Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)

Created 8/1/06

HIT1

(front)

TRICARE Plan Names
A. TRICARE for Life
B. TRICARE Plus
C. TRICARE Prime
D. TRICARE Extra
E. TRICARE Standard
F. TRICARE Pharmacy / TRICARE Senior
Pharmacy
G. TRICARE Dental Program
H. TRICARE Retiree Dental Program
I. TRICARE Reserve Select (TRS)

Created 8/1/06

HIT1

(back)
Beneficiary Information Card
for TRICARE For Life
FRONT OF CARD

TRICARE For Life
To Provider: File claims in the usual manner to Medicare.

To Patient : Services that are a benefit of both Medicare and

TRICARE :No deductible or cost share is required.
Medicare only benefit :Medicare deductible and
cost share required.
TRICARE only benefit:TRICARE deductible and
cost share required.
For benefit questions call 1-888-DoD-LIFE (1-888-363-5433)

www.tricare.osd.mil

For more information call 1-800-977-6753

www.hnfs.net

BACK OF CARD

TRICARE Senior Pharmacy
Military Treatment Facility: No Co-pay
National Mail Order Pharmacy: $3 generic;$9 brand name
(90 day supply)

TRICARE Network Pharmacy: $3 generic;$9 brand name
(30 day supply)

TRICARE Non-network Pharmacy: $9 or 20%of cost (30 day supply)
$150/person or $300/family
annual deductible applies.
For pharmacy questions call 1-877-DoD-MEDS
(Co-pays subject to change)
5007334 (9 /01 T85)

(1-877-363-6337)