Service
|
Cost
|
Annual Deductible
|
E1-E4: $50 per individual and $100 per family
E5 & above: $150 per individual and $300 per family
|
Ambulance Services
|
- Network: $15
- Non-Network: 20% of allowable charge
|
Ambulatory Surgery (Same Day)
|
- Network: $25
- Non-Network: 20% of allowable charge
|
Mental Health (Inpatient)
|
See TRICARE Mental Health Costs
|
Mental Health (Partial Hospitalization)
|
See TRICARE Mental Health Costs
|
Mental Health (Outpatient)
|
See TRICARE Mental Health Costs
|
Clinical Preventive Services
|
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
|
DME, Prosthetic Devices, Medical Supplies
|
|
Emergency Services
|
- Network: $40
- Non-Network: 20% of allowable charge
|
Home Health Care
|
$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.
|
Hospice Care
|
$0
Note: Only available in the US.
|
Hospitalization (Inpatient Care - Medical and Mental)
|
- Network: $60
- Non-Network: 20% of allowable charge
|
Immunizations
|
$0
|
Laboratory and X-ray
|
Network: $0
Non-Network: 20% of allowable charge
|
Maternity (office visits and hospitalization for delivery planned in a hospital in an inpatient setting)
|
- Network: $60
- Non-Network: 20% of allowable charge
|
Maternity (office visits for delivery planning in a TRICARE-authorized birthing center)
|
- Network: $25 for delivery
- Non-Network: 20% of allowable charge
|
Maternity (office visits for delivery planned at home or other setting)
|
- Network: $34
- Non-Network: 20% of allowable charge
|
Newborn Care
|
- 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.
|
Outpatient Visit (Medical and Mental)
|
- Network:
- Primary Care: $15
- Specialty Care: $25
- Non-Network: 20% of allowable charge
|
Skilled Nursing (Inpatient)
|
- Network: $25 per day
- Non-Network: $50 per day
Only available in the U.S. and U.S. Territories.
|
Urgent Care
|
- Network: $20
- Non-Network: 20% of allowable charge
|