Bread Crumbs

Cost Shares for Retired Service Members, Their Families and All Others

These costs are effective 10/1/2015.
Service Cost
Behavioral Health (Inpatient)

In-Network: 20% of the total charge, plus 20% for separately billed services

Non-Network:

  • High-volume Hospitals: 25% hospital specific per diem, plus 25% for separately billed services
  • Low-volume Hospitals: $229 per day or 25% of the billed charges, whichever is less, plus 25% for separately billed services
  • Residential Treatment Center: 25% of the allowed amount
  • Partial Hospitalization: 25% of the allowed amount, plus 25% of the allowable charge for separately billed professional services
Behavioral Health (Outpatient)

Network: 20% of negotiated feeThe discounted rate network providers agree to accept for covered services.
Non-Network: 25% of allowable charge

Laboratory and X-ray

Network: 20% of negotiated fee
Non-Network: 25% of allowable charge

Maternity (office visits for delivery planned at home or other setting)

Network: 20% of negotiated fee
Non-Network: 25% of allowable charge

Maternity (office visits and hospitalization for delivery planned in a hospital in an inpatient setting)

Network: $250 per day or 25% for institutional services, whichever is less, plus 20% for separately billed professional charges

Non-Network: $810 per day or 25% for institutional services, whichever is less, plus 25% for separately billed professional charges

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)

Network: 20% of negotiated fee
Non-Network: 25% of allowable charge

Skilled Nursing (Inpatient)

Network: $250 per day or 25% for institutional services, whichever is less, plus 20% for separately billed professional charges

Non-Network: 25% for institutional services, plus 25% cost share for separately billed professional charges

Only available in the U.S. and U.S. Territories.

Ambulance Services

Network: 20% of negotiated fee
Non-Network: 25% of allowable charge

Ambulatory Surgery (Same Day)

Network: 20% of negotiated fee
Non-Network: 25% of allowable charge

Clinical Preventive Services

$0 for the following services:

  • Cancer screenings* (colorectal, breast, cervical, prostate)
  • Immunizations*
  • Well-child care for children under age 6 (birth through age 5)

*This includes the office visit for beneficiaries age 6 and older when a covered cancer screening or immunization is provided during the visit.

For all other preventive services:

  • Network: 20% of negotiated fee
  • Non-Network: 25% of allowable charge
DME, Prosthetic Devices, Medical Supplies

Network: 20% of negotiated fee
Non-Network: 25% of allowable charge

Emergency Services

Network: 20% of negotiated fee
Non-Network: 25% of allowable charge

Home Health Care $0
Hospice Care $0
Hospitalization (Inpatient Care)

Network: $250 per day or 25% for institutional services, whichever is less, plus 20% for separately billed professional charges

Non-Network: $810 per day or 25% for institutional services, whichever is less, plus 25% for separately billed professional charges

Immunizations $0
Newborn Care

Network: The lower of the number of hospital days minus 3 multiplied by $250 or 25% of the negotiated rate for institutional services, plus 20% for separately billed professional charges

Non-Network: The lower of the number of hospital days minus 3 multiplied by $810 or 25% of billed charges for institutional services, plus 25% for separately billed professional charges.

Outpatient Visit

Network: 20% of negotiated fee
Non-Network: 25% of allowable charge

Enrolled in TRICARE Young Adult?

Newborn care is not covered unless the father of the child is a uniformed service member.

Last Updated 3/10/2015