes 

authority for the Director, DHA to 

establish preferred provider networks in 

areas outside the United States where it 

is determined to be economically in the 

best interests of the Department of 

Defense. As a result of the TRICARE 

Philippines Demonstration Project, 

which commenced in January 1, 2013, 

the Department has determined that the 

TRICARE contracted preferred provider 

network established in designated 

locations in the Philippines provided 

adequate access to beneficiaries with 97 

percent of care delivered by network 

providers. It also successfully achieved 

the demonstration goals of reducing 

aberrant billing activities, reduced outof-pocket expenses for beneficiaries, and 

increased overall beneficiary 

satisfaction while leading to a net 

savings to the government. Although the 

demonstration was projected to 

continue through December 31, 2018, 

the Philippines preferred provider 

network is determined to be 

economically in the interests of the 

Department of Defense and the 

demonstration shall terminate effective 

December 31, 2017, with transition of 

the demonstration’s approved preferred 

provider network to a TRICARE Select 

preferred provider network effective 

January 1, 2018. 

G. Recap: Cost Sharing Tables 

The following two tables summarize 

beneficiary fees (including enrollment 

fees, deductibles, cost sharing amounts, 

and catastrophic loss protection limits) 

under TRICARE Select and TRICARE 

Prime for calendar year 2018. For future 

calendar years, all fees are subject to 

review and annual updating in 

accordance with sections 1075, 1075a, 

and 1097 of title 10, United States Code. 

Table 1 is for active duty family 

members (ADFMs); Table 2 is for retiree 

families. As a guide for understanding 

the tables: 

➢ For services listed as ‘‘to be 

determined (TBD)’’, the Director, DHA 

will ensure the applicable fee for 

calendar year 2018 will be available at 

www.health.mil/rates before December 

1, 2017. 

➢ For services not specifically 

addressed in these tables, applicable 

cost-sharing requirements shall be 

established by the Director, DHA and 

published annually. 

➢ For services designated as ‘‘IN’’, the 

listed fee is for covered services or 

supplies obtained ‘‘in-network,’’ 

meaning received from TRICARE 

authorized network providers. 

➢ For TRICARE Prime beneficiaries, 

if covered services or supplies are not 

obtained in accordance with the rules 

and procedures of Prime (e.g., failure to 

obtain a required referral or 

unauthorized use of a non-network 

provider), the services or supplies will 

be reimbursed under a point-of-service 

option for which there is a deductible of 

$300 per person or $600 per family and 

a cost share of 50 percent of the 

allowable charges after the deductible. 

➢ For services designated as ‘‘OON’’, 

the listed fee for TRICARE Select 

beneficiaries is for covered services or 

supplies obtained ‘‘out-of-network’’, 

meaning received from non-network 

TRICARE authorized providers. 

➢ Certain preventive services have no 

cost sharing whether received from 

network or non-network providers. 

However, certain preventive services are 

not covered services for TRICARE Prime 

or Select beneficiaries unless obtained 

from network providers. Additionally, 

TRICARE Prime beneficiaries are 

required to obtain services in 

accordance with the rules and 

procedures of Prime to avoid point-ofservice charges. 

➢ Enrollment fees and deductibles 

are listed in the tables as individual/ 

family, indicating the dollar amounts 

applicable per individual or per family. 

➢ The criteria for fees associated with 

High Value Primary Care Outpatient 

Care and High Value Specialty 

Outpatient Care are under development 

but will be designed to encourage 

beneficiaries to receive health care 

services from high-value providers as 

highlighted in the contractor’s network 

provider directory. When finalized, the 

fees will be made available at 

www.health.mil/rates. 

➢ Inpatient subsistence refers to the 

rate charged for inpatient care obtained 

in a military treatment facility. 

➢ ‘‘COLA’’ is the cost-of-living 

adjustment for retired pay under 10 

U.S.C. 1401a by which certain fees are 

required to be annually indexed. 

➢ ‘‘<’’ means less than; ≤ means less 

than or equal to. 


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45444 Federal Register / Vol. 82, No. 188 / Friday, September 29, 2017 / Rules and Regulations 

TABLE 1—TRICARE SELECT AND TRICARE PRIME COST SHARING FOR ACTIVE DUTY FAMILY MEMBERS

FOR CALENDAR YEAR 2018 

Select Group A ADFMs Select Group B ADFMs Prime Group A ADFMs Prime Group B ADFMs 

Annual Enrollment ................... $0 ............................................. $0 ............................................. $0 $0 

Annual Deductible .................... E1–E4: $50/$100; E5 & above: 

$150/$300.

E1–E4: $50/$100; E5 & above: 

$150/$300.

0 0 

Annual Catastrophic Cap ......... $1,000 ...................................... $1,000 ...................................... 1,000 1,000 

Preventive Care Outpatient 

Visit.

$0 ............................................. $0 ............................................. 0 0 

Primary Care Outpatient Visit .. Fixed fee to = 15% of average 

allowable amount IN; 20% 

OON.

$15 primary care IN; 20% 

OON.

0 0 

Specialty Care Outpatient Visit Fixed fee to = 15% of average 

allowable amount IN; 20% 

OON.

$25 specialty care IN; 20% 

OON.

0 0 

High-Value Primary Care Outpatient Visit.Under Development; Less than 

normal primary care amount.

Under Development; Less than 

normal primary care amount.

0 0 

High-Value Specialty Care 

Outpatient Visit.

Under Development; Less than 

normal primary care amount.

Under Development; Less than 

normal primary care amount.

0 0 

Emergency Room Visit ............ Fixed fee to = 15% of average 

allowable amount IN; 20% 

OON.

$40 IN; 20% OON ................... 0 0 

Urgent Care Center ................. Same as primary care outpatient amount IN; 20% 

OON.

$20 IN; 20% OON ................... 0 0 

Ambulatory Surgery ................. $25 ........................................... $25 IN; 20% OON ................... 0 0 

Ambulance Service (not including air).Fixed fee to = 15% of average 

allowable amount IN; 20% 

OON.

$15 IN; 20% OON ................... 0 0 

Durable Medical Equipment .... 15% IN; 20% OON .................. 10% IN; 20% OON .................. 0 0 

Inpatient Hospital Admission ... Subsistence charge/day, minimum $25/admission.$60/admission IN; 20% OON .. 0 0 

Inpatient Skilled Nursing/ 

Rehab Facility.

Subsistence charge/day, minimum $25/admission.$25/day IN; $50/day OON ....... 0 0 

TABLE 2—TRICARE SELECT AND TRICARE PRIME COST SHARING FOR RETIREE FAMILIES FOR CALENDAR YEAR 2018 

Select Group A Retirees Select Group B Retirees Prime Group A Retirees Prime Group B Retirees 

Annual Enrollment ................... $0 until 2021; $150/$300 in 

2021 +COLA? 

$450/$900 ................................ FY17 amount ($282.60/ 

$565.20) +COLA.

$350/$700. 

Annual Deductible .................... $150/$300 ................................ $150/$300 IN; $300/$600 OON $0 ............................................. $0. 

Annual Catastrophic Cap ......... $3,000 until 2021; $3,500 in 

2021.

$3,500 ...................................... $3,000 ...................................... $3,500. 

Preventive Care Visit ............... $0 ............................................. $0 ............................................. $0 ............................................. $0. 

Primary Care Outpatient Visit .. Fixed fee that = 20% of average allowable amount IN; 

25% OON.

$25 primary IN; 25% OON ...... TBD, ≤$20 primary .................. $20 primary. 

Specialty Care Outpatient Visit Fixed fee that = 20% of average allowable amount IN; 

25% OON.

$40 specialty IN; 25% OON .... TBD, ≤$30 specialty ................ $30 specialty. 

High Value Primary Care OP 

Visit.

Under Development; <normal 

primary care amount.

Under Development; <normal 

primary care amount.

Under Development; <normal 

primary care amount.

Under Development; <normal 

primary care amount. 

High Value Specialty Care OP 

Visit.

Under Development; <normal 

specialty care amount.

Under Development; <normal 

specialty care amount.

Under Development; <normal 

specialty care amount.

Under Development; <normal 

specialty care amount. 

Emergency Room Visit ............ Fixed fee that = 20% of average allowable amount IN; 

25% OON.

$80 IN; 25% OON ................... TBD, ≤$60 ................................ $60. 

Urgent Care Center ................. Same as primary care outpatient amount IN; 25% 

OON.

$40 IN; 25% OON ................... TBD, ≤$30 ................................ $30. 

Ambulatory Surgery ................. 20% IN; 25% OON .................. $95 IN; 25% OON ................... TBD, ≤$60 ................................ $60. 

Ambulance Service (not including air).Fixed fee that = 20% of average allowable amount IN; 

25% OON.

$60 IN; 25% OON ................... TBD, ≤$40 ................................ $40. 

Durable Med. Equip ................. 20% IN; 25% OON .................. 20% IN; 25% OON .................. 20% .......................................... 20%. 

Inpatient Admission ................. $250/day up to 25% hosp. 

charge + 20% separately 

billed services IN; 25% OON.

$175/admission IN; 25% OON TBD, ≤$150/admission ............ $150/admission. 

Inpatient Skilled Nursing/ 

Rehab Admission.

$250/day up to 25% hospital 

charge + 20% separately 

billed services IN; 25% OON.

$50/day IN; Lesser of $300/ 

day or 20% OON.

TBD, ≤$30/day ......................... $30/day. 

III. Regulatory Procedures 

Public Comments Invited 

This is being issued as an interim 

final rule in order to comply with 

statutory specifications regarding 

effective dates of changes to TRICARE 

as a health care entitlement program. 

For example, the change from a fiscal 

year-based TRICARE plan year for 

purposes of enrollment fees, 

deductibles, and catastrophic caps to a 

calendar year-based TRICARE plan year 

requires that this regulation be in place 

by October 1, 2017. Many other changes 


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Federal Register / Vol. 82, No. 188 / Friday, September 29, 2017 / Rules and Regulations 45445 

must be in place by January 1, 2018, 

including the operation of TRICARE 

Select to replace TRICARE Extra and 

TRICARE Standard, which DoD no 

longer has authority to operate as of that 

date. In view of the statutory effective 

dates of the substantial changes in 

TRICARE, the Department finds that 

obtaining public comment in advance of 

issuing this rule is impracticable, 

unnecessary, and contrary to the public 

interest. Nonetheless, DoD invites 

public comments on this rule and is 

committed to considering all comments 

and issuing a final rule as soon as 

practicable. 

Executive Order (E.O.) 13771, 

‘‘Reducing Regulation and Controlling 

Regulatory Costs’’ 

E.O. 13771 seeks to control costs 

associated with the government 

imposition of private expenditures 

required to comply with Federal 

regulations and to reduce regulations 

that impose such costs. Consistent with 

the analysis of transfer payments under 

OMB Circular A–4, this interim final 

rule does not involve regulatory costs 

subject to E.O. 13771. 

Executive Order 12866, ‘‘Regulatory 

Planning and Review’’ and Executive 

Order 13563, ‘‘Improving Regulation 

and Regulatory Review’’ 

Executive Orders 13563 and 12866 

direct agencies to assess all costs and 

benefits of available regulatory 

alternatives and, if regulation is 

necessary, to select regulatory 

approaches that maximize net benefits 

(including potential economic, 

environmental, public health and safety 

effects, distribute impacts, and equity). 

Executive Order 13563 emphasizes the 

importance of quantifying both costs 

and benefits, of reducing costs, of 

harmonizing rules, and of promoting 

flexibility. This interim final rule has 

been designated ‘‘significant regulatory 

action,’’ although not economically 

significant, under section 3(f) of 

Executive Order 12866. Accordingly, 

this rule has been reviewed by the 

Office of Management and Budget 

(OMB). 

Congressional Review Act, 5 U.S.C. 

804(2) 

Under the Congressional Review Act, 

a major rule may not take effect until at 

least 60 days after submission to 

Congress of a report regarding the rule. 

A major rule is one that would have an 

annual effect on the economy of $100 

million or more or have certain other 

impacts. This interim final rule is not a 

major rule under the Congressional 

Review Act. 

Public Law 96–354, ‘‘Regulatory 

Flexibility Act’’ (RFA), (5 U.S.C. 601) 

The Regulatory Flexibility Act 

requires that each Federal agency 

analyze options for regulatory relief of 

small businesses if a rule has a 

significant impact on a substantial 

number of small entities. For purposes 

of the RFA, small entities include small 

businesses, nonprofit organizations, and 

small governmental jurisdictions. This 

interim final rule is not an economically 

significant regulatory action, and it will 

not have a significant impact on a 

substantial number of small entities. 

Therefore, this rule is not subject to the 

requirements of the RFA. 

Public Law 104–4, Sec. 202, ‘‘Unfunded 

Mandates Reform Act’’ 

Section 202 of the Unfunded 

Mandates Reform Act of 1995 also 

requires that agencies assess anticipated 

costs and benefits before issuing any 

rule whose mandates require spending 

in any one year of $100 million in 1995 

dollars, updated annually for inflation. 

That threshold level is currently 

approximately $140 million. This 

interim final rule will not mandate any 

requirements for state, local, or tribal 

governments or the private sector. 

Public Law 96–511, ‘‘Paperwork 

Reduction Act’’ (44 U.S.C. Chapter 35) 

This rulemaking does not contain a 

‘‘collection of information’’ 

requirement, and will not impose 

additional information collection 

requirements on the public under Public 

Law 96–511, ‘‘Paperwork Reduction 

Act’’ (44 U.S.C. Chapter 35). 

Executive Order 13132, ‘‘Federalism’’ 

This interim final rule has been 

examined for its impact under E.O. 

13132, and it does not contain policies 

that have federalism implications that 

would have substantial direct effects on 

the States, on the relationship between 

the national Government and the States, 

or on the distribution of powers and 

responsibilities among the various 

levels of Government. Therefore, 

consultation with State and local 

officials is not required. 

List of Subjects in 32 CFR Part 199 

Claims, Dental health, Health care, 

Health insurance, Individuals with 

disabilities, Mental health, Mental 

health parity, Military personnel. 

For the reasons stated in the 

preamble, the Department of Defense 

amends 32 CFR part 199 as set forth 

below: 

PART 199—CIVILIAN HEALTH AND 

MEDICAL PROGRAM OF THE 

UNIFORMED SERVICES (CHAMPUS) 

■ 1. The authority citation for part 199 

continues to read as follows: 

Authority: 5 U.S.C. 301; 10 U.S.C. chapter 

55. 

■ 2. In § 199.2, paragraph (b) is amended 

by: 

■ a. Revising the definitions of ‘‘Basic 

program,’’ ‘‘Deductible,’’ ‘‘Deductible 

certificate,’’ ‘‘Former member,’’ and 

‘‘Member.’’ 

■ b. Adding the definitions of ‘‘Program 

year’’ and ‘‘Retired category’’ in 

alphabetical order. 

■ c. Revising the definition of ‘‘Retiree.’’ 

■ d. Adding the definition of ‘‘TRICARE 

Extra’’ in alphabetical order. 

■ e. Removing the definition of 

‘‘TRICARE extra plan.’’ 

■ f. Adding the definition of ‘‘TRICARE 

for Life’’ and ‘‘TRICARE Prime’’ in 

alphabetical order. 

■ g. Removing the definition of 

‘‘TRICARE prime plan.’’ 

■ h. Revising the definitions of 

‘‘TRICARE program’’ and ‘‘TRICARE 

Retired Reserve.’’ 

