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Veterans Benefits Information

Know your costs before making a choice during TRICARE Open Season

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TRICARE Open Season is underway. If you want to enroll in or change between TRICARE Prime and TRICARE Select health plans, you have until Dec. 10.

Active duty service members (ADSMs) are required to have TRICARE PrimeA managed care option available in Prime Service Areas in the United States; you have an assigned primary care manager who provides most of your care.TRICARE Prime health coverage. Active duty family members (ADFMs), retirees, and eligible retiree family members can choose to have either TRICARE Prime or TRICARE SelectStarting on January 1, 2018, TRICARE Select replaces TRICARE Standard and Extra. TRICARE Select is a self-managed, preferred provider network plan. TRICARE Select is a fee-for-service option in the United States that allows you to get care from any TRICARE-authorized provider.  Enrollment is required to participate. TRICARE Select coverage.

For many people, cost is a major factor in picking a health care plan. Before you choose a plan, make sure you know what’s covered and what it costs. To help you understand your potential health care costs, here are a few key TRICARE terms you should know.

  • TRICARE beneficiaries fall into one of two groups: Group A or Group B. Each group has different enrollment fees, deductibles, and out-of-pocket costs. You’re in Group A if your initial enlistment or appointment or that of your uniformed services sponsor began before Jan. 1, 2018. You’re in Group B if your initial enlistment or appointment or that of your uniformed services sponsor began on or after Jan. 1, 2018. When enrolled in TRICARE Reserve SelectA premium-based plan for qualified Selected Reserve members and their families.TRICARE Reserve Select, TRICARE Retired ReserveA preimum-based plan for qualified Retired Reserve members and their families.TRICARE Retired Reserve, TRICARE Young AdultA premium-based plan for qualified adult children.TRICARE Young Adult, or Continued Health Care Benefit Program follow Group B deductibles, copayments, cost-shares, and catastrophic caps regardless of when the uniformed services sponsor enlisted or was appointed.
  • An enrollment fee is the yearly amount you pay to enroll in TRICARE Prime or TRICARE Select. ADSMs and ADFMs don’t have an enrollment fee with TRICARE Prime. However, TRICARE Prime retirees, their families, and some others pay yearly enrollment fees. With TRICARE Select, ADFMs don’t pay enrollment fees, and neither do Group A retirees, their families, and others with TRICARE Select. However, Group B retirees, their families, and others pay yearly enrollment fees. Visit Health Plan Costs for more information.
  • A deductible is a fixed amount you pay for covered services each calendar year before TRICARE pays anything. You may have a deductible if you have TRICARE Select or if you have TRICARE Prime but see a provider without a referral.
  • A cost-share is a percentage of the total cost of a covered health care service that you pay after you pay your deductible.
  • A copayment is the fixed amount those with TRICARE Prime (who aren’t active duty) and TRICARE Select (for certain services) pay for a covered health care service or drug.
  • The catastrophic cap is the most you or your family will pay out of pocket for covered health care services each calendar year. When met, TRICARE pays your copayment or cost-share for covered health care services for the rest of the calendar year.
  • Point-of-service is an option under TRICARE Prime where you pay extra when getting nonemergency care from any TRICARE-authorized provider. The point-of-service option isn’t available to ADSMs.
  • The TRICARE-allowable charge is the maximum amount a participating TRICARE provider can be paid for a covered service. Learn more about TRICARE provider types.

Health care costs can differ based on who you are and your health plan option. For specific plan costs and dollar amounts, use the TRICARE Compare Cost Tool. Also, download the 2019 TRICARE Costs and Fees Sheet. If you want to enroll in or change your TRICARE health plan during TRICARE Open Season, take command of your health benefit by understanding your health care costs.


