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Service
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Cost
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Annual Deductible
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E1-E4: $50 per individual and $100 per family
E5 & above: $150 per individual and $300 per family
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Ambulance Services
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- Network: $15
- Non-Network: 20% of allowable charge
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Ambulatory Surgery (Same Day)
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- Network: $25
- Non-Network: 20% of allowable charge
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Mental Health (Inpatient)
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See TRICARE Mental Health Costs
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Mental Health (Partial Hospitalization)
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See TRICARE Mental Health Costs
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Mental Health (Outpatient)
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See TRICARE Mental Health Costs
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Clinical Preventive Services
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Network:$0
Non-network: $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, non-network: 20% of allowable charge
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DME, Prosthetic Devices, Medical Supplies
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Emergency Services
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- Network: $40
- Non-Network: 20% of allowable charge
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Home Health Care
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$0
Note: You may have separate costs for additional services when receiving home health care. For example, DME, drugs, vaccines, orthotics/prosthetics, and nutritional therapy, among others. Only available in US.
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Hospice Care
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$0
Note: Only available in the US.
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Hospitalization (Inpatient Care - Medical and Mental)
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- Network: $60
- Non-Network: 20% of allowable charge
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Immunizations
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$0
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Laboratory and X-ray
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Network: $0
Non-Network: 20% of allowable charge
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Maternity (office visits and hospitalization for delivery planned in a hospital in an inpatient setting)
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- Network: $60
- Non-Network: 20% of allowable charge
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Maternity (office visits for delivery planning in a TRICARE-authorized birthing center)
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- Network: $25 for delivery
- Non-Network: 20% of allowable charge
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Maternity (office visits for delivery planned at home or other setting)
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- Network: $34
- Non-Network: 20% of allowable charge
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Newborn Care
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- Network: $0
- Non-Network: 20% of allowable charge
Note: If any family member is enrolled in TRICARE Prime, the newborn is also covered by Prime for up to the first 90 days and costs are $0.
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Outpatient Visit (Medical and Mental)
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- Network:
- Primary Care: $15
- Specialty Care: $25
- Non-Network: 20% of allowable charge
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Skilled Nursing (Inpatient)
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- Network: $25 per day
- Non-Network: $50 per day
Only available in the U.S. and U.S. Territories.
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Urgent Care
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- Network: $20
- Non-Network: 20% of allowable charge
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