Program for Persons With Disabilities

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Program for Persons With Disabilities

• TRICARE/CHAMPUS Programs
• a. Prime - most inexpensive way to go
• b. Extra (a PPO) next least expensive
  because providers give discount
• c. TRICARE Standard (most expensive way
  to). However, the most all active duty providers
  of services participates in their coverage).
  However, the most all active duty families should
  have to pay in any fiscal year is 1,000. (as
  long as all providers of services participate in
  their coverage)

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PFPWP

• PFPWD - Enhanced benefit program for A/D families
  only. Can be used in addition to their regular
  cover whether Prime or Standard
• Who qualifies? Must have severe diagnosis -
  sometimes can be a child who has never been
  diagnosed, i.e., developmentally delayed.

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PFPWD

• What relation is there between the PFPWD and
  EFMP? Non - two separate programs. However, if
  a family is applying for services under the
  PFPWD, then they should be enrolled in EFMP
  because
• What can you do to help these families
  transition from one area to another? Everything
  under the TRICARE/CHAMPUS Programs is physician
  driven, there fore the families should be
  referred to the closest TSC to enroll in Prime or
  accomplish Portability from one region to another
  and it is recommended they they go in person to
  do this. Then the HCF can assist with an
  appointment for the patient to be seen and the
  physicians portion of the request for benefits
  under PFPWD started. Even if a family indicates
  their desire to remain under TRICARE/Standard
  coverage and want to use the PFPWD, they need to
  contact the 1-800-931-9501 and get the name of
  some physicians in the Extra Network so that they
  can get started with their medical care.
• Also very good to refer them directly to the
  nurses in charge at 399-7649, ext 3021 or 3030

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PFPWD

• Must e pre-authorized. Applications are good for
  12 months w/authorization for for 6 months.
  Applications completed by a physician in another
  region is not acceptable however, if there is a
  really serious case that needs immediate
  assistance,please call one of the nurses to see
  what can be done to expedite care and an
  authorization.

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Program for Persons with Disabilities(PFPWD)

• Public funds must be utilized first and if not
  available to cover the need, then there is a form
  that must be completed that sates that is is not
  available and this forms must be submitted with
  the entire request package

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How much will it cost?

• Program pays up to 1,000 per month/with family
  paying a flat rate based on pay grade, i.e.,
  E-1-E-5 25 per month. Its like giving the
  family 1,000 to budget because anything over the
  1,000, the family will have to payDME is
  prorated and can be done in two ways wheelchair
  that costs 3,000, can be prorated x 3months.
  With family paying 75 however, if there is a
  possibility of the need for PT also then will go
  to a table whereby 1,000 is divided into 3,000.
  And, then multiplied by2 6 months prorate
  thereby enabling the family to have left over
  each month for PT.Most of the time, this is the
  cheapest way to go for therapies. It is the only
  way to obtain a hearing aid - not a covered
  benefit under Prime or Standard coverage. Even
  though you can use your regular coverage ad use
  this program in addition, you cannot receive the
  same service under both programs at the same
  time, I.e., you cannot receive PT under this
  program three times a week and under your Prime
  once a week. All PT will have to go under one
  program or the other.If there are more than one
  family member who qualifies for this program,
  family only pays for first person so the would
  need to look at which family member has the most
  serious diagnosis needs and let that member be
  the one who goes for free - example, child 1
  with moderate mental retardation and only needs
  speech therapy two times a week child 2 with
  cerebral palsy wheelchair confirmed and must have
  PT, OT speech and needs a gait trainer. This
  second child should be the one who gets to go for
  free. Only catch is that claims must be
  continuously going on child1 in order fore the
  child 2 to have their claims paid at 100 of
  allowable.Catastrophic cap does not apply to
  this program - only applies retrospectively when
  cap is met under the familys regular coverage
  and the family must request that claims be
  reconsidered for the FY.

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Points of Contact

• Tricare Service Center
  1-800-931-9501
• PFPWD Case Manager
  [phone] Ext.. 3020/3021

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For More Information Visit

• www.AnthemAlliance.com
• www.tma.med.navy.mil
• www.tricare.osd.mil
• www.myTRICARE.com