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Malaria in the Korean Peninsula: Risk Factors, Latent Infections, and the Possible Role of Tafenoquine, a New Antimalarial Weapon

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Malaria in the Korean Peninsula: Risk Factors, Latent Infections, and the Possible Role of Tafenoquine, a New Antimalarial Weapon

 

Mark M. Fukuda, MD (COL, USA); Mariusz Wojnarski, MD (MAJ, USA); Nicholas Martin, PhD (LCDR, USN); Victor Zottig, PhD (MAJ, USA); Norman C. Waters, PhD (COL, USA)

 

Editorial

For decades, malaria infections acquired in Korea have posed a significant threat to both Korean military and civilians and to U.S. Department of Defense (DoD) personnel. In Korea, malaria infections are caused exclusively by the species Plasmodium vivax (PV). Despite the use of chloroquine chemoprophylaxis during the Korean War (1950–1953), thousands of cases of PV malaria were diagnosed in Korea among U.S. military personnel.1 As troops returned home, however, many more cases were diagnosed stateside, inundating military hospitals and leading to research on the use of primaquine to treat what were termed “late attacks of Plasmodium vivax of Korean origin”.2

Since the Korean War, the Republic of Korea (ROK) has made significant strides in controlling the disease, chiefly through an aggressive eradication program in the 1970s. So successful was the program that the World Health Organization declared the ROK malaria free in 1979.However, in 1993, ROK experienced a PV malaria resurgence that reached a peak of 1,600 cases in 19974 before gradually tapering, with ROK experiencing only 601 cases in 2016.5

In this issue of the MSMR, Klein et al. report a cluster of 11 U.S. soldiers with PV.6 The cases were likely acquired at Dagmar North training area located near the southern border of the demilitarized zone (DMZ). As was true during the Korean War, more cases (n=9, 82%) in the cluster were diagnosed long after redeployment to the U.S., an estimated 8–11 months after presumed exposure to the mosquitoes that transmitted the infections. Due to recent historically low numbers of PV malaria cases among DoD personnel in the ROK, and no mortality due to PV, chemoprophylaxis is not routinely administered to service members in the ROK, except among Marine Corps personnel when training near the DMZ (Surgeon Office, U.S. Marine Corps Forces, Pacific; personal communication 25 October 2018).

The most relevant contemporary report of malaria risk in the ROK was published in 2016.In this study, mosquitoes were collected at ROK installations near the DMZ, speciated, assessed for PV infection, and correlated with human PV cases. The report concluded the following: 1) that the mosquito species Anopheles kleini was likely the main culprit vector responsible for PV transmission in the ROK; 2) population densities of PV-infected mosquitoes were highest in ROK installations closer to the DMZ; and 3) PV mosquito infection rates correlated highly with the number of PV cases in ROK Army soldiers.

From a chemoprophylaxis perspective, it is instructive to consider the peculiar biology of Korean PV malaria. Korean PV strains are classified as “temperate zone” and are unique in that as many as 40–50% of infected individuals may  not  manifest the symptoms of their primary illness until 6–11 months after infection.4,8 The Figure shows that time between primary infection and clinical illness among different PV strains ranges between 8 days and 8–13 months.Temperate zone PV biology reflects a possible evolutionary adaptation that enables these strains to remain latent as hypnozoites (i.e., “sleeping” parasites) through the cool or cold months that are inhospitable to mosquito vectors in temperate climates.As in the postKorean War period, late attacks of Plasmodium vivax of Korean origin continue to be observed. A 2007 review of malaria outbreaks in U.S. military personnel described 74 ROK-acquired PV malaria cases and an estimated 45% were diagnosed more than 240 days after the mid-points of their last ROK exposure period.9 Because U.S. military personnel rotate frequently in and out of the ROK, PV biology virtually ensures that a significant number of DoD personnel with ROK-acquired infections will not become symptomatic until their next duty station—whether in the U.S. or at another location outside of the contiguous U.S.