■ i. Adding the definitions of ‘‘TRICARE 

Select’’ and ‘‘TRICARE Standard’’ in 

alphabetical order. 

■ j. Removing the definition of 

‘‘TRICARE standard plan.’’ 

The revisions and additions read as 

follows: 

§ 199.2 Definitions. 

* * * * * 

(b) * * * 

Basic program. The primary medical 

benefits set forth in § 199.4, generally 

referred to as the Civilian Health and 

Medical Program of the Uniformed 

Services (CHAMPUS) as authorized 

under chapter 55 of title 10 United 

States Code, were made available to 

eligible beneficiaries under this part. 

* * * * * 

Deductible. Payment by an individual 

beneficiary or family of a specific first 

dollar amount of the TRICARE 

allowable amount for otherwise covered 

outpatient services or supplies obtained 

in any program year. The dollar amount 

of deductible per individual or family is 

calculated as specified by law. 

Deductible certificate. A statement 

issued to the beneficiary (or sponsor) by 

a TRICARE contractor certifying to 

deductible amounts satisfied by a 

beneficiary for any applicable program 

year. 

* * * * * 

Former member. An individual who 

is eligible for, or entitled to, retired pay, 

at age 60, for non-Regular service in 


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45446 Federal Register / Vol. 82, No. 188 / Friday, September 29, 2017 / Rules and Regulations 

accordance with chapter 1223, title 10, 

United States Code but who has been 

discharged and who maintains no 

military affiliation. These former 

members, at age 60, and their eligible 

dependents are entitled to medical care, 

commissary, exchange, and MWR 

privileges. Under age 60, they and their 

eligible dependents are entitled to 

commissary, exchange, and MWR 

privileges only. 

* * * * * 

Member. An individual who is 

affiliated with a Service, either an active 

duty member, Reserve member, active 

duty retired member, or Retired Reserve 

member. Members in a retired status are 

not former members. Also referred to as 

the sponsor. 

* * * * * 

Program year. The appropriate year 

(e.g., calendar year, fiscal year, rolling 

12-month period, etc.) specified in the 

administration of TRICARE programs 

for application of unique requirements 

or limitations (e.g., enrollment fees, 

deductibles, catastrophic loss 

protection, etc.) on covered health care 

services obtained or provided during the 

designated time period. 

* * * * * 

Retired category. Retirees and their 

family members who are beneficiaries 

covered by 10 U.S.C. 1086(c), other than 

Medicare-eligible beneficiaries as 

described in 10 U.S.C. 1086(d). 

Retiree. For ease of reference in this 

part only, and except as otherwise 

specified in this part, the term means a 

member or former member of a 

Uniformed Service who is entitled to 

retired, retainer, or equivalent pay based 

on duty in a Uniformed Service. 

* * * * * 

TRICARE Extra. The preferredprovider option of the TRICARE 

program made available prior to January 

1, 2018, under which TRICARE 

Standard beneficiaries may obtain 

discounts on cost sharing as a result of 

using TRICARE network providers. 

TRICARE for Life. The Medicare 

wraparound coverage option of the 

TRICARE program made available to an 

eligible beneficiary by reason of 10 

U.S.C. 1086(d). 

* * * * * 

TRICARE Prime. The managed care 

option of the TRICARE program 

established under § 199.17. 

TRICARE program. The program 

established under § 199.17. 

* * * * * 

TRICARE Retired Reserve. The 

program established under 10 U.S.C. 

1076e and § 199.25. 

* * * * * 

TRICARE Select. The self-managed, 

preferred-provider network option 

under the TRICARE Program established 

by 10 U.S.C. 1075 and § 199.17 to 

replace TRICARE Extra and Standard 

after December 31, 2017. 

TRICARE Standard. The TRICARE 

program made available prior to January 

1, 2018, under which the basic program 

of health care benefits generally referred 

to as CHAMPUS was made available to 

eligible beneficiaries under this part. 

* * * * * 

■ 3. Section 199.4 is amended by: 

■ a. Adding paragraph (c)(1)(iii); 

■ b. Revising paragraph (d)(3)(iii); 

■ c. Adding paragraph (d)(3)(vi)(D); 

■ d. Revising paragraph (e)(28)(iv); 

■ e. Adding paragraph (e)(28)(v); 

■ f. Removing the words ‘‘fiscal year’’ 

everywhere they appear and adding in 

their place the words ‘‘calendar year’’ in 

paragraphs (f)(2) through (4) and (10); 

■ g. Adding paragraph (f)(13); 

■ h. Revising paragraph (g)(39) 

introductory text and adding paragraph 

(g)(39)(v). 

■ i. Revising paragraph (g)(57). 

The revisions and additions read as 

follows: 

§ 199.4 Basic program benefits. 

* * * * * 

(c) * * * 

(1) * * * 

(iii) Telehealth services. Health care 

services covered by TRICARE and 

provided through the use of telehealth 

modalities are covered services to the 

same extent as if provided in person at 

the location of the patient if those 

services are medically necessary and 

appropriate for such modalities. The 

Director will establish special 

procedures for payment for such 

services. Additionally, where 

appropriate, in order to incentive the 

use of telehealth services, the Director 

may modify the otherwise applicable 

beneficiary cost-sharing requirements in 

paragraph (f) of this section which 

otherwise apply. 

* * * * * 

(d) * * * 

(3) * * * 

(iii) Medical supplies and dressings 

(consumables)—(A) In general. In 

general, medical supplies and dressings 

(consumables) are those that do not 

withstand prolonged, repeated use. 

Such items must be related directly to 

an appropriate and verified covered 

medical condition of the specific 

beneficiary for whom the item was 

purchased and obtained from a medical 

supply company, a pharmacy, or 

authorized institutional provider. 

Examples of covered medical supplies 

and dressings are disposable syringes 

for a known diabetic, colostomy sets, 

irrigation sets, and elastic bandages. An 

external surgical garment specifically 

designed for use follow a mastectomy is 

considered a medical supply item. 

Note 1 to paragraph (d)(3)(iii)(A): 

Generally, the allowable charge of a medical 

supply item will be under $100. Any item 

over this amount must be reviewed to 

determine whether it would qualify as a DME 

item. If it is, in fact, a medical supply item 

and does not represent an excessive charge, 

it can be considered for benefits under 

paragraph (d)(3)(iii) of this section. 

(B) Medically necessary food and 

medical equipment and supplies 

necessary to administer such food (other 

than durable medical equipment and 

supplies) when prescribed for dietary 

management of a covered disease or 

condition. (1) Medically necessary food, 

including a low protein modified food 

product or an amino acid preparation 

product, may be covered when: 

(i) Furnished pursuant to the 

prescription, order, or recommendation 

of a TRICARE authorized provider 

acting within the provider’s scope of 

license/certificate of practice, for the 

dietary management of a covered 

disease or condition; 

(ii) Is a specifically formulated and 

processed product (as opposed to a 

naturally occurring foodstuff used in its 

natural state) for the partial or exclusive 

feeding of an individual by means of 

oral intake or enteral feeding by tube; 

(iii) Is intended for the dietary 

management of an individual who, 

because of therapeutic or chronic 

medical needs, has limited or impaired 

capacity to ingest, digest, absorb, or 

metabolize ordinary foodstuffs or 

certain nutrients, or who has other 

special medically determined nutrient 

requirements, the dietary management 

of which cannot be achieved by the 

modification of the normal diet alone; 

(iv) Is intended to be used under 

medical supervision, which may 

include in a home setting; and 

(v) Is intended only for an individual 

receiving active and ongoing medical 

supervision under which the individual 

requires medical care on a recurring 

basis for, among other things, 

instructions on the use of the food. 

(2) Medically necessary food does not 

include: 

(i) Food taken as part of an overall 

diet designed to reduce the risk of a 

disease or medical condition or as 

weight-loss products, even if the food is 

recommended by a physician or other 

health care professional; 

(ii) Food marketed as gluten-free for 

the management of celiac disease or 

non-celiac gluten sensitivity; 


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(iii) Food marketed for the 

management of diabetes; or 

(iv) Such other products as the 

Director, Defense Health Agency 

determines appropriate. 

(3) Covered disease or condition 

under paragraph (d)(3)(iii)(B) of this 

section means: 

(i) Inborn errors of metabolism; 

(ii) Medical conditions of 

malabsorption; 

(iii) Pathologies of the alimentary tract 

or the gastrointestinal tract; 

(iv) A neurological or physiological 

condition; and 

(v) Such other diseases or conditions 

the Director, Defense Health Agency 

determines appropriate. 

* * * * * 

(vi) * * * 

(D) Medically necessary vitamins 

used for the management of a covered 

disease or condition pursuant to a 

prescription, order, or recommendation 

of a TRICARE authorized provider 

acting within the provider’s scope of 

license/certificate of practice. For 

purposes of this paragraph (d)(3)(vi)(D), 

the term ‘‘covered disease or condition’’ 

means: 

(1) Inborn errors of metabolism; 

(2) Medical conditions of 

malabsorption; 

(3) Pathologies of the alimentary tract 

or the gastrointestinal tract; 

(4) A neurological or physiological 

condition; 

(5) Pregnancy in relation to prenatal 

vitamins, with the limitation the 

prenatal vitamins that require a 

prescription in the United States may be 

covered for prenatal care only; 

(6) Such other disease or conditions 

the Director, Defense Health Agency 

determines appropriate. 

* * * * * 

(e) * * * 

(28) * * * 

(iv) Health promotion and disease 

prevention visits (which may include all 

of the services provided pursuant to 

§ 199.17(f)(2)) for beneficiaries 6 years of 

age or older may be provided in 

connection with immunizations and 

cancer screening examinations 

authorized by paragraphs (e)(28)(i) and 

(ii) of this section). 

(v) Breastfeeding support, supplies 

(including breast pumps and associated 

equipment), and counseling. 

* * * * * 

(f) * * * 

(13) Special transition rule for the last 

quarter of calendar year 2017. In order 

to transition deductibles and 

catastrophic caps from a fiscal year basis 

to a calendar year basis, the deductible 

amount and the catastrophic cap 

amount specified in paragraph (f) of this 

section will be applicable to the 15- 

month period of October 1, 2016 

through December 31, 2017. 

(g) * * * 

(39) Counseling. Educational, 

vocational, non-medical nutritional 

counseling, counseling for 

socioeconomic purposes, stress 

management, and/or lifestyle 

modification purposes, except the 

following are not excluded: 

* * * * * 

(v) Medical nutritional therapy (also 

referred to as medical nutritional 

counseling) required in the 

administration of the medically 

necessary foods, services and supplies 

authorized in paragraph (d)(3)(iii)(B) of 

this section, medically necessary 

vitamins authorized in paragraph 

(d)(3)(vi)(D) of this section, or when 

medically necessary for other 

authorized covered services. 

* * * * * 

(57) Food, food substitutes. Food, food 

substitutes, vitamins, or other 

nutritional supplements, including 

those related to prenatal care, except as 

authorized in paragraphs (d)(3)(iii)(B) 

and (d)(3)(vi)(D) of this section. 

* * * * * 

■ 4. Section 199.5 is amended by: 

■ a. Removing the words ‘‘fiscal year’’ 

everywhere they appear and adding in 

their place the words ‘‘program year’’ in 

paragraphs (c)(7)(iii), (f)(3), (g)(2)(i), and 

(h)(3)(v)(A); and 

■ b. Adding paragraph (a)(3). 

The addition reads as follows: 

§ 199.5 TRICARE Extended Health Care 

Option (ECHO). 

(a) * * * 

(3) The Government’s cost-share for 

ECHO or ECHO home health benefits 

during any program year is limited as 

stated in this section. In order to 

transition the program year from a fiscal 

year to a calendar year basis, the 

Government’s annual cost-share 

limitation specified in paragraph (f) of 

this section shall be prorated for the last 

quarter of calendar year 2018 as 

authorized by 10 U.S.C. 1079(f)(2)(A). 

* * * * * 

■ 5. Section 199.6 is amended by 

revising paragraphs (c)(3)(iii)(L) and (M) 

to read as follows: 

§ 199.6 TRICARE-authorized providers. 

* * * * * 

(c) * * * 

(3) * * * 

(iii) * * * 

(L) Nutritionist. The nutritionist must 

be licensed by the State in which the 

care is provided and must be under the 

supervision of a physician who is 

overseeing the episode of treatment or 

the covered program of services. 

(M) Registered dietician. The dietician 

must be licensed by the State in which 

the care is provided and must be under 

the supervision of a physician who is 

overseeing the episode of treatment or 

the covered program of services. 

* * * * * 

§ 199.7 [Amended] 

■ 6. Section 199.7(a)(6) is amended by 

removing the words ‘‘fiscal year’’ 

everywhere they appear and adding in 

their place the words ‘‘calendar year’’. 

§ 199.8 [Amended] 

■ 7. Section 199.8(d)(1)(v) is amended 

by removing ‘‘Sec. 199.4(f)(10)’’ and 

adding in its place ‘‘§ 199.4(f)(10)’’ and 

removing the words ‘‘fiscal year’’ and 

adding in their place the words 

‘‘calendar year’’. 

■ 8. Section 199.11 is amended by 

revising paragraph (a) to read as follows: 

§ 199.11 Overpayments recovery. 

(a) General. Actions to recover 

overpayments arise when the 

government has a right to recover 

money, funds, or property from any 

person, partnership, association, 

corporation, governmental body or other 

legal entity, foreign or domestic, except 

another Federal agency, because of an 

erroneous payment of benefits under 

both CHAMPUS and the TRICARE 

program under this part. The term 

‘‘Civilian Health and Medical Program 

of the Uniformed Services’’ (CHAMPUS) 

is defined in 10 U.S.C. 1072(2), referred 

to as the CHAMPUS basic program. 

Prior to January 1, 2018, the term 

‘‘TRICARE program’’ referred to the 

triple-option of health benefits known 

as TRICARE Prime, TRICARE Extra, and 

TRICARE Standard. Specifically, 

TRICARE Standard was the TRICARE 

program under which the basic program 

of health care benefits generally referred 

to as CHAMPUS was made available to 

eligible beneficiaries under this Part 

199. Effective January 1, 2018, the term 

‘‘TRICARE program’’ is defined in 10 

U.S.C. 1072(2) and includes TRICARE 

Prime, TRICARE Select and TRICARE 

for Life. It is the purpose of this section 

to prescribe procedures for 

investigation, determination, assertion, 

collection, compromise, waiver and 

termination of claims in favor of the 

United States for erroneous benefit 

payments arising out of the 

administration CHAMPUS and the 

TRICARE program. For the purpose of 

this section, references herein to 

TRICARE beneficiaries, claims, benefits, 


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payments, or appeals shall include 

CHAMPUS beneficiaries, claims, 

benefits, payments, or appeals. A claim 

against several joint debtors arising from 

a single incident or transaction is 

considered one claim. The Director, or 

a designee, may pursue collection 

against all joint debtors and is not 

required to allocate the burden of 

payment between debtors. 

* * * * * 

■ 9. Section 199.17 is revised to read as 

follows. 

§ 199.17 TRICARE program. 

(a) Establishment. The TRICARE 

program is established for the purpose 

of implementing a comprehensive 

managed health care program for the 

delivery and financing of health care 

services in the Military Health System. 

(1) Purpose. The TRICARE program 

implements a number of improvements 

primarily through modernized managed 

care support contracts that include 

special arrangements with civilian 

sector health care providers and better 

coordination between military medical 

treatment facilities (MTFs) and these 

civilian providers to deliver an 

integrated, health care delivery system 

that provides beneficiaries with access 

to high quality healthcare. 

