Use Standard and Extra
Now that you're disenrolled from TRICARE Prime, take some time to learn how to use TRICARE Standard and Extra before you get care. Watch Video: How to Use TRICARE Standard
Step 1: Find a Provider and Get Care
Unlike TRICARE Prime, where you got most care from an assigned primary care manager (PCM), TRICARE Standard and Extra gives you the freedom of choice. When you need an appointment for any type of care, you can go to any TRICARE-authorized provider, network or non-network. The type of provider you choose determines:
- which option you’re using: Standard or Extra,
- your out-of-pocket costs, and
- whether or not you have to file your own claims
You don't need to see a PCM first and you’ll never need a referral for any type of care.
Want to keep seeing your current provider for annual check ups and preventive care?
You can. Check with the provider who was your PCM to see if he or she is still a network provider. If the provider is no longer in the network, you can continue to see that provider using the Standard option.
Step 2: Pay for the Care
You are no longer required to pay annual enrollment fees to use TRICARE Standard and Extra. You will only pay for health care that you receive.
You must meet an annual deductible each fiscal year (October 1 - September 30) before cost sharing begins:
- Active Duty Sponsor Pay Grade E4 and below: $50 per individual, but no more than $100 per family
- Active Duty Sponsor Pay Grade E5 and above: $150 per individual, but no more than $300 per family
- Retired Sponsor and all others: $150 per individual, but no more than $300 per family
Instead of paying a fixed copyament for health care services like with TRICARE Prime, you'll pay a cost share—or percentage—of the total cost for services with TRICARE Standard and Extra. The cost share amount is based on the type of care and whether you visit a network or non-network provider.
Remember, when you are using TRICARE Extra and see network providers, you're only required to pay your cost share (after the deductible is met) at the time of your visit. With non-network providers, you may have to pay the full amount up front and file a claim for reimbursement. Additionally, non-network providers may charge up to 15% above the TRICARE allowable charge. You're also responsible for those additional charges.
The catastrophic cap is the maximum you'll pay for health care for your entire family during the fiscal year (October 1 - September 30). This includes annual deductibles, pharmacy copayments, and cost shares. The cap is the same whether you are using Prime, Standard or Extra.
- Active Duty Families: $1,000 per fiscal year
- Retired Families: $3,000 per fiscal year
Payment Example: Retired Family
A retired service member visits a network provider in October. The total cost charged is $200. The beneficiary will pay to the provider:
- $150 annual deductible
- 20% of the remaining amount: $10.00
Total paid at time of visit: $160.00. This amount is applied to the catastrophic cap.
The following month, the spouse visits a non-network provider. The allowable charge for the care is $300, but the provider balance bills (charges 15% above that amount) so the total cost charged is $345. The beneficiary pays the total cost up front and can then file a claim for the following:
- $150 annual deductible
- 25% of the remaining amount: $37.50
Total amount reimbursed: $187.50. This amount is applied to the catastrophic cap.
After these two appointments, the annual deductible has been met for the fiscal year and $347.50 has been applied to the catastrophic cap. At future appointments, family members are only required to pay the cost share (and balanced billed amounts if visiting a non-network provider). TRICARE will pay all the costs after the cap is reached, so the family will never pay more than $3,000 for the care each fiscal year.
Want to reduce out-of-pocket costs?
The easiest way is to visit network providers whenever possible. You'll pay a 5% lower cost share of a negotiated rate, which could be less than the TRICARE allowed amount. Plus, network providers will never balance bill.
Another option is to purchase a TRICARE supplement or use other health insurance, such as an employer-sponsored health plan.
- TRICARE is always second payer after other health insurance pays their allowable billed charges. >>Learn More
- TRICARE supplements will pay after allowable charges. TRICARE supplements pay after allowable charges are payed by TRICARE. >>Learn More