PV latency and entomological studies indicate that the following should be considered in anticipation of further exposure of DoD personnel in Korea. First, scientific reports unquestionably point to proximity to the DMZ as the highest PV risk factor, while few cases are diagnosed south of Seoul.It is impossible to determine how much of this risk is due to a specific ecology within the DMZ or to the presence of a high PV case burden in the nearby Democratic People’s Republic of Korea. Thus, continued emphasis on surveillance of Anopheles spp. and identification to species is warranted to identify the geographical and seasonal impact on malaria transmission in the ROK. Secondly, command emphasis on personal protective measures such as use of insecticide treated uniforms and impregnated bednets and on education about malaria risk and prevention is highly warranted. Lastly, because latent cases likely constitute the majority of cases acquired in the ROK, chemoprophylaxis practice should take into account both recent data on acute infections diagnosed shortly after exposure as well as latent infections presenting months thereafter. In this regard, analysis and dissemination of centralized DoD malaria data, such as in the annual MSMR issue,10 are critically important to inform DoD Force Health Protection malaria practice.

The possibility of latent PV infection and frequent deployment tempo warrant consideration of the role of chemoprophylaxis, particularly with respect to “terminal prophylaxis”—a term referring to the pre-emptive treatment of hypnozoites to prevent latent or relapsing malaria. A major challenge for terminal prophylaxis is compliance with up to 14 days of daily dosing with primaquine, until recently the only drug capable of killing hypnozites. For example, a survey of U.S. Army Rangers returning from Afghanistan found that self-reported compliance rates were 52% for weekly chemoprophylaxis, 41% for terminal (post-deployment) chemoprophylaxis, and 31% for both weekly and terminal chemoprophylaxis.11

In August 2018, tafenoquine, an oral long-acting primaquine analogue was approved by the U.S. Food and Drug Administration for prophylaxis against all malaria species for up to 6 months’ duration. Tafenoquine, (Arakoda™), was originally discovered by scientists at the Walter Reed Army Institute of Research (WRAIR) and further developed for a prophylaxis indication at the U.S. Army Medical Materiel Development Activity. Critically, tafenoquine/Arakoda™ confers a major advantage over primaquine because of its requirement for only weekly "maintenance" dosing during exposure in malaria endemic areas in contrast to the daily dosing requirement for doxycycline or Malarone®. Significantly, tafenoquine also includes an indication for terminal prophylaxis consisting of a single dose given 7 days after the last maintenance dose upon leaving the malaria endemic area.12 These dosing options provide commanders with the option to more feasibly monitor dosing by directly observed therapy. The implications of the “real world” effectiveness brought by this soldier/commander-friendly dosing option, whether employed to prevent latent P. vivax cases—or infections with other species—are a welcome advance in the fight against malaria.

Author affiliations: Department of Bacterial and Parasitic Disease, U.S. Army Directorate, Armed Forces Research Institute of Medical Science, Bangkok, Thailand (COL Fukuda, MAJ Wojnarski, LCDR Martin, COL Waters); U.S. Army Medical Materiel Development Activity, Fort Detrick, MD, (MAJ Zottig).

 

Disclaimer: Material has been reviewed by the Walter Reed Army Institute of Research and there is no objection to its publication. The opinions or assertions contained herein are the views of the authors and do not necessarily reflect the official policy or position of the Army, the Department of Defense, or the U.S. Government.

 

REFERENCES

1. Long AP. General Aspects of Preventive Medicine in the Far East Command. Recent Advances in Medicine and Surgery Based on Professional Medical Experiences in Japan and Korea. Vol II. Washington, D.C.: U.S. Army Medical Service Graduate School; 1954:248-269.

2. Jones R Jr, Jackson LS, Di Lorenzo A, et al. Korean vivax malaria. III. Curative effect and toxicity of primaquine in doses from 10 to 30 mg. daily. Am J Trop Med Hyg.1953;2(6):977–982.

3. World Health Organization. Synopsis of the World Malaria Situation, 1979. Wkly Epidem Rec. 1981;56(19):145–152.

4. Feighner BH, Pak SI, Novakoski WL, Kelsey LL, Strickman D. Reemergence of Plasmodium vivax malaria in the Republic of Korea. Emerg Infect Dis. 1998;4(2):295–297.

5. Global Malaria Programme. World Malaria Report 2017. Geneva: World Health Organization.

6. Klein TA, Seyoum B, Forshey BM, et al. Cluster of vivax malaria in U.S. Soldiers training near the demilitarized zone, Republic of Korea during 2015. MSMR. 2018;25(11):4–9.