Implementation of these improvements, 

to include enhanced access, improved 

health outcomes, increased efficiencies 

and elimination of waste, in addition to 

improving and maintaining operational 

medical force readiness, includes 

adoption of special rules and 

procedures not ordinarily followed 

under CHAMPUS or MTF requirements. 

This section establishes those special 

rules and procedures. 

(2) Statutory authority. Many of the 

provisions of this section are authorized 

by statutory authorities other than those 

which authorize the usual operation of 

the CHAMPUS program, especially 10 

U.S.C. 1079 and 1086. The TRICARE 

program also relies upon other available 

statutory authorities, including 10 

U.S.C. 1075 (TRICARE Select), 10 U.S.C. 

1075a (TRICARE Prime cost sharing), 10 

U.S.C. 1095f (referrals and preauthorizations under TRICARE Prime), 

10 U.S.C. 1099 (health care enrollment 

system), 10 U.S.C. 1097 (contracts for 

medical care for retirees, dependents 

and survivors: Alternative delivery of 

health care), and 10 U.S.C. 1096 

(resource sharing agreements). 

(3) Scope of the program. The 

TRICARE program is applicable to all 

the uniformed services. TRICARE Select 

and TRICARE-for-Life shall be available 

in all areas, including overseas as 

authorized in paragraph (u) of this 

section. The geographic availability of 

TRICARE Prime is generally limited as 

provided in this section. The Assistant 

Secretary of Defense (Health Affairs) 

may also authorize modifications to 

TRICARE program rules and procedures 

as may be appropriate to the area 

involved. 

(4) Rules and procedures affected. 

Much of this section relates to rules and 

procedures applicable to the delivery 

and financing of health care services 

provided by civilian providers outside 

military treatment facilities. This 

section provides that certain rules, 

procedures, rights and obligations set 

forth elsewhere in this part (and usually 

applicable to CHAMPUS) are different 

under the TRICARE program. To the 

extent that TRICARE program rules, 

procedures, rights and obligations set 

forth in this section are not different 

from or otherwise in conflict with those 

set forth elsewhere in this part as 

applicable to CHAMPUS, the 

CHAMPUS provisions are incorporated 

into the TRICARE program. In addition, 

some rules, procedures, rights and 

obligations relating to health care 

services in military treatment facilities 

are also different under the TRICARE 

program. In such cases, provisions of 

this section take precedence and are 

binding. 

(5) Implementation based on local 

action. The TRICARE program is not 

automatically implemented in all 

respects in all areas where it is 

potentially applicable. Therefore, not all 

provisions of this section are 

automatically implemented. Rather, 

implementation of the TRICARE 

program and this section requires an 

official action by the Director, Defense 

Health Agency. Public notice of the 

initiation of portions of the TRICARE 

program will be achieved through 

appropriate communication and media 

methods and by way of an official 

announcement by the Director 

identifying the military medical 

treatment facility catchment area or 

other geographical area covered. 

(6) Major features of the TRICARE 

program. The major features of the 

TRICARE program, described in this 

section, include the following: 

(i) Beneficiary categories. Under the 

TRICARE program, health care 

beneficiaries are generally classified 

into one of several categories: 

(A) Active duty members, who are 

covered by 10 U.S.C. 1074(a). 

(B) Active duty family members, who 

are beneficiaries covered by 10 U.S.C. 

1079 (also referred to in this section as 

‘‘active duty family category’’). 

(C) Retirees and their family members 

(also referred to in this section as 

‘‘retired category’’), who are 

beneficiaries covered by 10 U.S.C. 

1086(c) other than those beneficiaries 

eligible for Medicare Part A. 

(D) Medicare eligible retirees and 

Medicare eligible retiree family 

members who are beneficiaries covered 

by 10 U.S.C. 1086(d) as each become 

individually eligible for Medicare Part A 

and enroll in Medicare Part B. 

(E) Military treatment facility (MTF) 

only beneficiaries are beneficiaries 

eligible for health care services in 

military treatment facilities, but not 

eligible for a TRICARE plan covering 

non-MTF care. 

(ii) Health plans available. The major 

TRICARE health plans are as follows: 

(A) TRICARE Prime. ‘‘TRICARE 

Prime’’ is a health maintenance 

organization (HMO)-like program. It 

generally features use of military 

treatment facilities and substantially 

reduced out-of-pocket costs for care 

provided outside MTFs. Beneficiaries 

generally agree to use military treatment 

facilities and designated civilian 

provider networks and to follow certain 

managed care rules and procedures. The 

primary purpose of TRICARE Prime is 

to support the effective operation of an 

MTF, which exists to support the 

medical readiness of the armed forces 

and the readiness of medical personnel. 

TRICARE Prime will be offered in areas 

where the Director determines that it is 

appropriate to support the effective 

operation of one or more MTFs. 

(B) TRICARE Select. ‘‘TRICARE 

Select’’ is a self-managed, preferred 

provider organization (PPO) program. It 

allows beneficiaries to use the TRICARE 

provider civilian network, with reduced 

out-of-pocket costs compared to care 

from non-network providers, as well as 

military treatment facilities (where they 

exist and when space is available). 

TRICARE Select enrollees will not have 

restrictions on their freedom of choice 

with respect to authorized health care 

providers. However, when a TRICARE 

Select beneficiary receives services 

covered under the basic program from 

an authorized health care provider who 

is not part of the TRICARE provider 

network that care is covered by 

TRICARE but is subject to higher cost 

sharing amounts for ‘‘out-of-network’’ 

care. Those amounts are the same as 

under the basic program under § 199.4. 

(C) TRICARE for Life. ‘‘TRICARE for 

Life’’ is the Medicare wraparound 

coverage plan under 10 U.S.C. 1086(d). 

Rules applicable to this plan are 

unaffected by this section; they are 

generally set forth in §§ 199.3 

(Eligibility), 199.4 (Basic Program 

Benefits), and 199.8 (Double Coverage). 


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(D) TRICARE Standard. ‘‘TRICARE 

Standard’’ generally referred to the basic 

CHAMPUS program of benefits under 

§ 199.4. While the law required 

termination of TRICARE Standard as a 

distinct TRICARE plan December 31, 

2017, the CHAMPUS basic program 

benefits under § 199.4 continues as the 

baseline of benefits common to the 

TRICARE Prime and TRICARE Select 

plans. 

(iii) Comprehensive enrollment 

system. The TRICARE program includes 

a comprehensive enrollment system for 

all categories of beneficiaries except 

TRICARE-for-Life beneficiaries. When 

eligibility for enrollment for TRICARE 

Prime and/or TRICARE Select exists, a 

beneficiary must enroll in one of the 

plans. Refer to paragraph (o) of this 

section for TRICARE program 

enrollment procedures. 

(7) Preemption of State laws. (i) 

Pursuant to 10 U.S.C. 1103 the 

Department of Defense has determined 

that in the administration of 10 U.S.C. 

chapter 55, preemption of State and 

local laws relating to health insurance, 

prepaid health plans, or other health 

care delivery or financing methods is 

necessary to achieve important Federal 

interests, including but not limited to 

the assurance of uniform national health 

programs for military families and the 

operation of such programs at the lowest 

possible cost to the Department of 

Defense, that have a direct and 

substantial effect on the conduct of 

military affairs and national security 

policy of the United States. 

(ii) Based on the determination set 

forth in paragraph (a)(7)(i) of this 

section, any State or local law relating 

to health insurance, prepaid health 

plans, or other health care delivery or 

financing methods is preempted and 

does not apply in connection with 

TRICARE regional contracts. Any such 

law, or regulation pursuant to such law, 

is without any force or effect, and State 

or local governments have no legal 

authority to enforce them in relation to 

the TRICARE regional contracts. 

(However, the Department of Defense 

may by contract establish legal 

obligations of the part of TRICARE 

contractors to conform with 

requirements similar or identical to 

requirements of State or local laws or 

regulations). 

(iii) The preemption of State and local 

laws set forth in paragraph (a)(7)(ii) of 

this section includes State and local 

laws imposing premium taxes on health 

or dental insurance carriers or 

underwriters or other plan managers, or 

similar taxes on such entities. Such laws 

are laws relating to health insurance, 

prepaid health plans, or other health 

care delivery or financing methods, 

within the meaning of the statutes 

identified in paragraph (a)(7)(i) of this 

section. Preemption, however, does not 

apply to taxes, fees, or other payments 

on net income or profit realized by such 

entities in the conduct of business 

relating to DoD health services 

contracts, if those taxes, fees or other 

payments are applicable to a broad 

range of business activity. For purposes 

of assessing the effect of Federal 

preemption of State and local taxes and 

fees in connection with DoD health and 

dental services contracts, interpretations 

shall be consistent with those applicable 

to the Federal Employees Health 

Benefits Program under 5 U.S.C. 8909(f). 

(b) TRICARE Prime and TRICARE 

Select health plans in general. The two 

primary plans for beneficiaries in the 

active duty family category and the 

retired category (which does not include 

most Medicare-eligible retirees/ 

dependents) are TRICARE Prime and 

TRICARE Select. This paragraph (b) 

further describes the TRICARE Prime 

and TRICARE Select health plans. 

(1) TRICARE Prime. TRICARE Prime 

is a managed care option that provides 

enhanced medical services to 

beneficiaries at reduced cost-sharing 

amounts for beneficiaries whose care is 

managed by a designated primary care 

manager and provided by an MTF or 

network provider. TRICARE Prime is 

offered in a location in which an MTF 

is located (other than a facility limited 

to members of the armed forces) that has 

been designated by the Director as a 

Prime Service Area. In addition, where 

TRICARE Prime is offered it may be 

limited to active duty family members if 

the Director determines it is not 

practicable to offer TRICARE Prime to 

retired category beneficiaries. TRICARE 

Prime is not offered in areas where the 

Director determines it is impracticable. 

If TRICARE Prime is not offered in a 

geographical area, certain active duty 

family members residing in the area 

may be eligible to enroll in TRICARE 

Prime Remote program under paragraph 

(g) of this section. 

(2) TRICARE Select. TRICARE Select 

is the self-managed option under which 

beneficiaries may receive authorized 

basic program benefits from any 

TRICARE authorized provider. The 

TRICARE Select health care plan also 

provides enhanced program benefits to 

beneficiaries with access to a preferredprovider network with broad geographic 

availability within the United States at 

reduced out-of-pocket expenses. 

However, when a beneficiary receives 

services from an authorized health care 

provider who is not part of the 

TRICARE provider network, only basic 

program benefits (not enhanced Select 

care) are covered by TRICARE and the 

beneficiary is subject to higher cost 

sharing amounts for ‘‘out-of-network’’ 

care. Those amounts are the same as 

under the basic program under § 199.4. 

(c) Eligibility for enrollment in 

TRICARE Prime and TRICARE Select. 

Beneficiaries in the active duty family 

category and the retired category are 

eligible to enroll in TRICARE Prime 

and/or TRICARE Select as outlined in 

this paragraph (c). A retiree or retiree 

family member who becomes eligible for 

Medicare Part A is not eligible to enroll 

in TRICARE Select; however, as 

provided in this paragraph (c), some 

Medicare eligible retirees/family 

members may be allowed to enroll in 

TRICARE Prime where available. In 

general, when a retiree or retiree family 

member becomes individually eligible 

for Medicare Part A and enrolls in 

Medicare Part B, he/she is automatically 

eligible for TRICARE-for-Life and is 

required to enroll in the Defense 

Enrollment Eligibility Reporting System 

(DEERS) to verify eligibility. Further, 

some rules and procedures are different 

for dependents of active duty members 

and retirees, dependents, and survivors. 

(1) Active duty members. Active duty 

members are required to enroll in Prime 

where it is offered. Active duty 

members shall have first priority for 

enrollment in Prime. 

(2) Dependents of active duty 

members. Beneficiaries in the active 

duty family member category are 

eligible to enroll in Prime (where 

offered) or Select. 

(3) Survivors of deceased members. (i) 

The surviving spouse of a member who 

dies while on active duty for a period 

of more than 30 days is eligible to enroll 

in Prime (where offered) or Select for a 

3 year period beginning on the date of 

the member’s death under the same 

rules and provisions as dependents of 

active duty members. 

(ii) A dependent child or unmarried 

person (as described in § 199.3(b)(2)(ii) 

or (iv)) of a member who dies while on 

active duty for a period of more than 30 

days whose death occurred on or after 

October 7, 2001, is eligible to enroll in 

Prime (where offered) or Select and is 

subject to the same rules and provisions 

of dependents of active duty members 

for a period of three years from the date 

the active duty sponsor dies or until the 

surviving eligible dependent: 

(A) Attains 21 years of age; or 

(B) Attains 23 years of age or ceases 

to pursue a full-time course of study 

prior to attaining 23 years of age, if, at 

21 years of age, the eligible surviving 

dependent is enrolled in a full-time 

course of study in a secondary school or 


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in a full-time course of study in an 

institution of higher education approved 

by the Secretary of Defense and was, at 

the time of the sponsor’s death, in fact 

dependent on the member for over onehalf of such dependent’s support. 

(4) Retirees, dependents of retirees, 

and survivors (other than survivors of 

deceased members covered under 

paragraph (c)(3) of this section). All 

retirees, dependents of retirees, and 

survivors who are not eligible for 

Medicare Part A are eligible to enroll in 

Select. Additionally, retirees, 

dependents of retirees, and survivors 

who are not eligible for Medicare Part A 

based on age are also eligible to enroll 

in TRICARE Prime in locations where it 

is offered and where an MTF has, in the 

judgment of the Director, a significant 

number of health care providers, 

including specialty care providers, and 

sufficient capability to support the 

efficient operation of TRICARE Prime 

for projected retired beneficiary 

enrollees in that location. 

(d) Health benefits under TRICARE 

Prime—(1) Military treatment facility 

(MTF) care—(i) In general. All 

participants in Prime are eligible to 

receive care in military treatment 

facilities. Participants in Prime will be 

given priority for such care over other 

beneficiaries. Among the following 

beneficiary groups, access priority for 

care in military treatment facilities 

where TRICARE is implemented as 

follows: 

(A) Active duty service members; 

(B) Active duty service members’ 

dependents and survivors of service 

members who died on active duty, who 

are enrolled in TRICARE Prime; 

(C) Retirees, their dependents and 

survivors, who are enrolled in TRICARE 

Prime; 

(D) Active duty service members’ 

dependents and survivors of deceased 

members, who are not enrolled in 

TRICARE Prime; and 

(E) Retirees, their dependents and 

survivors who are not enrolled in 

TRICARE Prime. For purposes of this 

paragraph (d)(1), survivors of members 

who died while on active duty are 

considered as among dependents of 

active duty service members. 

(ii) Special provisions. Enrollment in 

Prime does not affect access priority for 

care in military treatment facilities for 

several miscellaneous beneficiary 

groups and special circumstances. 

Those include Secretarial designees, 

NATO and other foreign military 

personnel and dependents authorized 

care through international agreements, 

civilian employees under workers’ 

compensation programs or under safety 

programs, members on the Temporary 

Disability Retired List (for statutorily 

required periodic medical 

examinations), members of the reserve 

components not on active duty (for 

covered medical services), military 

prisoners, active duty dependents 

unable to enroll in Prime and 

temporarily away from place of 

residence, and others as designated by 

the Assistant Secretary of Defense 

(Health Affairs). Additional exceptions 

to the normal Prime enrollment access 

priority rules may be granted for other 

categories of individuals, eligible for 

treatment in the MTF, whose access to 

care is necessary to provide an adequate 

clinical case mix to support graduate 

medical education programs or 

readiness-related medical skills 

sustainment activities, to the extent 

approved by the ASD(HA). 

