Prime Network Copayments

Active Duty Service Members

  • You pay nothing out-of-pocket for any type of care

Active Duty Family Members

  • You pay nothing out-of-pocket for any type of care
  • If you get care without a referral, you will pay point-of-service charges

All Other Beneficiaries

  • You pay the copayments below for care from TRICARE network providers
  • If you get care without a referral, you will pay point-of-service charges
  • Your costs are for care from civilian primary care managers (PCMs), or for care received with a PCM referral, when required

These costs are effective 10/1/2014.
Service Cost
Annual Deductible $0 (unless using POS)
Ambulance Services $20 per occurance
Ambulatory Surgery (Same Day) $25
Behavioral Health (Inpatient) $40 per day
Behavioral Health (Outpatient) Individual: $25 / Group: $17
Clinical Preventive Services $0 from a network provider
DME, Prosthetic Devices, Medical Supplies Cost share is 20% of the negotiated fee
Emergency Services $30 per visit
Home Health Care $0
Hospice Care $0
Hospitalization (Inpatient Care) $11 per day ($25 minimum charge)
Immunizations $0 from a network provider
Laboratory & X-ray $0 for ancillary services* / $12 per visit for other radiology services
Maternity (office visits & hospitalization for delivery planned in a hospital in an inpatient setting) $11 per day ($25 minimum charge)
Note: this is one global fee for all of the maternity care and delivery.
Maternity (office visits for delivery planning in a TRICARE-authorized birthing center) $25 per visit
Maternity (office visits for delivery planned at home or other setting) $12 per visit
Newborn Care $11 per day ($25 minimum charge)
Outpatient Visit $12 per visit
Skilled Nursing (Inpatient) $11 per day ($25 minimum charge)
*Ancillary services include:
  • Diagnostic radiology and ultrasound
  • Diagnostic nuclear medicine
  • Pathology and laboratory services
  • Cardiovascular studies
  • Venipuncture
  • Collection of blood samples
  • Fetal monitoring

Last Updated 1/26/2015