Payment Example

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 chargeThe maximum amount TRICARE pays for each procedure or service.  This is tied by law to Medicare's allowable charges. 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 yearOctober 1 - September 30 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 insuranceHealth insurance you have in addition to TRICARE, such as Medicare or an employer-sponsored health insurance. TRICARE supplements don’t qualify as "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 paid by TRICARE. >>Learn More

Last Updated 9/2/2016