(2) Non-MTF care for active duty 

members. Under Prime, non-MTF care 

needed by active duty members 

continues to be arranged under the 

supplemental care program and subject 

to the rules and procedures of that 

program, including those set forth in 

§ 199.16. 

(3) Civilian sector Prime benefits. 

Health benefits for Prime enrollees for 

care received from civilian providers are 

those under § 199.4 and the additional 

benefits identified in paragraph (f) of 

this section. 

(e) Health benefits under the 

TRICARE Select plan—(1) Civilian 

sector care. The health benefits under 

TRICARE Select for enrolled 

beneficiaries received from civilian 

providers are those under § 199.4, and, 

in addition, those in paragraph (f) of this 

section when received from a civilian 

network provider. 

(2) Military treatment facility (MTF) 

care. All TRICARE Select enrolled 

beneficiaries continue to be eligible to 

receive care in military treatment 

facilities on a space available basis. 

(f) Benefits under TRICARE Prime and 

TRICARE Select—(1) In general. Except 

as specifically provided or authorized 

by this section, all benefits provided, 

and benefit limitations established, 

pursuant to this part, shall apply to 

TRICARE Prime and TRICARE Select. 

(2) Preventive care services. Certain 

preventive care services not normally 

provided as part of basic program 

benefits under § 199.4 are covered 

benefits when provided to Prime or 

Select enrollees by providers in the 

civilian provider network. Such 

additional services are authorized under 

10 U.S.C. 1097, including preventive 

care services not part of the entitlement 

under 10 U.S.C. 1074d and services that 

would otherwise be excluded under 10 

U.S.C. 1079(a)(10). Other authority for 

such additional services includes 

section 706 of the National Defense 

Authorization Act for Fiscal Year 2017. 

The specific set of such services shall be 

established by the Director and 

announced annually before the open 

season enrollment period. Standards for 

preventive care services shall be 

developed based on guidelines from the 

U.S. Department of Health and Human 

Services. Such standards shall establish 

a specific schedule, including frequency 

or age specifications for services that 

may include, but are not limited to: 

(i) Laboratory and imaging tests, 

including blood lead, rubella, 

cholesterol, fecal occult blood testing, 

and mammography; 

(ii) Cancer screenings (including 

cervical, breast, lung, prostate, and 

colon cancer screenings); 

(iii) Immunizations; 

(iv) Periodic health promotion and 

disease prevention exams; 

(v) Blood pressure screening; 

(vi) Hearing exams; 

(vii) Sigmoidoscopy or colonoscopy; 

(viii) Serologic screening; and 

(ix) Appropriate education and 

counseling services. The exact services 

offered shall be established under 

uniform standards established by the 

Director. 

(3) Treatment of obesity. Under the 

authority of 10 U.S.C. 1097 and sections 

706 and 729 of the National Defense 

Authorization Act for Fiscal Year 2017, 

notwithstanding 10 U.S.C. 1079(a)(10), 

treatment of obesity is covered under 

TRICARE Prime and TRICARE Select 

even if it is the sole or major condition 

treated. Such services must be provided 

by a TRICARE network provider and be 

medically necessary and appropriate in 

the context of the particular patient’s 

treatment. 

(4) High value services. Under the 

authority of 10 U.S.C. 1097 and other 

authority, including sections 706 and 

729 of the National Defense 

Authorization Act for Fiscal Year 2017, 

for purposes of improving populationbased health outcomes and 

incentivizing medical intervention 

programs to address chronic diseases 

and other conditions and healthy 

lifestyle interventions, the Director may 

waive or reduce cost sharing 

requirements for TRICARE Prime and 

TRICARE Select enrollees for care 

received from network providers for 

certain health care services designated 

for this purpose. The specific services 

designated for this purpose will be those 

the Director determines provide 

especially high value in terms of better 

health outcomes. The specific services 

affected for any plan year will be 

announced by the Director prior to the 


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open season enrollment period for that 

plan year. Services affected by actions of 

the Director under paragraph (f)(5) of 

this section may be associated with 

actions taken for high value medications 

under § 199.21(j)(3) for select 

pharmaceutical agents to be cost-shared 

at a reduced or zero dollar rate. 

(5) Other services. In addition to 

services provided pursuant to 

paragraphs (f)(2) through (4) of this 

section, other benefit enhancements 

may be added and other benefit 

restrictions may be waived or relaxed in 

connection with health care services 

provided to TRICARE Prime and 

TRICARE Select enrollees. Any such 

other enhancements or changes must be 

approved by the Director based on 

uniform standards. 

(g) TRICARE Prime Remote for Active 

Duty Family Members—(1) In general. In 

geographic areas in which TRICARE 

Prime is not offered and in which 

eligible family members reside, there is 

offered under 10 U.S.C. 1079(p) 

TRICARE Prime Remote for Active Duty 

Family Members as an enrollment 

option. TRICARE Prime Remote for 

Active Duty Family Members 

(TPRADFM) will generally follow the 

rules and procedures of TRICARE 

Prime, except as provided in this 

paragraph (g) and otherwise except to 

the extent the Director determines them 

to be infeasible because of the remote 

area. 

(2) Active duty family member. For 

purposes of this paragraph (g), the term 

‘‘active duty family member’’ means one 

of the following dependents of an active 

duty member of the Uniformed Services: 

(i) Spouse, child, or unmarried 

person, as defined in § 199.3(b)(2)(i), 

(ii), or (iv); 

(ii) For a 3-year period, the surviving 

spouse of a member who dies while on 

active duty for a period of more than 30 

days whose death occurred on or after 

October 7, 2001; and 

(iii) The surviving dependent child or 

unmarried person, as defined in 

§ 199.3(b)(2)(ii) or (iv), of a member who 

dies while on active duty for a period 

of more than 30 days whose death 

occurred on or after October 7, 2001. 

Active duty family member status is for 

a period of 3 years from the date the 

active duty sponsor dies or until the 

surviving eligible dependent: 

(A) Attains 21 years of age; or 

(B) Attains 23 years of age or ceases 

to pursue a full-time course of study 

prior to attaining 23 years of age, if, at 

21 years of age, the eligible surviving 

dependent is enrolled in a full-time 

course of study in a secondary school or 

in a full-time course of study in an 

institution of higher education approved 

by the Secretary of Defense and was, at 

the time of the sponsor’s death, in fact 

dependent on the member for over onehalf of such dependent’s support. 

(3) Eligibility. (i) An active duty 

family member is eligible for TRICARE 

Prime Remote for Active Duty Family 

Members if he or she is eligible for 

CHAMPUS and, on or after December 2, 

2003, meets the criteria of paragraphs 

(g)(3)(i)(A) and (B) or paragraph 

(g)(3)(i)(C) of this section or on or after 

October 7, 2001, meets the criteria of 

paragraph (g)(3)(i)(D) or (E) of this 

section: 

(A) The family member’s active duty 

sponsor has been assigned permanent 

duty as a recruiter; as an instructor at an 

educational institution, an administrator 

of a program, or to provide 

administrative services in support of a 

program of instruction for the Reserve 

Officers’ Training Corps; as a full-time 

adviser to a unit of a reserve component; 

or any other permanent duty designated 

by the Director that the Director 

determines is more than 50 miles, or 

approximately one hour driving time, 

from the nearest military treatment 

facility that is adequate to provide care. 

(B) The family members and active 

duty sponsor, pursuant to the 

assignment of duty described in 

paragraph (g)(3)(i)(A) of this section, 

reside at a location designated by the 

Director, that the Director determines is 

more than 50 miles, or approximately 

one hour driving time, from the nearest 

military medical treatment facility 

adequate to provide care. 

(C) The family member, having 

resided together with the active duty 

sponsor while the sponsor served in an 

assignment described in paragraph 

(g)(3)(i)(A) of this section, continues to 

reside at the same location after the 

sponsor relocates without the family 

member pursuant to orders for a 

permanent change of duty station, and 

the orders do not authorize dependents 

to accompany the sponsor to the new 

duty station at the expense of the United 

States. 

(D) For a 3 year period, the surviving 

spouse of a member who dies while on 

active duty for a period of more than 30 

days whose death occurred on or after 

October 7, 2001. 

(E) The surviving dependent child or 

unmarried person as defined in 

§ 199.3(b)(2)(ii) or (iv), of a member who 

dies while on active duty for a period 

of more than 30 days whose death 

occurred on or after October 7, 2001, for 

three years from the date the active duty 

sponsor dies or until the surviving 

eligible dependent: 

(1) Attains 21 years of age; or 

(2) Attains 23 years of age or ceases 

to pursue a full-time course of study 

prior to attaining 23 years of age, if, at 

21 years of age, the eligible surviving 

dependent is enrolled in a full-time 

course of study in a secondary school or 

in a full-time course of study in an 

institution of higher education approved 

by the Secretary of Defense and was, at 

the time of the sponsor’s death, in fact 

dependent on the member for over onehalf of such dependent’s support. 

(ii) A family member who is a 

dependent of a reserve component 

member is eligible for TRICARE Prime 

Remote for Active Duty Family 

Members if he or she is eligible for 

CHAMPUS and meets all of the 

following additional criteria: 

(A) The reserve component member 

has been ordered to active duty for a 

period of more than 30 days. 

(B) The family member resides with 

the member. 

(C) The Director, determines the 

residence of the reserve component 

member is more than 50 miles, or 

approximately one hour driving time, 

from the nearest military medical 

treatment facility that is adequate to 

provide care. 

(D) ‘‘Resides with’’ is defined as the 

TRICARE Prime Remote residence 

address at which the family resides with 

the activated reservist upon activation. 

(4) Enrollment. TRICARE Prime 

Remote for Active Duty Family 

Members requires enrollment under 

procedures set forth in paragraph (o) of 

this section or as otherwise established 

by the Director. 

(5) Health care management 

requirements under TRICARE Prime 

Remote for Active Duty Family 

Members. The additional health care 

management requirements applicable to 

Prime enrollees under paragraph (n) of 

this section are applicable under 

TRICARE Prime Remote for Active Duty 

Family Members unless the Director 

determines they are infeasible because 

of the particular remote location. 

Enrollees will be given notice of the 

applicable management requirements in 

their remote location. 

(6) Cost sharing. Beneficiary cost 

sharing requirements under TRICARE 

Prime Remote for Active Duty Family 

Members are the same as those under 

TRICARE Prime under paragraph (m) of 

this section, except that the higher 

point-of-service option cost sharing and 

deductible shall not apply to routine 

primary health care services in cases in 

which, because of the remote location, 

the beneficiary is not assigned a primary 

care manager or the Director determines 

that care from a TRICARE network 

provider is not available within the 


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TRICARE access standards under 

paragraph (p)(5) of this section. The 

higher point-of-service option cost 

sharing and deductible shall apply to 

specialty health care services received 

by any TRICARE Prime Remote for 

Active Duty Family Members enrollee 

unless an appropriate referral/ 

preauthorization is obtained as required 

by paragraph (n) of this section under 

TRICARE Prime. In the case of 

pharmacy services under § 199.21, 

where the Director determines that no 

TRICARE network retail pharmacy has 

been established within a reasonable 

distance of the residence of the 

TRICARE Prime Remote for Active Duty 

Family Members enrollee, cost sharing 

applicable to TRICARE network retail 

pharmacies will be applicable to all 

CHAMPUS eligible pharmacies in the 

remote area. 

(h) Resource sharing agreements. 

Under the TRICARE program, any 

military medical treatment facility 

(MTF) commander may establish 

resource sharing agreements with the 

applicable managed care support 

contractor for the purpose of providing 

for the sharing of resources between the 

two parties. Internal resource sharing 

and external resource sharing 

agreements are authorized. The 

provisions of this paragraph (h) shall 

apply to resource sharing agreements 

under the TRICARE program. 

(1) In connection with internal 

resource sharing agreements, beneficiary 

cost sharing requirements shall be the 

same as those applicable to health care 

services provided in facilities of the 

uniformed services. 

(2) Under internal resource sharing 

agreements, the double coverage 

requirements of § 199.8 shall be 

replaced by the Third Party Collection 

procedures of 32 CFR part 220, to the 

extent permissible under such part. In 

such a case, payments made to a 

resource sharing agreement provider 

through the TRICARE managed care 

support contractor shall be deemed to 

be payments by the MTF concerned. 

(3) Under internal or external resource 

sharing agreements, the commander of 

the MTF concerned may authorize the 

provision of services, pursuant to the 

agreement, to Medicare-eligible 

beneficiaries, if such services are not 

reimbursable by Medicare, and if the 

commander determines that this will 

promote the most cost-effective 

provision of services under the 

TRICARE program. 

(4) Under external resource sharing 

agreements, there is no cost sharing 

applicable to services provided by 

military facility personnel. Cost sharing 

for non-MTF institutional and related 

ancillary charges shall be as applicable 

to services provided under TRICARE 

Prime or TRICARE Select, as 

appropriate. 

(i) General quality assurance, 

utilization review, and preauthorization 

requirements under the TRICARE 

program. All quality assurance, 

utilization review, and preauthorization 

requirements for the basic CHAMPUS 

program, as set forth in this part (see 

especially applicable provisions in 

§§ 199.4 and 199.15), are applicable to 

Prime and Select except as provided in 

this chapter. Pursuant to an agreement 

between a military medical treatment 

facility and TRICARE managed care 

support contractor, quality assurance, 

utilization review, and preauthorization 

requirements and procedures applicable 

to health care services outside the 

military medical treatment facility may 

be made applicable, in whole or in part, 

to health care services inside the 

military medical treatment facility. 

(j) Pharmacy services. Pharmacy 

services under Prime and Select are as 

provided in the Pharmacy Benefits 

Program (see § 199.21). 

(k) Design of cost sharing structures 

under TRICARE Prime and TRICARE 

Select—(1) In general. The design of the 

cost sharing structures under TRICARE 

Prime and TRICARE Select includes 

several major factors: beneficiary 

category (e.g., active duty family 

member category or retired category, 

and there are some special rules for 

survivors of active duty deceased 

sponsors and medically retired members 

and their dependents); date of initial 

military affiliation (i.e., before or on or 

after January 1, 2018), category of health 

care service received, and network or 

non-network status of the provider. 

(2) Categories of health care services. 

This paragraph (k)(2) describes the 

categories of health care services 

relevant to determining copayment 

amounts. 

(i) Preventive care visits. These are 

outpatient visits and related services 

described in paragraph (f)(2) of this 

section. There are no cost sharing 

requirements for preventive care listed 

under §§ 199.4(e)(28)(i) through (iv) and 

199.17(f)(2). Beneficiaries shall not be 

required to pay any portion of the cost 

of these preventive services even if the 

beneficiary has not satisfied any 

applicable deductible for that year. 

(ii) Primary care outpatient visits. 

These are outpatient visits, not 

occurring in an ER or urgent care center, 

with the following provider specialties: 

(A) General Practice. 

(B) Family Practice. 

(C) Internal Medicine. 

(D) OB/GYN. 

(E) Pediatrics. 

(F) Physician’s Assistant. 

(G) Nurse Practitioner. 

