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Benefits

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Out-of-Pocket Costs

Your out-of-pocket costs are determined by the service you receive and whether or not it's covered by Medicare and TRICARE.

  • For services covered by both Medicare and TRICARE, you'll pay nothing.
  • For services covered by TRICARE, but not Medicare, TRICARE is the primary payer. See the chart below for details.
  • For services covered by Medicare, but not TRICARE, the Medicare deductible and cost sharing applies. Visit www.medicare.gov for details.
  • For services not covered by TRICARE or Medicare, you are responsible for the entire cost.
Retirees, Their Family Members, and Others
Service Received TRICARE
Prime
TRICARE
Extra
TRICARE
Standard

Annual Deductible

None

$150/individual or
$300/family

$150/individual or
$300/family

Annual Enrollment Fee

$230/individual $460/family

None

None

Civilian Outpatient Visits

$12   

20% of negotiated
fee

25% of allowable charges for covered service

Emergency Care

$30 

20% of negotiated
fee

25% of allowable charges for covered service

Outpatient Behavioral Health Visit

$25  (individual)
  $17 (group visit)

20% of negotiated
fee

25% of allowable charges for covered service

Civilian Inpatient
Cost Share

$11/day (minimum $25 charge per admission); no separate co-payment for separately billed professional charges.

Lesser of $250/day or 25% of negotiated charges plus 20% of negotiated professional fees

Lesser of $645/day or 25% of billed charges plus 25% of allowable professional fees

Civilian Inpatient Skilled Nursing Facility Care

$11/day (minimum $25 charge per admission)

$250 per diem cost share or 20% cost share of total charges, whichever is less, institutional services, plus 20% cost share of separately billed professional charges

25% cost share of allowable charges for institutional services, plus 25% cost share of allowable for separately billed professional charges.

Civilian Inpatient Behavioral Health

$40 per day; no charge for separately billed professional charges

20% of total charge. Plus, 20% of the allowable charge for separately billed professional services

High Volume Hospitals - 25% hospital specific per diem, plus 25% of the allowable charge for separately billed professional services; Low Volume Hospitals - $ 187 per day or 25% of the billed charges, whichever is lower, plus 25% of the allowable charge for separately billed services

Visit www.tricare.mil for more specific TRICARE benefit details.

Visit www.medicare.gov for more specific Medicare benefit details.