7. Chang KS, Yoo DH, Ju YR, et al. Distribution of malaria vectors and incidence of vivax malaria at Korean army installations near the demilitarized zone, Republic of Korea. Malar J. 2016;15(1)259.

8. White, NJ. Determinants of relapse periodicity in Plasmodium vivax malaria. Malar J. 2011 (10):297.

9. Ciminera P, Brundage J. Malaria in U.S. military forces: a description of deployment exposures from 2003 through 2005. Am J Trop Med Hyg. 2007;76(2):275–279.

10. Armed Forces Health Surveillance Branch. Update: Malaria, U.S. Armed Forces, 2017. MSMR. 2018;25(2):2–7.

11. Kotwal RS, Wenzel RB, Sterling RA, Porter WD, Jordan NN, Petruccelli BP. An outbreak of malaria in US Army Rangers returning from Afghanistan. JAMA. 2005;293(2):212–216. Erratum in: JAMA. 2005;293(6):678.

12. Arakoda [package insert]. Washington, D.C.: 60º Pharmaceuticals; 2018. https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/210607lbl.pdf. Accessed on 29 October 2018.

Time between primary infection and clinical illness among different P. vivax strains

 

Map showing Camps Casey/Hovey and the DNTA in northeastern Gyeonggi Province, ROK, near the demilitarized zone where the Plasmodium vivax infections occurred

 


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Navy surgeon general discusses DHA transition

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NATIONAL HARBOR, Md. — On Thursday, Nov. 29, Vice Adm. Forrest Faison, Navy surgeon general and chief, U.S. Navy of Bureau of Medicine and Surgery came together with military medicine leaders during AMSUS for a panel discussion on the future of the services as they begin to transition medical facilities to the Defense Health Agency.

On Oct. 1, 2018 Navy Medicine began phase one of the DHA transition, transferring Naval Hospital Jacksonville administration, management and control to the DHA. While this transition presents significant change for Navy Medicine, the mission to keep Sailors, Marines and their families healthy and ready does not.

“The Navy is taking advantage of the many opportunities that come with this transformation. It allows us to focus on our true north and ensure we’re doing all we can to save lives and return sons and daughters home to their families” said Faison.

Several transition initiatives and milestones were shared by the services, yet the recurring theme throughout the panel’s discussion revolved around the importance of readiness.

Faison went on to describe the unique ways in which Navy Medicine is supporting the transition and taking steps to maintain readiness as hospitals and clinics transition administration, management and control to the DHA. For patients, these reforms should have little or no effect on their experience, facility and physicians. Coverage will remain the same, and patients will continue to receive the same exceptional level of care and service.

“We are focused on a future of design, not default,” said Faison. To complement changes in the organizational construct of the DHA, Navy Medicine will establish Readiness and Training Commands that support the Navy’s mission and the DHA’s role of administration and management of the MTFs.

“The Navy Medicine Readiness and Training Commands will focus on platform readiness and training so that beneficiaries can continue to receive the same level of care,” said Faison.

While the transition itself presents a great amount of change, the evolving future of warfare and health care will also continue to drive changes in the way the Navy delivers care. The emergence of great power competition and the growing capabilities of near-peer competitors to project seapower could indicate the next war at sea.

“If you’re going to fight tonight, you’ve got to be able to save lives tonight,” Faison said. “Every mom and dad in America is depending on us to do that.”

As the transition continues and the warfighting environment evolves, Navy Medicine will adapt and provide the necessary functions and capabilities needed to fight the next fight, whether it be on sea, land or in the air.

Disclaimer: Re-published content may have been edited for length and clarity. Read original post.


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SAL national commander encourages membership in new PSAs

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Sons of The American Legion National Commander Greg “Doc” Gibbs is encouraging those eligible to join the Sons to do so through a series of public service announcements (PSAs) that are available on the Legion’s Vimeo channel and LegionTV.