(H) Nurse Midwife. 

(iii) Specialty care outpatient visits. 

This category applies to outpatient care 

provided by provider specialties other 

than those listed under primary care 

outpatient visits under paragraph 

(k)(2)(ii) of this section and not 

specifically included in one of the other 

categories of care (e.g., emergency room 

visits etc.) under paragraph (k)(2) of this 

section. This category also includes 

partial hospitalization services, 

intensive outpatient treatment, and 

opioid treatment program services. The 

per visit fee shall be applied on a per 

day basis on days services are received, 

with the exception of opioid treatment 

program services reimbursed in 

accordance with 

§ 199.14(a)(2)(ix)(A)(3)(i) which per visit 

fee will apply on a weekly basis. 

(iv) Emergency room visits. 

(v) Urgent care center visits. 

(vi) Ambulance services. This is for 

ground ambulance services. 

(vii) Ambulatory surgery. This is for 

facility-based outpatient ambulatory 

surgery services. 

(viii) Inpatient hospital admissions. 

(ix) Skilled nursing facility or 

rehabilitation facility admissions. This 

category includes a residential treatment 

center, or substance use disorder 

rehabilitation facility residential 

treatment program. 

(x) Durable medical equipment, 

prosthetic devices, and other authorized 

supplies. 

(xi) Outpatient prescription 

pharmaceuticals. These are addressed in 

§ 199.21. 

(3) Beneficiary categories further 

subdivided. For purposes of both 

TRICARE Prime and TRICARE Select, 

enrollment fees and cost sharing by 

beneficiary category (e.g., active duty 

family member category or retired 

category) are further differentiated 

between two groups: 

(i) Group A consists of Prime or Select 

enrollees whose sponsor originally 

enlisted or was appointed in a 

uniformed service before January 1, 

2018. 

(ii) Group B consists of Prime or 

Select enrollees whose sponsor 

originally enlisted or was appointed in 

a uniformed service on or after January 

1, 2018. 

(l) Enrollment fees and cost sharing 

(including deductibles and catastrophic 

cap) amounts. This paragraph (l) 

provides enrollment fees and cost 

sharing requirements applicable to 

TRICARE Prime and TRICARE Select 

enrollees. 


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(1) Enrollment fee and cost sharing 

under TRICARE Prime. (i) For Group A 

enrollees: 

(A) There is no enrollment fee for the 

active duty family member category. 

(B) The retired category enrollment 

fee in calendar year 2018 is equal to the 

Prime enrollment fee for fiscal year 

2017, indexed to calendar year 2018 and 

thereafter in accordance with 10 U.S.C. 

1097. The Assistant Secretary of Defense 

(Health Affairs) may exempt survivors 

of active duty deceased sponsors and 

medically retired Uniformed Services 

members and their dependents from 

future increases in enrollment fees. The 

Assistant Secretary of Defense (Health 

Affairs) may also waive the enrollment 

fee requirements for Medicare-eligible 

beneficiaries. 

(C) The cost sharing amounts are 

established annually in connection with 

the open season enrollment period. An 

amount is established for each category 

of care identified in paragraph (k)(2) of 

this section, taking into account all 

applicable statutory provisions, 

including 10 U.S.C. chapter 55. The 

amount for each category of care may 

not exceed the amount for Group B as 

set forth in 10 U.S.C. 1075a. 

(D) The catastrophic cap is $1,000 for 

active duty families and $3,000 for 

retired category families. 

(ii) For Group B enrollees, the 

enrollment fee, catastrophic cap and 

cost sharing amounts are as set forth in 

10 U.S.C. 1075a. 

(iii) For both Group A and Group B, 

for health care services obtained by a 

Prime enrollee but not obtained in 

accordance with the rules and 

procedures of Prime (e.g. failure to 

obtain a primary care manager referral 

when such a referral is required or 

seeing a non-network provider when 

Prime rules require use of a network 

provider and one is available) will not 

be paid under Prime rules but may be 

covered by the point-of-service option. 

For services obtained under the pointof-service option, the deductible is $300 

per person and $600 per family. The 

beneficiary cost share is 50 percent of 

the allowable charges for inpatient and 

outpatient care, after the deductible. 

Point-of-service charges do not count 

against the annual catastrophic cap. 

(2) Enrollment fee and cost sharing 

under TRICARE Select. (i) For Group A 

enrollees: 

(A) The enrollment fee in calendar 

years 2018 through 2020 is zero and the 

catastrophic cap is as provided in 10 

U.S.C. 1079 or 1086. The enrollment fee 

and catastrophic cap in 2021 and 

thereafter for certain beneficiaries in the 

retired category is as provided in 10 

U.S.C. 1075(e), except the enrollment 

fee and catastrophic cap adjustment 

shall not apply to survivors of active 

duty deceased sponsors and medically 

retired Uniformed Services members 

and their dependents. 

(B) The cost sharing amounts for 

network care for Group A enrollees are 

calculated for each category of care 

described in paragraph (k)(2) of this 

section by taking into account all 

applicable statutory provisions, 

including 10 U.S.C. chapter 55, as if 

TRICARE Extra and Standard programs 

were still being implemented. When 

determined practicable, including 

efficiency and effectiveness in 

administration, the amounts established 

are converted to fixed dollar amounts 

for each category of care for which a 

fixed dollar amount is established by 10 

U.S.C. 1075. When determined not to be 

practicable, as in the categories of care 

including ambulatory surgery, inpatient 

admissions, and inpatient skilled 

nursing/rehabilitation admissions, the 

calculated cost-sharing amounts are not 

converted to fixed dollar amounts. The 

fixed dollar amount for each category is 

set prospectively for each calendar year 

as the amount (rounded down to the 

nearest dollar amount) equal to 15% for 

enrollees in the active duty family 

beneficiary category or 20% for 

enrollees in the retired beneficiary 

category of the projected average 

allowable payment amount for each 

category of care during the year, as 

estimated by the Director. The projected 

average allowable payment amount for 

primary care (including urgent care) and 

specialty care outpatient appointments 

include payments for ancillary services 

(e.g., laboratory and radiology services) 

that are provided in connection with the 

respective outpatient visit. As such, 

there is no separate cost sharing for 

these ancillary services. 

(C) The cost share for care received 

from non-network providers is as 

provided in § 199.4. 

(D) The annual deductible amount is 

as provided in 10 U.S.C. 1079 or 1086. 

(ii) For Group B enrollees, the 

enrollment fee, annual deductible for 

services received while in an outpatient 

status, catastrophic cap and cost sharing 

amounts are as provided in 10 U.S.C. 

1075 and as consistent with this section. 

(3) Special cost-sharing rules. (A) 

There is no separate cost-sharing 

applicable to ancillary health care 

services obtained in conjunction with 

an outpatient primary or specialty care 

visit under TRICARE Prime or from 

network providers under TRICARE 

Select. 

(B) Cost-sharing for maternity care 

services shall be determined in 

accordance with § 199.4(e)(16). 

(4) Special transition rule for the last 

quarter of calendar year 2017. In order 

to transition enrollment fees, 

deductibles, and catastrophic caps from 

a fiscal year basis to a calendar year 

basis, the following special rules apply 

for the last quarter of calendar year 

2017: 

(A) A Prime enrollee’s enrollment fee 

for the quarter is one-fourth of the 

enrollment fee for fiscal year 2017. 

(B) The deductible amount and the 

catastrophic cap amount for fiscal year 

2017 will be applicable to the 15-month 

period of October 1, 2016 through 

December 31, 2017. 

(m) Limit on out-of-pocket costs under 

TRICARE Prime and TRICARE Select. 

For the purpose of this paragraph (m), 

out-of-pocket costs means all payments 

required of beneficiaries under 

paragraph (l) of this section, including 

enrollment fees, deductibles, and costsharing amounts, with the exception of 

point-of-service charges. In any case in 

which a family reaches their applicable 

catastrophic cap, all remaining 

payments that would have been 

required of the beneficiary under 

paragraph (l) of this section for 

authorized care, with the exception of 

applicable point-of-service charges 

pursuant to paragraph (l)(1)(iii) of this 

section, will be paid by the program for 

the remainder of that calendar year. 

(n) Additional health care 

management requirements under 

TRICARE Prime. Prime has additional, 

special health care management 

requirements not applicable under 

TRICARE Select. 

(1) Primary care manager. (i) All 

active duty members and Prime 

enrollees will be assigned a primary 

care manager pursuant to a system 

established by the Director, and 

consistent with the access standards in 

paragraph (p)(5)(i) of this section. The 

primary care manager may be an 

individual, physician, a group practice, 

a clinic, a treatment site, or other 

designation. The primary care manager 

may be part of the MTF or the Prime 

civilian provider network. The enrollee 

will be given the opportunity to register 

a preference for primary care manager 

from a list of choices provided by the 

Director. This preference will be entered 

on a TRICARE Prime enrollment form or 

similar document. Preference requests 

will be considered, but primary care 

manager assignments will be subject to 

availability under the MTF beneficiary 

category priority system under 

paragraph (d) of this section and subject 

to other operational requirements. (ii) 

Prime enrollees who are dependents of 

active duty members in pay grades E– 

1 through E–4 shall have priority over 


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other active duty dependents for 

enrollment with MTF PCMs, subject to 

MTF capacity. 

(2) Referral and preauthorization 

requirements. (i) Under TRICARE Prime 

there are certain procedures for referral 

and preauthorization. 

(A) For the purpose of this paragraph 

(n)(2), referral addresses the issue of 

who will provide authorized health care 

services. In many cases, Prime 

beneficiaries will be referred by a 

primary care manager to a medical 

department of an MTF if the type of care 

needed is available at the MTF. In such 

a case, failure to adhere to that referral 

will result in the care being subject to 

point-of-service charges. In other cases, 

a referral may be to the civilian provider 

network, and again, point-of-service 

charges would apply to a failure to 

follow the referral. 

(B) In contrast to referral, 

preauthorization addresses the issue of 

whether particular services may be 

covered by TRICARE, including 

whether they appear necessary and 

appropriate in the context of the 

patient’s diagnosis and circumstances. 

A major purpose of preauthorization is 

to prevent surprises about coverage 

determinations, which are sometimes 

dependent on particular details 

regarding the patient’s condition and 

circumstances. While TRICARE Prime 

has referral requirements that do not 

exist for TRICARE Select, TRICARE 

Select has some preauthorization 

requirements that do not exist for 

TRICARE Prime. 

(ii) Except as otherwise provided in 

this paragraph (n)(2), a beneficiary 

enrolled in TRICARE Prime is required 

to obtain a referral for care through a 

designated primary care manager (or 

other authorized care coordinator) prior 

to obtaining care under the TRICARE 

program. 

(iii) There is no referral requirement 

under paragraph (n)(2)(i) of this section 

in the following circumstances: 

(A) In emergencies; 

(B) For urgent care services for a 

certain number of visits per year (zero 

to unlimited), with the number 

specified by the Director and notice 

provided in connection with the open 

season enrollment period preceding the 

plan year; and 

(C) In any other special circumstances 

identified by the Director, generally 

with notice provided in connection with 

the open season enrollment period for 

the plan year. 

(iv) A primary care manager who 

believes a referral to a specialty care 

provider is medically necessary and 

appropriate need not obtain preauthorization from the managed care 

support contractor before referring a 

patient to a network specialty care 

provider. Such preauthorization is only 

required with respect to a primary care 

manager’s referral for: 

(A) Inpatient hospitalization; 

(B) Inpatient care at a skilled nursing 

facility; 

(C) Inpatient care at a rehabilitation 

facility; and 

(D) Inpatient care at a residential 

treatment facility. 

(v) The restrictions in paragraph 

(n)(2)(iv) of this section on 

preauthorization requirements do not 

apply to any preauthorization 

requirements that are generally 

applicable under TRICARE, 

independent of TRICARE Prime 

referrals, such as: 

(A) Under the Pharmacy Benefits 

Program under 10 U.S.C. 1074g and 

§ 199.21. 

(B) For laboratory and other ancillary 

services. 

(C) Durable medical equipment. 

(vi) The cost-sharing requirement for 

a beneficiary enrolled in TRICARE 

Prime who does not obtain a referral for 

care when it is required, including care 

from a non-network provider, is as 

provided in paragraph (l)(1)(iv) of this 

section concerning point-of-service care. 

(vii) In the case of care for which 

preauthorization is not required under 

paragraph (n)(2)(iv) of this section, the 

Director may authorize a managed care 

support contractor to offer a voluntary 

pre-authorization program to enable 

beneficiaries and providers to confirm 

covered benefit status and/or medical 

necessity or to understand the criteria 

that will be used by the managed care 

support contractor to adjudicate the 

claim associated with the proposed care. 

A network provider may not be required 

to use such a program with respect to 

a referral. 

(3) Restrictions on the use of 

providers. The requirements of this 

paragraph (n)(3) shall be applicable to 

health care utilization under TRICARE 

Prime, except in cases of emergency 

care and under point-of-service option 

(see paragraph (n)(4) of this section). 

(i) Prime enrollees must obtain all 

primary health care from the primary 

care manager or from another provider 

to which the enrollee is referred by the 

primary care manager or otherwise 

authorized. 

(ii) For any necessary specialty care 

and non-emergent inpatient care, the 

primary care manager or other 

authorized individual will assist in 

making an appropriate referral. 

(iii) Though referrals for specialty care 

are generally the responsibility of the 

primary care managers, subject to 

discretion exercised by the TRICARE 

Regional Directors, and established in 

regional policy or memoranda of 

understanding, specialist providers may 

be permitted to refer patients for 

additional specialty consultation 

appointment services within the 

TRICARE contractor’s network without 

prior authorization by primary care 

managers. 

(iv) The following procedures will 

apply to health care referrals under 

TRICARE Prime: 

(A) The first priority for referral for 

specialty care or inpatient care will be 

to the local MTF (or to any other MTF 

in which catchment area the enrollee 

resides). 

(B) If the local MTF(s) are unavailable 

for the services needed, but there is 

another MTF at which the needed 

services can be provided, the enrollee 

may be required to obtain the services 

at that MTF. However, this requirement 

will only apply to the extent that the 

enrollee was informed at the time of (or 

prior to) enrollment that mandatory 

referrals might be made to the MTF 

involved for the service involved. 

(C) If the needed services are available 

within civilian preferred provider 

network serving the area, the enrollee 

may be required to obtain the services 

from a provider within the network. 

Subject to availability, the enrollee will 

have the freedom to choose a provider 

from among those in the network. 

(D) If the needed services are not 

available within the civilian preferred 

provider network serving the area, the 

enrollee may be required to obtain the 

services from a designated civilian 

provider outside the area. However, this 

requirement will only apply to the 

extent that the enrollee was informed at 

the time of (or prior to) enrollment that 

mandatory referrals might be made to 

the provider involved for the service 

involved (with the provider and service 

either identified specifically or in 

connection with some appropriate 

classification). 

(E) In cases in which the needed 

health care services cannot be provided 

pursuant to the procedures identified in 

paragraphs (n)(3)(iv)(A) through (D) of 

this section, the enrollee will receive 

authorization to obtain services from a 

TRICARE-authorized civilian 

provider(s) of the enrollee’s choice not 

affiliated with the civilian preferred 

provider network. 

(iv) When Prime is operating in noncatchment areas, the requirements in 

paragraphs (n)(3)(iv)(B) through (E) of 

this section shall apply. 