To share the commander’s PSAs on social media, such as Facebook and Twitter, click here. And for promotional efforts within your community, view PSAs on Vimeo here.

All male descendants, adopted sons and stepsons of members of The American Legion, and such male descendants of veterans who died in service during World I, World War II, the Korean War, the Vietnam War, Lebanon, Grenada, Panama, the Persian Gulf War and the War on Terrorism, during the delimiting periods set forth in Article IV, Section 1, of the National Constitution of The American Legion, or who died subsequent to their honorable discharge from such service, shall be eligible for membership in the Sons of The American Legion.

For additional American Legion PSAs and promotional videos that highlight Team 100, Legion programs and more, click here. These short PSAs and videos on the Legion's Vimeo channel can be shared via mobile devices or downloaded onto a computer hard drive and shared without the need for internet connection. Use these videos to tell the Legion's story, as well as aid in membership recruiting, fundraising efforts, support for programs and events, and more.


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Legion helps save Vietnam veteran’s memorial from removal

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For more than 50 years, a memorial honoring the life and service of Vietnam War veteran Jim B. Robison has stood tall in the desert in Ocotillo Wells, Calif. From their living room window, Elmo and Nancy Robison could see the memorial that was dedicated to their son, who was killed Feb. 7, 1966.

In January 2017, a single complaint was lodged, citing the First Amendment. This jeopardized the memorial’s future because at the time it sat on public land owned by the Ocotillo Wells Airport. San Diego County, which oversees the airport, considered moving the memorial to another location, which drew an outcry from local residents.

Robison’s nephew, Tom Lemmon, and Ocotillo Wells resident Sherri Kukla led the movement to save the memorial. Along the way, American Legion District 22 of California and First Liberty Institute joined in to save the memorial and preserve the remembrance of a fallen servicemember.

“We firmly believe that the greatest gift that we can give our fallen warriors, the men and women they served with, and the families they leave behind is the gift of remembrance,” District 22 Commander Chris Yates said. “The American Legion has a big commitment to make sure that we preserve the memories and the incidents of our associations in the great wars. We’re fulfilling that obligation by making sure that we’re preserving the memory of the men and women, like Jim Robison, who gave their lives for this country.”

On Dec. 1, American Legion Post 853 officially purchased the quarter-acre parcel of land where the memorial sits. Robison’s family members are pleased with the outcome.

Lemmon said the memorial is visible from the family homestead.

“It’s something my grandparents (Elmo and Nancy Robison) looked at every day,” he recalled. “I know it gave them a lot of peace. Literally from their house they could see the Gold Star flag (in the window) and see the cross just behind it.”

Lemmon, who was not quite 7 when his uncle was killed, said he remembers Robison well. He went to Vietnam around Christmas Day 1965 and was killed the following February.

“I have lots of memories of him,” said Lemmon, a Marine veteran. “He was athletic, smart and loved the Army like crazy.

“After he was killed, I wanted to join the military.”

Evon DeLauder is Robison’s older sister and Lemmon’s mother. She remembers her brother as being very sweet and athletic. “He would put Tom on his shoulders and run around with him. Tom loved it.”

Robison lived with his sister and her husband when he was 16 and she was 19 in Florida. “He’d come through the living room, hear the music on the radio, grab me and we’d start dancing.”

Shortly before leaving for Vietnam, Robison visited his sister and her family in Oxnard, Calif. He bought presents for Tom and his sister. “Everyone prayed for him,” DeLauder recalls. “He said, ‘I am not afraid to die. Pray that I am not captured or maimed.'”

DeLauder had written him three letters and received one from Robison. He concluded the letter with, “I’ll be home soon,” she remembers. “His death was very hard on us.”

Robison carried a book by Billy Graham during the war. “It had to do with life after death,” said DeLauder, who kept the book and recently passed it on to her daughter. “He accepted the Lord and in the book he underlined every passage that had to do with life after death. It wasn’t a gruesome thing. It was a beautiful thing.”

Now living in Virginia, DeLauder hasn’t seen the memorial in years. “It’s a beacon of life,” she said. “He’s still alive in our hearts.”