(4) Point-of-service option. TRICARE 

Prime enrollees retain the freedom to 

obtain services from civilian providers 


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on a point-of service basis. Any health 

care services obtained by a Prime 

enrollee, but not obtained in accordance 

with the rules and procedures of Prime, 

will be covered by the point-of-service 

option. In such cases, all requirements 

applicable to health benefits under 

§ 199.4 shall apply, except that there 

shall be higher deductible and cost 

sharing requirements (as set forth in 

paragraph (l)(1)(iii)) of this section). 

However, Prime rules may cover such 

services if the enrollee did not know 

and could not reasonably have been 

expected to know that the services were 

not obtained in accordance with the 

utilization management rules and 

procedures of Prime. 

(5) Prime travel benefit. In accordance 

with guidelines issues by the Assistant 

Secretary of Defense (Health Affairs), 

certain travel expenses may be 

reimbursed when a TRICARE Prime 

enrollee is referred by the primary care 

manager for medically necessary 

specialty care more than 100 miles away 

from the primary care manager’s office. 

Such guidelines shall be consistent with 

appropriate provisions of generally 

applicable Department of Defense rules 

and procedures governing travel 

expenses. 

(o) TRICARE program enrollment 

procedures. There are certain 

requirements pertaining to procedures 

for enrollment in TRICARE Prime, 

TRICARE Select, and TRICARE Prime 

Remote for Active Duty Family 

Members. (These procedures do not 

apply to active duty members, whose 

enrollment is mandatory and 

automatic.) 

(1) Annual open season enrollment. 

(i) As a general rule, enrollment (or a 

modification to a previous enrollment) 

must occur during the open season 

period prior to the plan year, which is 

on a calendar year basis. The open 

season enrollment period will be of at 

least 30 calendar days duration. An 

enrollment choice will be applicable for 

the plan year. 

(ii) Open season enrollment 

procedures may include automatic reenrollment in the same plan for the next 

plan year for enrollees or sponsors that 

will occur in the event the enrollee does 

not take other action during the open 

season period. 

(2) Exceptions to the calendar year 

enrollment process. The Director will 

identify certain qualifying events that 

may be the basis for a change in 

enrollment status during a plan year, 

such as a change in eligibility status, 

marriage, divorce, birth of a new family 

member, relocation, loss of other health 

insurance, or other events. In the case of 

such an event, a beneficiary eligible to 

enroll in a plan may newly enroll, disenroll, or modify a previous enrollment 

during the plan year. Initial payment of 

the applicable enrollment fee shall be 

collected for new enrollments in 

accordance with established procedures. 

Any applicable enrollment fee will be 

pro-rated. A beneficiary who dis-enrolls 

without enrolling at the same time in 

another plan is not eligible to enroll in 

a plan later in the same plan year unless 

there is another qualifying event. A 

beneficiary who is dis-enrolled for 

failure to pay a required enrollment fee 

installment is not eligible to re-enroll in 

a plan later in the same plan year unless 

there is another qualifying event. 

Generally, the effective date of coverage 

will coincide with the date of the 

qualifying event. 

(3) Installment payments of 

enrollment fee. The Director will 

establish procedures for installment 

payments of enrollment fees. (4) Effect 

of failure to enroll. Beneficiaries eligible 

to enroll in Prime or Select and who do 

not enroll will no longer have coverage 

under the TRICARE program until the 

next annual open season enrollment or 

they have a qualifying event, except that 

they do not lose any statutory eligibility 

for space-available care in military 

medical treatment facilities. There is a 

limited grace period exception to this 

enrollment requirement for calendar 

year 2018, as provided in section 

701(d)(3) of the National Defense 

Authorization Act for Fiscal Year 2017. 

(5) Automatic enrollment for certain 

dependents. Under 10 U.S.C. 1097a, in 

the case of dependents of active duty 

members in the grade of E–1 to E–4, 

such dependents who reside in a 

catchment area of a military treatment 

facility shall be enrolled in TRICARE 

Prime. The Director may provide for the 

automatic enrollment in TRICARE 

Prime for such dependents of active 

duty members in the grade of E–5 and 

higher. In any case of automatic 

enrollment under this paragraph (o)(5), 

the member will be provided written 

notice and the automatic enrollment 

may be cancelled at the election of the 

member. 

(6) Grace periods. The Director may 

make provisions for grace periods for 

enrollment-related actions to facilitate 

effective operation of the enrollment 

program. 

(p) Civilian preferred provider 

networks. A major feature of the 

TRICARE program is the civilian 

preferred provider network. 

(1) Status of network providers. 

Providers in the preferred provider 

network are not employees or agents of 

the Department of Defense or the United 

States Government. Although network 

providers must follow numerous rules 

and procedures of the TRICARE 

program, on matters of professional 

judgment and professional practice, the 

network provider is independent and 

not operating under the direction and 

control of the Department of Defense. 

(2) Utilization management policies. 

Preferred providers are required to 

follow the utilization management 

policies and procedures of the TRICARE 

program. These policies and procedures 

are part of discretionary judgments by 

the Department of Defense regarding the 

methods of delivering and financing 

health care services that will best 

achieve health and economic policy 

objectives. 

(3) Quality assurance requirements. A 

number of quality assurance 

requirements and procedures are 

applicable to preferred network 

providers. These are for the purpose of 

assuring that the health care services 

paid for with government funds meet 

the standards called for in the contract 

and provider agreement. 

(4) Provider qualifications. All 

preferred providers must meet the 

following qualifications: 

(i) They must be TRICARE-authorized 

providers and TRICARE- participating 

providers. In addition, a network 

provider may not require payment from 

the beneficiary for any excluded or 

excludable services that the beneficiary 

received from the network provider (i.e., 

the beneficiary will be held harmless) 

except as follows: 

(A) If the beneficiary did not inform 

the provider that he or she was a 

TRICARE beneficiary, the provider may 

bill the beneficiary for services 

provided. 

(B) If the beneficiary was informed in 

writing that the specific services were 

excluded or excludable from TRICARE 

coverage and the beneficiary agreed in 

writing, in advance of the services being 

provided, to pay for the services, the 

provider may bill the beneficiary. 

(ii) All physicians in the preferred 

provider network must have staff 

privileges in a hospital accredited by 

The Joint Commission (TJC) or other 

accrediting body determined by the 

Director. This requirement may be 

waived in any case in which a 

physician’s practice does not include 

the need for admitting privileges in such 

a hospital, or in locations where no 

accredited facility exists. However, in 

any case in which the requirement is 

waived, the physician must comply 

with alternative qualification standards 

as are established by the Director. 

(iii) All preferred providers must 

agree to follow all quality assurance, 

utilization management, and patient 


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referral procedures established pursuant 

to this section, to make available to 

designated DoD utilization management 

or quality monitoring contractors 

medical records and other pertinent 

records, and to authorize the release of 

information to MTF Commanders 

regarding such quality assurance and 

utilization management activities. 

(iv) All preferred network providers 

must be Medicare participating 

providers, unless this requirement is 

waived based on extraordinary 

circumstances. This requirement that a 

provider be a Medicare participating 

provider does not apply to providers 

who not eligible to be participating 

providers under Medicare. 

(v) The network provider must be 

available to all TRICARE beneficiaries. 

(vi) The provider must agree to accept 

the same payment rates negotiated for 

Prime enrollees for any person whose 

care is reimbursable by the Department 

of Defense, including, for example, 

Select participants, supplemental care 

cases, and beneficiaries from outside the 

area. 

(vii) All preferred providers must 

meet all other qualification 

requirements, and agree to comply with 

all other rules and procedures 

established for the preferred provider 

network. 

(viii) In locations where TRICARE 

Prime is not available, a TRICARE 

provider network will, to the extent 

practicable, be available for TRICARE 

Select enrollees. In these locations, the 

minimal requirements for network 

participation are those set forth in 

paragraph (p)(4)(i) of this section. Other 

requirements of this paragraph (p) will 

apply unless waived by the Director. 

(5) Access standards. Preferred 

provider networks will have attributes 

of size, composition, mix of providers 

and geographical distribution so that the 

networks, coupled with the MTF 

capabilities (when applicable), can 

adequately address the health care 

needs of the enrollees. In the event that 

a Prime enrollee seeks to obtain from 

the managed care support contractor an 

appointment for care but is not offered 

an appointment within the access time 

standards from a network provider, the 

enrollee will be authorized to receive 

care from a non-network provider 

without incurring the additional fees 

associated with point-of-service care. 

The following are the access standards: 

(i) Under normal circumstances, 

enrollee travel time may not exceed 30 

minutes from home to primary care 

delivery site unless a longer time is 

necessary because of the absence of 

providers (including providers not part 

of the network) in the area. 

(ii) The wait time for an appointment 

for a well-patient visit or a specialty 

care referral shall not exceed four 

weeks; for a routine visit, the wait time 

for an appointment shall not exceed one 

week; and for an urgent care visit the 

wait time for an appointment shall 

generally not exceed 24 hours. 

(iii) Emergency services shall be 

available and accessible to handle 

emergencies (and urgent care visits if 

not available from other primary care 

providers pursuant to paragraph 

(p)(5)(ii) of this section), within the 

service area 24 hours a day, seven days 

a week. 

(iv) The network shall include a 

sufficient number and mix of board 

certified specialists to meet reasonably 

the anticipated needs of enrollees. 

Travel time for specialty care shall not 

exceed one hour under normal 

circumstances, unless a longer time is 

necessary because of the absence of 

providers (including providers not part 

of the network) in the area. This 

requirement does not apply under the 

Specialized Treatment Services 

Program. 

(v) Office waiting times in 

nonemergency circumstances shall not 

exceed 30 minutes, except when 

emergency care is being provided to 

patients, and the normal schedule is 

disrupted. 

(6) Special reimbursement methods 

for network providers. The Director, 

may establish, for preferred provider 

networks, reimbursement rates and 

methods different from those 

established pursuant to § 199.14. Such 

provisions may be expressed in terms of 

percentage discounts off CHAMPUS 

allowable amounts, or in other terms. In 

circumstances in which payments are 

based on hospital-specific rates (or other 

rates specific to particular institutional 

providers), special reimbursement 

methods may permit payments based on 

discounts off national or regional 

prevailing payment levels, even if 

higher than particular institutionspecific payment rates. 

(q) Preferred provider network 

establishment. (1) The any qualified 

provider method may be used to 

establish a civilian preferred provider 

network. Under this method, any 

TRICARE-authorized provider that 

meets the qualification standards 

established by the Director, or designee, 

may become a part of the preferred 

provider network. Such standards must 

be publicly announced and uniformly 

applied. Also under this method, any 

provider who meets all applicable 

qualification standards may not be 

excluded from the preferred provider 

network. Qualifications include: 

(i) The provider must meet all 

applicable requirements in paragraph 

(p)(4) of this section. 

(ii) The provider must agree to follow 

all quality assurance and utilization 

management procedures established 

pursuant to this section. 

(iii) The provider must be a 

participating provider under TRICARE 

for all claims. 

(iv) The provider must meet all other 

qualification requirements, and agree to 

all other rules and procedures, that are 

established, publicly announced, and 

uniformly applies by the Director (or 

other authorized official). 

(v) The provider must sign a preferred 

provider network agreement covering all 

applicable requirements. Such 

agreements will be for a duration of one 

year, are renewable, and may be 

canceled by the provider or the Director 

(or other authorized official) upon 

appropriate notice to the other party. 

The Director shall establish an 

agreement model or other guidelines to 

promote uniformity in the agreements. 

(2) In addition to the above 

requirements, the Director, or designee, 

may establish additional categories of 

preferred providers of high quality/high 

value that require additional 

qualifications. 

(r) General fraud, abuse, and conflict 

of interest requirements under TRICARE 

program. All fraud, abuse, and conflict 

of interest requirements for the basic 

CHAMPUS program, as set forth in this 

part (see especially applicable 

provisions of § 199.9) are applicable to 

the TRICARE program. 

(s) [Reserved] 

(t) Inclusion of Department of 

Veterans Affairs Medical Centers in 

TRICARE networks. TRICARE preferred 

provider networks may include 

Department of Veterans Affairs health 

facilities pursuant to arrangements, 

made with the approval of the Assistant 

Secretary of Defense (Health Affairs), 

between those centers and the Director, 

or designated TRICARE contractor. 

(u) Care provided outside the United 

States. The TRICARE program is not 

automatically implemented in all 

respects outside the United States. This 

paragraph (u) sets forth the provisions of 

this section applicable to care received 

outside the United States under the 

following TRICARE health plans. 

(1) TRICARE Prime. The Director may, 

in conjunction with implementation of 

the TRICARE program, authorize a 

special Prime program for command 

sponsored dependents of active duty 

members who accompany the members 

in their assignments in foreign 

countries. Under this special program, a 

preferred provider network may be 


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established through contracts or 

agreements with selected health care 

providers. Under the network, Prime 

covered services will be provided to the 

enrolled covered dependents subject to 

applicable Prime deductibles, 

copayments, and point-of-service 

charges. To the extent practicable, rules 

and procedures applicable to TRICARE 

Prime under this section shall apply 

unless specific exemptions are granted 

in writing by the Director. The use of 

this authority by the Director for any 

particular geographical area will be 

published on the primary publicly 

available Internet Web site of the 

Department and on the publicly 

available Internet Web site of the 

managed care support contractor that 

has established the provider network 

under the TRICARE program. Published 

information will include a description 

of the preferred provider network 

program and other pertinent 

information. The Director shall also 

issue policies, instructions, and 

guidelines necessary to implement this 

special program. 

(2) TRICARE Select. The TRICARE 

Select option shall be available outside 

the United States except that a preferred 

provider network of providers shall only 

be established in areas where the 

Director determines that it is 

economically in the best interest of the 

Department of Defense. In such a case, 

the Director shall establish a preferred 

provider network through contracts or 

agreements with selected health care 

providers for eligible beneficiaries to 

receive covered benefits subject to the 

enrollment and cost-sharing amounts 

applicable to the specific category of 

beneficiary. When an eligible 

beneficiary, other than a TRICARE for 

Life beneficiary, receives covered 

services from an authorized TRICARE 

non-network provider, including in 

areas where a preferred provider 

network has not been established by the 

Director, the beneficiary shall be subject 

to cost-sharing amounts applicable to 

out-of-network care. To the extent 

practicable, rules and procedures 

applicable to TRICARE Select under this 

section shall apply unless specific 

exemptions are granted in writing by the 

Director. The use of this authority by the 

Director to establish a TRICARE 

preferred provider network for any 

particular geographical area will be 

published on the primary publicly 

available Internet Web site of the 

Department and on the publicly 

available Internet Web site of the 

managed care support contractor that 

has established the provider network 

under the TRICARE program. Published 

information will include a description 

of the preferred provider network 

program and other pertinent 

information. The Director shall also 

issue policies, instructions, and 

guidelines necessary to implement this 

special program. 

(3) TRICARE for Life. The TRICARE 

for Life (TFL) option shall be available 

outside the United States. Eligible TFL 

beneficiaries may receive covered 

services and supplies authorized under 

§ 199.4, subject to the applicable 

catastrophic cap, deductibles and costshares under § 199.4, whether received 

from a network provider or any 

authorized TRICARE provider not in a 

preferred provider network. However, if 

a TFL beneficiary receives covered 

services from a PPN provider, the 

beneficiary’s out-of-pocket costs will 

generally be lower. 