Post 853 members will work with the family to care for the memorial.

“Any memorial that represents or even associates itself with a fallen veteran or any veteran is a memorial to all of us,” Post 853 Commander Lee Quarcelino said, noting the post voted unanimously to undertake the project. “We all paid the price. That’s what the Legion is about; helping community, children, the nation.”

The memorial sits on a small hill in a barren desert, often used by dune buggy enthusiasts. The memorial’s concrete and brick base supports a metal cross, which is about 20 feet high.

Such peaceful remembrance is especially important to Dale Jones, Post 853 second vice commander and chaplain.

“A memorial allows us to remember the sacrifices, the past,” Jones said. “As we move forward in the future years, future generations – the Great War, World War II, Vietnam – all the conflicts grow further and further apart. History can be lost. But these memorials, they are that moment in time where you can take the quiet time to remember those who have fallen and given the ultimate sacrifice. This memorial is a place where we can go and recognize those who have paid the ultimate price.”

The Legion’s acquisition of the land concludes a lengthy period when local advocates, public officials and others joined forces to save the memorial.

Kukla is a co-founder of S&S Off Road Magazine. The land around the memorial is popular among off-road enthusiasts.

When Kukla learned that San Diego County was quietly considering removing the memorial she feared Robison family members, veterans, off-road participants and others would lose their place of quiet remembrance. She posted a message on her magazine’s Facebook page and started an online petition, which generated an outpouring of support for the memorial. The tight-knit off-road community immediately got involved, spreading the word and contacting local lawmakers.

“I was overwhelmed,” Kukla said, noting that other veterans and civilians have had their ashes scattered at the site. “Everybody was really upset that it might come down. Everyone feels like it’s their memorial.”

Lemmon contacted county supervisors and worked with them for over a year, while also getting California Rep. Duncan Hunter involved to assist with the land transfer from the Federal Aviation Administration (FAA). Last summer, Hunter sent a letter to the FAA requesting it consider a request from the county to sell the land to a private party to keep the memorial in place.

With Lemmon’s and Kukla’s involvement and commitment, the pieces started falling into place to save the memorial. With the county and congressional staffs engaged, the Legion and the legal team joined the effort.

First Liberty Institute senior counsel Roger Byron worked with the Legion, Robison’s family and others to secure the deal.

“The memorial will continue to stand for years to come in honor of the fallen American solider it was erected to commemorate,” Byron said. “In my mind, the Legion rode in on a white horse and ensured that the honor of the fallen American servicemember — as well as the sanctity of the memorial erected to honor him — would continue to stand for years to come.”

Byron is a Navy veteran and member of The American Legion.

“All veterans memorials should be honored, and all veterans memorials should be preserved,” he said. “This isn’t Arlington National Cemetery, but it’s the next best thing. Fallen servicemembers can’t be here to defend themselves. They’re not here to defend the memorials that honor them so we should do it for them.”

Lemmon praised Byron for his role. “He had an amazing compassion and a desire to do the right thing.”

Robison’s nephew is thankful for the support from the Legion, First Liberty and others.

“My goal was to save the cross but I hadn’t given it much thought to what that meant,” Lemmon said. “I really liked the connection to my uncle — who had an American Legion post named after him in Ocotillo Wells. I really like how The American Legion’s mission is to support veterans and their families.”

Now, the memorial will remain in place where it has been for more than a half century.

“It’s a low-key memorial, something my family looked at every day,” Lemmon said. “It gave us a gentle reminder of Jim Robison. But we saw fairly quickly that others latched onto it for memorials for their families, which is a big part of the story. While it will forever be known as the Jim B. Robison Memorial, it’s really everyone’s.”


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Did you know?

Military Funeral Honors ceremonies must be scheduled in advance.

The law requires that every eligible veteran receive a military funeral honors ceremony, which includes the folding and presentation of the United States flag and the playing of “taps,” upon the family’s request. This Department of Defense program calls for the funeral director to request military funeral honors on behalf of the veteran’s family.