(v) Administration of the TRICARE 

program in the state of Alaska. In view 

of the unique geographical and 

environmental characteristics impacting 

the delivery of health care in the state 

of Alaska, administration of the 

TRICARE program in the state of Alaska 

will not include financial underwriting 

of the delivery of health care by a 

TRICARE contractor. All other 

provisions of this section shall apply to 

administration of the TRICARE program 

in the state of Alaska as they apply to 

the other 49 states and the District of 

Columbia. 

(w) Administrative procedures. The 

Assistant Secretary of Defense (Health 

Affairs), the Director, and MTF 

Commanders (or other authorized 

officials) are authorized to establish 

administrative requirements and 

procedures, consistent with this section, 

this part, and other applicable DoD 

Directives or Instructions, for the 

implementation and operation of the 

TRICARE program. 

§ 199.18 [Removed and Reserved] 

■ 10. Section 199.18 is removed and 

reserved. 

■ 11. Section 199.20 is amended by: 

■ a. Revising paragraph (a); 

■ b. Removing the words ‘‘TRICARE 

Standard program’’ and adding in their 

place the words ‘‘TRICARE Select 

program’’ in paragraph (c); 

■ c. Revising paragraphs (d)(7)(i)(D) 

introductory text, (d)(7)(i)(D)(1) and (2), 

and (e)(1) and (3); 

■ d. Removing the words ‘‘TRICARE 

Standard’’ and adding in their place the 

words ‘‘TRICARE Select program’’ in 

paragraphs (f) through (n); 

■ e. Removing and reserving paragraph 

(o); 

■ f. Revising paragraph (p)(1); 

■ g. Removing the semicolon at the end 

of paragraph (p)(2)(iii) and adding ‘‘; 

and’’ in its place; 

■ h. Revising paragraph (p)(2)(iv); and 

■ i. Removing paragraph (p)(2)(v). 

The revisions and additions read as 

follows: 

§ 199.20 Continued Health Care Benefit 

Program (CHCBP). 

(a) Purpose. The CHCBP is a 

premium-based temporary health care 

coverage program, authorized by 10 

U.S.C. 1078a, and available to 

individuals who meet the eligibility and 

enrollment criteria as set forth in 

paragraph (d)(1) of this section. The 

CHCBP is not part of the TRICARE 

program. However, as set forth in this 

section, it functions under similar rules 

and procedures to the TRICARE Select 

program. Because the purpose of the 

CHCBP is to provide a continuation 

health care benefit for Department of 

Defense and the other uniformed 

services beneficiaries losing eligibility, 

it will be administered so that it 

appears, to the maximum extent 

practicable, to be part of the TRICARE 

Select program. Medical coverage under 

this program will be the same as the 

benefits payable under the TRICARE 

Select program. There is a cost for 

enrollment to the CHCBP and these 

premium costs must be paid by CHCBP 

enrollees before any care may be cost 

shared. 

* * * * * 

(d) * * * 

(7) * * * 

(i) * * * 

(D) In the case of a former spouse of 

a member or former member (other than 

the former spouse whose marriage was 

dissolved after the separation of the 

member from the service unless such 

separation was by retirement), the 

period of coverage under the CHCBP is 

unlimited, if former spouse: 

(1) Has not remarried before age of 55 

after the marriage to the member or 

former member was dissolved; and 

(2) Was eligible for TRICARE as a 

dependent or enrolled in CHCBP at any 

time during the 18 month period before 

the date of the divorce, dissolution, or 

annulment; and 

* * * * * 

(e) * * * 

(1) In general. Except as provided in 

paragraph (e)(2) of this section, the 

provisions of § 199.4 shall apply to the 

CHCBP as they do to TRICARE Select 

under § 199.17. 

* * * * * 

(3) Beneficiary liability. For purposes 

of CHCBP coverage, the beneficiary 

deductible, catastrophic cap and cost 


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share provisions of the TRICARE Select 

plan applicable to Group B beneficiaries 

under § 199.17(l)(2)(ii) shall apply based 

on the category of beneficiary (e.g., 

Active Duty Family Member or Retiree 

Family) to which the CHCBP enrollee 

last belonged, except that for separating 

active duty members, amounts 

applicable to TRICARE Select Active 

Duty Family Members shall apply. The 

premium under paragraph (q) of this 

section applies instead of any TRICARE 

Select plan enrollment fee under 

§ 199.17. 

* * * * * 

(p) * * * 

(1) In general. Special programs 

established under this part that are not 

part of the TRICARE Select program are 

not, unless specifically provided in this 

section, available to participants in the 

CHCBP. 

(2) * * * 

(iv) The TRICARE Prime Program 

under § 199.17. 

* * * * * 

■ 12. Section 199.21 is amended by: 

■ a. Revising paragraphs (i)(2) 

introductory text and (i)(2)(i) through 

(iv); 

■ b. Removing and reserving paragraph 

(i)(2)(v); and 

■ c. Revising paragraphs (i)(2)(vi) 

through (viii) and (i)(2)(x)(A). 

The revisions read as follows: 

§ 199.21 TRICARE Pharmacy Benefits 

Program. 

* * * * * 

(i) * * * 

(2) Cost-sharing amounts. Active duty 

members of the uniformed services do 

not pay cost-shares or annual 

deductibles. For other categories of 

beneficiaries, after applicable annual 

deductibles are met, cost-sharing 

amounts prior to October 1, 2016, are set 

forth in this paragraph (i)(2). 

(i) For pharmaceutical agents obtained 

from a military treatment facility, there 

is no cost-sharing or annual deductible. 

(ii) For pharmaceutical agents 

obtained from a retail network 

pharmacy there is a: 

(A) $24.00 cost-share per prescription 

required for up to a 30-day supply of a 

formulary pharmaceutical agent. 

(B) $10.00 cost-share per prescription 

for up to a 30-day supply of a generic 

pharmaceutical agent. 

(C) $0.00 cost-share for vaccines/ 

immunizations authorized as preventive 

care for eligible beneficiaries. 

(iii) For formulary and generic 

pharmaceutical agents obtained from a 

retail non-network pharmacy, except as 

provided in paragraph (i)(2)(vi) of this 

section, there is a 20 percent or $20.00 

cost-share (whichever is greater) per 

prescription for up to a 30-day supply 

of the pharmaceutical agent. 

(iv) For pharmaceutical agents 

obtained under the TRICARE mail-order 

program there is a: 

(A) $20 cost-share per prescription for 

up to a 90-day supply of a formulary 

pharmaceutical agent. 

(B) $0.00 cost-share for up to a 90-day 

supply of a generic pharmaceutical 

agent. 

(C) $49.00 cost-share for up to a 90- 

day supply of a non-formulary 

pharmaceutical agent. 

(D) $0.00 cost-share for smoking 

cessation pharmaceutical agents covered 

under the smoking cessation program. 

* * * * * 

(vi) For TRICARE Prime beneficiaries 

there is no annual deductible applicable 

for pharmaceutical agents obtained from 

retail network pharmacies or the 

TRICARE mail-order program. However, 

for TRICARE Prime beneficiaries who 

obtain formulary or generic 

pharmaceutical agents from retail nonnetwork pharmacies, an enrollment year 

deductible of $300 per person and $600 

per family must be met after which 

there is a beneficiary cost-share of 50 

percent per prescription for up to a 30- 

day supply of the pharmaceutical agent. 

(vii) For TRICARE Select beneficiaries 

the annual deductible which must be 

met before the cost-sharing amounts for 

pharmaceutical agents in paragraph 

(i)(2) of this section are applicable is as 

provided for each category of TRICARE 

Select enrollee in § 199.17(l)(2). 

(viii) For TRICARE beneficiaries not 

otherwise qualified to enroll in 

TRICARE Prime or Select, the annual 

deductible which must be met before 

the cost-sharing amounts for 

pharmaceutical agents in paragraph 

(i)(2) of this section are applicable is as 

provided in § 199.4(f). 

* * * * * 

(x) * * * 

(A) Beginning October 1, 2016, the 

amounts specified in this paragraph 

(i)(2) shall be increased annually by the 

percentage increase in the cost-of-living 

adjustment by which retired pay is 

increased under 10 U.S.C. 1401a for the 

year. If the amount of the increase is 

equal to or greater than 50 cents, the 

amount of the increase shall be rounded 

to the nearest multiple of $1. If the 

amount of the increase is less than 50 

cents, the increase shall not be made for 

that year, but shall be carried over to, 

and accumulated with, the amount of 

the increase for the subsequent year or 

years and made when the aggregate 

amount of increases for a year is equal 

to or greater than 50 cents. 

* * * * * 

■ 13. In § 199.22, paragraph (a) is 

revised to read as follows: 

§ 199.22 TRICARE Retiree Dental Program 

(TRDP). 

(a) Establishment. The TRDP is a 

premium based indemnity dental 

insurance coverage program that will be 

available to certain retirees and their 

surviving spouses, their dependents, 

and certain other beneficiaries, as 

specified in paragraph (d) of this 

section. The TRDP is authorized by 10 

U.S.C. 1076c. 

(1) The Director will, except as 

authorized in paragraph (a)(2) of this 

section, make available a premium 

based indemnity dental insurance plan 

for eligible TRDP beneficiaries specified 

in paragraph (d) of this section 

consistent with the provisions of this 

section. 

(2) The TRDP premium based 

indemnity dental insurance program 

under paragraph (a) of this section may 

be provided by allowing eligible 

beneficiaries specified in paragraph (d) 

of this section to enroll in an insurance 

plan under chapter 89A of title 5, 

United States Code that provides 

benefits similar to those benefits 

provided under paragraph (f) of this 

section. Such enrollment shall be 

authorized pursuant to an agreement 

entered into between the Department of 

Defense and the Office of Personnel 

Management which agreement, in the 

event of any inconsistency, shall take 

precedence over provisions in this 

section. 

* * * * * 

■ 14. Section 199.24 is amended by 

revising paragraphs (a) introductory 

text, (a)(4)(i) heading, (a)(4)(i)(A), 

(a)(4)(iv), (c) introductory text, (d) 

introductory text, (d)(1)(ii) and (iii), 

(d)(2) and (3), (f), and (g)(1) to read as 

follows: 

§ 199.24 TRICARE Reserve Select. 

(a) Establishment. TRICARE Reserve 

Select offers the TRICARE Select selfmanaged, preferred-provider network 

option under § 199.17 to qualified 

members of the Selected Reserve, their 

immediate family members, and 

qualified survivors under this section. 

* * * * * 

(4) * * * 

(i) TRICARE Select rules applicable. 

(A) Unless specified in this section or 

otherwise prescribed by the Director, 

provisions of TRICARE Select under 

§ 199.17 apply to TRICARE Reserve 

Select. 

* * * * * 

(iv) Benefits. When their coverage 

becomes effective, TRICARE Reserve 


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Select beneficiaries receive the 

TRICARE Select benefit including 

access to military treatment facility 

services and pharmacies, as described in 

§§ 199.17 and 199.21. TRICARE Reserve 

Select coverage features the deductible, 

catastrophic cap and cost share 

provisions of the TRICARE Select plan 

applicable to Group B active duty family 

members under § 199.17(l)(2)(ii) for both 

the member and the member’s covered 

family members; however, the TRICARE 

Reserve Select premium under 

paragraph (c) of this section applies 

instead of any TRICARE Select plan 

enrollment fee under § 199.17. Both the 

member and the member’s covered 

family members are provided access 

priority for care in military treatment 

facilities on the same basis as active 

duty service members’ dependents who 

are not enrolled in TRICARE Prime as 

described in § 199.17(d)(1)(i)(D). 

* * * * * 

(c) TRICARE Reserve Select 

premiums. Members are charge 

premiums for coverage under TRICARE 

Reserve Select that represent 28 percent 

of the total annual premium amount 

that the Director determines on an 

appropriate actuarial basis as being 

appropriate for coverage under the 

TRICARE Select benefit for the 

TRICARE Reserve Select eligible 

population. Premiums are to be paid 

monthly, except as otherwise provided 

through administrative implementation, 

pursuant to procedures established by 

the Director. The monthly rate for each 

month of a calendar year is one-twelfth 

of the annual rate for that calendar year. 

* * * * * 

(d) Procedures. The Director may 

establish procedures for the following. 

(1) * * * 

(ii) Qualifying event. Procedures for 

qualifying events in TRICARE Select 

plans under § 199.17(o) shall apply to 

TRICARE Reserve Select coverage. 

Additionally, the Director may identify 

other events unique to needs of the 

Reserve Components as qualifying 

events. 

(iii) Enrollment. Procedures for 

enrollment in TRICARE Select plans 

under § 199.17(o) shall apply to 

TRICARE Reserve Select enrollment. 

Generally, the effective date of coverage 

will coincide with the first day of a 

month unless enrollment is due to a 

qualifying event and a different date on 

or after the qualifying event is required 

to prevent a lapse in health care 

coverage. 

* * * * * 

(2) Termination. Termination of 

coverage for the TRS member/survivor 

will result in termination of coverage for 

the member’s/survivor’s family 

members in TRICARE Reserve Select. 

Procedures may be established for 

coverage to be terminated as follows. 

(i) Coverage shall terminate when 

members or survivors no longer qualify 

for TRICARE Reserve Select as specified 

in paragraph (b) of this section, with one 

exception. If a member is involuntarily 

separated from the Selected Reserve 

under other than adverse conditions, as 

characterized by the Secretary 

concerned, and is covered by TRICARE 

Reserve Select on the last day of his or 

her membership in the Selected 

Reserve, then TRICARE Reserve Select 

coverage may terminate up to 180 days 

after the date on which the member was 

separated from the Selected Reserve. 

This applies regardless of type of 

coverage. This exception expires 

December 31, 2018. 

(ii) Coverage may terminate for 

members, former members, and 

survivors who gain coverage under 

another TRICARE program. 

(iii) In accordance with the provisions 

of § 199.17(o)(2) coverage terminates for 

members/survivors who fail to make 

premium payments in accordance with 

established procedures. 

(iv) Coverage may be terminated for 

members/survivors upon request at any 

time by submitting a completed request 

in the appropriate format in accordance 

with established procedures. 

(3) Re-enrollment following 

termination. Absent a new qualifying 

event, members/survivors (subject to 

paragraph (d)(1)(iv) of this section) are 

not eligible to re-enroll in TRICARE 

Reserve Select until the next annual 

open season. 

* * * * * 

(f) Administration. The Director may 

establish other rules and procedures for 

the effective administration of TRICARE 

Reserve Select, and may authorize 

exceptions to requirements of this 

section, if permitted by law. 

(g) * * * 

(1) Coverage. This term means the 

medical benefits covered under the 

TRICARE Select program as further 

outlined in § 199.17 whether delivered 

in military treatment facilities or 

purchased from civilian sources. 

* * * * * 

■ 15. Section 199.25 is amended by 

revising paragraphs (a) introductory 

text, (a)(4)(i) heading, (a)(4)(i)(A), 

(a)(4)(iv), (c) introductory text, (d) 

introductory text, (d)(1)(ii) and (iii), 

(d)(2) and (3), (f), and (g)(1) to read as 

follows: 

§ 199.25 TRICARE Retired Reserve. 

(a) Establishment. TRICARE Retired 

Reserve offers the TRICARE Select selfmanaged, preferred-provider network 

option under § 199.17 to qualified 

members of the Retired Reserve, their 

immediate family members, and 

qualified survivors under this section. 

* * * * * 

(4) * * * 

(i) TRICARE Select rules applicable. 

(A) Unless specified in this section or 

otherwise prescribed by the ASD (HA), 

provisions of TRICARE Select under 

§ 199.17 apply to TRICARE Retired 

Reserve. 

* * * * * 

(iv) Benefits. When their coverage 

becomes effective, TRICARE Retired 

Reserve beneficiaries receive the 

TRICARE Select benefit including 

access to military treatment facilities on 

a space available basis and pharmacies, 

as described in § 199.17. TRICARE 

Retired Reserve coverage features the 

deductible, cost sharing, and 

catastrophic cap provisions of the 

TRICARE Select plan applicable to 

Group B retired members and 

dependents of retired members under 

§ 199.17(l)(2)(ii); however, the TRICARE 

Reserve Select premium under 

paragraph (c) of this section applies 

instead of any TRICARE Select plan 

enrollment fee under § 199.17. Both the 

member and the member’s covered 

family members are provided access 

priority for care in military treatment 

facilities on the same basis as retired 

members and their dependents who are 

not enrolled in TRICARE Prime as 

described in § 199.17(d)(1)(i)(E). 

* * * * * 

(c) TRICARE Retired Reserve 

premiums. Members are charged for 

coverage under TRICARE Retired 

Reserve that represent the full cost of 

the program as determined by the 

Director utilizing an appropriate 

actuarial basis for the provision of the 

benefits provided under the TRICARE 

Select program for the TRICARE Retired 

Reserve eligible beneficiary population. 

Premiums are to be paid monthly, 

except as otherwise provided through 

administrative implementation, 

pursuant to procedures established by 

the Director. The monthly rate for each 

month of a calendar year is one-twelfth 

of the annual rate for that calendar year. 

* * * * * 

(d) Procedures. The Director may 

establish procedures for the following. 

(1) * * * 

(ii) Qualifying event. Procedures for 

qualifying events in TRICARE Select 

plans under § 199.17(o) shall apply to 

TRICARE Retired Reserve coverage. 

(iii) Enrollment. Procedures for 

enrollment in TRICARE Select plans 

under § 199.17(o) shall apply to 


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TRICARE Retired Reserve enrollment. 

Generally, the effective date of coverage 

will coincide with the first day of a 

month unless enrollment is due to a 

qualifying event and a different date on 

or after the qualifying event is required 

to prevent a lapse in health care 

coverage. 

* * * * * 

(2) Termination. Termination of 

coverage for the TRR member/survivor 

will result in termination of coverage for 

the member’s/survivor’s family 

members in TRICARE Retired Reserve. 

Procedures may be established for 

coverage to be terminated as follows. 

(i) Coverage shall terminate when 

members or survivors no longer qualify 

for TRICARE Retired Reserve as 

specified in paragraph (c) of this 

section. For purposes of this section, the 

member or their survivor no longer 

qualifies for TRICARE Retired Reserve 

when the member has been eligible for 

coverage in a health benefits plan under 

Chapter 89 of Title 5, U.S.C. for more 

than 60 days. Further, coverage shall 

terminate when the Retired Reserve 

member attains the age of 60 or, if 

survivor coverage is in effect, when the 

deceased Retired Reserve member 

would have attained the age of 60. 

(ii) Coverage may terminate for 

members, former members, and 

survivors who gain coverage under 

another TRICARE program. 

(iii) In accordance with the provisions 

of § 199.17(o)(2) coverage terminates for 

members/survivors who fail to make 

premium payments in accordance with 

established procedures. 

(iv) Coverage may be terminated for 

members/survivors upon request at any 

time by submitting a completed request 

in the appropriate format in accordance 

with established procedures. 

(3) Re-enrollment following 

termination. Absent a new qualifying 

event, members/survivors are not 

eligible to re-enroll in TRICARE Retired 

Reserve until the next annual open 

season. 

* * * * * 

(f) Administration. The Director may 

establish other rules and procedures for 

the effective administration of TRICARE 

Retired Reserve, and may authorize 

exceptions to requirements of this 

section, if permitted by law. 

(g) * * * 

(1) Coverage. This term means the 

medical benefits covered under the 

TRICARE Select program as further 

outlined in § 199.17 whether delivered 

in military treatment facilities or 

purchased from civilian sources. 

* * * * * 

■ 16. Section 199.26 is amended by: 

■ a. Revising paragraphs (a) 

introductory text, (a)(4)(i)(C), (a)(4)(i)(D) 

introductory text, and (a)(4)(ii) and (iv); 

■ b. Removing paragraph (a)(4)(v); 

■ c. Revising paragraphs (c) 

introductory text, (d) introductory text, 

and (d)(1)(ii); 

■ d. Removing paragraph (d)(1)(iii); 

■ e. Revising paragraphs (d)(2) 

introductory text, (d)(2)(v), (vi), and 

(vii), and (f); and 

■ f. Removing paragraph (g). 

The revisions read as follows: 

§ 199.26 TRICARE Young Adult. 

(a) Establishment. The TRICARE 

Young Adult (TYA) program offers 

options of medical benefits provided 

under the TRICARE program to 

qualified unmarried adult children of 

TRICARE-eligible uniformed service 

sponsors who do not otherwise have 

eligibility for medical coverage under a 

TRICARE program at age 21 (23 if 

enrolled in a full-time course of study 

at an approved institution of higher 

learning, and the sponsor provides over 

50 percent of the student’s financial 

support), and are under age 26. 

* * * * * 

(4) * * * 

(i) * * * 

(C) TRICARE Select is available to all 

TYA-eligible young adult dependents. 

(D) TRICARE Prime is available to 

TYA-eligible young adult dependents, 

provided that TRICARE Prime 

(including the Uniformed Services 

Family Health Plan) is available in the 

geographic location where the TYA 

enrollee resides. TYA-eligible young 

adults are: 

* * * * * 

(ii) Premiums. TYA coverage is a 

premium based program that an eligible 

young adult dependent may purchase. 

There is only individual coverage, and 

a premium shall be charged for each 

dependent even if there is more than 

one qualified dependent in the 

uniformed service sponsor’s family that 

qualifies for TYA coverage. Dependents 

qualifying for TYA status can purchase 

individual TRICARE Select or TRICARE 

Prime coverage (as applicable) 

according to the rules governing the 

TRICARE option for which they are 

qualified on the basis of their uniformed 

service sponsor’s TRICARE-eligible 

status (active duty, retired, Selected 

Reserve, or Retired Reserve) and the 

availability of a desired option in their 

geographic location. Premiums shall be 

determined in accordance with 

paragraph (c) of this section. 

* * * * * 

(iv) Benefits. When their TYA 

coverage becomes effective, qualified 

beneficiaries receive the benefit of the 

TRICARE option that they selected, 

including, if applicable, access to 

military treatment facilities and 

pharmacies. TYA coverage features the 

cost share, deductible and catastrophic 

cap provisions applicable to Group B 

beneficiaries based on the program 

selected, i.e., the TRICARE Select 

program under § 199.17(l)(2)(ii) or the 

TRICARE Prime program under 

§ 199.17(l)(ii), as well as the status of 

their military sponsor. Access to 

military treatment facilities under the 

system of access priorities in 

§ 199.17(d)(1) is also based on the 

program selected as well as the status of 

the military sponsor. Premiums are not 

credited to deductibles or catastrophic 

caps; however, TYA premiums shall 

apply instead of any applicable 

TRICARE Prime or Select enrollment 

fee. 

* * * * * 

(c) TRICARE Young Adult premiums. 

Qualified young adult dependents are 

charged premiums for coverage under 

TYA that represent the full cost of the 

program, including reasonable 

administrative costs, as determined by 

the Director utilizing an appropriate 

actuarial basis for the provision of 

TRICARE benefits for the TYA-eligible 

beneficiary population. Separate 

premiums shall be established for 

TRICARE Select and Prime plans. There 

may also be separate premiums based 

on the uniformed services sponsor’s 

status. Premiums are to be paid 

monthly, except as otherwise provided 

through administrative implementation, 

pursuant to procedures established by 

the Director. The monthly rate for each 

month of a calendar year is one-twelfth 

of the annual rate for that calendar year. 

* * * * * 

(d) Procedures. The Director may 

establish procedures for the following. 

(1) * * * 

(ii) Enrollment. Procedures for 

enrollment in TRICARE plans under 

§ 199.17(o) shall apply to a qualified 

dependent purchasing TYA coverage. 

Generally, the effective date of coverage 

will coincide with the first day of a 

month unless enrollment is due to a 

qualifying event and a different date on 

or after the qualifying event is required 

to prevent a lapse in health care 

coverage. 

(2) Termination. Procedures may be 

established for TYA coverage to be 

terminated as follows. 

* * * * * 

(v) Coverage may be terminated for 

young adult dependents upon request at 

any time by submitting a completed 


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Federal Register / Vol. 82, No. 188 / Friday, September 29, 2017 / Rules and Regulations 45461 

request in the appropriate format in 

accordance with established procedures. 

(vi) In accordance with the provisions 

of § 199.17(o)(2), coverage terminates for 

young adult dependents who fail to 

make premium payments in accordance 

with established procedures. 

(vii) Absent a new qualifying event, 

young adults are not eligible to re-enroll 

in TYA until the next annual open 

season. 

* * * * * 

(f) Administration. The Director may 

establish other processes, policies and 

procedures for the effective 

administration of the TYA Program and 

may authorize exceptions to 

requirements of this section, if 

permitted. 

Dated: September 20, 2017. 

Aaron Siegel, 

Alternate OSD Federal Register Liaison 

Officer, Department of Defense. 

[FR Doc. 2017–20392 Filed 9–28–17; 8:45 am] 

BILLING CODE 5001–06–P 

DEPARTMENT OF HOMELAND 

SECURITY 

Coast Guard 

33 CFR Part 165 

[Docket Number USCG–2017–0172] 

RIN 1625–AA00 

Safety Zone; Pacific Ocean, Kilauea 

Lava Flow Ocean Entry on Southeast 

Side of Island of Hawaii, HI 

AGENCY: Coast Guard, DHS. 

ACTION: Temporary final rule. 

SUMMARY: The Coast Guard is extending, 

for an additional six months, the 

existing temporary safety zone 

surrounding the entry of lava from the 

Kilauea volcano into the navigable 

waters of the Pacific Ocean on the 

southeast side of the Island of Hawaii, 

HI. The extension of this safety zone is 

necessary to protect persons and vessels 

from hazards associated with molten 

lava entering the ocean while the 

proposed rule is reviewed. 

DATES: This rule is effective from 

September 28, 2017 through March 28, 

2018. 

ADDRESSES: To view documents 

mentioned in this preamble as being 

available in the docket, go to https://

www.regulations.gov, type USCG–2017– 

0172 in the ‘‘SEARCH’’ box and click 

‘‘SEARCH.’’ Click on Open Docket 

Folder on the line associated with this 

rule. 

FOR FURTHER INFORMATION CONTACT: If 

you have questions on this rule, call or 

email Lieutenant Commander John 

Bannon, Waterways Management 

Division, Coast Guard; telephone: 808– 

541–4359, email: John.E.Bannon@

uscg.mil. 

SUPPLEMENTARY INFORMATION: 

I. Table of Abbreviations 

BLS Bureau of Labor Statistics 

COTP Captain of the Port 

DHS Department of Homeland Security 

FR Federal Register 

NPRM Notice of proposed rulemaking 

§ Section symbol 

OMB Office of Management and Budget 

RFA Regulatory Flexibility Act 

SNPRM Supplemental notice of proposed 

rulemaking 

TFR Temporary final rule 

U.S.C. United States Code 

II. Background Information and 

Regulatory History 

The Coast Guard is extending, for an 

additional six months, an existing 

temporary safety zone for the navigable 

waters surrounding the entry of lava 

from the Kilauea Volcano into the 

Pacific Ocean on the southeast side of 

the Island of Hawaii, HI. Extending this 

safety zone ensures mariners remain 

safe from the potential hazards 

associated with molten lava entering the 

ocean while the proposed rule is being 

reviewed. This safety zone will continue 

to encompass all waters within 300 

meters (984 feet) of all entry points of 

lava flow into the ocean. Because the 

entry points of the lava vary, the safety 

zone location will also vary. Entry of 

persons or vessels into this safety zone 

remains prohibited, unless specifically 

authorized by the Captain of the Port 

(COTP) Honolulu, or his designated 

representative. 

Lava flow that enters the ocean can be 

potentially hazardous to anyone near it, 

particularly when lava deltas collapse. 

A lava delta is new land that forms 

when lava accumulates above sea level, 

and extends from the existing base of a 

sea cliff. Persons near active lava flow 

entry sites incur potential hazards, 

particularly when lava deltas collapse. 

These hazards include, but are not 

limited to, plumes of hot, corrosive 

seawater laden with hydrochloric acid, 

and fine volcanic particles that can 

irritate the skin, eyes, and lungs; 

explosions of debris and eruptions of 

scalding water from hot rock entering 

the ocean; sudden lava delta collapses; 

and waves associated with these 

explosions and collapses. 

Lava has been entering the ocean at 

the Kamokuna lava delta on Kilauea 

Volcano’s south coast since July 2016. 

On December 31, 2016, a large portion 

of lava delta collapsed into the ocean at 

the Kamokuna entry point. Following 

this collapse, portions of the adjacent 

sea cliff fell into the ocean, producing 

localized waves, and showers of debris. 

As of March 2017, a new delta has 

begun to form at the Kamokuna ocean 

entry point. This lava delta continues to 

grow and collapse, and cracks parallel 

to the sea cliff surrounding it persist, 

indicating further collapses may occur 

with little or no warning. 

On March 28, 2017, the Coast Guard 

established a temporary final rule (TFR) 

and put into place a safety zone for 

mariners near lava entry points to 

address the hazards of the lava entering 

the ocean. The TFR discussed Sector 

Honolulu’s review of nearly 30 years of 

delta collapse and ejecta distance 

observations from the Hawaii Volcano 

Observatory records. The TFR was 

published in the April 3, 2017 Federal 

Register (82 FR 16109). 

On April 3, 2017, the Coast Guard 

also published a notice of proposed 

rulemaking (NPRM) to establish a 

permanent safety zone that would 

encompass all waters extending 300 

meters (984 feet) in every direction 

around all entry points of lava flow into 

the navigable waters surrounding the 

entry of lava from the Kilauea Volcano 

into the Pacific Ocean on the southeast 

side of the Island of Hawaii, HI (82 FR 

16142). We determined that a radius of 

300 meters was a reasonable, minimum 

high-hazard zone around a point of 

active lava flow entering the ocean. The 

safety zone allows the Coast Guard to 

impose and enforce restrictions on 

vessels operating closely to the lava 

entry area, which protects persons and 

vessels from the potential hazards 

associated with molten lava entering the 

ocean. The NPRM addressed this 

concern and invited the public to 

comment on the safety zone. The 

comment period, which ended on June 

2, 2017, received 67 comments. On May 

8, 2017, at a public meeting held in 

Hilo, HI, meeting participants discussed 

the proposed rule and NPRM’s public 

comments. 

During the period of the TFR, four 

tour operators and one photographer 

with economic ties to lava tourism 

petitioned the COTP Honolulu for entry 

within 300 meters of the high-hazard 

zone. They also requested and 

petitioned for various levels of entry 

distances—ranging from a close, safe 

distance to 50 meters—based on sea 

conditions resulting from the lava entry. 

The COTP Honolulu granted express 

authorization for entry within 300 

meters to the five operators. The 

authorization included operational 

restrictions and other vessel safety 

criteria requirements considered by the 


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